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Hendren C, Li W, Stegemann JP, Hall TL, Deng CX. Multichannel resonant acoustic rheometry system for quantification of coagulation of multiple human plasma samples. Sci Rep 2023; 13:19237. [PMID: 37935776 PMCID: PMC10630367 DOI: 10.1038/s41598-023-46518-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 11/02/2023] [Indexed: 11/09/2023] Open
Abstract
Resonant Acoustic Rheometry (RAR), a newly developed ultrasound-based technique for non-contact characterization of soft viscoelastic materials, has shown promise for quantitative viscoelastic assessment of temporally changing soft biomaterials in real time, and may be used to monitor blood coagulation process. Here, we report the development of a novel, multichannel RAR (mRAR) system for simultaneous measurements of multiple temporally evolving samples and demonstration of its use for monitoring the coagulation of multiple small-volume plasma samples. The mRAR system was constructed using an array of 4 custom-designed ultrasound transducers at 5.0 MHz and a novel electronic driving system that controlled the generation of synchronized ultrasound pulses for real time assessment of multiple samples simultaneously. As a proof-of-concept of the operation of the mRAR system, we performed tests using pooled normal human plasma samples and anti-coagulated plasma samples from patients treated with warfarin with a range of International Normalized Ratio (INR) values as well-characterized samples with different coagulation kinetics. Our results show that simultaneous tracking of dynamic changes in 4 plasma samples triggered by either kaolin or tissue factor was achieved for the entire duration of coagulation. The mRAR system captured distinct changes in the samples and identified parameters including the clotting start time and parameters associated with the stiffness of the final clots that were consistent with INR levels. Data from this study demonstrate the feasibility of the mRAR system for efficient characterization of the kinetic coagulation processes of multiple plasma samples.
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Affiliation(s)
- Christina Hendren
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Weiping Li
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Jan P Stegemann
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Timothy L Hall
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA.
| | - Cheri X Deng
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA.
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI, USA.
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Liu J, Liu Z, Zhao T, Su T, Jin Q. Thromboelastography and Traditional Coagulation Testing in Non-ICU-Admitted Patients with Acute Kidney Injury: An Observational Cohort Study. Am J Nephrol 2023; 54:208-218. [PMID: 37364534 DOI: 10.1159/000530777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 04/05/2023] [Indexed: 06/28/2023]
Abstract
INTRODUCTION This study aimed to elucidate the coagulation disorders in non-ICU patients with acute kidney injury (AKI) and their contribution to clotting-related outcomes of intermittent kidney replacement therapy (KRT). METHODS We included non-ICU-admitted patients with AKI requiring intermittent KRT, clinically having a risk of bleeding and against systemic anticoagulant use during KRT between April and December 2018. The premature termination of treatment due to circuit clotting was considered a poor outcome. We analyzed the characteristics of thromboelastography (TEG)-derived and traditional coagulation parameters and explored the potential-affecting factors. RESULTS In total, 64 patients were enrolled. Hypocoagulability was detected in 4.7%-15.6% of patients by a combination of the traditional parameters, i.e., prothrombin time (PT)/international normalized ratio, activated partial PT, and fibrinogen. No patient had hypocoagulability observed on TEG-derived reaction time; only 2.1%, 3.1%, and 10.9% of patients had hypocoagulability on TEG-derived kinetic time (K-time), α-angle, and maximum amplitude (MA), respectively, which were also platelet-related coagulation parameters, despite 37.5% of the cohort having thrombocytopenia. In contrast, hypercoagulability was more prevalent, involving 12.5%, 43.8%, 21.9%, and 48.4% of patients on TEG K-time, α-angle, MA, and coagulation index (CI), respectively, although thrombocytosis was only in 1.5% of the cohort. Patients with thrombocytopenia showed lower fibrinogen level (2.6 vs. 4.0 g/L, p = 0.00), α-angle (63.5° vs. 73.3°, p = 0.00), MA (53.5 vs. 66.1 mm, p = 0.00), and CI (1.8 vs. 3.6, p = 0.00) but higher thrombin time (17.8 vs. 16.2 s, p = 0.00) and K-time (2.0 vs. 1.2 min, p = 0.00) than those with a platelet count over 100 × 109/L. 41 patients were treated with heparin-free protocol, and 23 were treated with regional citrate anticoagulation (RCA). The premature termination rate was 41.5% on heparin-free patients, while 8.7% of patients underwent an RCA protocol (p = 0.006). Heparin-free protocol was the strongest adverse factor to poor outcomes. A heparin-free subgroup analysis found that the circuit clotting risk was increased by 61.7% with a 10 × 109/L elevation in platelet count (odds ratio [OR] = 1.617, p = 0.049) and decreased by 67.5% following a second increase of PT (OR = 0.325, p = 0.041). No significant correlation was found between TEG parameters and premature circuit clotting. CONCLUSIONS Most non-ICU-admitted patients with AKI had normal-to-enhanced hemostasis and activated platelet function based on TEG results, as well as a high rate of premature circuit clotting when receiving heparin-free protocol despite thrombocytopenia. Further studies are needed to better determine the use of TEG in respect to management of anticoagulation and bleeding complications in AKI patients with KRT.
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Affiliation(s)
- Jiajia Liu
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
| | - Zhongyuan Liu
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
| | - Tao Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
| | - Tao Su
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
| | - Qizhuang Jin
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
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Duclos G, Fleury M, Grosdidier C, Lakbar I, Antonini F, Lassale B, Arbelot C, Albaladejo P, Zieleskiewicz L, Leone M. Blood coagulation test abnormalities in trauma patients detected by sonorheometry: a retrospective cohort study. Res Pract Thromb Haemost 2023; 7:100163. [PMID: 37251493 PMCID: PMC10208882 DOI: 10.1016/j.rpth.2023.100163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 03/17/2023] [Accepted: 04/03/2023] [Indexed: 05/31/2023] Open
Abstract
Background Traumatic hemorrhage guidelines include point-of-care viscoelastic tests as a standard of care. Quantra (Hemosonics) is a device based on sonic estimation of elasticity via resonance (SEER) sonorheometry to assess whole blood clot formation. Objectives Our study aimed to assess the ability of an early SEER evaluation to detect blood coagulation test abnormalities in trauma patients. Methods We conducted an observational retrospective cohort study with data collected at hospital admission of consecutive multiple trauma patients from September 2020 to February 2022 at a regional level 1 trauma center. We performed a receiving operator characteristic curve analysis to determine the ability of the SEER device to detect blood coagulation test abnormalities. Four values on the SEER device were analyzed: clot formation time, clot stiffness (CS), platelet contribution to CS, and fibrinogen contribution to CS. Results A total of 156 trauma patients were analyzed. The clot formation time value predicted an activated partial thromboplastin time ratio of >1.5 with an area under the curve (AUC) of 0.93 (95% CI, 0.86-0.99). The AUC of the CS value in detecting an international normalized ratio of prothrombin time of >1.5 was 0.87 (95% CI, 0.79-0.95). The AUC of fibrinogen contribution to CS to detect a fibrinogen concentration of <1.5 g/L was 0.87 (95% CI, 0.80-0.94). The AUC of platelet contribution to CS to detect a platelet concentration of <50 G/L was 0.99 (95% CI, 0.99-1.00). Conclusion Our results suggest that the SEER device may be useful for the detection of blood coagulation test abnormalities at trauma admission.
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Affiliation(s)
- Gary Duclos
- Service of Anesthesia and Intensive Care, Hôpital Nord, Aix-Marseille Université, Marseille, France
| | - Marie Fleury
- Service of Anesthesia and Intensive Care, Hôpital Nord, Aix-Marseille Université, Marseille, France
| | - Charlotte Grosdidier
- Service of Medical Biology, Hôpital Nord, Aix-Marseille Université, Marseille, France
| | - Ines Lakbar
- Service of Anesthesia and Intensive Care, Hôpital Nord, Aix-Marseille Université, Marseille, France
| | - François Antonini
- Service of Anesthesia and Intensive Care, Hôpital Nord, Aix-Marseille Université, Marseille, France
| | - Bernard Lassale
- French Establishment for Blood, Hôpital Nord, Aix-Marseille Université, Marseille, France
| | - Charlotte Arbelot
- Service of Anesthesia and Intensive Care, Hôpital Nord, Aix-Marseille Université, Marseille, France
| | - Pierre Albaladejo
- Department of Anesthesiology and Critical Care, Grenoble Alpes University Hospital, Grenoble, France
| | - Laurent Zieleskiewicz
- Service of Anesthesia and Intensive Care, Hôpital Nord, Aix-Marseille Université, Marseille, France
| | - Marc Leone
- Service of Anesthesia and Intensive Care, Hôpital Nord, Aix-Marseille Université, Marseille, France
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Kasireddy N, Orie JC, Khismatullin DB. Drop-of-sample rheometry of biological fluids by noncontact acoustic tweezing spectroscopy. LAB ON A CHIP 2022; 22:3067-3079. [PMID: 35851909 PMCID: PMC10661770 DOI: 10.1039/d2lc00356b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Knowledge of rheological properties, such as viscosity and elasticity, is necessary for efficient material processing and transportation as well as biological analysis. Existing rheometers operate with large sample volume and induce sample contact with container or device walls, which are inadequate for rheological analysis of sensitive fluids limited in availability. In this work, we introduce acoustic tweezing spectroscopy (ATS), a novel noncontact rheological technique that operates with a single 4-6 μl drop of fluid sample. In ATS, a sample drop is acoustically levitated and then exposed to a modulated acoustic signal to induce its forced oscillation. The time-dependent sample viscosity and elasticity are measured from the resulting drop response. The ATS measurements of polymeric solutions (dextran, xanthan gum, gelatin) agree well with previously reported data. The ATS predicts that the shear viscosity of blood plasma increases from 1.5 cP at 1.5 min of coagulation onset to 3.35 cP at 9 min, while its shear elastic modulus grows from a negligible value to 10.7 Pa between 3.5 min and 6.5 min. Coagulation increases whole blood viscosity from 5.4 cP to 20.7 cP and elasticity from 0.1 Pa to 19.2 Pa at 15 min. In summary, ATS provides the opportunity for sensitive small-volume rheological analysis in biomedical research and medical, pharmaceutical, and chemical industries.
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Affiliation(s)
- Nithya Kasireddy
- Department of Biomedical Engineering, Tulane University, 6823 St. Charles Avenue, New Orleans, Louisiana, 70118, USA.
| | - Jeremy C Orie
- Department of Biomedical Engineering, Tulane University, 6823 St. Charles Avenue, New Orleans, Louisiana, 70118, USA.
| | - Damir B Khismatullin
- Department of Biomedical Engineering, Tulane University, 6823 St. Charles Avenue, New Orleans, Louisiana, 70118, USA.
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VanDyck K, Mazzeffi M, Tanaka K. Viscoelastic Hemostatic Assays-Training the Next Canary for Hemostatic Resuscitation in Trauma. Anesth Analg 2022; 134:e41-e42. [PMID: 35595706 DOI: 10.1213/ane.0000000000006003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Kofi VanDyck
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma,
| | - Michael Mazzeffi
- Department of Anesthesiology and Critical Care, George Washington University School of Medicine and Health Sciences
| | - Kenichi Tanaka
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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Blaine KP, Dudaryk R. Pro-Con Debate: Viscoelastic Hemostatic Assays Should Replace Fixed Ratio Massive Transfusion Protocols in Trauma. Anesth Analg 2022; 134:21-31. [PMID: 34908543 DOI: 10.1213/ane.0000000000005709] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Major trauma patients at risk of traumatic coagulopathy are commonly treated with early clotting factor replacement to maintain hemostasis and prevent microvascular bleeding. In the United States, trauma transfusions are often dosed by empiric, low-ratio massive transfusion protocols, which pair plasma and platelets in some ratio relative to the red cells, such as the "1:1:1" combination of 1 units of red cells, 1 unit of plasma, and 1 donor's worth of pooled platelets. Empiric transfusion increases the rate of overtransfusion when unnecessary blood products are administered based on a formula and not on at patient's hemostatic profile. Viscoelastic hemostatic assays (VHAs) are point-of-care hemostatic assays that provided detailed information about abnormal clotting pathways. VHAs are used at many centers to better target hemostatic therapies in trauma. This Pro/Con section will address whether VHA guidance should replace empiric fixed ratio protocols in major trauma.
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Affiliation(s)
- Kevin P Blaine
- From the Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, Oregon
| | - Roman Dudaryk
- Department of Anesthesiology, Perioperative Medicine, and Pain Management, University of Miami Health System/Ryder Trauma Center, Miami, Florida
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Martinez S, Garcia I, Ruiz A, Tàssies D, Reverter JC, Colmenero J, Beltran J, Fondevila C, Blasi A. Is antivitamin K reversal required in patients with cirrhosis undergoing liver transplantation? Transfusion 2021; 61:3008-3016. [PMID: 34358342 DOI: 10.1111/trf.16607] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 06/13/2021] [Accepted: 07/05/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Antivitamin K agent (AVK) reversal in patients with cirrhosis awaiting liver transplantation (LT) is not defined in guidelines. We investigated the effect of reversion with prothrombin complex concentrate (PCC) on intraoperative transfusion, bleeding, and safety in LT patients on AVK. STUDY DESIGN AND METHODS In 511 patients undergoing LT, we identified 25 patients treated with AVK (AVK group) and 13 patients with incidental portal vein thrombosis (PVT) without AVK (incidental PVT group). Fifty patients who underwent LT without PVT or AVK matched by age, model for end stage of liver disease (MELD), body mass index (BMI), and cirrhosis etiology were selected as the control group. RESULTS There were no significant differences between the three groups in intraoperative blood loss, transfusion, and postoperative bleeding. In the AVK group, there were no differences between patients who received PCC and those who did not in intraoperative blood loss, red blood cells, fibrinogen, and platelet transfusion, or postoperative bleeding. PCC use had no effect on RBC transfusion in patients who had international normalized ratio or clotting time above versus below median values of the two parameters at baseline (2.3 and 103 s, respectively). No thrombotic events were detected in patients who received PCC. DISCUSSION These data suggest that systematic administration of PCC to revert AVK prior to LT should be reconsidered.
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Affiliation(s)
- Samira Martinez
- Anesthesia Department, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Isabel Garcia
- Anesthesia Department, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Angel Ruiz
- Donation and Transplantation Coordination Unit, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Dolors Tàssies
- Hemostasis Department, IDIBAPS, Hospital Clinic de Barcelona, Barcelona, Spain
| | | | - Jordi Colmenero
- Hepatology Department, Hospital Clinic Barcelona IDIBAPS, Barcelona, Spain
| | - Joan Beltran
- Anesthesia Department, Hospital Clinic de Barcelona, Barcelona, Spain
| | | | - Annabel Blasi
- Anesthesia Department, Hospital Clinic de Barcelona, IDIBAPS, Barcelona, Spain
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8
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Tanaka KA, Henderson RA, Strauss ER. Evolution of viscoelastic coagulation testing. Expert Rev Hematol 2020; 13:697-707. [DOI: 10.1080/17474086.2020.1758929] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
| | | | - Erik R. Strauss
- School of Medicine, University of Maryland, Baltimore, MD, USA
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9
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Chow JH, Fedeles B, Richards JE, Tanaka KA, Morrison JJ, Rock P, Scalea TM, Mazzeffi MA. Thromboelastography Reaction-Time Thresholds for Optimal Prediction of Coagulation Factor Deficiency in Trauma. J Am Coll Surg 2020; 230:798-808. [PMID: 32142926 DOI: 10.1016/j.jamcollsurg.2020.01.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 01/10/2020] [Accepted: 01/27/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Coagulopathy is common in multitrauma patients and repletion of procoagulant factor deficiency with fresh frozen plasma (FFP) improves hemostasis. Optimal kaolin-thromboelastography thresholds for FFP transfusion in trauma patients have not been well established. STUDY DESIGN Adult trauma patients with an Injury Severity Score ≥15 were included in this retrospective observational cohort study. The primary end point was area under the receiver operating characteristic curve (AUROC) for reaction time (R-time) to detect procoagulant factor deficiency, as reflected by an elevated international normalized ratio (INR) or aPTT. Test characteristics for the optimal R-time threshold calculated in our study were compared against thresholds recommended by the American College of Surgeons for FFP transfusion. RESULTS Six hundred and ninety-four pairs of thromboelastography and conventional coagulation tests were performed in 550 patients, with 144 patients having additional pairs of tests after the first hour. The R-time was able to detect procoagulant factor deficiency (INR ≥1.5 AUROC 0.80; 95% CI, 0.75 to 0.85; aPTT ≥40 seconds AUROC 0.85; 95% 0.80 to 0.89) and severe procoagulant factor deficiency (INR ≥2.0 AUROC 0.82; 95% CI, 0.73 to 0.99; aPTT ≥60 seconds AUROC 0.89; 95% CI, 0.81 to 0.98) with good accuracy. Optimal thresholds to maximize sensitivity and specificity were 3.9 minutes for detection of INR ≥1.5, 4.1 minutes for detection of aPTT ≥40 seconds, 4.3 minutes for detection of INR ≥2.0, and 4.3 for detection of aPTT ≥60 seconds. Currently recommended R-time thresholds for FFP transfusion had 100% specificity for detecting procoagulant factor deficiency, but low sensitivity (3% to 7%). CONCLUSIONS R-time can detect procoagulant factor deficiency in multitrauma patients with good accuracy, but currently recommended R-time thresholds are highly specific and not sensitive. Use of low-sensitivity thresholds might result in undertreatment of many patients with procoagulant factor deficiency.
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Affiliation(s)
- Jonathan H Chow
- Divisions of Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD; Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD.
| | - Benjamin Fedeles
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Justin E Richards
- Divisions of Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD; Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Kenichi A Tanaka
- Cardiothoracic Anesthesiology, University of Maryland School of Medicine, Baltimore, MD; Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Jonathan J Morrison
- Department of Surgery, R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - Peter Rock
- Divisions of Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD; Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Thomas M Scalea
- Department of Surgery, R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - Michael A Mazzeffi
- Divisions of Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD; Cardiothoracic Anesthesiology, University of Maryland School of Medicine, Baltimore, MD; Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
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10
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Blaine KP, Steurer MP. Viscoelastic Monitoring to Guide the Correction of Perioperative Coagulopathy and Massive Transfusion in Patients with Life-Threatening Hemorrhage. Anesthesiol Clin 2018; 37:51-66. [PMID: 30711233 DOI: 10.1016/j.anclin.2018.09.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The resuscitation of patients with traumatic hemorrhage remains a challenging clinical scenario. The appropriate and aggressive support of the patient's coagulation is of critical importance. Conventional coagulation assays present several shortcomings in this setting. The integration of viscoelastic monitoring in clinical practice has the potential to result in significant improvements. In order to be successful, the provider must understand basics of the methodology, read outs, and the limitations of the technique.
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Affiliation(s)
- Kevin P Blaine
- Department of Anesthesiology, Keck School of Medicine of the University of Southern California, 1450 San Pablo Street, HC4 Suite 3600, Los Angeles, CA 90033, USA; Trauma Anesthesiology Society, Inc, 1001 Fannin St Ste 3700, Houston, TX 77002-6785, USA.
| | - Marc P Steurer
- Trauma Anesthesiology Society, Inc, 1001 Fannin St Ste 3700, Houston, TX 77002-6785, USA; Department of Anesthesia and Perioperative Care, Zuckerberg San Francisco General Hospital and Trauma Center, UCSF School of Medicine, 1001 Potrero Avenue, Building 5, Room 3C-38, San Francisco, CA 94110, USA
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11
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Hawkins RB, Raymond SL, Hartjes T, Efron PA, Larson SD, Andreoni KA, Thomas EM. Review: The Perioperative Use of Thromboelastography for Liver Transplant Patients. Transplant Proc 2018; 50:3552-3558. [PMID: 30577236 DOI: 10.1016/j.transproceed.2018.07.032] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 07/09/2018] [Accepted: 07/18/2018] [Indexed: 12/12/2022]
Abstract
Thromboelastography (TEG) is a viscoelastic test that allows rapid evaluation of clot formation and fibrinolysis from a sample of whole blood. TEG is increasingly utilized to guide blood product resuscitation in surgical patients and transfusions for liver transplant patients. Patients with severe liver failure have significant derangement of their clotting function due to impaired production of procoagulant and anticoagulant factors. Traditional coagulation studies are limited by the short time needed for the result and provide little information about the dynamics and strength of clot formation. In addition, traditional coagulation studies do not correlate well with bleeding episodes and may lead to over-transfusion of various blood products. Evidence is less robust regarding the use of TEG for transfusion management decisions in severe liver failure patients awaiting, undergoing, or immediately after liver transplant surgery. However, the available evidence suggests that systematic implementation of TEG rather than traditional coagulation studies results in the administration of fewer blood products without increased mortality or complications. The purpose of this study is to review the literature regarding the use of TEG in liver failure patients prior to liver transplant, intraoperatively, and postoperatively. Additional high-quality randomized controlled studies should be performed to evaluate the use of TEG to guide transfusion decisions, particularly in the postoperative period following liver transplantation.
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Affiliation(s)
- R B Hawkins
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - S L Raymond
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - T Hartjes
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA; University of Florida College of Nursing, Gainesville, FL, USA
| | - P A Efron
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - S D Larson
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - K A Andreoni
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - E M Thomas
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA.
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12
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Nilsson CU, Strandberg K, Reinstrup P. Warfarin monitoring with viscoelastic haemostatic assays, thrombin generation, coagulation factors and correlations to Owren and Quick prothrombin time. Scandinavian Journal of Clinical and Laboratory Investigation 2018; 78:358-364. [PMID: 29792060 DOI: 10.1080/00365513.2018.1474492] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The anticoagulant warfarin is commonly monitored with prothrombin time (PT). Viscoelastic haemostatic assays (VHA) are primarily used in situations of acute bleeding to guide haemostatic therapy. Much research has focused on VHA monitoring of new oral anticoagulants. However, many patients are still anticoagulated with warfarin and effect of warfarin anticoagulation on VHA is uncertain. The aim of this study was to assess warfarin anticoagulation on three different VHA and compare these findings with prothrombin time (PT), coagulation factor analyses and a thrombin generation assay (TGA). Citrated whole blood was drawn from 80 patients admitted for routine PT-INR Owren. VHA analysis with ROTEM (EXTEM, INTEM and FIBTEM), ReoRox (Fibscreen 1 and 2) and Sonoclot (gbACT+) was performed. Blood was also drawn for plasma analysis with PT (PT-INR Owren and PT Quick), TGA and analysis of factors I, II, VII, IX and X. Extrinsically activated VHA, including ROTEM EXTEM and FIBTEM Clotting Time (CT) and ReoRox Fibscreen1 and 2 clot onset time 1 correlated moderately with PT-INR Owren , with R 0.66-0.71. These four variables were likely to be prolonged above reference interval in patients with prolonged PT-INR Owren >1.2. Two patients with normal ROTEM CTs had Owren PT-INRs >1.5. Warfarin affects extrinsically activated VHA variables of initial clotting. The role of VHA for clinical decision-making in patients planned for invasive procedures, such as spinal/epidural anaesthesia needs further study. None of the recent guidelines on regional anaesthesia include VHA testing to define adequate haemostasis.
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Affiliation(s)
- Caroline U Nilsson
- a Department of Anesthesia and Intensive Care , Clinical Sciences Lund, Lund University, Sweden and Skåne University Hospital Lund , Lund , Sweden
| | - Karin Strandberg
- b Department of Laboratory Medicine , Lund University and Skåne University Hospital Malmö , Malmö , Sweden
| | - Peter Reinstrup
- a Department of Anesthesia and Intensive Care , Clinical Sciences Lund, Lund University, Sweden and Skåne University Hospital Lund , Lund , Sweden
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van Wessem KJP, Leenen LPH. Thromboelastography does not provide additional information to guide resuscitation in the severely injured. ANZ J Surg 2017; 88:697-701. [PMID: 29266754 DOI: 10.1111/ans.14357] [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] [Received: 08/21/2017] [Revised: 10/23/2017] [Accepted: 11/09/2017] [Indexed: 12/29/2022]
Abstract
BackgroundHaemostasis assessment is essential to determine the early need for massive transfusion in the treatment of polytrauma. Strategies to guide correction of coagulopathy vary widely. In order to evaluate thromboelastography (TEG) for this goal, a prospective study was performed comparing TEG to conventional coagulation assays (CCAs) in severely injured patients.MethodsConsecutive polytrauma patients admitted to the intensive care unit of a level‐1 trauma centre were prospectively included over a 30‐month period. All patients had CCA on arrival in emergency department. Patients who needed massive transfusion and underwent urgent surgery had additionally a Kaolin‐activated TEG.ResultsOne hundred and thirty‐five patients were included, 76% male, median age 45 years, 96% blunt injuries and median injury severity score was 29. One hundred and fourteen patients had CCA only and 21 patients had both CCA and TEG. Patients who had both CCA and TEG were acidotic, hypothermic and coagulopathic on arrival in emergency department. All 21 patients had normal TEG results even though prothrombin time was prolonged.ConclusionsTEGs were normal in all polytrauma patients even though patients were severely injured. They had prolonged prothrombin time, acidosis and hypothermia both on arrival and when TEG was measured. Caution should be exercised in interpretation of TEG results in treating polytrauma patients. In our system, with aggressive early haemostatic resuscitation, TEG does not provide additional information in guiding resuscitation.
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Affiliation(s)
- Karlijn J P van Wessem
- Department of Trauma Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Luke P H Leenen
- Department of Trauma Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
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Holt RG, Luo D, Gruver N, Khismatullin DB. Quasi-static acoustic tweezing thromboelastometry. J Thromb Haemost 2017; 15:1453-1462. [PMID: 28453901 PMCID: PMC5495613 DOI: 10.1111/jth.13724] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Indexed: 11/29/2022]
Abstract
Essentials Blood coagulation measurement during contact with an artificial surface leads to unreliable data. Acoustic tweezing thromboelastometry is a novel non-contact method for coagulation monitoring. This method detects differences in the blood coagulation state within 10 min. Coagulation data were obtained using a much smaller sample volume (4 μL) than currently used. SUMMARY Background Thromboelastography is widely used as a tool to assess the coagulation status of critical care patients. It allows observation of changes in material properties of whole blood, beginning with early stages of clot formation and ending with clot lysis. However, the contact activation of the coagulation cascade at surfaces of thromboelastographic systems leads to inherent variability and unreliability in predicting bleeding or thrombosis risks. Objectives To develop acoustic tweezing thromboelastometry as a non-contact method for perioperative assessment of blood coagulation. Methods Acoustic tweezing is used to levitate microliter drops of biopolymer and human blood samples. By quasi-statically changing the acoustic pressure we control the sample drop location and deformation. Sample size, deformation and location are determined by digital imaging at each pressure. Results Simple Newtonian liquid solutions maintain a constant, reversible location vs. deformation curve. In contrast, the location/deformation curves for gelatin, alginate, whole blood and blood plasma uniquely change as the samples solidify. Increasing elasticity causes the sample to deform less, leading to steeper stress/strain curves. By extracting a linear regime slope, we show that whole blood or blood plasma exhibits a unique slope profile as it begins to clot. By exposing blood samples to pro- or antithrombotic agents, the slope profile changes, allowing detection of hyper- or hypocoagulable states. Conclusions We demonstrate that quasi-static acoustic tweezing can yield information about clotting onset, maturation and strength. The advantages of small sample size, non-contact and rapid measurement make this technique desirable for real-time monitoring of blood coagulation.
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Affiliation(s)
- R. G. Holt
- Department of Mechanical Engineering, Boston University, Boston, MA 02215, USA
| | - D. Luo
- Department of Biomedical Engineering, Tulane University, New Orleans, LA 70118, USA
| | - N. Gruver
- Department of Mechanical Engineering, Boston University, Boston, MA 02215, USA
| | - D. B. Khismatullin
- Department of Biomedical Engineering, Tulane University, New Orleans, LA 70118, USA
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Shin KH, Kim IS, Lee HJ, Kim HH, Chang CL, Hong YM, Yoon KT, Cho M. Thromboelastographic Evaluation of Coagulation in Patients With Liver Disease. Ann Lab Med 2017; 37:204-212. [PMID: 28224766 PMCID: PMC5339092 DOI: 10.3343/alm.2017.37.3.204] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 09/14/2016] [Accepted: 01/23/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The aims of this study were to investigate the parameters of thromboelastography (TEG) for evaluating coagulopathy and to reveal an association with disease severity and/or transfusion requirement in patients with chronic liver disease (CLD) in a clinical laboratory setting. METHODS We enrolled two groups of adult patients with cirrhotic (N=123) and non-cirrhotic liver disease (N=52), as well as 84 healthy controls. Reaction time (R), kinetic time (K), α-angle (α), maximal amplitude (MA), and coagulation index (CI) were measured with kaolin-activated citrated blood with the TEG 5000 system (Haemonetics Corporation, USA). Platelet count, prothrombin time international normalized ratio (PT INR), albumin, bilirubin, and creatinine were simultaneously measured. The CLD severity was calculated by using the Child-Pugh (C-P) and Model for End-stage Liver Disease (MELD) scores. Transfusion history was also reviewed. RESULTS All TEG parameters, PT INR, and platelet count in the cirrhotic group showed significant differences from those in other groups. At least one or more abnormal TEG parameters were identified in 17.3% and 44.7% of patients in the non-cirrhotic and cirrhotic group, respectively. Patients with cirrhotic disease had hypocoagulability. A weak correlation between R and PT INR (r=0.173) was noted. The TEG parameters could not predict CLD severity using the C-P and MELD scores. Patients with normal TEG parameters did not receive transfusion. CONCLUSIONS Clinical application of TEG measurements in CLD can be informative for investigating coagulopathy or predicting the risk of bleeding. Further studies are warranted.
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Affiliation(s)
- Kyung Hwa Shin
- Department of Laboratory Medicine, Pusan National University School of Medicine and Biomedical Research Institute Research Institute, Pusan National University Hospital, Busan, Korea
| | - In Suk Kim
- Department of Laboratory Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.
| | - Hyun Ji Lee
- Department of Laboratory Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Hyung Hoi Kim
- Department of Laboratory Medicine, Pusan National University School of Medicine and Biomedical Research Institute Research Institute, Pusan National University Hospital, Busan, Korea
| | - Chulhun L Chang
- Department of Laboratory Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Young Mi Hong
- Department of Internal Medicine, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Ki Tae Yoon
- Department of Internal Medicine, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Mong Cho
- Department of Internal Medicine, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
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Silvetti S, Crivellari M, Castiglioni A, Landoni G, Zangrillo A, Alfieri O, Koster A, Faraoni D, Bolliger D, Tanaka KA. CASE 12—2016 Ascending Aorta Dissection in a Jehovah’s Witness Patient on Warfarin. J Cardiothorac Vasc Anesth 2016; 30:1709-1715. [DOI: 10.1053/j.jvca.2016.02.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Indexed: 01/01/2023]
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De Pietri L, Bianchini M, Garcia-Tsao G, Villa E. Reply. Hepatology 2016; 64:683-4. [PMID: 26547626 DOI: 10.1002/hep.28335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Affiliation(s)
- Lesley De Pietri
- Division of Anaesthesiology and Intensive Care Unit, Department of Surgery, AOU Policlinico di Modena, Modena, Italy
| | - Marcello Bianchini
- Gastroenterology Unit Department of Internal Medicine AOU Policlinico di Modena, Modena, Italy
| | - Guadalupe Garcia-Tsao
- Section of Digestive Diseases Department of Internal Medicine Yale University School of Medicine and VA CT Healthcare System, New Haven, CT
| | - Erica Villa
- Gastroenterology Unit Department of Internal Medicine AOU Policlinico di Modena, Modena, Italy
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Abuelkasem E, Mazzeffi MA, Lu SY, Planinsic RM, Sakai T, Tanaka KA. Ex vivo evaluation of 4 different viscoelastic assays for detecting moderate to severe coagulopathy during liver transplantation. Liver Transpl 2016; 22:468-75. [PMID: 26610182 DOI: 10.1002/lt.24379] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 11/16/2015] [Accepted: 11/23/2015] [Indexed: 02/07/2023]
Abstract
Prolonged prothrombin time (PT) and its ratio are routinely used for the assessment of candidates for liver transplantation (LT), but intraoperative coagulation management of transfusion is hindered by its long turnaround time. Abnormal reaction time (R time) on thromboelastography (TEG) or clotting time (CT) of rotational thromboelastometry (ROTEM) are presumably an alternative, but there is a paucity of clinical data on abnormal R time/CT values compared to PT during LT. After receiving institutional review board approval and informed consent, we obtained blood samples from 36 LT patients for international normalized ratio (INR), factor (F) X level, and viscoelastic tests (EXTEM/INTEM and kaolin/rapid TEG) at baseline and 30 minutes after graft reperfusion. Receiver operating characteristic (ROC) curves were calculated for INR > 1.5 and viscoelastic R time/CT thresholds to assess the ability to diagnose FX deficiency at the moderate (<50%) or severe (<35%) level. The FX deficiency data were calculated using cutoff values of INR (>1.5) and abnormal R time/CT for TEG and ROTEM. Tissue factor (TF)-activated INR and EXTEM-CT performed well in diagnosing FX below 50%, but rapid TEG with combined TF and kaolin activators failed. Improved performance of INTEM-CT in diagnosing FX below 35% underlies multifactorial deficiency involving both intrinsic and common pathways. In conclusion, the differences among different viscoelastic tests and clinical situations should be carefully considered when they are used to guide transfusion during LT.
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Affiliation(s)
| | | | - Shu Yang Lu
- Department of Anesthesiology, Massachusetts General Hospital, Boston, MA
| | | | - Tetsuro Sakai
- Department of Anesthesiology, University of Pittsburgh, Pittsburgh, PA
| | - Kenichi A Tanaka
- Department of Anesthesiology, University of Maryland, Baltimore, MD
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Abstract
PURPOSE OF REVIEW Recent advances in the understanding of transfusion practices during hemorrhagic shock in trauma have led to early administration of thawed plasma in increased ratios to packed red blood cells and have improved survival in the most severely injured patients. As an appreciation for the sequelae of massive transfusion continues to mature, it is becoming apparent that a more targeted approach to coagulation deficiencies may offer an advantage. RECENT FINDINGS Factor concentrate therapy offers the advantage of smaller volumes of resuscitative fluids directed at specific phases of coagulation identified by alternative laboratory assays (e.g., viscoelastic testing). Case reports, animal studies, and retrospective reviews offer encouraging data on the ability of factor concentrates to reverse coagulopathy and reduce blood product usage. SUMMARY The use of factor concentrates to target specific phases of coagulation may offer benefit over blood product ratio-driven transfusion. The outcome benefit of factor concentrates, however, has not yet been demonstrated in well powered prospective trials.
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Reliability of thromboelastometry for detecting the safe coagulation threshold in patients taking acenocoumarol after elective heart valve replacement. Thromb Res 2015; 136:669-72. [DOI: 10.1016/j.thromres.2015.07.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2015] [Revised: 07/02/2015] [Accepted: 07/07/2015] [Indexed: 11/20/2022]
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Ortmann E, Besser MW, Sharples LD, Gerrard C, Berman M, Jenkins DP, Klein AA. An Exploratory Cohort Study Comparing Prothrombin Complex Concentrate and Fresh Frozen Plasma for the Treatment of Coagulopathy After Complex Cardiac Surgery. Anesth Analg 2015; 121:26-33. [DOI: 10.1213/ane.0000000000000689] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Detection of elevated INR by thromboelastometry and thromboelastography in warfarin treated patients and healthy controls. Thromb Res 2015; 135:1007-11. [DOI: 10.1016/j.thromres.2015.02.022] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 01/29/2015] [Accepted: 02/18/2015] [Indexed: 11/24/2022]
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Oh CS, Choi JW, Jung E, Kang WS, Kim SH. Warfarin therapy and perioperative transfusion requirement with bleeding amount in patients undergoing cardiac surgery with cardiopulmonary bypass: a retrospective study. Transfus Med 2015; 25:33-7. [PMID: 25683623 DOI: 10.1111/tme.12175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Revised: 01/13/2015] [Accepted: 01/17/2015] [Indexed: 12/01/2022]
Abstract
OBJECTIVES The study was designed to evaluate the effect of warfarin on perioperative transfusion, bleeding and coagulation status in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). BACKGROUND There were controversy about the effect of warfarin on perioperative transfusion and bleeding. METHODS/MATERIALS Medical records from 107 consecutive patients with atrial fibrillation (AF) on warfarin therapy undergoing cardiac surgery with cardiopulmonary bypass (CPB) from 2008 to 2013 at a single university teaching hospital were retrospectively reviewed to compare the patients on to those not on warfarin therapy in terms of perioperative transfusion requirement, postoperative 24-h bleeding amount, and coagulation status assessment using prothrombin time (PT), international normalised ratio (INR) and rotational thromboelastometry (ROTEM®). RESULTS Although PT/INR was significantly prolonged both before and after surgery in patients on warfarin therapy, ROTEM® data, perioperative transfusion requirement and postoperative 24-h bleeding amount (785 ± 331 vs 676 ± 303 mL, P = 0·089, respectively) were not significantly different between the patients on and those not on warfarin therapy. CONCLUSION In patients on warfarin therapy undergoing cardiac surgery with CPB, warfarin therapy did not significantly increase perioperative transfusion requirement and bleeding.
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Affiliation(s)
- C-S Oh
- Department of Anaesthesiology and Pain Medicine, Konkuk University Medical Centre, Konkuk University School of Medicine, Seoul, Korea
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Da Luz LT, Nascimento B, Shankarakutty AK, Rizoli S, Adhikari NK. Effect of thromboelastography (TEG®) and rotational thromboelastometry (ROTEM®) on diagnosis of coagulopathy, transfusion guidance and mortality in trauma: descriptive systematic review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:518. [PMID: 25261079 PMCID: PMC4206701 DOI: 10.1186/s13054-014-0518-9] [Citation(s) in RCA: 201] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Accepted: 08/29/2014] [Indexed: 11/26/2022]
Abstract
Introduction The understanding of coagulopathies in trauma has increased interest in thromboelastography (TEG®) and thromboelastometry (ROTEM®), which promptly evaluate the entire clotting process and may guide blood product therapy. Our objective was to review the evidence for their role in diagnosing early coagulopathies, guiding blood transfusion, and reducing mortality in injured patients. Methods We considered observational studies and randomized controlled trials (MEDLINE, EMBASE, and Cochrane databases) to February 2014 that examined TEG®/ROTEM® in adult trauma patients. We extracted data on demographics, diagnosis of early coagulopathies, blood transfusion, and mortality. We assessed methodologic quality by using the Newcastle-Ottawa scale (NOS) for observational studies and QUADAS-2 tool for diagnostic accuracy studies. Results Fifty-five studies (12,489 patients) met inclusion criteria, including 38 prospective cohort studies, 15 retrospective cohort studies, two before-after studies, and no randomized trials. Methodologic quality was moderate (mean NOS score, 6.07; standard deviation, 0.49). With QUADAS-2, only three of 47 studies (6.4%) had a low risk of bias in all domains (patient selection, index test, reference standard and flow and timing); 37 of 47 studies (78.8%) had low concerns regarding applicability. Studies investigated TEG®/ROTEM® for diagnosis of early coagulopathies (n = 40) or for associations with blood-product transfusion (n = 25) or mortality (n = 24). Most (n = 52) were single-center studies. Techniques examined included rapid TEG® (n =12), ROTEM® (n = 18), TEG® (n = 23), or both TEG® and rapid TEG® (n = 2). Many TEG®/ROTEM® measurements were associated with early coagulopathies, including some (hypercoagulability, hyperfibrinolysis, platelet dysfunction) not assessed by routine screening coagulation tests. Standard measures of diagnostic accuracy were inconsistently reported. Many abnormalities predicted the need for massive transfusion and death, but predictive performance was not consistently superior to routine tests. One observational study suggested that a ROTEM®-based transfusion algorithm reduced blood-product transfusion, but TEG®/ROTEM®-based resuscitation was not associated with lower mortality in most studies. Conclusions Limited evidence from observational data suggest that TEG®/ROTEM® tests diagnose early trauma coagulopathy and may predict blood-product transfusion and mortality in trauma. Effects on blood-product transfusion, mortality, and other patient-important outcomes remain unproven in randomized trials. Electronic supplementary material The online version of this article (doi:10.1186/s13054-014-0518-9) contains supplementary material, which is available to authorized users.
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In vitro combinations of red blood cell, plasma and platelet components evaluated by thromboelastography. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2014; 12:491-6. [PMID: 24960655 DOI: 10.2450/2014.0285-13] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Accepted: 10/25/2013] [Indexed: 12/27/2022]
Abstract
BACKGROUND Thromboelastography is increasingly used to evaluate coagulation in massively bleeding patients. The aim of this study was to investigate how different combinations of blood components affect in vitro whole blood clotting measured by thromboelastography. MATERIALS AND METHODS Packed red blood cells, plasma and platelets from fresh and old blood components were mixed in vitro, in proportions of 4:4:1, 5:5:2, 8:4:1 and 2:1:0, and analysed with thromboelastography. For the ratio 4:4:1 the experiment was done at both 37 °C and 32 °C. RESULTS Thromboelastography curves were within normal reference values for the blood component proportions of 4:4:1 and 5:5:2. For 8:4:1, the angle and maximal amplitude were reduced below normal values, indicating low levels of fibrinogen and/or platelets. For the 2:1:0 proportion, all parameters were affected resulting in severely impaired in vitro clot formation. The reaction-time, reflecting the coagulation factor-dependent, initial clot formation, was slightly increased at a low temperature. Prolonged storage of the components did not affect the curve. DISCUSSION With the introduction of guidelines on the management of massive bleeding it is important to have tools for the assessment of the new protocols. In vitro evaluation of mixtures of packed red blood cells, plasma and platelets by thromboelastography may be relevant in the prediction of in vivo clot formation and haemostasis.
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Dunham CM, Rabel C, Hileman BM, Schiraldi J, Chance EA, Shima MT, Molinar AA, Hoffman DA. TEG® and RapidTEG® are unreliable for detecting warfarin-coagulopathy: a prospective cohort study. Thromb J 2014; 12:4. [PMID: 24495462 PMCID: PMC3928617 DOI: 10.1186/1477-9560-12-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Accepted: 01/28/2014] [Indexed: 11/25/2022] Open
Abstract
Background Thromboelastography® (TEG) utilizes kaolin, an intrinsic pathway activator, to assess clotting function. Recent published studies suggest that TEG results are commonly normal in patients receiving warfarin, despite an increased International Normalized Ratio (INR). Because RapidTEG™ includes tissue factor, an extrinsic pathway activator, as well as kaolin, we hypothesized that RapidTEG would be more sensitive in detecting a warfarin-effect. Methods Included in this prospective study were 22 consecutive patients undergoing elective cardioversion and receiving warfarin. Prior to cardioversion, blood was collected to assess INR, Prothrombin Time, TEG, and RapidTEG. Results INR Results: 2.8 ± 0.5 (1.6 to 4.2). Prothrombin Time Results: 19.1 ± 2.2 (13.9. to 24.3). TEG Results (Reference Range): R-Time: 8.3 ± 2.7 (2–8); K-Time: 2.1 ± 1.4 (1–3); Angle: 62.5 ± 10.3 (55–78); MA: 63.2 ± 10.3 (51–69); G: 9.4 ± 3.5 (4.6-10.9); R-Time within normal range: 10 (45.5%) with INR 2.9 ± 0.3; Correlation coefficients for INR and each of the 5 TEG variables were insignificant (P > 0.05). RapidTEG Results (Reference Range): ACT: 132 ± 58 (86–118); K-Time: 1.2 ± 0.5 (1–2); Angle: 75.4 ± 5.2 (64–80); MA: 63.4 ± 5.1 (52–71); G: 8.9 ± 2.0 (5.0-11.6); ACT within normal range: 9 (40.9%) with INR 2.7 ± 0.5; Correlation coefficients for INR and each of the 5 RapidTEG variables were insignificant (P > 0.05). Conclusions TEG, using kaolin activation, and RapidTEG, with kaolin and tissue factor activation, were normal in a substantial percent of warfarin patients, despite an increased INR. The false-negative rate for detecting warfarin coagulopathy with either test is unacceptable. The lack of correlation between INR and all TEG and RapidTEG components further indicates that these methodologies are insensitive to warfarin effects. Findings suggest that intrinsic pathway activation may mitigate detection of an extrinsic pathway coagulopathy.
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Affiliation(s)
- C Michael Dunham
- Trauma/Critical Services, St, Elizabeth Health Center, 1044 Belmont Avenue, Youngstown, OH 44501, USA.
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Tanaka K, Esper S, Bolliger D. Perioperative factor concentrate therapy. Br J Anaesth 2013; 111 Suppl 1:i35-49. [DOI: 10.1093/bja/aet380] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
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Bolliger D, Tanaka KA. Roles of thrombelastography and thromboelastometry for patient blood management in cardiac surgery. Transfus Med Rev 2013; 27:213-20. [PMID: 24075802 DOI: 10.1016/j.tmrv.2013.08.004] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Revised: 08/26/2013] [Accepted: 08/26/2013] [Indexed: 12/28/2022]
Abstract
The value of thrombelastography (TEG) and thromboelastometry (ROTEM) to improve perioperative hemostasis is under debate. We aimed to assess the effects of TEG- or ROTEM-guided therapy in patients undergoing cardiac surgery on the use of allogeneic blood products. We analyzed 12 trials including 6835 patients, 749 of them included in 7 randomized controlled trials (RCTs). We collected data on the amount of transfused allogeneic blood products and on the proportion of patients who received allogeneic blood products or coagulation factor concentrates. Including all trials, the odds ratios (ORs) for transfusion of red blood cell (RBC) concentrates, fresh-frozen plasma (FFP), and platelets were 0.62 (95% confidence interval [CI], 0.56-0.69; P<.001), 0.28 (95% CI, 0.24-0.33; P<.001), and 0.55 (95% CI, 0.49-0.62; P<.001), respectively. However, more than 50% of the patients in this analysis were derived from one retrospective study. Including RCTs only, the ORs for transfusion of RBC, FFP, and platelets were 0.54 (95% CI, 0.38-0.77; P<.001), 0.36 (95% CI, 0.25-0.53; P<.001), and 0.57 (95% CI, 0.39-0.81; P=.002), respectively. The use of coagulation factor concentrates was reported in 6 studies, 2 of them were RCTs. The ORs for the infusion of fibrinogen and prothrombin complex concentrate were 1.56 (95% CI, 1.29-1.87; P<.001) and 1.74 (95% CI, 1.40-2.18; P<.001), respectively. However, frequencies and amounts were similar in the intervention and control group in the 2 RCTs. It is presumed that TEG- or ROTEM-guided hemostatic management reduces the proportion of patients undergoing cardiac surgery transfused with RBC, FFP, and platelets. This presumption is strongly supported by similar ORs found in the analysis including RCTs only. Patient blood management based on the transfusion triggers by TEG or ROTEM appears to be more restrictive than the one based on conventional laboratory testing. However, evidence for improved clinical outcome is limited at this time.
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Affiliation(s)
- Daniel Bolliger
- Department of Anesthesia and Intensive Care Medicine, University Hospital, Basel, Switzerland.
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Mallett SV, Chowdary P, Burroughs AK. Clinical utility of viscoelastic tests of coagulation in patients with liver disease. Liver Int 2013; 33:961-74. [PMID: 23638693 DOI: 10.1111/liv.12158] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Accepted: 02/28/2013] [Indexed: 12/18/2022]
Abstract
The prothrombin time (PT) and international normalised ratio (INR) are used in scoring systems (Child-Pugh, MELD, UKELD) in chronic liver disease and as a prognostic tool and for dynamic monitoring of hepatic function in acute liver disease. These tests are known to be poor predictors of bleeding risk in liver disease; however, they continue to influence clinical management decisions. Recent work on coagulation in liver disease, in particular thrombin generation studies, has led to a paradigm shift in our understanding and it is now recognised that haemostasis is relatively well preserved. Whole blood global viscoelastic tests (TEG(®) /ROTEM(®) ) produce a composite dynamic picture of the entire coagulation process and have the potential to provide more clinically relevant information in patients with liver disease. We performed a systematic review of all relevant studies that have used viscoelastic tests (VET) of coagulation in patients with liver disease. Although many studies are observational and small in size, it is clear that VET provide additional information that is in keeping with the new concepts of how coagulation is altered in these patients. This review provides the basis for large scale, prospective outcome studies to establish the clinical value of these tests.
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Affiliation(s)
- Susan V Mallett
- Department of Anaesthesia, Royal Free London NHS Foundation Trust, London, UK
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Tanaka KA, Bader SO, Sturgil EL. Diagnosis of Perioperative Coagulopathy—Plasma versus Whole Blood Testing. J Cardiothorac Vasc Anesth 2013; 27:S9-15. [DOI: 10.1053/j.jvca.2013.05.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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