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Duler L, Visser L, Nguyen N, Johnson LR, Stern JA, Li RHL. Platelet hyperresponsiveness and increased platelet-neutrophil aggregates in dogs with myxomatous mitral valve disease and pulmonary hypertension. J Vet Intern Med 2024. [PMID: 38773707 DOI: 10.1111/jvim.17067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 03/25/2024] [Indexed: 05/24/2024] Open
Abstract
BACKGROUND Pulmonary hypertension (PH) in dogs with myxomatous mitral valve disease (MMVD) is caused by increased pulmonary venous pressure. Thrombosis, vascular remodeling, and vasoconstriction mediated by platelets could exacerbate PH. HYPOTHESIS Dogs with PH will exhibit a hypercoagulable state, characterized by increased platelet activation, platelet-leukocyte, and platelet-neutrophil aggregate formation. ANIMALS Eleven dogs (≥3.5 kg) diagnosed with MMVD and PH and 10 dogs with MMVD lacking PH. METHODS Prospective cohort ex vivo study. All dogs underwent echocardiographic examination, CBC, 3-view thoracic radiographs, and heartworm antigen testing. Severity of PH and MMVD were assessed by echocardiography. Viscoelastic monitoring of coagulation was assessed using thromboelastography (TEG). Platelet activation and platelet-leukocyte/platelet-neutrophil interactions were assessed using flow cytometry. Plasma serotonin concentrations were measured by ELISA. RESULTS Unstimulated platelets from dogs with MMVD and PH expressed more surface P-selectin than MMVD controls (P = .03). Platelets from dogs with MMVD and PH had persistent activation in response to agonists. The number of platelet-leukocyte aggregates was higher in dogs with MMVD and PH compared with MMVD controls (P = .01). Ex vivo stimulation of whole blood resulted in higher numbers of platelet-neutrophil aggregates in dogs with MMVD and PH (P = .01). Assessment of hypercoagulability based on TEG or plasma serotonin concentrations did not differ between groups. CONCLUSION AND CLINICAL IMPORTANCE Platelet hyperresponsiveness and increased platelet-neutrophil interaction occur in dogs with MMVD and PH, suggesting that platelets play a role of in the pathogenesis of PH. Clinical benefits of antiplatelet drugs in dogs with MMVD and PH require further investigation.
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Affiliation(s)
- Laetitia Duler
- William R. Pritchard Veterinary Medicine Teaching Hospital, School of Veterinary Medicine, University of California Davis, Davis, California, USA
| | - Lance Visser
- Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, Colorado, USA
| | - Nghi Nguyen
- Department of Surgical and Radiological Science, School of Veterinary Medicine, University of California Davis, Davis, California, USA
| | - Lynelle R Johnson
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California Davis, Davis, California, USA
| | - Joshua A Stern
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California Davis, Davis, California, USA
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
| | - Ronald H L Li
- Department of Surgical and Radiological Science, School of Veterinary Medicine, University of California Davis, Davis, California, USA
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2
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Diebel LN, Liberati DM, Karadjoff A, Terasaki Y, Srour A, McPherson S. Detection of glycocalyx degradation in real time: A conceptual model of thromboelastography. Surgery 2024; 175:613-617. [PMID: 37863690 DOI: 10.1016/j.surg.2023.08.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 08/15/2023] [Accepted: 08/17/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND The endothelial glycocalyx is a critical component of the vascular barrier; its disruption after shock states may contribute to coagulopathy in a variety of conditions. Measurement of glycocalyx components in plasma have been used to index glycocalyx degradation but are not available as a point of care test. Heparanoids, such as heparan sulfate, may affect coagulation which may be detected by either thromboelastography or activated clotting time. METHODS Endothelial glycocalyx components syndecan-1 and heparan sulfate were added to blood samples at clinically relevant concentrations. Thromboelastography values included clot reaction time, clot amplification and fibrinogen values, and maximum clot strength (maximum amplitude, platelets). The heparinase thromboelastography cartridge was used to detect a heparin-like effect. The activated clotting time test was performed subsequently using the heparan sulfate blood samples to compare a standard coagulation test with thromboelastography clot reaction times. RESULTS Both thromboelastography clot reaction time (with comparison to heparinase) and activated clotting time were useful to detect effects of coagulation. Thromboelastography also detected platelet and fibrinogen abnormalities at higher heparan sulfate concentrations. Studies using thromboelastography or even activated clotting time may be useful to detect glycocalyx degradation after shock states and may guide clinical decision making. CONCLUSION Thromboelastography and or activated clotting time may be useful to detect glycocalyx degradation as a point of care test in patients in the acute setting. Additionally, these assays may detect previous undisclosed coagulopathy due to glycocalyx degradation.
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Affiliation(s)
- Lawrence N Diebel
- Michael and Marian Ilitch Department of Surgery, Wayne State University, Detroit, MI.
| | - David M Liberati
- Michael and Marian Ilitch Department of Surgery, Wayne State University, Detroit, MI
| | - Alison Karadjoff
- Michael and Marian Ilitch Department of Surgery, Wayne State University, Detroit, MI
| | - Yusuke Terasaki
- Michael and Marian Ilitch Department of Surgery, Wayne State University, Detroit, MI
| | - Ali Srour
- Michael and Marian Ilitch Department of Surgery, Wayne State University, Detroit, MI
| | - Steve McPherson
- Michael and Marian Ilitch Department of Surgery, Wayne State University, Detroit, MI
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3
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Ramanujam V, DiMaria S, Varma V. Thromboelastography in the Perioperative Period: A Literature Review. Cureus 2023; 15:e39407. [PMID: 37362492 PMCID: PMC10287184 DOI: 10.7759/cureus.39407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2023] [Indexed: 06/28/2023] Open
Abstract
Assessing coagulation status is essential for prompt intervention to reduce morbidity and mortality related to bleeding and thrombotic complications during the perioperative period. Traditional coagulation tests such as platelet count, activated partial thromboplastin time (aPTT), prothrombin time (PT), international normalized ratio (INR), and activated clotting time (ACT) provide only static evaluation. These tests are not designed for assessment of dynamically changing coagulation conditions during the perioperative time. However, viscoelastic coagulation testing such as thromboelastography (TEG) produces a rapid numerical and graphical representation that helps to detect and direct targeted hemostatic therapy. Searching the literature through PubMed, Medline, Ovid, CINAHL, and ClinicalTrials.gov we retrieved 210 studies, which represent the use of TEG in the perioperative period. The included studies were categorized under various settings such as trauma, obstetrics, orthopedics, intensive care unit (ICU), cardiovascular, transplant, and miscellaneous scenarios. TEG showed promising results in trauma surgeries in predicting mortality, hypercoagulability, and bleeding even when it was compared to conventional methods. TEG was also useful in monitoring anticoagulant therapy in orthopedic and obstetric surgeries; however, its role in predicting thrombotic events, hypercoagulability, or complications was questionable. In ICU patients, it showed promising results, especially in the prediction or improvement of sepsis, coagulopathy, thrombotic events, ICU duration, hospital stay, and ventilator duration. TEG parameters effectively predicted hypercoagulation in transplant surgeries. Regarding cardiovascular surgeries, they were effective in the prediction of the need for blood products, coagulopathy, thrombotic events, and monitoring anticoagulation therapy. More randomized clinical trials comparing TEG parameters with standardized tools are needed to produce robust results to standardize its use in different perioperative settings.
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Affiliation(s)
- Vendhan Ramanujam
- Department of Anesthesiology, Rhode Island Hospital/The Warren Alpert Medical School of Brown University, Providence, USA
| | - Stephen DiMaria
- Department of Anesthesiology, Rhode Island Hospital/The Warren Alpert Medical School of Brown University, Providence, USA
| | - Vivek Varma
- Department of Anesthesiology, Rhode Island Hospital/The Warren Alpert Medical School of Brown University, Providence, USA
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4
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Maslow A, Cheves T, Joyce MF, Apruzzese P, Sweeney J. Interaction Between Platelet and Fibrinogen on Clot Strength in Healthy Patients. J Cardiothorac Vasc Anesth 2023; 37:942-947. [PMID: 36933991 DOI: 10.1053/j.jvca.2023.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 02/12/2023] [Accepted: 02/13/2023] [Indexed: 02/22/2023]
Abstract
OBJECTIVE The purpose of this study was to explore the relationship between platelet concentration (PLT) (× 109/L) and clot strength measured by thromboelastography maximum amplitude (TEG-MA) in healthy volunteers without a history of coagulation abnormalities. Secondarily, the relationship between fibrinogen (mg/dL) and TEG-MA was analyzed. DESIGN A prospective study. SETTING At a university's tertiary-care center. MEASUREMENTS AND MAIN RESULTS Using whole blood, PLT was reduced in the first part, and hematocrit was reduced in the second part of the study by hemodilution with platelet-rich and -poor plasma. Thromboelastography (TEG 5000 Haemonetics) was performed to measure clot formation and strength. Spearman correlation coefficients regression analyses and receiver-operating characteristics (ROC) were obtained to analyze the relationships among PLT, fibrinogen, and TEG-MA. Strong correlations were found in univariate analysis between PLT and TEG-MA (r = 0.88; p < 0.0001) and between Fibrinogen and TEG-MA (r = 0.70; p = 0.003). A biphasic relationship between PLT and TEG-MA was linear below a PLT 90 × 109/L, followed by a plateau above 100 × 109/L (p = 0.001). A linear relationship between fibrinogen (190-474 mg/dL) and TEG-MA (53-76 mm) was found (p = 0.0007). The ROC analysis found that PLT = 60 × 109/L was associated with a TEG-MA of 53.0 mm. The product of PLT and fibrinogen concentrations was more strongly correlated (r = 0.91) to TEG-MA than either PLT (r = 0.86) or fibrinogen (r = 0.71) alone. A ROC analysis revealed that a TEG-MA of 55 mm was associated with a PLT × fibrinogen of 16,720. CONCLUSION In healthy patients, a PLT of 60 × 109/L was associated with normal clot strength (TEG-MA ≥53 mm), and there was little change in clot strength with PLT >90 × 109/L. Although prior analyses described the contributions of platelets and fibrinogen toward clot strength, they are presented and discussed independently. The data above described clot strength as an interaction among them. Future analyses and clinical care should evaluate and recognize the interplay.
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Affiliation(s)
- Andrew Maslow
- Department of Anesthesiology, Rhode Island Hospital, Providence, RI.
| | - Tracey Cheves
- Department of Hematology, Rhode Island Hospital, Providence, RI
| | | | | | - Joseph Sweeney
- Department of Hematology, Rhode Island Hospital, Providence, RI
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5
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Matkovic E, Lindholm PF. Role of Viscoelastic and Conventional Coagulation Tests for Management of Blood Product Replacement in the Bleeding Patient. Semin Thromb Hemost 2022; 48:785-795. [PMID: 36174609 DOI: 10.1055/s-0042-1756192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
An important aim of viscoelastic testing (VET) is to implement transfusion algorithms based on coagulation test results to help reduce transfusion rates and improve patient outcomes. Establishing a rapid diagnosis and providing timely treatment of coagulopathy is the cornerstone of management of severely bleeding patients in trauma, postpartum hemorrhage, and major surgery. As the nature of acute bleeding and trauma leads to an unstable and tenuous physiologic state, conventional coagulation tests (CCTs) are too slow to diagnose, manage, and also course correct any hemostatic abnormalities that accompany an acute critical illness. Viscoelastic point-of-care tests strongly correlate with results from standard laboratory tests but are designed to enable clinicians to make timely, informed bleeding management decisions when time to intervene is critical. These assays provide an individualized and goal-oriented approach to patient blood management and are increasingly becoming involved in transfusion algorithms. The scope of this review aims to evaluate the current literature on VETs and their impact on actionable outputs in clinical decision making and their relationship to CCT.
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Affiliation(s)
- Eduard Matkovic
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Paul F Lindholm
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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6
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Bunch CM, Berquist M, Ansari A, McCoy ML, Langford JH, Brenner TJ, Aboukhaled M, Thomas SJ, Peck E, Patel S, Cancel E, Al-Fadhl MD, Zackariya N, Thomas AV, Aversa JG, Greene RB, Seder CW, Speybroeck J, Miller JB, Kwaan HC, Walsh MM. The Choice between Plasma-Based Common Coagulation Tests and Cell-Based Viscoelastic Tests in Monitoring Hemostatic Competence: Not an either-or Proposition. Semin Thromb Hemost 2022; 48:769-784. [PMID: 36174601 DOI: 10.1055/s-0042-1756302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
There has been a significant interest in the last decade in the use of viscoelastic tests (VETs) to determine the hemostatic competence of bleeding patients. Previously, common coagulation tests (CCTs) such as the prothrombin time (PT) and partial thromboplastin time (PTT) were used to assist in the guidance of blood component and hemostatic adjunctive therapy for these patients. However, the experience of decades of VET use in liver failure with transplantation, cardiac surgery, and trauma has now spread to obstetrical hemorrhage and congenital and acquired coagulopathies. Since CCTs measure only 5 to 10% of the lifespan of a clot, these assays have been found to be of limited use for acute surgical and medical conditions, whereby rapid results are required. However, there are medical indications for the PT/PTT that cannot be supplanted by VETs. Therefore, the choice of whether to use a CCT or a VET to guide blood component therapy or hemostatic adjunctive therapy may often require consideration of both methodologies. In this review, we provide examples of the relative indications for CCTs and VETs in monitoring hemostatic competence of bleeding patients.
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Affiliation(s)
- Connor M Bunch
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Margaret Berquist
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Aida Ansari
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Max L McCoy
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Jack H Langford
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Toby J Brenner
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Michael Aboukhaled
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Samuel J Thomas
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Ethan Peck
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Shivani Patel
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Emily Cancel
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Mahmoud D Al-Fadhl
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Nuha Zackariya
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Anthony V Thomas
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - John G Aversa
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Ryan B Greene
- Department of Interventional Radiology, St. Joseph Regional Medical Center, Mishawaka, Indiana
| | - Christopher W Seder
- Department of Cardiovascular and Thoracic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Jacob Speybroeck
- Department of Orthopedic Surgery, Case Western Medical Center, Cleveland, Ohio
| | - Joseph B Miller
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Hau C Kwaan
- Division of Hematology and Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mark M Walsh
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana.,Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
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7
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Pîrlog BO, Grotta JC. The Applicability of Thromboelastography in Acute Ischemic Stroke: A Literature Review. Semin Thromb Hemost 2022. [PMID: 36063851 DOI: 10.1055/s-0042-1757134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Acute ischemic stroke (AIS) due to cerebral artery occlusion is often treated by thrombolytics or antithrombotic drugs. Thromboelastography (TEG) is a noninvasive test that provides a dynamic overview of the coagulation process. TEG may help guide thrombolytic and antithrombotic therapy in AIS. This article aims to highlight the potential use of TEG in AIS patients by reviewing available studies. We conducted a literature review, including PubMed and Cochrane library databases. The following keywords were used to find relevant studies: thromboelastography, TEG, acute ischemic stroke, stroke, coagulopathy, antiplatelet, and anticoagulant treatment. We identified 142 papers and after abstract review, we included 24 studies in this report. TEG identified a hypercoagulable state in AIS patients represented by short R, K, and greater α: angle in all papers included. Modification of TEG parameters induced by intravenous thrombolysis was inconsistent but prolonged lysis (increased LY30) and weaker clots (lower maximum amplitude) were most frequent. TEG detected hypo-coagulopathy induced by dual antiplatelet therapy as well as antiplatelet drug resistance, with ticagrelor and aspirin having greater inhibition of platelet activity. A prolonged R-value seems to be the most reliable TEG parameter in detecting the anticoagulant effect of factor Xa inhibitor treatment. TEG might represent a useful point-of-care test for emergency decision-making in AIS patients and a tool for individualized treatment options. This hypothesis needs validation in a large cohort of prospectively studied AIS patients.
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Affiliation(s)
- Bianca O Pîrlog
- Department of Neurology, County Emergency Hospital, Cluj-Napoca, Romania.,University of Medicine and Pharmacy "Iuliu Hațieganu" Cluj-Napoca, Romania
| | - James C Grotta
- Memorial Hermann Hospital-Texas Medical Center, Houston, Texas
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8
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Pîrlog BO, Grotta JC. The Applicability of Thromboelastography in Acute Ischemic Stroke: A Literature Review. Semin Thromb Hemost 2022; 48:842-849. [PMID: 36055271 DOI: 10.1055/s-0042-1753529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Acute ischemic stroke (AIS) due to cerebral artery occlusion is often treated by thrombolytics or antithrombotic drugs. Thromboelastography (TEG) is a noninvasive test that provides a dynamic overview of the coagulation process. TEG may help guide thrombolytic and antithrombotic therapy in AIS. This article aims to highlight the potential use of TEG in AIS patients by reviewing available studies. We conducted a literature review, including PubMed and Cochrane library databases. The following keywords were used to find relevant studies: thromboelastography, TEG, acute ischemic stroke, stroke, coagulopathy, antiplatelet, and anticoagulant treatment. We identified 142 papers and after abstract review, we included 24 studies in this report. TEG identified a hypercoagulable state in AIS patients represented by short R, K, and greater α: angle in all papers included. Modification of TEG parameters induced by intravenous thrombolysis was inconsistent but prolonged lysis (increased LY30) and weaker clots (lower maximum amplitude) were most frequent. TEG detected hypo-coagulopathy induced by dual antiplatelet therapy as well as antiplatelet drug resistance, with ticagrelor and aspirin having greater inhibition of platelet activity. A prolonged R-value seems to be the most reliable TEG parameter in detecting the anticoagulant effect of factor Xa inhibitor treatment. TEG might represent a useful point-of-care test for emergency decision-making in AIS patients and a tool for individualized treatment options. This hypothesis needs validation in a large cohort of prospectively studied AIS patients.
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Affiliation(s)
- Bianca O Pîrlog
- Department of Neurology, County Emergency Hospital, Cluj-Napoca, Romania.,University of Medicine and Pharmacy "Iuliu Hațieganu" Cluj-Napoca, Romania
| | - James C Grotta
- Memorial Hermann Hospital-Texas Medical Center, Houston, Texas
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9
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Lu ZY, Zhu ZY, Yang JX, Zhou YZ, Jiang YZ, Wei W, Wang X, Li SJ. Platelet Aggregation Before Aspirin Initiation in Pediatric Patients With Congenital Heart Disease at High Risk of Thrombosis. Front Cardiovasc Med 2022; 9:813190. [PMID: 35911558 PMCID: PMC9328390 DOI: 10.3389/fcvm.2022.813190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 06/16/2022] [Indexed: 11/24/2022] Open
Abstract
Background Aspirin following unfractionated heparin is the most common anticoagulation strategy for pediatric patients who experienced cardiac surgery at high risk of thrombosis. The platelet aggregation test is the golden method to evaluate the aspirin effect on platelet function. However, the platelet aggregation basal status before postoperative aspirin initiation and the related clinical influencing factors hasn't been investigated systemically in this population. Methods In a prospective cohort of 247 children, arachidonic acid-induced platelet aggregation (PAG-AA) was measured by means of light transmission aggregometry (LTA) before the first dose of aspirin after cardiac surgical procedure and the perioperative variables were also collected. Distribution of this population's PAG-AA basal status was described. Univariate and multivariate logistic regression analysis were performed to identify the main influencing factors of PAG-AA. Results The median time of aspirin administration was 2 (1–27) days after surgery and the corresponding median value of basal PAG-AA was 20.70% (1.28–86.49%), with 67.6% population under 55% and 47.8% population under 20%. Patients undergoing cardiopulmonary bypass (CPB) had a significantly lower basal PAG-AA than those without (30.63 ± 27.35 vs. 57.91 ± 27.58, p = 0.013). While patients whose test done within 3 days after CPB had a significantly lower PAG-AA than those out of 3 days (25.61 ± 25.59 vs. 48.59 ± 26.45, p = 0.001). Univariate analysis implied that the influencing factors of the basal PAG-AA including CPB use, test time point, cyanosis, and platelet count. Multivariate regression analysis indicated that only CPB use, test time point, and platelet count were the main independent influencing factors for the basal PAG-AA. Conclusion The majority of children have impaired basal platelet aggregometry responses before postoperative aspirin initiation. The main influencing factors are CPB use, test time point, and platelet count. To establish the platelet aggregometry baseline prior to commencement of aspirin therapy, testing should be performed 3 days later following the procedure when effect of CPB is basically over.
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Affiliation(s)
- Zhong-Yuan Lu
- Pediatric Intensive Care Unit, Pediatric Cardiac Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Zhi-Yuan Zhu
- Pediatric Intensive Care Unit, Pediatric Cardiac Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Ju-Xian Yang
- Pediatric Intensive Care Unit, Pediatric Cardiac Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yu-Zi Zhou
- Pediatric Intensive Care Unit, Pediatric Cardiac Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Ya-Zhou Jiang
- Pediatric Intensive Care Unit, Pediatric Cardiac Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Wei Wei
- Pediatric Intensive Care Unit, Pediatric Cardiac Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xu Wang
- Pediatric Intensive Care Unit, Pediatric Cardiac Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- *Correspondence: Xu Wang
| | - Shou-Jun Li
- Department of Cardiac Surgery, Pediatric Cardiac Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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10
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Tantry US, Hartmann J, Neal MD, Schöechl H, Bliden KP, Agarwal S, Mason D, Dias JD, Mahla E, Gurbel PA. The role of viscoelastic testing in assessing peri-interventional platelet function and coagulation. Platelets 2021; 33:520-530. [PMID: 34369848 DOI: 10.1080/09537104.2021.1961709] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
We carried out a literature search in MEDLINE (PubMed) and EMBASE literature databases to provide a concise review of the role of viscoelastic testing in assessing peri-interventional platelet function and coagulation. The search identified 130 articles that were relevant for the review, covering the basic science of VHA and VHA in clinical settings including cardiac surgery, cardiology, neurology, trauma, non-cardiac surgery, obstetrics, liver disease, and COVID-19. Evidence from these articles is used to describe the important role of VHAs and platelet function testing in various peri-interventional setups. VHAs can help us to comprehensively assess the contribution of platelets and coagulation dynamics to clotting at the site-of-care much faster than standard laboratory measures. In addition to standard coagulation tests, VHAs are beneficial in reducing allogeneic transfusion requirements and bleeding, in predicting ischemic events, and improving outcomes in several peri-interventional care settings. Further focused studies are needed to confirm their utility in the peri-interventional case.
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Affiliation(s)
- Udaya S Tantry
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Jan Hartmann
- Medical Affairs and Clinical Development, Haemonetics Corporation, Boston, MA, USA
| | - Matthew D Neal
- Department of General Surgery, The University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Herbert Schöechl
- Department of Anesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Salzburg, Austria.,AUVA Trauma Research Centre, Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Vienna, Austria
| | - Kevin P Bliden
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Seema Agarwal
- Department of Anaesthesia, Manchester University Foundation Trust, Manchester, UK
| | - Dan Mason
- Medical Affairs and Clinical Development, Haemonetics Corporation, Boston, MA, USA
| | - Joao D Dias
- Medical Affairs and Clinical Development, Haemonetics Corporation, Boston, MA, USA
| | - Elisabeth Mahla
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Paul A Gurbel
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, USA
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11
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Datta SS, De D, Bose S. Thromboelastography Platelet Mapping—A Useful Preoperative Tool to Reduce Transfusion Requirement by Determining Timing of Coronary Artery Bypass Graft Surgery in Patients taking Dual Antiplatelet Medication: A Pilot Study from Eastern India. JOURNAL OF CARDIAC CRITICAL CARE TSS 2021. [DOI: 10.1055/s-0041-1723622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
AbstractIn this pilot study, we proposed an algorithm to use thromboelastography platelet mapping (TEG-PM) as an effective preoperative platelet function assessment tool in coronary artery bypass graft surgery (CABG) to reduce the transfusion requirement by determining timing of surgery in patients who are on dual antiplatelet therapy (DAPT). Total 15 elective CABG patients who were receiving DAPT were tested by TEG-PM assay after 72 hours’ stoppage of both medications. Four patients who had < 50% inhibition with agonists (arachidonic acid [AA] and adenosine diphosphate [ADP]) were operated within 24 hours of assay. Eight patients who had > 70% inhibition with AA/ADP, surgery was deterred till 48 hours, and 3 patients with > 50% but < 70% inhibition were operated within 24 hours after preoperative prophylactic platelet transfusion. Transfusion requirement was recorded and compared with the previous transfusion data for CABG cases operated without TEG-PM. Distribution of ADP inhibition was 67.54 ± 30.03% and AA inhibition was 60.69 ± 30.14%, showing a variable offset of the effect of both medications starting after 72 hours of cessation. Overall transfusion requirement was decreased by using TEG-PM algorithm. Preoperative platelet function testing to determine the timing of surgery by TEG-PM assay in DAPT-treated patients may be a useful strategy to reduce transfusion requirement in CABG.
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Affiliation(s)
- Suvro Sankha Datta
- Department of Transfusion Medicine, The Mission Hospital, Durgapur, West Bengal, India
| | - Dibyendu De
- Department of Clinical Hematology, The Mission Hospital, Durgapur, West Bengal, India
| | - Satyajit Bose
- Department of Cardio-Vascular Surgery, The Mission Hospital, Durgapur, West Bengal, India
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12
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Viscoelastic Hemostatic Assays and Platelet Function Testing in Patients with Atherosclerotic Vascular Diseases. Diagnostics (Basel) 2021; 11:diagnostics11010143. [PMID: 33478051 PMCID: PMC7835760 DOI: 10.3390/diagnostics11010143] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/14/2021] [Accepted: 01/18/2021] [Indexed: 11/16/2022] Open
Abstract
Platelets play crucial role in acute vascular atherosclerotic diseases, including myocardial infarction and stroke. Additionally, platelet aggregation is a key target of antiplatelet agents, forming the keystone of pharmacotherapy of various atherosclerotic cardiovascular diseases. Thromboelastography and thromboelastometry, representing currently available viscoelastic hemostatic assays (VHA), are designed as whole blood, real-time analyzers of clot formation and clot resolution. These assays could, in theory, overcome some limitations of currently available platelet function testing assays. This article reviews the current experience with the use of VHA for platelet function testing and for monitoring of the response to antiplatelet therapy.
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13
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Woźniak MJ, Abbasciano R, Monaghan A, Lai FY, Corazzari C, Tutino C, Kumar T, Whiting P, Murphy GJ. Systematic Review and Meta-Analysis of Diagnostic Test Accuracy Studies Evaluating Point-of-Care Tests of Coagulopathy in Cardiac Surgery. Transfus Med Rev 2020; 35:7-15. [PMID: 33187808 DOI: 10.1016/j.tmrv.2020.09.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 09/08/2020] [Accepted: 09/19/2020] [Indexed: 02/01/2023]
Abstract
Treatment guidelines recommend the routine use of point-of-care diagnostic tests for coagulopathy in the management of cardiac surgery patients at risk of severe bleeding despite uncertainty as to their diagnostic accuracy. We performed a systematic review and meta-analysis of studies that evaluated the diagnostic accuracy of viscoelastometry, platelet function tests, and modified thromboelastography (TEG) tests, for coagulopathy in cardiac surgery patients. The reference standard included resternotomy for bleeding, transfusion of non-red cell components, or massive transfusion. We searched MEDLINE, EMBASE, CINAHL, and Clinical Trials.gov, from inception to June 2019. Study quality was assessed using QUADAS-2. Bivariate models were used to estimate summary sensitivity and specificity with (95% confidence intervals). All 29 studies (7440 participants) included in the data synthesis evaluated the tests as predictors of bleeding. No study evaluated their role in the management of bleeding. None was at low risk of bias. Four were judged as low concern regarding applicability. Pooled estimates of diagnostic accuracy were; Viscoelastic tests, 12 studies, sensitivity 0.61 (0.44, 0.76), specificity 0.83 (0.70, 0.91) with significant heterogeneity. Platelet function tests, 12 studies, sensitivity 0.63 (0.53, 0.72), specificity 0.75 (0.64, 0.84) with significant heterogeneity. TEG modification tests, 3 studies, sensitivity 0.80 (0.67, 0.89), specificity 0.76 (0.69, 0.82) with no evidence of heterogeneity. Studies reporting the highest values for sensitivity and specificity had important methodological limitations. In conclusion, we did not demonstrate predictive accuracy for commonly used point-of-care devices for coagulopathic bleeding in cardiac surgery. However, the certainty of the evidence was low.
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Affiliation(s)
- Marcin J Woźniak
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre in Cardiovascular Medicine, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, UK.
| | - Riccardo Abbasciano
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre in Cardiovascular Medicine, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, UK
| | - Alexandra Monaghan
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre in Cardiovascular Medicine, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, UK
| | - Florence Y Lai
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre in Cardiovascular Medicine, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, UK
| | - Claudio Corazzari
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre in Cardiovascular Medicine, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, UK; Cardiac Surgery Unit, Insubria University, Varese, Italy
| | | | - Tracy Kumar
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre in Cardiovascular Medicine, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, UK
| | - Penny Whiting
- Centre for Research Synthesis and Decision Analysis (CReSyDA), Bristol Medical School, University of Bristol, Bristol, UK
| | - Gavin J Murphy
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre in Cardiovascular Medicine, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, UK
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14
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Qureshi AI, Jahngir MU, Qualls K, Akinci Y, Lobanova I, Liaqat J, Gao X, Akhtar IN, Kraus J, Uzun G, French B, Siddiq F, Ramiro Gomez C. The Effect of Ticagrelor on Platelet Reactivity in Patients with Clopidogrel Resistance Undergoing Neuroendovascular Procedures. J Neuroimaging 2020; 30:327-334. [PMID: 32301181 DOI: 10.1111/jon.12714] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 03/27/2020] [Accepted: 03/27/2020] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND AND PURPOSE Suboptimal platelet inhibition by clopidogrel (clopidogrel resistance) may be associated with high rates of stent thrombosis and ischemic events. Our objective was to determine if ticagrelor, a P2Y12 receptor inhibitor, can result in platelet inhibition in patients with clopidogrel resistance. METHODS A thromboelastography-platelet mapping assay was used in all patients undergoing neuroendovascular procedures requiring oral clopidogrel. In patients with suboptimal platelet inhibition (<60%) on clopidogrel, ticagrelor was imitated after an oral bolus of 180 mg followed by 90 mg twice daily and the platelet mapping assay was repeated. The primary endpoint was hemorrhagic complications classified as major (hemoglobin decrease >5 g/dL or intracranial hemorrhage with deficits), minor (hemoglobin decrease 3-5 g/dL or intracranial hemorrhage without residual deficits), or insignificant. RESULTS Suboptimal platelet inhibition on clopidogrel was seen in 70 of 106 patients undergoing neuroendovascular procedures. There was a significantly higher magnitude of platelet inhibition with ticagrelor compared with clopidogrel in patients with clopidogrel resistance (mean ± SD: 85.90 ± 10.74% vs. 29.26 ± 17.71%; P < .001); 50 of 70 patients showed optimal inhibition. Two patients had major (fatal) hemorrhagic events (both received either intravenous thrombolytics and/or eptifibatide infusion). Three patients had minor hemorrhagic events, and two patients had insignificant hemorrhagic events. Four of seven hemorrhagic events occurred in patients with optimal response to clopidogrel, two occurred in patients with suboptimal response to ticagrelor, and one occurred in a patient with optimal response to ticagrelor. CONCLUSIONS Oral ticagrelor can augment platelet inhibition in patients who have clopidogrel resistance.
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Affiliation(s)
- Adnan Iqbal Qureshi
- Zeenat Qureshi Stroke Institutes, Columbia, MO.,Department of Neurology, University of Missouri, Columbia, MO
| | | | - Kathryn Qualls
- Zeenat Qureshi Stroke Institutes, Columbia, MO.,Department of Neurology, University of Missouri, Columbia, MO
| | - Yasemin Akinci
- Zeenat Qureshi Stroke Institutes, Columbia, MO.,Department of Neurology, University of Missouri, Columbia, MO
| | - Iryna Lobanova
- Zeenat Qureshi Stroke Institutes, Columbia, MO.,Department of Neurology, University of Missouri, Columbia, MO
| | - Jahanzeb Liaqat
- Zeenat Qureshi Stroke Institutes, Columbia, MO.,Department of Neurology, University of Missouri, Columbia, MO
| | - Xiaoyu Gao
- Zeenat Qureshi Stroke Institutes, Columbia, MO.,Department of Neurology, University of Missouri, Columbia, MO
| | - Iqra Naveed Akhtar
- Zeenat Qureshi Stroke Institutes, Columbia, MO.,Department of Neurology, University of Missouri, Columbia, MO
| | | | - Guven Uzun
- Zeenat Qureshi Stroke Institutes, Columbia, MO.,Department of Neurology, University of Missouri, Columbia, MO
| | - Brandi French
- Department of Neurology, University of Missouri, Columbia, MO
| | - Farhan Siddiq
- Division of Neurological Surgery, University of Missouri, Columbia, MO
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15
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Xia R, Varnado S, Graviss EA, Nguyen DT, Cruz-Solbes A, Guha A, Krisl JC. Role of thromboelastography in predicting and defining pump thrombosis in left ventricular assist device patients. Thromb Res 2020; 192:29-35. [PMID: 32447105 DOI: 10.1016/j.thromres.2020.03.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Revised: 02/05/2020] [Accepted: 03/18/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Optimal anticoagulation for left ventricular assist device recipients aims to balance thrombosis and bleeding complications. Routine plasma-based coagulation tests may not accurately reflect overall hemostasis, and surrogate markers are used to help guide clinicians in the diagnosis of pump thrombosis. Thromboelastography derived coagulation index (CI) has been shown to be a parameter that can reflect "normocoagulability" in mechanical circulatory support device patients, but there is minimal data with regard to outcomes available. Our aim was to determine the role of CI in predicting and defining suspected pump thrombosis in HeartMate II™ recipients. MATERIALS AND METHODS We performed a single center, retrospective longitudinal cohort study with a nested case-control analysis to compare serial CI values over time in adult HeartMate II™ recipients who had confirmed or suspected pump thrombosis to those who did not. RESULTS AND CONCLUSIONS A multivariate linear mixed model analysis of the suspected pump thrombosis versus no pump thrombosis groups found a significantly lower mean change in CI over time when recipients were followed for 24 months post-implant [0.71 (95% CI 0.1-1.32, p = .02)]; CI was first significant at six months. Within each arm, CI significantly decreased in the no pump thrombosis group, but did not significantly differ within the suspected pump thrombosis group. No significant differences were found between the two groups regarding the outcomes of death, transplant, or neurological events.
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Affiliation(s)
- Ranran Xia
- Houston Methodist Hospital, Department of Pharmacy, Houston, TX, USA.
| | - Sara Varnado
- Houston Methodist Hospital, Department of Pharmacy, Houston, TX, USA
| | - Edward A Graviss
- Houston Methodist Research Institute, Departent of Pathology and Genomic Medicine, Houston, TX, USA.
| | - Duc T Nguyen
- Houston Methodist Research Institute, Departent of Pathology and Genomic Medicine, Houston, TX, USA.
| | - Ana Cruz-Solbes
- Houston Methodist Hospital, DeBakey Heart & Vascular Center, Houston, TX, USA
| | - Ashrith Guha
- Houston Methodist Hospital, DeBakey Heart & Vascular Center, Houston, TX, USA.
| | - Jill C Krisl
- Houston Methodist Hospital, Department of Pharmacy, Houston, TX, USA.
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16
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Griffin BR, Bronsert M, Reece TB, Pal JD, Cleveland JC, Fullerton DA, Gist KM, Jovanovich A, Jalal D, Faubel S, Aftab M. Thrombocytopenia After Cardiopulmonary Bypass Is Associated With Increased Morbidity and Mortality. Ann Thorac Surg 2019; 110:50-57. [PMID: 31816284 DOI: 10.1016/j.athoracsur.2019.10.039] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 08/10/2019] [Accepted: 10/02/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Thrombocytopenia is a risk factor for morbidity and mortality in critically ill patients, and is common after cardiopulmonary bypass (CPB). In this study, we evaluate whether thrombocytopenia after CPB is an independent risk factor for postoperative morbidity and mortality. METHODS We retrospectively evaluated 1364 patients requiring CPB at the University of Colorado Hospital between January 2011 and May 2016. Platelet nadir, absolute change in platelets, and percent change in platelets were modeled as continuous variables. Patients with postoperative thrombocytopenia (defined a nadir <75 × 103/μL within 72 hours) were also compared with patients without thrombocytopenia in a propensity-matched model. The primary outcome was in-hospital mortality, and secondary outcomes included postoperative infection, postoperative acute kidney injury (AKI), postoperative stroke, and prolonged intensive care unit (ICU) and hospital lengths of stay (LOS). RESULTS Postoperative thrombocytopenia occurred in 356 (26.0%) patients. In multivariable analysis, platelet nadir was significantly inversely associated with mortality (odds ratio [OR], 0.955; 95% confidence interval [CI], 0.934-0.975; P < .001), postoperative infection (OR, 0.992; 95% CI, 0.986-0.999; P = .03), AKI (all stage) (OR, 0.993; 95% CI, 0.988-0.998; P = .01), AKI (stage 3) (OR, 0.966; 95% CI, 0.951-0.982; P < .001), postoperative stroke (OR, 0.974; 95% CI, 0.956-0.992; P = .006), prolonged ICU stay (OR, 0.986; 95% CI, 0.981-0.991; P < .001), and hospital LOS (OR, 0.998; 95% CI, 0.997-0.999; P = .001). Percent change in platelets from baseline was also significantly associated with all primary and secondary outcomes. CONCLUSIONS Postoperative thrombocytopenia is independently associated with postoperative mortality, AKI, infection, stroke, and prolonged ICU and hospital LOS. Serial platelet monitoring may help identify patients at higher risk of postoperative complications. Further studies investigating strategies to reduce postoperative thrombocytopenia, including reducing CPB time, are needed.
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Affiliation(s)
- Benjamin R Griffin
- Division of Nephrology, Department of Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Michael Bronsert
- Adult and Child Consortium for Health Outcomes Research and Delivery Science and Surgical Outcomes and Applied Research, University of Colorado, Aurora, Colorado
| | - T Brett Reece
- Division of Cardiothoracic Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Jay D Pal
- Division of Cardiothoracic Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Joseph C Cleveland
- Division of Cardiothoracic Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - David A Fullerton
- Division of Cardiothoracic Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Katja M Gist
- Department of Pediatrics, Children's Hospital Colorado, The Heart Institute, Aurora, Colorado
| | - Anna Jovanovich
- Division of Nephrology, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Department of Medicine, Rocky Mountain Regional VA Medical Center, Denver, Colorado
| | - Diana Jalal
- Division of Nephrology, Department of Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Sarah Faubel
- Division of Nephrology, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Department of Medicine, Rocky Mountain Regional VA Medical Center, Denver, Colorado
| | - Muhammad Aftab
- Division of Cardiothoracic Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Department of Medicine, Rocky Mountain Regional VA Medical Center, Denver, Colorado.
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17
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Yaw HP, Van Den Helm S, MacLaren G, Linden M, Monagle P, Ignjatovic V. Platelet Phenotype and Function in the Setting of Pediatric Extracorporeal Membrane Oxygenation (ECMO): A Systematic Review. Front Cardiovasc Med 2019; 6:137. [PMID: 31620448 PMCID: PMC6759781 DOI: 10.3389/fcvm.2019.00137] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 08/29/2019] [Indexed: 11/13/2022] Open
Abstract
Background: Despite increasing technical improvement and extracorporeal membrane oxygenation (ECMO)-related knowledge over the past three decades, morbidity and mortality associated with bleeding and clotting complications remain high in pediatric patients undergoing ECMO. Platelets, a key element of the coagulation system, have been proposed to be the main cause of coagulopathy in the setting of ECMO. This systematic review aims to summarize and discuss the existing knowledge of platelet phenotype and function in the pediatric ECMO population. Methods: A systematic review was conducted for the Embase, Medline, and PubMed databases following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Results: The detailed study selection process yielded a total of 765 studies and only 3 studies that fulfilled the selection criteria were included in this review. Techniques used to assess platelet function in the three existing studies included platelet aggregometry, flow cytometry, and thromboelastography-platelet mapping. The finding that is common to the three studies is reduced platelet function in pediatric patients during ECMO either compared to before the initiation of ECMO or in non-survivors compared to survivors. Two studies demonstrated reduced platelet aggregation that are irreversible by platelet transfusion during ECMO. Two studies reported bleeding events and mortality in children on ECMO and none of the studies investigated thrombotic events. Conclusions: This systematic review demonstrates the extremely limited information available for platelet phenotype and function in the pediatric ECMO population. Evidence from the existing literature suggests reduced platelet aggregation and increased platelet activation in children during ECMO. However, this needs to be interpreted with care due to the limitations associated with the techniques used for platelet function testing. Furthermore, the association between platelet dysfunction and clinical outcomes in the pediatric ECMO population remains elusive. Multiple research gaps have been identified when it comes to the knowledge of platelet phenotype and function of children on ECMO, highlighting the need for robust, well-designed studies in this setting.
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Affiliation(s)
- Hui Ping Yaw
- Department of Haematology Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| | - Suelyn Van Den Helm
- Department of Haematology Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Graeme MacLaren
- Department of Haematology Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia.,Paediatric Intensive Care Unit, The Royal Children's Hospital, Melbourne, VIC, Australia.,Cardiothoracic Intensive Care Unit, National University Health System, Singapore, Singapore
| | - Matthew Linden
- School of Biomedical Sciences, The University of Western Australia, Perth, WA, Australia
| | - Paul Monagle
- Department of Haematology Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia.,Department of Clinical Haematology, The Royal Children's Hospital, Melbourne, VIC, Australia
| | - Vera Ignjatovic
- Department of Haematology Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
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18
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Hess AS, Ramamoorthy J, Connor J, Raife T, Hess JR. Stored platelet number and viscoelastic maximum amplitude are not altered by warming or rapid infusion. Transfusion 2019; 59:2997-3001. [DOI: 10.1111/trf.15446] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 06/08/2019] [Indexed: 01/19/2023]
Affiliation(s)
- Aaron S. Hess
- Department of AnesthesiologyUniversity of Wisconsin Hospital and Clinics Madison Wisconsin
- Department of PathologyUniversity of Wisconsin Madison School of Medicine and Public Health Madison Wisconsin
| | - Jagan Ramamoorthy
- Department of AnesthesiologyUniversity of Wisconsin Hospital and Clinics Madison Wisconsin
| | - Joseph Connor
- Department of PathologyUniversity of Wisconsin Madison School of Medicine and Public Health Madison Wisconsin
| | - Thomas Raife
- Department of Pathology and Laboratory MedicineUniversity of Wisconsin Madison Wisconsin
| | - John R. Hess
- Department of Laboratory MedicineThe University of Washington Seattle Washington
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19
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van Rooyen LJ, Hooijberg EH, Schoeman JP, Goddard A. Thromboelastographic platelet mapping in dogs with complicated Babesia rossi infection. Vet Clin Pathol 2019; 48:11-18. [PMID: 30924545 DOI: 10.1111/vcp.12689] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 05/22/2018] [Accepted: 06/25/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Dogs with Babesia rossi infection display a normocoagulable thromboelastogram, despite being markedly thrombocytopenic, which is purportedly due to large-scale platelet activation. Thromboelastographic platelet mapping (TEG-PM) evaluates individual contributions of thrombin, fibrinogen, and platelets to clot formation, and may elucidate some of the pathomechanisms of thrombocytopenia-associated hemostatic alterations. OBJECTIVE This study investigated potential differences in TEG-PM variables in dogs with complicated B rossi infection compared with healthy controls, and whether these variables correlated with platelet activation indices. METHODS The maximum amplitude (MA) following thrombin generation (MAThrombin ) was determined using kaolin-activated TEG. The TEG-PM variables included MA following the addition of platelet agonists arachidonic acid (MAAA ) and adenosine diphosphate (MAADP ), and MA due to fibrin alone (MAFibrin ). In addition, platelet indices and fibrinogen concentrations were determined. RESULTS Thirteen dogs with complicated B rossi infection and five healthy controls were included. The median MAFibrin and fibrinogen concentrations were significantly higher (P < 0.01 for both) and median platelet count was significantly lower (P < 0.01) in the babesiosis group vs the control group. No significant differences were found for MAThrombin and MAAA/ADP . maximum amplitude due to fibrin alone was positively correlated with fibrinogen concentration (r = 0.735), mean platelet volume (r = 0.517), and mean platelet mass (r = 0.498), and negatively correlated with hematocrit (r = -0.685), platelet count (r = -0.476), and plateletcrit (r = -0.479) (P < 0.05 for all). CONCLUSIONS This study suggests that the presence of hyperfibrinogenemia offsets the severe thrombocytopenia associated with B rossi to result in normal thromboelastograms and lack of overt clinical bleeding.
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Affiliation(s)
- Liesl J van Rooyen
- Department of Companion Animal Clinical Studies, Faculty of Veterinary Science, University of Pretoria, Pretoria, South Africa.,IDEXX Laboratories (Pty) Ltd., Johannesburg, South Africa
| | - Emma H Hooijberg
- Department of Companion Animal Clinical Studies, Faculty of Veterinary Science, University of Pretoria, Pretoria, South Africa
| | - Johan P Schoeman
- Department of Companion Animal Clinical Studies, Faculty of Veterinary Science, University of Pretoria, Pretoria, South Africa
| | - Amelia Goddard
- Department of Companion Animal Clinical Studies, Faculty of Veterinary Science, University of Pretoria, Pretoria, South Africa
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20
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Barker EE, Saini A, Gazit AZ, Shea SM, Baltagi S, Gage BF, Spinella PC. TEG Platelet Mapping and Impedance Aggregometry to Predict Platelet Transfusion During Cardiopulmonary Bypass in Pediatric Patients. Front Pediatr 2019; 7:509. [PMID: 31921722 PMCID: PMC6921926 DOI: 10.3389/fped.2019.00509] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 11/25/2019] [Indexed: 11/13/2022] Open
Abstract
Background: Cardiopulmonary bypass-related platelet dysfunction can increase the risk of intra- and post-operative bleeding in children undergoing cardiac surgery. More accurate laboratory tests that identify acquired platelet abnormalities could allow for rapid identification of patients at risk of bleeding and provide therapies that could reduce bleeding and platelet transfusions. We hypothesized that thromboelastography with platelet mapping (TEG-PM) and multiple electrode impedance aggregometry (MEIA) as functional measures of platelet function would predict who will require platelet transfusion. Our secondary hypothesis was that platelet aggregation at both arachidonic acid (AA) and adenosine diphosphate (ADP) receptors would correlate between TEG-PM and MEIA results. Methods: In this prospective study from August 2013 to December 2015, children from newborn to 5 years of age with congenital heart disease undergoing cardiopulmonary bypass had blood samples collected and analyzed at four time points: pre-bypass, post-bypass, post-operatively on arrival to the Cardiac Intensive Care Unit, and 24 h after arrival. Results: Of the 44 patients analyzed, the 10 patients who received peri-operative platelet transfusion were significantly younger (p = 0.05), had higher STAT (Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery) Mortality Categories (p < 0.002) and longer cardiopulmonary bypass times (p = 0.02). In univariate analysis, four variables were associated with peri-operative platelet transfusion: pre-operative age [OR 0.95 (0.93, 0.98), p = 0.03], cardiopulmonary bypass time [1.5 (1.31, 1.68), p = 0.008], STAT Mortality Category [3.64 (3.40, 3.87), p < 0.001], and TEG-PM ADP [0.79 (0.65, 0.93), p = 0.04]. ROC analysis demonstrated moderate predictive value of TEG-PM ADP with AUC of 0.745 (0.59, 0.91). A TEG-PM ADP value of less than or equal to 21 had 85% sensitivity and 70% specificity for platelet transfusion. In the multivariate analysis, only STAT Mortality Category predicted platelet transfusion. TEG-PM and MEIA results correlated for the AA receptor at all 4 time points, but the same tests at the ADP receptors did not correlate. Conclusions: TEG-PM ADP may provide more clinically relevant information regarding platelet function compared to the MEIA at the ADP receptor in children requiring cardiopulmonary bypass. There was limited correlation between TEG-PM and MEIA results which raises a concern about the accuracy of these tests at the ADP receptor. Lower pre-operative TEG-PM ADP MA may predict intra-operative platelet transfusions; however, larger studies are needed to determine the utility of TEG-PM and MEIA in guiding platelet transfusions in this population.
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Affiliation(s)
- Erin E Barker
- Division of Pediatric Critical Care, University of Rochester, Rochester, NY, United States.,Division of Pediatric Critical Care, Washington University School of Medicine, St. Louis, MO, United States
| | - Arun Saini
- Division of Pediatric Critical Care, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States
| | - Avihu Z Gazit
- Division of Pediatric Critical Care, Washington University School of Medicine, St. Louis, MO, United States
| | - Susan M Shea
- Division of Pediatric Critical Care, Washington University School of Medicine, St. Louis, MO, United States
| | - Sirine Baltagi
- Department of Critical Care Medicine, Saint Joseph Children's Hospital, Tampa, FL, United States
| | - Brian F Gage
- Division of General Medical Sciences, Washington University School of Medicine, St. Louis, MO, United States
| | - Philip C Spinella
- Division of Pediatric Critical Care, Washington University School of Medicine, St. Louis, MO, United States
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21
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Malhotra Kapoor P, Karanjkar A, Bhardwaj V. Evaluation of coagulopathy on veno-arterial ECMO (VA) extracorporeal membrane oxygenation using platelet aggregometry and standard tests: A narrative review. THE EGYPTIAN JOURNAL OF CRITICAL CARE MEDICINE 2018. [DOI: 10.1016/j.ejccm.2018.12.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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22
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Patregnani JT, Sochet AA, Zurakowski D, Klugman D, Diab Y, Berger JT, Sinha P. Cardiopulmonary Bypass Reduces Early Thrombosis of Systemic-to-Pulmonary Artery Shunts. World J Pediatr Congenit Heart Surg 2018; 9:276-282. [PMID: 29692234 DOI: 10.1177/2150135118755985] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Shunt thrombosis is a significant cause of morbidity and mortality after systemic-to-pulmonary artery shunt (SPS) placement. Concurrent procedures with placement of SPS may require cardiopulmonary bypass (CPB). Cardiopulmonary bypass is known to cause bleeding and platelet dysfunction in infants, which may protect from early shunt thrombosis. We hypothesized that infants undergoing SPS placement on CPB have a lower incidence of early shunt thrombosis. METHODS Retrospective cohort study of infants undergoing SPS placement from January 2008 to December 2014 was performed. Patients with and without early shunt thrombosis and on or off CPB were compared using the Mann-Whitney U test or Fisher exact test. Multivariable regression analysis was performed to identify independent predictors of early shunt thrombosis and to assess effect of CPB independent of other factors. RESULTS Seventy-five infants underwent SPS placement during the study period (on CPB, n = 25; off CPB, n = 50). Operative mortality was 11% (8/75). Nine (12%) patients developed early shunt thrombosis, all of whom had shunt placement off CPB. Independent risk factors for early shunt thrombosis were identified to be SPS placement off CPB ( P = .011), prematurity ( P = .034), and competitive antegrade pulmonary blood flow ( P = .038). CONCLUSION Prematurity, competitive antegrade pulmonary blood flow, and shunt placement off CPB lead to higher risk of early shunt thrombosis. We speculate that the protection offered by use of CPB may be accounted for by the associated complex coagulopathy and platelet dysfunction associated with CPB.
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Affiliation(s)
- Jason T Patregnani
- 1 Division of Cardiac Intensive Care Medicine, Children's National Health System, The George Washington School of Medicine, Washington, DC, USA
| | - Anthony A Sochet
- 2 Division of Critical Care Medicine, Johns Hopkins All Children's Hospital, Johns Hopkins University, St Petersburg, FL, USA
| | - David Zurakowski
- 3 Department of Anesthesia, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,4 Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Darren Klugman
- 1 Division of Cardiac Intensive Care Medicine, Children's National Health System, The George Washington School of Medicine, Washington, DC, USA
| | - Yaser Diab
- 5 Division of Hematology/Oncology, Children's National Health System, The George Washington School of Medicine, Washington, DC, USA
| | - John T Berger
- 1 Division of Cardiac Intensive Care Medicine, Children's National Health System, The George Washington School of Medicine, Washington, DC, USA
| | - Pranava Sinha
- 6 Division of Cardiovascular Surgery, Children's National Health System, The George Washington School of Medicine, Washington, DC, USA
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Ichikawa J, Osada Y, Kodaka M, Nishiyama K, Komori M. Association Between Platelet Count and Postoperative Blood Loss in Patients Undergoing Cardiac Surgery With Cardiopulmonary Bypass and Fresh Frozen Plasma Administration Guided by Thromboelastometry. Circ J 2018; 82:677-683. [DOI: 10.1253/circj.cj-17-0712] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Junko Ichikawa
- Department of Anesthesiology, Tokyo Women’s Medical University Medical Center East
| | - Yoshiko Osada
- Department of Anesthesiology, Tokyo Women’s Medical University Medical Center East
| | - Mitsuharu Kodaka
- Department of Anesthesiology, Tokyo Women’s Medical University Medical Center East
| | - Keiko Nishiyama
- Department of Anesthesiology, Tokyo Women’s Medical University Medical Center East
| | - Makiko Komori
- Department of Anesthesiology, Tokyo Women’s Medical University Medical Center East
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24
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Olechowski B, Khanna V, Mariathas M, Ashby A, Dalton RT, Nordon I, Englyst N, Harris S, Nicholas Z, Thayalasamy K, Mahmoudi M, Curzen N. Changes in platelet function with inflammation in patients undergoing vascular surgery. Platelets 2017; 30:190-198. [DOI: 10.1080/09537104.2017.1392498] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Bartosz Olechowski
- Wessex Cardiothoracic Centre University, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Vikram Khanna
- Wessex Cardiothoracic Centre University, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Mark Mariathas
- Wessex Cardiothoracic Centre University, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Alexander Ashby
- Wessex Cardiothoracic Centre University, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Richard T Dalton
- Wessex Cardiothoracic Centre University, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Ian Nordon
- Wessex Cardiothoracic Centre University, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Nicola Englyst
- Institute of Developmental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Scott Harris
- Wessex Cardiothoracic Centre University, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Zoe Nicholas
- Wessex Cardiothoracic Centre University, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Kala Thayalasamy
- Wessex Cardiothoracic Centre University, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Michael Mahmoudi
- Wessex Cardiothoracic Centre University, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Nick Curzen
- Wessex Cardiothoracic Centre University, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Mazzeffi MA, Lee K, Taylor B, Tanaka KA. Perioperative management and monitoring of antiplatelet agents: a focused review on aspirin and P2Y 12 inhibitors. Korean J Anesthesiol 2017; 70:379-389. [PMID: 28794832 PMCID: PMC5548939 DOI: 10.4097/kjae.2017.70.4.379] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 06/26/2017] [Indexed: 01/02/2023] Open
Abstract
Platelets play pivotal roles in hemostasis as well as pathological arterial thrombosis. The combination of aspirin and a P2Y12 inhibitor has become the mainstay therapy in the ageing population with cardiovascular conditions, particularly during and after percutaneous coronary intervention. A number of novel P2Y12 inhibitors has become available in the recent years, and they markedly vary in pharmacokinetic and pharmacodynamic properties. Perioperative physicians today face a challenge of preventing hemorrhage due to platelet inhibitors, while minimizing thrombotic risks. There are several point-of-care platelet function tests available in the peri-procedural assessment of residual platelet aggregation. However, these platelet function tests are not standardized in terms of sample processing, agonist type and potency as well as methods of detecting platelet activity. Understanding the differences in pharmacological properties of antiplatelet agents, principles of platelet function tests, and pertinent hemostatic strategies may be useful to anesthesiologists and intensivists who manage perioperative issues associated with antiplatelet agents. The objectives of this review are: 1) to discuss clinical data on aspirin and P2Y12 inhibitors relating to perioperative bleeding, 2) to outline different features of point-of-care platelet function tests, and 3) to discuss therapeutic options for the prevention and treatment of bleeding associated with antiplatelet agents.
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Affiliation(s)
- Michael A Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Khang Lee
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Bradley Taylor
- Department of Surgery, Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kenichi A Tanaka
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
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26
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Sivapalan P, Bäck AC, Ostrowski SR, Ravn HB, Johansson PI. Transfusion requirements in elective cardiopulmonary bypass surgery patients: predictive value of Multiplate and Thromboelastography (TEG) Platelet Mapping Assay. Scandinavian Journal of Clinical and Laboratory Investigation 2017; 77:345-351. [PMID: 28537454 DOI: 10.1080/00365513.2017.1325000] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Managing haemostasis in patients undergoing cardiopulmonary bypass (CPB) surgery remains a challenge. There is no established laboratory test to predict transfusion requirements in cardiac surgery. We investigated whether preoperative Thromboelastography (TEG) with Platelet Mapping Assay (PMA) or Multiple Electrode Aggrometry (MEA) could predict transfusion requirements in patients undergoing elective coronary artery bypass grafting (CABG) or combined CABG with aortic or mitral valve replacement. We prospectively investigated 199 patients undergoing elective CABG or combined procedures. PMA and MEA were performed at baseline (after anaesthesia induction), upon arrival at the intensive care unit and on the first postoperative day. Patients receiving fresh frozen plasma and/or platelets (FFP/PLT) had a lower PMA maximum amplitude (MA) for adenosine diphosphate (PMA-ADP) and arachidonic acid (PMA-AA) at baseline, at arrival in the intensive care unit and the first postoperative day compared to non-transfused patients. Receiver operating characteristic curves on PMA showed that lower values predicted FFP/PLT transfusion: PMA-ActF 0.64 (p = 0.04), PMA-ADP 0.69 (p = 0.01) and PMA-AA 0.71 (p = 0.002). In contrast, MEA values were not able to predict FFP/PLT transfusions. This study shows that preoperative PMA potentially is a better screening tool for platelet inhibition associated with transfusion requirements in patients undergoing CABG or combined procedures.
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Affiliation(s)
- Praleene Sivapalan
- a Department of Cardiothoracic Anaesthesiology , Copenhagen University Hospital , Copenhagen , Denmark
| | - Anne Caroline Bäck
- b Department of Cardiothoracic Surgery , Copenhagen University Hospital , Copenhagen , Denmark
| | - Sisse Rye Ostrowski
- c Section for Transfusion Medicine, Capital Region Blood Bank , Copenhagen University Hospital , Copenhagen , Denmark
| | - Hanne Berg Ravn
- a Department of Cardiothoracic Anaesthesiology , Copenhagen University Hospital , Copenhagen , Denmark
| | - Pär Ingemar Johansson
- d Department of Surgery , University of Texas Health Medical School , Houston , TX , USA.,e Center for Systems Biology, The School of Engineering and Natural Sciences , University of Iceland , Reykjavik , Iceland
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27
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Fahrendorff M, Oliveri RS, Johansson PI. The use of viscoelastic haemostatic assays in goal-directing treatment with allogeneic blood products - A systematic review and meta-analysis. Scand J Trauma Resusc Emerg Med 2017; 25:39. [PMID: 28403868 PMCID: PMC5390346 DOI: 10.1186/s13049-017-0378-9] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 03/21/2017] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Management of the critically bleeding patient can be encountered in many medical and surgical settings. Common for these patients is a high risk of dying from exsanguination secondary to developing coagulopathy. The purpose of this meta-analysis was to systematically review and assess randomised controlled trials (RCTs) performed on patients in acute need for blood transfusions due to bleeding to evaluate the effect of viscoelastic haemostatic assay (VHA) guidance on bleeding, transfusion requirements and mortality. METHODS PubMed and EMBASE were searched for RCTs that 1) randomised patients into receiving transfusions based on either a VHA-guided (thromboelastography [TEG] or rotational thromboelastometry [ROTEM]) algorithm (intervention group) or at the clinician's discretion and/or based on conventional coagulation tests (control group) and 2) adequately reported on the outcomes bleeding and/or transfusions and/or mortality. Data on bleeding, transfusions and mortality were extracted from each trial and included in a meta-analysis. RESULTS Fifteen RCTs (n = 1238 patients) were included. Nine trials referred to cardiothoracic patients, one to liver transplantation, one to surgical excision of burn wounds and one to trauma. One trial was conducted with cirrhotic patients, one with patients undergoing scoliosis surgery while one trial randomised treatment in post-partum females presenting with bleeding. The amount of transfused red blood cells (RBCs), fresh frozen plasma (FFP) and bleeding volume was found to be significantly reduced in the VHA-guided groups, whereas no significant difference was found for platelet transfusion requirements or mortality.
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Affiliation(s)
- Mathilde Fahrendorff
- Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK–2100 Copenhagen, Denmark
| | - Roberto S. Oliveri
- Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK–2100 Copenhagen, Denmark
| | - Pär I. Johansson
- Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK–2100 Copenhagen, Denmark
- Department of Surgery, Centre for Translational Injury Research, UT Health, University of Texas Health Science Center at Houston, Houston, TX USA
- Center for Systems Biology. The School of Engineering and Natural Sciences, University of Iceland, Reykjavik, Iceland
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28
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Hernandez Conte A, Perotti D, Farac L. Thromboelastrography (TEG) Is Still Relevant in the 21st Century as a Point-of-Care Test for Monitoring Coagulation Status in the Cardiac Surgical Suite. Semin Cardiothorac Vasc Anesth 2017; 21:212-216. [DOI: 10.1177/1089253217699282] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Since their introduction into clinical practice in the early 1960s, viscoelastic point-of-care (POC) testing—thromboelastrography (TEG) and thromboelastrometry (ROTEM)—has become increasingly popular in intensive care units, operating rooms, and emergency room settings. As TEG has been an established POC viscoelastic testing modality for many years, there has been more research and analysis of its utility and ability to reduce transfusions in the general, cardiac, and liver surgical sectors compared with ROTEM. The role of TEG versus ROTEM has been greatly disputed, although both continue to be utilized in the cardiac suite to guide transfusion in cardiac surgery as these procedures produce a profoundly different form of bleeding compared to other surgical interventions.
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Affiliation(s)
| | | | - Lauren Farac
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
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29
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Clendenen N, Tollefson A, Dzieciatkowska M, Cambiaghi A, Ferrario M, Kroehl M, Banerjee A, D'Alessandro A, Hansen KC, Weitzel N. Correlation of pre-operative plasma protein concentrations in cardiac surgery patients with bleeding outcomes using a targeted quantitative proteomics approach. Proteomics Clin Appl 2017; 11. [PMID: 28176468 DOI: 10.1002/prca.201600175] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 01/05/2017] [Accepted: 02/02/2017] [Indexed: 01/13/2023]
Abstract
PURPOSE Despite recent advancements in the use of thrombelastography (TEG) in the surgical setting, adequate technology to accurately predict bleeding phenotypes for patients undergoing cardiopulmonary bypass on the basis of non-mechanical parameters is lacking. While basic science and translational studies have provided key mechanistic insights about the protein components of coagulation cascades and regulatory mediators of hemostasis and fibrinolysis, targeted protein assays are still missing and the association of protein profiles to bleeding phenotypes and TEG readouts have yet to be discovered. OBJECTIVE To identify protein biomarkers of bleeding phenotypes of cardiopulmonary bypass patients in pre-operative plasma. EXPERIMENTAL DESIGN We applied a targeted proteomics approach to quantify 123 plasma proteins from 23 patients undergoing cardiopulmonary bypass (CPB) and sternotomy. We then correlated these measurements to bleeding outcomes and TEG parameters, associated with speed of clot formation and strength. RESULTS In this pilot study, we demonstrate the feasibility of protein quantitation as a viable strategy to predict low versus high bleeding phenotypes (loss of < or > than 20% of estimated blood volume, calculated as 70 mL/kg for BMI<29.9, 60 mL/kg for BMI = 30-39.9, and 50 mL/kg for BMI>40. Statistical elaborations highlighted a core set of proteins showing significant correlations to either total blood loss or TEG R/MA parameters. CONCLUSION AND CLINICAL RELEVANCE Though prospective verification and validation in larger cohorts will be necessary, this report suggests a potential for targeted quantitative proteomics of pre-operative plasma protein concentrations in the prediction of estimated blood loss following CPB.
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Affiliation(s)
- Nathan Clendenen
- Department of Anesthesiology, University of Colorado Denver, Aurora, CO, USA
| | - Ashley Tollefson
- Department of Anesthesiology, University of Colorado Denver, Aurora, CO, USA.,Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Monika Dzieciatkowska
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver, Aurora, CO, USA
| | | | | | - Miranda Kroehl
- Department of Biostatistics and Informatics, University of Colorado Denver, Aurora, CO, USA
| | - Anirban Banerjee
- Department of Surgery, University of Colorado Denver, Aurora, CO, USA
| | - Angelo D'Alessandro
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver, Aurora, CO, USA
| | - Kirk C Hansen
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver, Aurora, CO, USA
| | - Nathaen Weitzel
- Department of Anesthesiology, University of Colorado Denver, Aurora, CO, USA
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30
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Gautam NK, Cai C, Pawelek O, Rafique MB, Cattano D, Pivalizza EG. Performance of functional fibrinogen thromboelastography in children undergoing congenital heart surgery. Paediatr Anaesth 2017; 27:181-189. [PMID: 27901294 DOI: 10.1111/pan.13048] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/03/2016] [Indexed: 01/09/2023]
Abstract
BACKGROUND Functional Fibrinogen assay of the Thromboelastography (FFTEG), a whole blood viscoelastic hemostatic assay, has been used to estimate fibrinogen levels in adult patients undergoing major surgery but its performance in pediatric patients undergoing cardiac surgery requires evaluation. In this study, we evaluate the correlation between FFTEG parameters and standard laboratory tests for fibrinogen and platelet counts before and after cardiopulmonary bypass in children undergoing repair for congenital heart disease. METHODS In this prospective observational study, whole blood samples were obtained from children less than 5 years of age undergoing congenital heart surgery with cardiopulmonary bypass before surgical incision and immediately after administration of protamine. Blood samples were analyzed for Thromboelastography, Functional Fibrinogen level measured by FFTEG (FLEV), complete blood counts with platelet count and plasma fibrinogen assay (LFib, Clauss). The primary outcome of this study was to assess the correlation between FFTEG parameters, LFib and platelet counts in neonates, infants, and small children less than 5 years old. Additionally, we studied if postbypass FFTEG parameters could predict critical thresholds of hypofibrinogenemia LFib ≤200 mg·dl-1 . RESULTS One hundred and five children (22 neonates, 51 infants, and 32 small children) were included in the final analysis. FLEV estimated higher fibrinogen levels than LFib in all patients. Before bypass, FLEV was on average 133 mg·dl-1 higher than LFib (95% confidence interval, CI, 116-150, P < 0.001) for all the patients; after bypass, FLEV was 48 mg·dl-1 (95% CI: 37-59, P < 0.001) higher than LFib for all the patients. Linear correlation coefficients between FLEV and LFib in all patients were R = 0.41 (95% CI: 0.24-0.56, P < 0.001) before bypass and increased to R = 0.63 (95% CI: 0.51-0.74, P < 0.001) after bypass. Bland Altman analysis performed on postbypass values of FLEV and LFib showed a positive bias of FLEV in estimation of LFib. The magnitude and the variability of the bias for all the patients group was decreased with lower mean of the difference of FLEV and LFib when the average values of FLEV and LFib were <200 mg·dl-1 . Low linear correlations were noticed between maximal amplitude of platelet contribution to FFTEG and platelet counts both before and after bypass. For predicting the clinical thresholds of postbypass hypofibrinogenemia at plasma fibrinogen levels ≤200 mg·dl-1 , FLEV and maximal amplitude of the fibrinogen clot generated area under receiver operative curves at 0.90 (95% CI = 0.76-1.0) in neonates, 0.6 (95% CI- 0.42-0.78) in infants, and 0.97 (95% CI = 0.91-1.0) in small children. Based on the receiver operative curves, values of postbypass hypofibrinogenemia with LFib ≤200 g·dl-1 corresponded to cutoffs of FLEVPOST ≤245 mg·dl-1 and maximal amplitude of the fibrinogen clot ≤13.4 mm. CONCLUSION In pediatric patients undergoing cardiac surgery, FLEV derived from Functional Fibrinogen correlated linearly with plasma fibrinogen levels (Clauss) both before and after CPB. FLEV estimation of plasma fibrinogen was improved after CPB in neonates, infants, and small children. After CPB, FFTEG can be used to predict laboratory diagnosis of critical hypofibrinogenemia (≤200 mg·dl-1 ) during pediatric cardiac surgery. Further studies are required to assess the impact of predictability of FFTEG on component transfusion during pediatric cardiac surgery.
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Affiliation(s)
- Nischal K Gautam
- Department of Anesthesiology, The University of Texas Medical School, Houston, TX, USA
| | - Chunyan Cai
- Center for Clinical and Translational Sciences, The University of Texas Medical School, Houston, TX, USA
| | - Olga Pawelek
- Department of Anesthesiology, The University of Texas Medical School, Houston, TX, USA
| | - Muhammad B Rafique
- Department of Anesthesiology, The University of Texas Medical School, Houston, TX, USA
| | - Davide Cattano
- Department of Anesthesiology, The University of Texas Medical School, Houston, TX, USA
| | - Evan G Pivalizza
- Department of Anesthesiology, The University of Texas Medical School, Houston, TX, USA
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31
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Blum FE, Weiss GM, Cleveland JC, Weitzel NS. Postoperative Management for Patients With Durable Mechanical Circulatory Support Devices. Semin Cardiothorac Vasc Anesth 2016; 19:318-30. [PMID: 26660056 DOI: 10.1177/1089253214568528] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Mechanical circulatory support devices have been approved as bridge to transplantation, as bridge to recovery, or as destination therapy to treat end-stage heart failure. The perioperative challenges for the anesthesiologist and the intensivist caring for these patients include device-related complications, hemodynamic instability, arrhythmias, right ventricular failure, and coagulopathy. Perioperative management in this high-risk population has a significant impact on patient outcomes. This review focuses immediate postoperative intensive care unit management of device-related complications.
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Ellis J, Valencia O, Crerar-Gilbert A, Phillips S, Meeran H, Sharma V. Point-of-care platelet function testing to predict blood loss after coronary artery bypass grafting surgery: a prospective observational pilot study. Perfusion 2016; 31:676-682. [DOI: 10.1177/0267659116656774] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Aim: With an increase in the number of patients who are on antiplatelet medications until the day of surgery, we undertook a prospective observational study to assess the ability of thromboelastography, thromboelastography platelet mapping and aggregometry via multiplate to detect platelet dysfunction and predict blood loss following coronary artery bypass grafting (CABG) surgery. Methods: Platelet function was evaluated pre- and post-cardiopulmonary bypass via thromboelastography, thromboelastography platelet mapping and aggregometry via multiplate in 52 patients undergoing coronary artery bypass grafting surgery. The median chest tube drainage of all patients in the study was ascertained to stratify patients into two groups: patients with and those without evidence of excessive blood loss after cardiac surgery. Results: Although all modalities could detect a decrease in platelet function following cardiopulmonary bypass, univariate and multivariate regression analysis identified preoperative arachidonic acid and adenosine diphosphate testing via multiplate as independent predictors of bleeding after cardiac surgery. Receiver operating curves on these multiplate parameters showed an area under the curve of 0.68 (p=0.03) and 0.66 (p=0.01) for arachidonic acid and adenosine diphosphate assays, respectively. Conclusion: This pilot study shows that preoperative multiplate testing may be a better predictor of platelet dysfunction and the resultant blood loss following cardiac surgery.
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Affiliation(s)
- James Ellis
- Department of Clinical Perfusion, St George’s Hospital, London, UK
| | | | | | - Simon Phillips
- Department of Clinical Perfusion, St George’s Hospital, London, UK
| | - Hanif Meeran
- Department of Anaesthesia, St George’s Hospital, London, UK
| | - Vivek Sharma
- Department of Anaesthesia, St George’s Hospital, London, UK
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33
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Tan Z, Zhou L, Qin Z, Luo M, Chen H, Xiong J, Li J, Liu T, Du L, Zhou J. Low-Dose Sevoflurane May Reduce Blood Loss and Need for Blood Products After Cardiac Surgery: A Prospective, Randomized Pilot Study. Medicine (Baltimore) 2016; 95:e3424. [PMID: 27124028 PMCID: PMC4998691 DOI: 10.1097/md.0000000000003424] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Patients undergoing cardiac surgery often experience abnormal bleeding, due primarily to cardiopulmonary bypass (CPB)-induced activation of platelets. Sevoflurane may inhibit platelet activation, raising the possibility that administering it during CPB may reduce blood loss.Patients between 18 and 65 years old who were scheduled for cardiac surgery under CPB at our hospital were prospectively enrolled and randomized to receive intravenous anesthetics alone (control group, n = 77) or together with sevoflurane (0.5-1.0 vol/%) from an oxygenator (sevoflurane group, n = 76). The primary outcome was postoperative blood loss, the secondary outcome was postoperative need for blood products.Volume of blood loss was 48% lower in the sevoflurane group than the control group at 4 hours after surgery, and 33% lower at 12 hours after surgery. Significantly fewer patients in the sevoflurane group lost >700 mL blood within 24 hours (9 of 76 vs 28 of 77, P < 0.001). As a result, the sevoflurane group received significantly smaller volumes of packed red blood cells (1.25 ± 2.36 vs 2.23 ± 3.75 units, P = 0.011) and fresh frozen plasma (97 ± 237 vs 236 ± 344 mL, P = 0.004). Thus the sevoflurane group was at significantly lower risk of requiring complex blood products after surgery (adjusted odds ratio [OR] 0.34, 95% confidence interval [CI] 0.17-0.68, P = 0.002).Sevoflurane inhalation from an oxygenator during CPB may reduce blood loss and need for blood products after cardiac surgery.
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Affiliation(s)
- Zhaoxia Tan
- From the Department of Anesthesiology and Translational Neuroscience Center, West China Hospital (ZT, LZ, ZQ, ML, JX, JL, TL, LD); and Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China (HC, JZ)
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34
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Gosselin RC, Estacio EE, Song JY, Dwyre DM. Verifying the performance characteristics of the TEG5000 thromboelastogram in the clinical laboratory. Int J Lab Hematol 2016; 38:183-92. [PMID: 26847002 DOI: 10.1111/ijlh.12464] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2015] [Accepted: 12/07/2015] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To verify the manufacturer performance claims of the TEG5000 with traditional laboratory methods. MATERIALS AND METHODS Samples were concurrently measured using the TEG5000 analyzer and either PT, APTT, fibrinogen, factor activities, platelet count, or platelet function testing using whole blood or platelet-rich plasma methods. RESULTS Within-run imprecision yielded coefficient of variation (CV) of <5%. There was no correlation of PT or APTT with R time. Only Factor VIII and factor XII activity significantly correlated with R time. There was significant correlation between k and angle with FBG, PLT count, and factor levels. There was weak inverse correlation between angle results and measures of platelet function. All laboratory methods were significantly correlated with MA. There were significant differences between citrated whole blood and fresh citrated plasma for angle and MA, and between fresh and frozen plasma for R time and MA. We demonstrated a high % inhibition noted with normal, drug naïve donors, especially with ADP PLT mapping (50% inhibition), but less so with AA PLT mapping (20% inhibition). For TEG platelet mapping, 19/22 (86.3%) and 17/22 (77.3%) results were concordant with traditional aggregation results. CONCLUSION We demonstrated both the lack of, and strong correlation between laboratory tests and the TEG parameters.
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Affiliation(s)
- R C Gosselin
- Department of Pathology and Laboratory Medicine, UC Davis Health System, Sacramento, CA, USA
| | - E E Estacio
- Department of Pathology and Laboratory Medicine, UC Davis Health System, Sacramento, CA, USA
| | - J Y Song
- Department of Pathology, City of Hope National Medical Center, Los Angeles, CA, USA
| | - D M Dwyre
- Department of Pathology and Laboratory Medicine, UC Davis Health System, Sacramento, CA, USA
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35
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Corredor C, Wasowicz M, Karkouti K, Sharma V. The role of point-of-care platelet function testing in predicting postoperative bleeding following cardiac surgery: a systematic review and meta-analysis. Anaesthesia 2015; 70:715-31. [PMID: 25916344 DOI: 10.1111/anae.13083] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2015] [Indexed: 12/23/2022]
Abstract
This systematic review and meta-analysis appraises the utility of point-of-care platelet function tests for predicting blood loss and transfusion requirements in cardiac surgical patients, and analyses whether their use within a transfusion management algorithm is associated with improved patient outcomes. We included 30 observational studies incorporating 3044 patients in the qualitative assessment, and nine randomised controlled trials including 1057 patients in the meta-analysis. Platelet function tests demonstrated significant variability in their ability to predict blood loss and transfusion requirements. Their use within a blood transfusion algorithm demonstrated a reduction in blood loss at longest follow-up (mean difference -102.9 ml (95% CI -149.9 to -56.1 ml), p < 0.001), and transfusion of packed red cells (RR 0.86 (95% CI 0.78-0.94), p = 0.001) and fresh frozen plasma (RR 0.42 (95% CI 0.30-0.59), p < 0.001). Viscoelastic methods used in combination with other platelet function tests achieved greater reduction in blood loss (mean difference -111.8 ml (95% CI -174.9 to -49.1 ml), p = 0.0005) compared with their use alone (mean difference -90.6 ml (95% CI 166.1-15.0 ml), p = 0.02). We conclude that incorporation of point-of-care platelet function tests into transfusion management algorithms is associated with a reduction in blood loss and transfusion requirements in cardiac surgery patients.
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Affiliation(s)
- C Corredor
- Department of Anaesthesia, St. George's Hospital, London, UK
| | - M Wasowicz
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
| | - K Karkouti
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
| | - V Sharma
- Department of Anaesthesia, St. George's Hospital, London, UK
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Abstract
PURPOSE OF REVIEW There exists an imbalance between our understanding of the physiology of the blood coagulation process and the translation of this understanding into useful assays for clinical application. As technology advances, the capabilities for merging the two areas have become more attainable. Global assays have advanced our understanding of the dynamics of the blood coagulation process beyond end point assays and are at the forefront of implementation in the clinic. RECENT FINDINGS We will review recent advances in the main global assays with a focus on thrombin generation that have potential for clinical utility. These assays include direct (thrombogram, whole blood, purified systems) and indirect empirical measures of thrombin generation (thromboelastography) and mechanism-based computational models that use plasma composition data from individuals to generate thrombin generation profiles. SUMMARY Empirical thrombin generation assays (direct and indirect) and computational modeling of thrombin generation have greatly advanced our understanding of the hemostatic balance. Implementation of these types of assays and visualization approaches in the clinic will potentially provide a basis for the development of individualized patient care. Advances in both empirical and computational global assays have made the goal of predicting precrisis changes in an individual's hemostatic state one step closer.
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Saini A, Hartman ME, Gage BF, Said A, Gazit AZ, Eghtesady P, Boston US, Spinella PC. Incidence of Platelet Dysfunction by Thromboelastography-Platelet Mapping in Children Supported with ECMO: A Pilot Retrospective Study. Front Pediatr 2015; 3:116. [PMID: 26779465 PMCID: PMC4702183 DOI: 10.3389/fped.2015.00116] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 12/14/2015] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Bleeding complications are common and decrease the odds of survival in children supported with extracorporeal membrane oxygenation (ECMO). The role of platelet dysfunction on ECMO-induced coagulopathy and resultant bleeding complications is not well understood. The primary objective of this pilot study was to determine the incidence and magnitude of platelet dysfunction according to thromboelastography (TEG(®))-platelet mapping (PM) testing. METHODS Retrospective chart review of children <18 years old who required ECMO at a tertiary level hospital. We collected TEG(®)-PM and conventional coagulation tests data. We also collected demographic, medications, blood products administered, and clinical outcome data. We defined severe platelet dysfunction as <50% aggregation in response to an agonist. RESULTS We identified 24 out of 46 children on ECMO, who had TEG(®)-PM performed during the study period. We found the incidence of severe bleeding was 42% and mortality was 54% in our study cohort. In all samples measured, severe qualitative platelet dysfunction was more common for adenosine diphosphate (ADP)-mediated aggregation (92%) compared to arachidonic acid (AA)-mediated aggregation (75%) (p = 0.001). Also, ADP-mediated percent of platelet aggregation was significant lower than AA-mediated platelet aggregation [15% (interquartile range, IQR 2.8-48) vs. 49% (IQR 22-82.5), p < 0.001]. There was no difference in kaolin-activated heparinase TEG(®) parameters between the bleeding group and the non-bleeding group. Only absolute platelet count and TEG(®)-PM had increased predictive value on receiver operating characteristics analyses for severe bleeding and mortality compared to activated clotting time. CONCLUSION We found frequent and severe qualitative platelet dysfunction on TEG(®)-PM testing in children on ECMO. Larger studies are needed to determine if the assessment of qualitative platelet function by TEG(®)-PM can improve prediction of bleeding complications for children on ECMO.
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Affiliation(s)
- Arun Saini
- Department of Pediatrics, The University of Tennessee Health Science Center , Memphis, TN , USA
| | - Mary E Hartman
- Department of Pediatrics, Washington University in St. Louis , St. Louis, MO , USA
| | - Brian F Gage
- Department of Medicine, Washington University in St. Louis , St. Louis, MO , USA
| | - Ahmed Said
- Department of Pediatrics, Washington University in St. Louis , St. Louis, MO , USA
| | - Avihu Z Gazit
- Department of Pediatrics, Washington University in St. Louis , St. Louis, MO , USA
| | - Pirooz Eghtesady
- Department of Cardiothoracic Surgery, Washington University in St. Louis , St. Louis, MO , USA
| | - Umar S Boston
- Department of Cardiothoracic Surgery, Washington University in St. Louis , St. Louis, MO , USA
| | - Philip C Spinella
- Department of Pediatrics, Washington University in St. Louis , St. Louis, MO , USA
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Chowdhury M, Shore-Lesserson L, Mais AM, Leyvi G. Thromboelastograph with Platelet Mapping(TM) predicts postoperative chest tube drainage in patients undergoing coronary artery bypass grafting. J Cardiothorac Vasc Anesth 2014; 28:217-23. [PMID: 24630471 DOI: 10.1053/j.jvca.2013.12.010] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2013] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The goal of this study was to evaluate the ability of Thromboelastograph with Platelet Mapping (TEG-PM(TM)) to predict postoperative bleeding tendency in patients with a history of recent anti-platelet therapy undergoing coronary artery bypass grafting (CABG). DESIGN A retrospective analysis. Association between predictor variables (MAADP [maximum amplitude produced by adenosine diphosphate], MAAA [maximum amplitude produced by arachidonic acid], percent of platelets inhibited by clopidogrel, percent of platelets inhibited by aspirin) and the outcomes as elevated chest tube drainage (CTD) and blood transfusion were investigated by logistic regression model. CTD was considered elevated if it was ≥ 600 mL within 12 hours after surgery. SETTING A university hospital. PARTICIPANTS Patients on antiplatelet therapy scheduled to undergo CABG that had TEG-PM(TM) done as a point-of-care test. INTERVENTIONS None. RESULTS A total of 78 patients had preoperative TEG-PM(TM) test and on-pump CABG surgeries performed on the same day. Among them, 20 patients (25.6%) had elevated CTD. Decreased MAADP (odds ratio [OR] 0.94), increased percent inhibition of platelets by clopidogrel (OR 1.03), and lower body mass index (BMI) (OR 0.78) were significantly associated with elevated CTD. The same parameters were also associated with platelets transfusion: MAADP (OR 0.94), percent of inhibition of platelets by clopidogrel (OR 1.03) and BMI (OR 0.77). CONCLUSIONS TEG-PM(TM) parameters and BMI are predictive of elevated CTD and platelets transfusion. A 1 mm decrease in MAADP increases the likelihood of elevated CTD and the likelihood of platelets transfusion by 6% whereas 1 unit decrease in BMI is associated with an increased likelihood of elevated CTD and platelets transfusion by 22% and 23% respectively.
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Affiliation(s)
- Mohsin Chowdhury
- Department of Anesthesiology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx.
| | - Linda Shore-Lesserson
- Department of Anesthesiology, North Shore-Long Island Jewish Medical Center, New Hyde Park, NY
| | - Alec M Mais
- A.M.M. assisted with the article as a high school summer student
| | - Galina Leyvi
- Department of Anesthesiology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx
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Wolf MJ, Maher KO, Kanter KR, Kogon BE, Guzzetta NA, Mahle WT. Early postoperative bleeding is independently associated with increased surgical mortality in infants after cardiopulmonary bypass. J Thorac Cardiovasc Surg 2014; 148:631-6.e1. [DOI: 10.1016/j.jtcvs.2013.10.050] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Revised: 09/12/2013] [Accepted: 10/29/2013] [Indexed: 12/18/2022]
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Blum FE. [Noncardiological surgical procedure for patients implanted with a ventricular assist device. Anesthesiological management concepts]. Med Klin Intensivmed Notfmed 2014; 110:197-203. [PMID: 24981063 DOI: 10.1007/s00063-014-0398-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2014] [Revised: 06/03/2014] [Accepted: 06/10/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND The implantation of a ventricular assist device (VAD) is more frequently used as destination therapy of end-stage heart failure compared to the use of the device as bridge-to-transplantation, this results in an increasing number of noncardiac surgical procedures for patients implanted with a VAD. OBJECTIVE For these procedures, the anesthesia provider faces various device-related complications, such as an increased risk for bleeding complications, thromboembolism, hypotension, infections, mechanical device limitations, and right heart failure. Anesthesia care is challenging in this high-risk patient population and has significant implications on patient outcome. CONCLUSION More research is needed to determine specific guidelines for the anesthesiological management of VAD patients undergoing noncardiac surgical procedures. In this manuscript, device-related perioperative complications and concepts of anesthesia care for noncardiac procedures in patients implanted with a VAD are briefly reviewed.
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Affiliation(s)
- F E Blum
- Department of Internal Medicine, Weiss Memorial Hospital, affiliate of the University of Illinois, 4646 North Marine Drive, 60640, Chicago, IL, USA,
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Thiele RH, Raphael J. A 2014 Update on Coagulation Management for Cardiopulmonary Bypass. Semin Cardiothorac Vasc Anesth 2014; 18:177-89. [DOI: 10.1177/1089253214534782] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Coagulopathy after cardiac surgery with cardiopulmonary bypass is a serious complication that may result in massive bleeding requiring transfusion of significant amounts of blood products, plasma, and platelets. In addition to increased patient morbidity and mortality it is associated with longer hospital stay and increased resource utilization. The current review discusses aspects in cardiopulmonary bypass–induced coagulopathy with emphasis on point-of-care testing and individualized “goal-directed” therapy in patients who develop excessive bleeding after cardiac surgery.
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Affiliation(s)
| | - Jacob Raphael
- University of Virginia Health System, Charlottesville, VA, USA
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Quarterman C, Shaw M, Johnson I, Agarwal S. Intra‐ and inter‐centre standardisation of thromboelastography (TEG
®
). Anaesthesia 2014; 69:883-90. [DOI: 10.1111/anae.12748] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2014] [Indexed: 02/05/2023]
Affiliation(s)
- C. Quarterman
- Department of Anaesthesia Liverpool Heart and Chest Hospital NHS Foundation Trust Liverpool UK
| | - M. Shaw
- Liverpool Heart and Chest Hospital NHS Foundation Trust Liverpool UK
| | - I. Johnson
- Liverpool Heart and Chest Hospital NHS Foundation Trust Liverpool UK
| | - S. Agarwal
- Department of Anaesthesia Liverpool Heart and Chest Hospital NHS Foundation Trust Liverpool UK
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44
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Point of Care Testing in Cardiac Surgery: Diagnostic Modalities to Assess Coagulation and Platelet Function. Drug Dev Res 2013. [DOI: 10.1002/ddr.21099] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Faraoni D, Savan V, Levy JH, Theusinger OM. Goal-directed coagulation management in the perioperative period of cardiac surgery. J Cardiothorac Vasc Anesth 2013; 27:1347-54. [PMID: 24103717 DOI: 10.1053/j.jvca.2013.08.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2013] [Indexed: 01/15/2023]
Affiliation(s)
- David Faraoni
- Department of Anesthesiology, Queen Fabiola Children's University Hospital (QFCUH), Free University of Brussels, Brussels, Belgium.
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