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Barbu M, Kolsrud O, Radulovic V, Dellgren G, Björk K, Thorén A, Pivodic A, Ricksten SE, Jeppsson A. Hemostatic effects of a dextran-based priming solution for cardiopulmonary bypass: A secondary analysis of a randomized clinical trial. Thromb Res 2023; 223:139-145. [PMID: 36753875 DOI: 10.1016/j.thromres.2023.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 01/15/2023] [Accepted: 01/27/2023] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Intravascular fluids administered to patients may influence hemostasis. In patients undergoing cardiac surgery with cardiopulmonary bypass, the heart-lung machine is primed with 1300 ml of fluid. We assessed postoperative coagulation and platelet function in patients randomized to two different priming solutions, one colloid-based (dextran 40) and one crystalloid-based. MATERIALS AND METHODS Eighty-four elective cardiac surgery patients were randomized to either a dextran-based prime or Ringer's acetate with added mannitol. Blood samples were collected before, and 2 and 24 h after cardiopulmonary bypass. Coagulation was assessed by standard coagulation tests and rotational thromboelastometry. Platelet function was assessed with impedance aggregometry. Bleeding volumes and transfusion requirements were recorded. RESULTS Comparing the groups 2 h after bypass, the dextran group showed lower hemoglobin concentration, hematocrit, platelet count, and fibrinogen concentration, and higher INR and aPTT, as well as longer clot formation time (+41 ± 21 % vs. +8 ± 18 %, p < 0.001) and a larger reduction in fibrinogen-dependent clot strength (-37 ± 12 % vs. -7 ± 20 %, p < 0.001). Adenosine diphosphate-dependent platelet activation was reduced in the dextran group but not in the crystalloid group 2 h after bypass (-14 ± 29 % vs. -1 ± 41 %, p = 0.041). No significant between-group differences in hemostatic variables remained after 24 h, and no significant differences in perioperative bleeding volumes, re-explorations for bleeding, or transfusion rates were observed. CONCLUSIONS Compared to a crystalloid solution, a dextran-based prime had measurable negative impact on hemostatic variables but no detectable increase in bleeding volume or transfusion requirements in cardiac surgery patients.
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Affiliation(s)
- Mikael Barbu
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Cardiology, Karlskrona Hospital, Karlskrona, Sweden
| | - Oscar Kolsrud
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Vladimir Radulovic
- Department of Haematology and Coagulation Disorders, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Göran Dellgren
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kerstin Björk
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anders Thorén
- Department of Cardiothoracic Anesthesiology and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Aldina Pivodic
- APNC Sweden, Gothenburg, Sweden; Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Sven-Erik Ricksten
- Department of Cardiothoracic Anesthesiology and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anders Jeppsson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.
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Datzmann T, Völtl T, Ortner N, Wieder V, Liebold A, Reinelt H, Hoenicka M. Effects of colloid-based (hydroxyethylstarch 6% 130/0.42, gelafundin 4%) and crystalloid-based volume regimes in cardiac surgery: a retrospective analysis. J Thorac Dis 2022; 14:3782-3800. [PMID: 36389310 PMCID: PMC9641334 DOI: 10.21037/jtd-22-450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 08/19/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND The restriction of hydroxyethylstarch (HES) necessitated changes in volume management in cardiac surgery, increasing the use of gelatin (GELA) and crystalloid (CRYS) mono strategies. METHODS This retrospective study evaluated the effects of changed volume replacement management to a GELA or CRYS mono therapy on mortality, acute kidney injury (AKI), blood loss, and transfusion in cardiac surgery patients with at least one coronary artery bypass grafting (CABG) at a university hospital. Three groups (HES n=938, GELA n=397, CRYS n=205) were derived from 1,540 patients with complete data sets. Data were analyzed by multiple regression models. RESULTS Patients had similar risk profiles, comorbidities, and preoperative routine diagnostics prior to surgery. No difference was observed in mortality and AKI. HES treated patients showed highest blood loss, followed by GELA while CRYS patients had the lowest (P<0.0001). Patients in the HES group had highest transfusion of packed red blood cells (PRBCs) and platelet concentrates (PCs), followed by GELA, whereas CRYS had the lowest (P<0.0001). Fresh frozen plasma (FFP) transfusion, administration of fibrinogen, and prothrombin complex concentrates (PCCs) were highest in HES group. CRYS showed the shortest time of mechanical ventilation (P<0.0001) and left the intensive care unit (ICU) significantly earlier (P<0.0001). Multivariable regression analysis found that colloid volume significantly predicted hospital mortality and renal replacement therapy (RRT), but not AKI. CONCLUSIONS Administration of crystalloids without any colloid showed no differences in mortality or AKI, but less blood loss and transfusion. Colloids should be considered critically and further studies should investigate effects of GELA in cardiac surgery.
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Affiliation(s)
- Thomas Datzmann
- Department of Anesthesiology, University Hospital Ulm, Ulm, Germany;,Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University Hospital Ulm, Ulm, Germany
| | - Theresa Völtl
- Department of Anesthesiology, University Hospital Ulm, Ulm, Germany
| | - Nicola Ortner
- Department of Anesthesiology, University Hospital Ulm, Ulm, Germany
| | - Victoria Wieder
- Department of Anesthesiology, University Hospital Ulm, Ulm, Germany
| | - Andreas Liebold
- Department of Cardiothoracic and Vascular Surgery, University Hospital Ulm, Ulm, Germany
| | - Helmut Reinelt
- Department of Anesthesiology, University Hospital Ulm, Ulm, Germany
| | - Markus Hoenicka
- Department of Cardiothoracic and Vascular Surgery, University Hospital Ulm, Ulm, Germany
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Koponen T, Musialowicz T, Lahtinen P. Gelatin and the risk of bleeding after cardiac surgery. Acta Anaesthesiol Scand 2020; 64:1438-1445. [PMID: 32735701 DOI: 10.1111/aas.13677] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 07/11/2020] [Accepted: 07/12/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Gelatins has been used in cardiac surgery because of their ability to preserve intravascular volume better than crystalloids. Unfortunately, gelatin has been associated with impaired coagulation and hemostasis, that may cause increased bleeding. We investigated whether the administration of gelatin increases postoperative bleeding after cardiac surgery. METHODS Retrospective, observational single-center cohort study in the intensive care unit of a tertiary teaching hospital. Postoperative bleeding, chest tube drainage volume and consumption of blood products were compared between groups. RESULTS Cohort included 3067 consecutive patients who underwent cardiac surgery. First 1698 patients received gelatin (gelatin group), and 1369 patients did not (crystalloid group). The characteristics of the patients in the gelatin and crystalloid groups were comparable. Postoperative chest tube drainage was 18% (95% CI 11%-20%) greater during the first 12 hours (P < .001) and 15% (95% CI 7%-17%) greater during the first 24 hours (P < .001) in the gelatin group compared to the crystalloid group. Severe and massive postoperative bleeding was more common in the gelatin group compared to the crystalloid group (21% vs 16%, P < .001). Patients in the gelatin group received red blood cells (40% vs 20%, P < .001) and platelets (12% vs 8%, P < .001) more frequently than patients in the crystalloid group. However, the number of administered fresh-frozen plasma transfusions did not differ between the groups. CONCLUSION Gelatin may increase postoperative bleeding and the need for blood product transfusions after cardiac surgery.
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Affiliation(s)
- Timo Koponen
- Department of Anesthesia and Intensive Care Medicine North Karelia Central Hospital Joensuu Finland
| | - Tadeusz Musialowicz
- Department of Anesthesia and Intensive Care Medicine Kuopio University Hospital Kuopio Finland
| | - Pasi Lahtinen
- Department of Anesthesia and Intensive Care Medicine Kuopio University Hospital Kuopio Finland
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Erdoes G, Koster A, Meesters MI, Ortmann E, Bolliger D, Baryshnikova E, Ahmed A, Lance MD, Ravn HB, Ranucci M, Heymann C, Agarwal S. The role of fibrinogen and fibrinogen concentrate in cardiac surgery: an international consensus statement from the Haemostasis and Transfusion Scientific Subcommittee of the European Association of Cardiothoracic Anaesthesiology. Anaesthesia 2019; 74:1589-1600. [DOI: 10.1111/anae.14842] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2019] [Indexed: 12/23/2022]
Affiliation(s)
- G. Erdoes
- Department of Anaesthesiology and Pain Medicine Inselspital, Bern University Hospital University of Bern Switzerland
| | - A. Koster
- Institute for Anaesthesiology, Heart and Diabetes Centre NRW Ruhr‐University Bochum Bad Oeynhausen Germany
| | - M. I. Meesters
- Department of Anaesthesiology University Medical Centre Utrecht The Netherlands
| | - E. Ortmann
- Department of Anaesthesia Kerckhoff Heart and Lung Centre Bad Nauheim Germany
| | - D. Bolliger
- Department of Anaesthesia Surgical Intensive Care Prehospital Emergency Medicine, and Pain Therapy University Hospital Basel Switzerland
| | - E. Baryshnikova
- Department of Cardiovascular Anaesthesia and Intensive Care Unit IRCCS Policlinico San Donato Milan Italy
| | - A. Ahmed
- Department of Anaesthesia University Hospitals of Leicester NHS Trust LeicesterUK
| | - M. D. Lance
- Hamad Medical Corporation, HMC Anaesthesiology ICU and Peri‐operative Medicine Doha Qatar
| | - H. B. Ravn
- Department of Cardiothoracic Anaesthesiology Copenhagen University Hospital Copenhagen Denmark
| | - M. Ranucci
- Department of Cardiovascular Anaesthesia and Intensive Care Unit IRCCS Policlinico San Donato Milan Italy
| | - C. Heymann
- Department of Anaesthesia Intensive Care Medicine, Emergency Medicine and Pain Therapy Vivantes Klinikum im Friedrichshain Berlin Germany
| | - S. Agarwal
- Department of Anaesthesia Manchester University Hospitals Manchester UK
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High-dose Factor XIII administration induces effective hemostasis for trauma-associated coagulopathy (TAC) both in vitro and in rat hemorrhagic shock in vivo models. J Trauma Acute Care Surg 2019; 85:588-597. [PMID: 29851904 DOI: 10.1097/ta.0000000000001998] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Trauma-associated coagulopathy (TAC) is an early and primary complication in severe trauma patients. Factor XIII (FXIII) is reported to stabilize a clot in the late phase of the coagulation cascade. The goal of this study was to investigate whether the administration of FXIII improves the condition of TAC both in vitro and in vivo. METHODS We evaluated the effects of different doses, including a very high dose of FXIII (3.6-32.4 IU/mL) on tissue-plasminogen activator-induced hyperfibrinolysis and the combined condition of dilutional coagulopathy and tissue-plasminogen activator-induced hyperfibrinolysis in vitro. The coagulation status was analyzed by rotational thromboelastometry (ROTEM) and Sonoclot. Then, we evaluated the effect of high-dose FXIII (300 IU/kg) for severe coagulopathy in vivo using a rat liver trauma model in which coagulopathy similar to TAC was observed. Survival time and the amount of intra-abdominal bleeding of rats were measured, and a coagulation test was also performed. Histologic evaluations of rats' lung and kidney after FXIII administration were completed. RESULTS High-dose FXIII significantly improved clot strength as well as increased resistance to hyperfibrinolysis in vitro which was confirmed by ROTEM. Platelet function on Sonoclot was significantly increased by FXIII in a dose-dependent manner. Factor XIII significantly decreased the total amount of bleeding and prolonged the survival time compared to control (control vs FXIII: 108.9 ± 11.4 vs 32.6 ± 5.5 mL/kg; p < 0.001; 26.0 ± 8.8 vs 120 minutes, p < 0.001) in a rat model. Rotational thromboelastometry parameters and platelet function on Sonoclot were significantly improved in the FXIII (+) group compared to control. No adverse effects of FXIII were detected histologically. CONCLUSION Factor XIII not only generated stable clot resistance to hyperfibrinolysis but also enhanced platelet function by facilitating clot retraction. High-dose FXIII administration therapy has significant clinical impact for severe trauma accompanied with TAC. STUDY TYPE Human in vitro and rat in vivo experimental study.
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Cushing MM, Asmis LM, Harris RM, DeSimone RA, Hill S, Ivascu N, Haas T. Efficacy of a new pathogen-reduced cryoprecipitate stored 5 days after thawing to correct dilutional coagulopathy in vitro. Transfusion 2019; 59:1818-1826. [PMID: 30719724 DOI: 10.1111/trf.15157] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Revised: 12/27/2018] [Accepted: 12/29/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND Fibrinogen supplementation during bleeding restores clot strength and hemostasis. Cryoprecipitate, a concentrated source of fibrinogen, has prolonged preparation time for thawing, a short shelf life resulting in frequent wastage, and infectious disease risk. This in vitro study investigated the efficacy of a new pathogen-reduced cryoprecipitate thawed and stored at room temperature for 5 days (PR Cryo) to treat dilutional hypofibrinogenemia, compared to immediately thawed standard cryoprecipitate (Cryo) or fibrinogen concentrate (FC). STUDY DESIGN AND METHODS Ten phlebotomy specimens from healthy volunteers were diluted 1:1 with crystalloid and supplemented with PR Cryo and Cryo (at a dose replicating transfusion of two pooled doses [10 units]) and FC at a dose replicating 50 mg/kg. Changes in clot firmness (thromboelastometry) and in coagulation factor activity were assessed at baseline, after dilution, and after supplementation. RESULTS Clinical dosing was used, as described above, and consequently the FC dose contained 24% and 36% more fibrinogen versus PR Cryo and Cryo, respectively. At baseline, subjects had a median FIBTEM maximum clot firmness of 13.5 mm, versus 6.5 mm after 50% dilution (p = 0.005). After supplementation with PR Cryo, a median FIBTEM maximum clot firmness of 13 mm was observed versus 9.0 mm for Cryo (p = 0.005) or 16.5 mm for FC (p = 0.005). Median factor XIII was higher after PR Cryo (64.8%) versus Cryo (48.3%) (p = 0.005). Fibrinogen activity was higher after FC (269.0 mg/dL) versus PR Cryo (187.0 mg/dL; p = 0.005) or Cryo (193.5 mg/dL; p = 0.005); the difference between PR Cryo and Cryo supplementation (p = 0.445) was not significant. CONCLUSION PR Cryo used 5 days after thawing effectively restores clot strength after in vitro dilution.
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Affiliation(s)
- Melissa M Cushing
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York.,Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Lars M Asmis
- Centre for Perioperative Thrombosis and Haemostasis, Zurich, Switzerland
| | - Rebecca M Harris
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York
| | - Robert A DeSimone
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York
| | - Shanna Hill
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Natalia Ivascu
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Thorsten Haas
- Department of Anaesthesia, Zurich University Children's Hospital, Zurich, Switzerland
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7
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Carneiro JMGVDM, Alves J, Conde P, Xambre F, Almeida E, Marques C, Luís M, Godinho AMMG, Fernandez-Llimos F. Factor XIII-guided treatment algorithm reduces blood transfusion in burn surgery. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2018. [PMID: 29269148 PMCID: PMC9391805 DOI: 10.1016/j.bjane.2017.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background and objectives Major burn surgery causes large hemorrhage and coagulation dysfunction. Treatment algorithms guided by ROTEM® and factor VIIa reduce the need for blood products, but there is no evidence regarding factor XIII. Factor XIII deficiency changes clot stability and decreases wound healing. This study evaluates the efficacy and safety of factor XIII correction and its repercussion on transfusion requirements in burn surgery. Methods Randomized retrospective study with 40 patients undergoing surgery at the Burn Unit, allocated into Group A those with factor XIII assessment (n = 20), and Group B, those without assessment (n = 20). Erythrocyte transfusion was guided by a hemoglobin trigger of 10 g.dL−1 and the other blood products by routine coagulation and ROTEM® tests. Analysis of blood product consumption included units of erythrocytes, fresh frozen plasma, platelets, and fibrinogen. The coagulation biomarker analysis compared the pre- and post-operative values. Results and conclusions Group A (with factor XIII study) and Group B had identical total body surface area burned. All patients in Group A had a preoperative factor XIII deficiency, whose correction significantly reduced units of erythrocyte concentrate transfusion (1.95 vs. 4.05, p = 0.001). Pre- and post-operative coagulation biomarkers were similar between groups, revealing that routine coagulation tests did not identify factor XIII deficiency. There were no recorded thromboembolic events. Correction of factor XIII deficiency in burn surgery proved to be safe and effective for reducing perioperative transfusion of erythrocyte units.
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Algoritmo de tratamento guiado pelo fator XIII reduz a transfusão sanguínea na cirurgia de queimados. Braz J Anesthesiol 2018; 68:238-243. [DOI: 10.1016/j.bjan.2017.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 10/30/2017] [Accepted: 11/20/2017] [Indexed: 11/19/2022] Open
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Sanders JO, Friedrich K, Gerlach R, Platz J, Miesbach W, Hanke AA, Hofstetter C, Weber CF. Stellenwert der Thrombelastometrie für das Monitoring von Faktor XIII. Hamostaseologie 2017; 31:111-7. [DOI: 10.5482/ha-1132] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
SummaryRecently published studies give evidence, that an increased maximum lysis in the APTEM® – test (ML60 > 12%) of the ROTEM® (Tem International GmbH, Munich, Germany) might indicate a factor XIII deficiency (FXIII < 70%). It was the aim of this study to investigate the feasibility of thrombelastometric measurements with the ROTEM device to reflect the isolated influence of FXIII on clot stability and therefore to indicate potential factor XIII deficiencies. Patients, method: After approval by the local Scientific and Ethic Review Board, 26 consecutive patients, scheduled for elective craniotomy for tumour resection, were prospectively enrolled into this study. Blood samples were taken for conventional laboratory coagulation analyses, FXIII analyses and thrombelastometric measurements (EXTEM, FIBTEM and APTEM tests) after induction of general anaesthesia (T1), before skin incision (T2) as well as at (T3) and 24 hours after (T4) postoperative admission to ICU, respectively. Statistical analyses included Spearman rank order correlations and multiple linear regressions. Results: FXIII concentrations did not correlate with the ML60 in the APTEM test at any measuring point. Neither platelet count nor fibrinogen nor FXIII concentrations were of predictive value for ML60 of the APTEM test. Conclusion: The results lead to the assumption that thrombelastometric measurements may not be appropriate for the perioperative monitoring of FXIII concentration.
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Shams Hakimi C, Carling MS, Hansson EC, Brisby H, Hesse C, Radulovic V, Jeppsson A. The Effect of Ex Vivo Factor XIII Supplementation on Clot Formation in Blood Samples From Cardiac and Scoliosis Surgery Patients. Clin Appl Thromb Hemost 2017. [PMID: 28651441 DOI: 10.1177/1076029617713872] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Excessive perioperative bleeding remains a substantial problem. Factor XIII (FXIII) contributes to clot stability, and it has therefore been suggested that supplementation with FXIII concentrate may improve perioperative hemostasis. We evaluated the effects of increasing doses of FXIII, alone or in combination with fibrinogen or platelet concentrate, in blood samples from 2 considerably different groups of surgical patients: cardiac and scoliosis surgery patients. Whole-blood samples were collected immediately after operation from cardiac and scoliosis surgery patients. The samples were supplemented with 3 clinically relevant doses of FXIII concentrate (+20%, +40%, and +60%), alone or in combination with a fixed dose of fibrinogen concentrate (+1.0 g/L) or fresh apheresis platelets (+92 × 109/L). Clot formation was assessed with rotational thromboelastometry (ROTEM). When the highest dose of FXIII concentrate was added, EXTEM clotting time was shortened by 10% in both cardiac and scoliosis surgery patients (95% confidence intervals: 2.4%-17% and 3.3%-17%, respectively), and FIBTEM maximum clot firmness was increased by 25% (9.3%-41%) in cardiac patients, relative to baseline. When fibrinogen was added, the dose-dependent effect of FXIII on clot stability was maintained, but the total effect was markedly greater than with FXIII alone, +150% (100%-200%) and +160% (130%-200%) for the highest FXIII dose in cardiac and scoliosis patients, respectively. Ex vivo supplementation with clinically relevant doses of FXIII improved clot formation moderately in blood samples from cardiac and scoliosis surgery patients, both alone and when given in combination with fibrinogen or platelet concentrate.
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Affiliation(s)
- Caroline Shams Hakimi
- 1 Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Malin S Carling
- 2 Department of Orthopedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Emma C Hansson
- 1 Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Helena Brisby
- 2 Department of Orthopedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Camilla Hesse
- 3 Department of Clinical Chemistry and Transfusion Medicine, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Vladimir Radulovic
- 4 Department of Medicine/Hematology and Coagulation Disorders, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anders Jeppsson
- 1 Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Nicińska B, Pluta J, Kosieradzki M, Lągiewska B, Wasiak D, Lazowski T, Chmura A, Trzebicki J. The effects of in vitro hemodilution and fibrinogen concentrate substitution on thromboelastometry analysis in patients qualified for liver transplantation - preliminary results. Transplant Proc 2015; 46:2758-61. [PMID: 25380911 DOI: 10.1016/j.transproceed.2014.09.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Dilutional coagulopathy might cause life-threatening hemorrhages in liver transplantation. Liver insufficiency is usually accompanied by alteration in fibrinogen (Fib) synthesis, which is one of the main clotting factors providing appropriate hemostasis. Intraoperative hemodilution results in further Fib concentration reduction enhancing coagulopathy and blood loss. Exogenous Fib substitution might prevent this. METHODS A prospective study with a control group was designed. The study group consists of patients with cirrhosis who qualified for liver transplantation. Inclusion and exclusion criteria were strictly established. The blood collected from participants was diluted up to 30% and 60% with crystalloid (saline) or colloid (hydroxyethyl starch) in 2 parallel series. The first series consisted of diluted blood, the second of diluted blood with Fib concentrate. Thromboelastometry tests were performed on every blood sample. After collecting data from the first 12 participants, we performed a preliminary analysis. RESULTS The maximum clot formation (MCF) in the EXTEM test decreased with progressive blood dilution in both study arms. The MCF values were lower than 35 mm in every diluted blood sample of the study group. The recovery of decreased MCF after Fib concentrate substitution was observed in both groups. The improvement in clot formation was also expressed as amplitude of clot firmness in the 10th minute (A10) in the FIBTEM test. CONCLUSIONS Clot formation is disturbed more profoundly by hemodilution in cirrhotic patients. Fib concentrate substitution might be effective in the management of dilutional coagulopathy.
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Affiliation(s)
- B Nicińska
- Department of Anesthesiology and Intensive Care Unit, Medical University of Warsaw, Clinical Hospital Dzieciątka Jezus, Warsaw, Poland
| | - J Pluta
- Department of Anesthesiology and Intensive Care Unit, Medical University of Warsaw, Clinical Hospital Dzieciątka Jezus, Warsaw, Poland
| | - M Kosieradzki
- Department of General Surgery and Transplantology, Transplantation Institute, Medical University of Warsaw, Clinical Hospital Dzieciątka Jezus, Warsaw, Poland
| | - B Lągiewska
- Department of General Surgery and Transplantology, Transplantation Institute, Medical University of Warsaw, Clinical Hospital Dzieciątka Jezus, Warsaw, Poland
| | - D Wasiak
- Department of Surgical and Transplant Nursing, Medical University of Warsaw, Poland
| | - T Lazowski
- Department of Anesthesiology and Intensive Care Unit, Medical University of Warsaw, Clinical Hospital Dzieciątka Jezus, Warsaw, Poland
| | - A Chmura
- Department of General Surgery and Transplantology, Transplantation Institute, Medical University of Warsaw, Clinical Hospital Dzieciątka Jezus, Warsaw, Poland
| | - J Trzebicki
- Department of Anesthesiology and Intensive Care Unit, Medical University of Warsaw, Clinical Hospital Dzieciątka Jezus, Warsaw, Poland.
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12
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Winstedt D, Thomas OD, Nilsson F, Olanders K, Schött U. Correction of hypothermic and dilutional coagulopathy with concentrates of fibrinogen and factor XIII: an in vitro study with ROTEM. Scand J Trauma Resusc Emerg Med 2014; 22:73. [PMID: 25510409 PMCID: PMC4272532 DOI: 10.1186/s13049-014-0073-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Accepted: 11/26/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Fibrinogen concentrate treatment can improve coagulation during massive traumatic bleeding. The aim of this in vitro study was to determine whether fibrinogen concentrate, or a combination of factor XIII and fibrinogen concentrates, could reverse a haemodilution-induced coagulopathy during hypothermia. METHODS Citrated venous blood from 10 healthy volunteers was diluted in vitro by 33% with 130/0.42 hydroxyethyl starch (HES) or Ringer's acetate (RAc). The effects of fibrinogen concentrate corresponding to 4 gram per 70 kg, or a combination of the same dose of fibrinogen with factor XIII (20 IU per kg), were measured using rotational thromboelastometry (ROTEM). The blood was analysed at 33°C or 37°C with ROTEM EXTEM and FIBTEM reagents. Clotting time (CT), clot formation time (CFT), alpha angle (AA) and maximal clot formation (MCF) were recorded. RESULTS Fibrinogen with or without factor XIII improved all ROTEM parameters in either solution irrespective of temperature, with the exception of EXTEM-AA and EXTEM-CFT in HES haemodilution. Fibrinogen increased FIBTEM-MCF more in the samples diluted with RAc than HES, particularly in presence of factor XIII. CONCLUSIONS Fibrinogen improved in vitro haemodilution-induced coagulopathy at both 33°C and 37°C, though more efficiently after crystalloid than HES haemodilution. Factor XIII had an additional effect on FIBTEM-MCF, but only after crystalloid dilution.
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Affiliation(s)
- Dag Winstedt
- Faculty of Medicine, Lund University, Lund, Sweden.
- Department of Anaesthesia and Intensive Care, Skåne University Hospital Lund, Lund, 221 85, Sweden.
| | - Owain D Thomas
- Faculty of Medicine, Lund University, Lund, Sweden.
- Department of Paediatric Anaesthesia and Intensive Care, Skåne University Hospital Lund, Lund, 221 85, Sweden.
| | - Fredrik Nilsson
- Research and Development Centre, Skåne, Skåne University Hospital Lund, Lund, 221 85, Sweden.
| | - Knut Olanders
- Faculty of Medicine, Lund University, Lund, Sweden.
- Department of Anaesthesia and Intensive Care, Skåne University Hospital Lund, Lund, 221 85, Sweden.
| | - Ulf Schött
- Faculty of Medicine, Lund University, Lund, Sweden.
- Department of Anaesthesia and Intensive Care, Skåne University Hospital Lund, Lund, 221 85, Sweden.
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Abstract
Colloids are frequently used for fluid expansion in the intensive care unit, although its use on several clinical scenarios remains unproven of any relevant clinical benefit. The purpose of this article was to carry out a narrative review regarding the safety and efficacy of colloids in patients with sepsis and septic shock, with emphasis on the most commonly used colloids, albumin and starches. Colloids are effective fluid expanders and are able to restore the hemodynamic profile with less total volume than crystalloids. These properties appear to be preserved even in patients with sepsis with increased capillary permeability. However, some colloids are associated with renal impairment and coagulation abnormalities. Starch use was associated with increased mortality in two large clinical trials. Also, starches probably have significant renal adverse effects and may be related to more need for renal replacement therapy in severe sepsis. Albumin is the only colloid that has been shown safe in patients with sepsis and that may be associated with improved outcomes on specific subpopulations. No trial so far found any robust clinical end point favoring colloid use in patients with sepsis. Because there is no proven benefit of the use of most colloids in patients with sepsis, its use should not be encouraged outside clinical trials. Albumin is the only colloid solution that has proven to be safe, and its use may be considered on hypoalbuminemic patients with sepsis. Nevertheless, there are no robust data to recommend routine albumin administration in sepsis. Starch use should be avoided in patients with sepsis because of the recent findings of a multicenter randomized study until further evidence is available.
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Hanna J, Winstedt D, Schött U. Fibrinogen and FXIII dose response effects on albumin-induced coagulopathy. Scandinavian Journal of Clinical and Laboratory Investigation 2013; 73:553-62. [DOI: 10.3109/00365513.2013.821710] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Falco S, Bruno B, Maurella C, Bellino C, D'Angelo A, Gianella P, Tarducci A, Zanatta R, Borrelli A. In vitro evaluation of canine hemostasis following dilution with hydroxyethyl starch (130/0.4) via thromboelastometry. J Vet Emerg Crit Care (San Antonio) 2013; 22:640-5. [PMID: 23216838 DOI: 10.1111/j.1476-4431.2012.00816.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2011] [Accepted: 09/27/2012] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To assess the effects of in vitro hemodilution of canine blood with a low molecular weight hy-droxyethyl starch (HES 130/0.4) by means of thromboelastometry (TEM). DESIGN In vitro experimental study. SETTING University Teaching Hospital. ANIMALS Ten healthy adult staff-owned dogs were sampled for the purposes of the study. Samples were also collected from 45 clinically normal dogs to establish thromboelastometric reference intervals. INTERVENTIONS For each dog whole blood was collected by jugular venipuncture and placed into tubes containing 3.8% trisodium citrate and stored at 37°C. Two standard dilutions (1:4 and 1:10) from canine blood specimens were prepared with HES 130/0.4 and saline 0.9%. MEASUREMENTS AND MAIN RESULTS The effects of dilution were studied by TEM. No statistically significant differences were observed between the TEM values of the control samples and the samples diluted with saline solution (ratio 1:10 and 1:4). In contrast, hypocoagulability was observed in the samples treated with HES 130/0.4, with more severe effects at 1:4 dilution than at 1:10 dilution. The 1:4 dilution with HES 130/0.4 produced marked alterations: CT (P = 0.035) and CFT (P = 0.0007) on the ex-TEM profile, CT (P = 0.0005) and ML (P = 0.0017) on the fib-TEM profile and CFT (P = 0.0043) on the in-TEM, were all significantly increased (P < 0.05), whereas MCF (P = 0.0042) and alpha angle (P = 0.002) on the in-TEM and MCF (P = 0.011) and alpha angle (P = 0.001) ex-TEM profiles and MCF (P = 0.0001) on the fib-TEM profile were significantly decreased (P < 0.05). CONCLUSIONS Dilution of canine blood with HES 130/0.4 results in a thromboelastometric pattern consistent with hypocoagulation and this effect appears to result from a dose-dependent alteration in fibrinogen concentration and inhibition of platelet function. As this is an in vitro study, further in vivo investigations are necessary to confirm the results.
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Affiliation(s)
- Sara Falco
- Department of Animal Pathology, Clinical Medicine Section, via Leonardo da Vinci 44, 10095, Grugliasco (TO), Italy
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Winstedt D, Hanna J, Schött U. Albumin-induced coagulopathy is less severe and more effectively reversed with fibrinogen concentrate than is synthetic colloid-induced coagulopathy. Scandinavian Journal of Clinical and Laboratory Investigation 2013; 73:161-9. [DOI: 10.3109/00365513.2012.762114] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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The effect of fibrinogen concentrate and factor XIII on thromboelastometry in 33% diluted blood with albumin, gelatine, hydroxyethyl starch or saline in vitro. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2012; 11:510-7. [PMID: 23245725 DOI: 10.2450/2012.0171-12] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Accepted: 09/25/2012] [Indexed: 01/02/2023]
Abstract
BACKGROUND Fluid replacement results in dilutional coagulopathy. We investigated the potential role of fibrinogen, factor XIII and a combination of both to reverse dilutional coagulopathy, assessed by thromboelastometry (ROTEM(®)). MATERIAL AND METHODS Blood samples from healthy volunteers were analysed undiluted and after 33% dilution in vitro with albumin, gelatine, 130/0.4 hydroxyethyl starch or saline. Diluted samples were incubated with fibrinogen (3 g/70 kg bodyweight equivalent), factor XIII (10,000 IU/70 kg bodyweight equivalent), or a combination of both. Measurements were performed using an extrinsic activated assay (EXTEM(®)) and a functional fibrin polymerisation test (FIBTEM(®)). RESULTS Compared with baseline, EXTEM clotting time increased with hydroxyethyl starch, exceeding the upper limit of the reference value. Albumin prolonged clotting time within normal limits. Gelatine did not change clotting time, and saline reduced clotting time. Clot formation time increased in colloids only. Maximum clot firmness of both EXTEM and FIBTEM decreased with all fluids, but was less pronounced in saline. Incubation with fibrinogen had no effect on EXTEM maximum clot firmness but improved FIBTEM maximum clot firmness in saline (P <0.001) and albumin (P <0.05), but not gelatine and hydroxyethyl starch). Factor XIII had no effect on any EXTEM and FIBTEM maximum clot firmness results. Fibrinogen and factor XIII combined did not improve EXTEM maximum clot firmness. Fibrinogen and factor XIII did not change FIBTEM maximum clot firmness in hydroxyethyl starch but improved FIBTEM maximum clot firmness in albumin (P <0.001), gelatine (P <0.01) and saline (P <0.001). DISCUSSION ROTEM parameters in dilutional coagulopathy in vitro cannot be improved with factor XIII alone in any tested diluent. The combination of fibrinogen and factor XIII is highly effective in raising FIBTEM maximum clot firmness after dilution with albumin, gelatine and saline back to normal values, but is ineffective in 130/0.4 hydroxyethyl starch.
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The in-vitro effect of fibrinogen, factor XIII and thrombin-activatable fibrinolysis inhibitor on clot formation and susceptibility to tissue plasminogen activator-induced fibrinolysis in hemodilution model. Blood Coagul Fibrinolysis 2012; 23:370-8. [DOI: 10.1097/mbc.0b013e328352cb3f] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Solomon C, Sørensen B, Hochleitner G, Kashuk J, Ranucci M, Schöchl H. Comparison of whole blood fibrin-based clot tests in thrombelastography and thromboelastometry. Anesth Analg 2012; 114:721-30. [PMID: 22314689 DOI: 10.1213/ane.0b013e31824724c8] [Citation(s) in RCA: 90] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Fibrin-based clot firmness is measured as maximum amplitude (MA) in the functional fibrinogen (FF) thrombelastographic assay and maximum clot firmness (MCF) in the FIBTEM thromboelastometric assay. Differences between the assays/devices may be clinically significant. Our objective was to compare clot firmness parameters through standard (FF on a thrombelastography device [TEG®]; FIBTEM on a thromboelastometry device [ROTEM®]) and crossover (FF on ROTEM®; FIBTEM on TEG®) analyses. METHODS Whole-blood samples from healthy volunteers were subjected to thrombelastography and thromboelastometry analyses. Samples were investigated native and following stepwise dilution with sodium chloride solution (20%, 40%, and 60% dilution). Samples were also assessed after in vitro addition of medications (heparin, protamine, tranexamic acid) and 50% dilution with hydroxyethyl starch, gelatin, sodium chloride, and albumin. RESULTS FF produced higher values than FIBTEM, regardless of the device, and TEG® produced higher values than ROTEM®, regardless of the assay. With all added medications except heparin 400 U/kg bodyweight, FF MA remained significantly higher (P < 0.05) than FIBTEM MCF, which was largely unchanged. FF MA was significantly reduced (P = 0.04) by high-dose heparin and partially restored with protamine. Fifty percent dilution with hydroxyethyl starch, albumin, and gelatin decreased FIBTEM MCF and FF MA by >50%. CONCLUSIONS These results demonstrate differences when measuring fibrin-based clotting via the FF and FIBTEM assays on the TEG® and ROTEM® devices. Point-of-care targeted correction of fibrin-based clotting may be influenced by the assay and device used. For the FF assay, data are lacking.
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Affiliation(s)
- Cristina Solomon
- Department of Anaesthesiology and Intensive Care, Salzburger Landeskliniken SALK, 48 Müllner Hauptstrasse, 5020 Salzburg, Austria.
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Shenkman B, Livnat T, Misgav M, Budnik I, Einav Y, Martinowitz U. The in vivo effect of fibrinogen and factor XIII on clot formation and fibrinolysis in Glanzmann's thrombasthenia. Platelets 2012; 23:604-10. [PMID: 22273510 DOI: 10.3109/09537104.2011.642031] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Glanzmann's thrombasthenia (GT) is characterized by increased bleeding risk. The treatment options in GT are limited. The aim of this study was to test the effect of GT blood supplementation with fibrinogen and factor XIII on thrombin generation, blood clotting, and fibrinolysis. Whole blood samples of GT patients and normal donors treated with eptifibatide (GT model) were subjected to clotting by CaCl(2) and tissue factor. Thrombin generation was measured in platelet-rich plasma. Clot formation and tPA-induced fibrinolysis were evaluated in whole blood by rotation thromboelastometry (ROTEM). Blood was supplemented with fibrinogen (3 g/L) and/or FXIII (2 IU/mL). Thrombin generation analysis of blood derived from GT model and GT patients revealed decreased endogenous thrombin potential and peak height and extended lag time compared to control. However, this method was not sensitive to blood spiking with fibrinogen and FXIII. ROTEM revealed lower maximum clot firmness (MCF) and area under curve (AUC) in the blood of GT model and GT patients. In the absence of exogenous tPA, blood spiking with fibrinogen markedly enhanced clot quality while FXIII had no effect. Combination of fibrinogen and FXIII did not add to the effect of fibrinogen. In contrast, by the addition of tPA, both fibrinogen and FXIII separately and, to more extent, in combination enhanced clot quality as well as resistance against tPA-induced fibrinolysis (increasing MCF, AUC, and lysis onset time). In conclusion, fibrinogen and FXIII exerted stimulation of blood clotting and inhibition of fibrinolysis. Treating normal blood with eptifibatide mimics the changes of coagulopathy in GT blood.
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Affiliation(s)
- Boris Shenkman
- Institute of Thrombosis & Hemostasis and the National Hemophilia Center, Chaim Sheba Medical Center, Tel-Hashomer, Israel.
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Schramko AA. Post-operative volume therapy in cardiac surgery: effects on hemostatic and circulatory variables. Acta Anaesthesiol Scand 2011. [DOI: 10.1111/j.1399-6576.2011.02470.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Appelman MH, van Barneveld LJM, Romijn JWA, Vonk ABA, Boer C. The impact of balanced hydroxylethyl starch cardiopulmonary bypass priming solution on the fibrin part of clot formation: ex vivo rotation thromboelastometry. Perfusion 2010; 26:175-80. [DOI: 10.1177/0267659110394711] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction: Balanced colloidal priming solutions are supposed to further minimize the effects of cardiopulmonary bypass (CPB) on haemostasis as compared to gelatin-based preparations. This exploratory study investigated whether clot formation, in particular the fibrin part of the clot, is less altered by a modern balanced HES solution as compared to a gelatin-based priming solution. Methods: CPB priming solutions containing 60% gelatin (Gelofusin®) or balanced HES starch (100% or 60% Tetraspan®) were mixed with blood samples from healthy volunteers and compared with respect to their impact on clotting time (CT), alpha angle, maximum clot firmness (MCF), and fibrinogen, using thromboelastometry. Results: The 100% and 60% HES priming solutions significantly increased the EXTEM CT from 66 ± 9 s to 82 ± 19 and 83 ± 13, respectively (both P<0.05 vs. baseline). The speed of solid clot formation decreased significantly for all priming solutions compared with baseline values. The INTEM MCF decreased from 59 ± 4 mm to 47 ± 4, 44 ± 4 and 43 ± 3 mm, whereas the EXTEM MCF decreased from 57 ± 4 mm to 51 ± 4, 51 ± 4 and 50 ± 4 mm after dilution with 60% gelatin, 100% HES or 60% HES priming solution, respectively (all P<0.01 vs. baseline). The priming solutions containing HES induced the largest decrease in MCF attributed to fibrinogen from 12 ± 3 mm to 4 ± 4 mm and 3 ± 2 mm (both P<0.05) for the 100% and mixed priming solution, respectively. Conclusions: Ex vivo rotation thromboelastometry did not reveal the expected preservation of coagulation parameters, in particular the fibrin part of clot formation, by a balanced HES priming solution.
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Affiliation(s)
- Marly H Appelman
- Department of Anesthesiology, Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, the Netherlands
| | - Lerau J M van Barneveld
- Department of Cardio-thoracic Surgery, Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, the Netherlands
| | - Johannes W A Romijn
- Department of Anesthesiology, Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, the Netherlands
| | - Alexander B A Vonk
- Department of Cardio-thoracic Surgery, Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, the Netherlands
| | - Christa Boer
- Department of Anesthesiology, Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, the Netherlands,
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Huet R, de Vries AJ, Cernak V, van Oeveren W. Impact of platelet adhesion on thromboelastometry in dilutional consumption coagulopathy with either HES or gelatin. Acta Anaesthesiol Scand 2010; 54:783-4. [PMID: 20618163 DOI: 10.1111/j.1399-6576.2010.02223.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Schramko A, Suojaranta-Ylinen R, Kuitunen A, Raivio P, Kukkonen S, Niemi T. Hydroxyethylstarch and gelatin solutions impair blood coagulation after cardiac surgery: a prospective randomized trial. Br J Anaesth 2010; 104:691-7. [PMID: 20388624 DOI: 10.1093/bja/aeq084] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- A Schramko
- Department of Anaesthesiology and Intensive Care Medicine, Helsinki University Hospital, Meilahti Hospital, Helsinki HUS, Finland.
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Brinkman AC, Romijn JW, van Barneveld LJ, Greuters S, Veerhoek D, Vonk AB, Boer C. Profound Effects of Cardiopulmonary Bypass Priming Solutions on the Fibrin Part of Clot Formation: An Ex Vivo Evaluation Using Rotation Thromboelastometry. J Cardiothorac Vasc Anesth 2010; 24:422-6. [DOI: 10.1053/j.jvca.2009.10.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2009] [Indexed: 11/11/2022]
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