1
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Yoshii R, Takahashi Y, Tanaka KA, Kawajiri H, Sawa T, Amaya F, Ogawa S. Point-of-care testing for tranexamic acid efficacy: a proof-of-concept study in cardiac surgical patients. Br J Anaesth 2024; 132:1211-1218. [PMID: 38677950 DOI: 10.1016/j.bja.2024.03.023] [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: 12/19/2023] [Revised: 03/03/2024] [Accepted: 03/08/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND Low-dose tranexamic acid (TXA) has been recently recommended for cardiopulmonary bypass (CPB) to reduce associated complications. Although point-of-care laboratory tests for TXA concentrations are unavailable, a novel TPA-test on the ClotPro® system can measure TXA-induced inhibition of fibrinolysis. We evaluated the performance of the TPA-test in vitro and in patients undergoing surgery requiring CPB. METHODS Blood samples were obtained from six volunteers for in vitro evaluation of tissue plasminogen activator (tPA)-triggered fibrinolysis and the effects of TXA. This was followed by an observational study in 20 cardiac surgery patients to assess clinical effects of TXA on the TPA-test. RESULTS Hyperfibrinolysis induced by tPA was inhibited by TXA ≥2 mg L-1 in a concentration-dependent manner, and was completely inhibited at TXA ≥10 mg L-1. In patients undergoing CPB, antifibrinolytic effect was detectable on TPA-test parameters after a 0.1 g bolus of TXA at the end of CPB, and complete inhibition of fibrinolysis was obtained with TXA ≥0.5 g. The antifibrinolytic effects of 1 g TXA on TPA-test parameters were gradually attenuated over 18 h after surgery. However, the fibrinolytic inhibition continued in four patients with estimated glomerular filtration rate (eGFR) ≤30 ml min-1 1.73 m-2. The eGFR had strong correlations with TPA-test parameters at 18 h after surgery (r=0.86-0.92; P<0.0001). CONCLUSIONS The TPA-test is sensitive to low concentrations of TXA and serves as a practical monitoring tool for postoperative fibrinolytic activity in cardiac surgery patients. This test might be particularly useful in patients with severe renal impairment.
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Affiliation(s)
- Ryogo Yoshii
- Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yuya Takahashi
- Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kenichi A Tanaka
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Hidetake Kawajiri
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Teiji Sawa
- Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Fumimasa Amaya
- Department of Pain Management and Palliative Care Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Satoru Ogawa
- Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan; Department of Pain Management and Palliative Care Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan.
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2
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Larsson M, Zindovic I, Sjögren J, Svensson PJ, Strandberg K, Nozohoor S. A prospective, controlled study on the utility of rotational thromboelastometry in surgery for acute type A aortic dissection. Sci Rep 2022; 12:18950. [PMID: 36347972 PMCID: PMC9643344 DOI: 10.1038/s41598-022-23701-z] [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: 05/11/2022] [Accepted: 11/03/2022] [Indexed: 11/11/2022] Open
Abstract
To evaluate the hemostatic system with ROTEM in patients undergoing surgery for acute type aortic dissection (ATAAD) using elective aortic procedures as controls. This was a prospective, controlled, observational study. The study was performed at a tertiary referral center and university hospital. Twenty-three patients with ATAAD were compared to 20 control patients undergoing elective surgery of the ascending aorta or the aortic root. ROTEM (INTEM, EXTEM, HEPTEM and FIBTEM) was tested at 6 points in time before, during and after surgery for ATAAD or elective aortic surgery. The ATAAD group had an activated coagulation coming into the surgical theatre. The two groups showed activation of both major coagulation pathways during surgery, but the ATAAD group consistently had larger deficiencies. Reversal of the coagulopathy was successful, although none of the groups reached elective baseline until postoperative day 1. ROTEM did not detect low levels of clotting factors at heparin reversal nor low levels of platelets. This study demonstrated that ATAAD is associated with a coagulopathic state. Surgery causes additional damage to the hemostatic system in ATAAD patients as well as in patients undergoing elective surgery of the ascending aorta or the aortic root. ROTEM does not adequately catch the full coagulopathy in ATAAD. A transfusion protocol in ATAAD should be specifically created to target this complex coagulopathic state and ROTEM does not negate the need for routine laboratory tests.
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Affiliation(s)
- Mårten Larsson
- grid.411843.b0000 0004 0623 9987Department of Clinical Sciences, Department of Cardiothoracic Surgery, Skåne University Hospital, Lund University, 221 85 Lund, Sweden
| | - Igor Zindovic
- grid.411843.b0000 0004 0623 9987Department of Clinical Sciences, Department of Cardiothoracic Surgery, Skåne University Hospital, Lund University, 221 85 Lund, Sweden
| | - Johan Sjögren
- grid.411843.b0000 0004 0623 9987Department of Clinical Sciences, Department of Cardiothoracic Surgery, Skåne University Hospital, Lund University, 221 85 Lund, Sweden
| | - Peter J. Svensson
- grid.411843.b0000 0004 0623 9987Department of Coagulation Disorders, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Karin Strandberg
- University and Regional Laboratories, Region Skåne, Malmö, Sweden
| | - Shahab Nozohoor
- grid.411843.b0000 0004 0623 9987Department of Clinical Sciences, Department of Cardiothoracic Surgery, Skåne University Hospital, Lund University, 221 85 Lund, Sweden
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3
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Yoshii R, Sawa T, Kawajiri H, Amaya F, Tanaka KA, Ogawa S. A comparison of the ClotPro system with rotational thromboelastometry in cardiac surgery: a prospective observational study. Sci Rep 2022; 12:17269. [PMID: 36241854 PMCID: PMC9568545 DOI: 10.1038/s41598-022-22119-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 10/10/2022] [Indexed: 01/06/2023] Open
Abstract
Viscoelastic coagulation tests have been increasingly used for hemostasis management in cardiac surgery. The ClotPro system is a novel viscoelastic device based on principles of rotational thromboelastometry. We aimed to compare ClotPro with ROTEM and plasma coagulation assays in cardiopulmonary bypass (CPB) patients. Blood samples were collected from 25 CPB patients at (1) baseline, (2) start of CPB, (3) end of CPB, and (4) end of surgery. The EX-test, IN-test, HI-test, FIB-test parameters on ClotPro were compared with corresponding ROTEM assay (EXTEM, INTEM, HEPTEM, and FIBTEM). Standard plasma coagulation assays and endogenous thrombin generation (TG) were simultaneously evaluated. Pearson correlation analyses showed moderate correlations between clotting times (CTs) (r = 0.63-0.67; p < 0.001, respectively), and strong correlations with maximal clot firmness (MCF) (r = 0.93-0.98; p < 0.001, respectively) between ClotPro and ROTEM. EX-test and IN-test MCF parameters were interchangeable with acceptable percentage errors (EX-test MCF: 7.3%, IN-test MCF: 8.3%), but FIB-test MCF (27.0%) and CT results were not (EX-test CT: 44.7%, IN-test CT: 31.4%). The correlations of PT/INR or peak TG with EX-test CTs were higher than with EXTEM CTs (PT/INR: r = 0.80 and 0.41, peak TG: 0.43 and 0.18, respectively). FIB-test MCF has strong correlation with plasma fibrinogen and factor XIII level (r = 0.84 and 0.66, respectively). ROC analyses showed that ClotPro was capable of emulating well-established ROTEM thresholds (area under curves: 0.83-1.00). ClotPro demonstrated strong correlations in MCF parameters of ROTEM in CPB patients. It may be reasonable to modify ROTEM-based transfusion algorithm pertaining to MCF parameters to establish cut-off values for ClotPro device.
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Affiliation(s)
- Ryogo Yoshii
- grid.272458.e0000 0001 0667 4960Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Teiji Sawa
- grid.272458.e0000 0001 0667 4960Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hidetake Kawajiri
- grid.272458.e0000 0001 0667 4960Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, Kyoto, Kyoto, Japan
| | - Fumimasa Amaya
- grid.272458.e0000 0001 0667 4960Department of Pain Management and Palliative Care Medicine, Kyoto Prefectural University of Medicine, Kawaramachi Hirokoji, Kamigyo, Kyoto, 602-8566 Japan
| | - Kenichi A. Tanaka
- grid.266902.90000 0001 2179 3618Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma, USA
| | - Satoru Ogawa
- grid.272458.e0000 0001 0667 4960Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan ,grid.272458.e0000 0001 0667 4960Department of Pain Management and Palliative Care Medicine, Kyoto Prefectural University of Medicine, Kawaramachi Hirokoji, Kamigyo, Kyoto, 602-8566 Japan
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4
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Choi S, Mazzeffi MA, Henderson R, Mondal S, Morita Y, Deshpande S, Tanaka KA. The
FIBTEM
paradox: Do coronary artery bypass grafting patients with high baseline
FIBTEM
clot firmness need more allogeneic blood transfusion? Transfusion 2022; 62:2020-2028. [DOI: 10.1111/trf.17065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 06/10/2022] [Accepted: 07/30/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Seung Choi
- Department of Anesthesiology University of Maryland School of Medicine Baltimore Maryland USA
| | - Michael A. Mazzeffi
- Department of Anesthesiology and Critical Care Medicine George Washington University School of Medicine and Health Sciences Washington District of Columbia USA
| | - Reney Henderson
- Department of Anesthesiology University of Maryland School of Medicine Baltimore Maryland USA
| | - Samhati Mondal
- Department of Anesthesiology University of Maryland School of Medicine Baltimore Maryland USA
| | - Yoshihisa Morita
- Department of Anesthesiology Thomas Jefferson University Philadelphia Pennsylvania USA
| | - Seema Deshpande
- Department of Anesthesiology University of Maryland School of Medicine Baltimore Maryland USA
| | - Kenichi A. Tanaka
- Department of Anesthesiology University of Oklahoma Health Sciences Center Oklahoma City Oklahoma USA
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5
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Evaluation of the Effect of Storage Time on ROTEM S® Parameters in Healthy and Ill Dogs. Animals (Basel) 2022; 12:ani12151996. [PMID: 35953985 PMCID: PMC9367567 DOI: 10.3390/ani12151996] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 08/02/2022] [Accepted: 08/04/2022] [Indexed: 01/24/2023] Open
Abstract
Simple Summary Bleeding disorders can cause life-threatening illness in dogs. The need for fast recognition and diagnosis of these conditions is therefore of the utmost importance to have a positive impact on the patients’ survival. In the past decade, the use of viscoelastic testing for rapid assessment of global haemostasis has gained popularity. However, the most reliable time for testing after blood collection has not been determined. For this reason, blood samples were taken from healthy client-/staff-owned dogs and repeated measurements were performed at three different time points (10 min, 30 min, and 70 min after blood collection). Additionally, a group of currently ill patients was included and Ex-TEM S measurements were performed at the same three timepoints. We found that there was a significant change of results over time, suggesting the need for time-specific reference intervals. Which of these time points reflects the “true” coagulation status of our patients currently remains unknown. Abstract Viscoelastic testing as a bedside test to assess global haemostasis has gained popularity in the past decade, with rotational thromboelastometry (ROTEM) and thromboelastography (TEG) being the two commonly used devices. TEG studies suggest analysis 30 min after blood sampling. However, the reproducibility of results over time for ROTEM analysis using lyophilized samples in dogs has not been established. In this study, we investigated the influence of time on viscoelastic testing, using 33 healthy staff-/client-owned dogs for blood sampling and repeated measurements of ROTEM tracings at three different time points after blood collection. Additionally, a group of 21 hospitalized patients with suspected coagulation disorders were included to investigate whether stability over time was comparable between healthy and ill dogs. We demonstrated a significant difference of ROTEM tracings over time, with a tendency towards hypocoagulability over time. These changes do have a clinical relevance as they exceed reference intervals and could therefore lead to erroneous conclusions about a patient’s coagulation status. Therefore, time-specific reference intervals are proposed and presented in this publication.
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6
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Majiyagbe OO, Akinsete AM, Adeyemo TA, Salako AO, Ekure EN, Okoromah CAN. Coagulation abnormalities in children with uncorrected congenital heart defects seen at a teaching hospital in a developing country. PLoS One 2022; 17:e0263948. [PMID: 35901057 PMCID: PMC9333323 DOI: 10.1371/journal.pone.0263948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 04/30/2022] [Indexed: 11/23/2022] Open
Abstract
Background Coagulation abnormality is a significant complication and cause of mortality in children with uncorrected congenital heart defects (CHD). The aim of this study was to determine the prevalence of coagulation abnormalities and the associated factors in children with uncorrected CHD. Method A cross sectional study conducted to determine the prevalence of coagulation abnormalities among 70 children with uncorrected CHD aged six months to 17 years and 70 age and sex matched apparently healthy controls. Coagulation abnormalities was determined using complete blood count, prothrombin time, activated partial thromboplastin time and D-dimer assay. Results The prevalence of coagulation abnormalities among children with CHD and controls was 37.1% and 7.1% respectively. Children with Cyanotic CHD had a significantly higher prevalence of coagulation abnormalities compared to children with Acyanotic CHD (57.1% versus 17.1%). Haematocrit and oxygen saturation levels were significantly associated with coagulation abnormalities. Conclusion This study affirms that coagulation abnormalities are frequent in children with uncorrected CHD. Oxygen saturation and haematocrit are risk factors of coagulation abnormalities. Routine coagulation screen is recommended especially in children with cyanotic congenital heart defects to improve their quality of life and reduce morbidity and mortality while awaiting definitive surgeries.
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Affiliation(s)
- Omotola O. Majiyagbe
- Department of Paediatrics, Lagos University Teaching Hospital, Lagos, Nigeria
- Department of Paediatrics, Massey Street Children’s Hospital, Lagos Island, Lagos, Nigeria
- * E-mail:
| | - Adeseye M. Akinsete
- Department of Paediatrics, Lagos University Teaching Hospital, Lagos, Nigeria
- Department of Paediatrics, College of Medicine of the University of Lagos, Lagos, Nigeria
| | - Titilope A. Adeyemo
- Department of Pathology, College of Medicine of the University of Lagos, Lagos, Nigeria
| | - Abideen O. Salako
- Clinical Sciences Department, Nigerian Institute of Medical Research, Lagos, Nigeria
| | - Ekanem N. Ekure
- Department of Paediatrics, Lagos University Teaching Hospital, Lagos, Nigeria
- Department of Paediatrics, College of Medicine of the University of Lagos, Lagos, Nigeria
| | - Christy A. N. Okoromah
- Department of Paediatrics, Lagos University Teaching Hospital, Lagos, Nigeria
- Department of Paediatrics, College of Medicine of the University of Lagos, Lagos, Nigeria
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7
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Gauger MS, Kaufmann P, Kamber F, Quitt J, Berdajs D, Bolliger D, Mauermann E. Rotational Thromboelastometry Values After On-Pump Cardiac Surgery - A Retrospective Cohort Study. Semin Cardiothorac Vasc Anesth 2022; 26:209-220. [PMID: 35616448 DOI: 10.1177/10892532221088216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Viscoelastic coagulation monitoring is recommended for coagulation management after cardiac surgery, but optimum target values are poorly defined. AIMS To determine "to-be-expected" values in rotational thromboelastometry (ROTEM) after heparin reversal, to correlate ROTEM parameters with fibrinogen levels and platelet count, and to estimate the effect of hemoglobin levels on these measurements. METHODS We retrospectively analyzed 571 consecutive adult patients undergoing cardiac surgery with cardiopulmonary bypass from 12/2018 to 08/2020. ROTEM and conventional laboratory measurements were performed 5 to 10 minutes after protamine administration. RESULTS Clotting times in EXTEM, INTEM, and FIBTEM were significantly prolonged (72.6%, 96.1%, and 31.8% above reference ranges, respectively). Clot firmness parameters in EXTEM and INTEM were relevantly reduced (7.9% to 14.4% and 9.1% to 32.3% below the reference ranges, respectively). There was an excellent linear correlation of FIBTEM amplitude after 10 min (A10) and of maximal clot firmness (MCF) with fibrinogen concentrations (r = .81 and .80). Areas under receiver operating characteristic (AUROC) for identifying hypofibrinogenemia <1.5 g/L were between .80 and .87. No effect of hematocrit was observed. We also found a linear correlation of EXTEM, INTEM, and EXTEM-FIBTEM at both A10 and MCF with platelet counts (.32 to .68). The AUROCs for identifying thrombocytopenia (<100,000/μL) were .79 to .84, and were greater for A10 than for MCF measurements (P=.074, .001, and <.001, respectively). CONCLUSIONS "To-be-expected" ROTEM values after CPB are different from the published reference ranges. ROTEM parameters might allow for reliable estimation of fibrinogen level and platelet count without being influenced by hematocrit.
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Affiliation(s)
- Maria S Gauger
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Philip Kaufmann
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Firmin Kamber
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Jonas Quitt
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Denis Berdajs
- Clinic for Cardiac Surgery, University Hospital Basel, Basel, Switzerland
| | - Daniel Bolliger
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Eckhard Mauermann
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
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8
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Pavoni V, Gianesello L, Conti D, Ballo P, Dattolo P, Prisco D, Görlinger K. "In Less than No Time": Feasibility of Rotational Thromboelastometry to Detect Anticoagulant Drugs Activity and to Guide Reversal Therapy. J Clin Med 2022; 11:1407. [PMID: 35268498 PMCID: PMC8911211 DOI: 10.3390/jcm11051407] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 02/23/2022] [Accepted: 03/03/2022] [Indexed: 02/04/2023] Open
Abstract
Anticoagulant drugs (i.e., unfractionated heparin, low-molecular-weight heparins, vitamin K antagonists, and direct oral anticoagulants) are widely employed in preventing and treating venous thromboembolism (VTE), in preventing arterial thromboembolism in nonvalvular atrial fibrillation (NVAF), and in treating acute coronary diseases early. In certain situations, such as bleeding, urgent invasive procedures, and surgical settings, the evaluation of anticoagulant levels and the monitoring of reversal therapy appear essential. Standard coagulation tests (i.e., activated partial thromboplastin time (aPTT) and prothrombin time (PT)) can be normal, and the turnaround time can be long. While the role of viscoelastic hemostatic assays (VHAs), such as rotational thromboelastometry (ROTEM), has successfully increased over the years in the management of bleeding and thrombotic complications, its usefulness in detecting anticoagulants and their reversal still appears unclear.
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Affiliation(s)
- Vittorio Pavoni
- Anesthesia and Intensive Care Unit, Emergency Department and Critical Care Area, Santa Maria Annunziata Hospital, Bagno a Ripoli, 50012 Florence, Italy; (V.P.); (D.C.)
| | - Lara Gianesello
- Department of Anesthesia and Intensive Care, Orthopedic Anesthesia, University-Hospital Careggi, 50134 Florence, Italy
| | - Duccio Conti
- Anesthesia and Intensive Care Unit, Emergency Department and Critical Care Area, Santa Maria Annunziata Hospital, Bagno a Ripoli, 50012 Florence, Italy; (V.P.); (D.C.)
| | - Piercarlo Ballo
- Cardiology Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, 50012 Florence, Italy;
| | - Pietro Dattolo
- Nephrology Unit Florence 1, Santa Maria Annunziata Hospital, Bagno a Ripoli, 50012 Florence, Italy;
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy;
| | - Klaus Görlinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, 45147 Essen, Germany;
- Medical Department, Tem Innovations, 81829 Munich, Germany
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9
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Abstract
Background: Fibrinogen is a substrate for blood clots formation. In cardiac surgery, a number of different mechanisms lead to a decrease in fibrinogen levels and consequent impaired haemostasis. Patients undergoing cardiac surgery are therefore frequently exposed to blood loss and allogeneic blood transfusion, which are risk factors associated with morbidity and mortality. Thus, particular efforts in fibrinogen management should be made to decrease bleeding and the need for blood transfusion. Therefore, fibrinogen remains an active focus of investigations from basic science to clinical practice. This review aims to summarise the latest evidence regarding the role of fibrinogen and current practices in fibrinogen management in adult cardiac surgery. Methods: The PubMed database was systematically searched for literature investigating the role and disorders of fibrinogen in cardiac surgery and diagnostic and therapeutic procedures related to fibrinogen deficiency aimed at reducing blood loss and transfusion requirements. Clinical trials and reviews from the last 10 years were included. Results: In total, 146 articles were analysed. Conclusion: The early diagnosis and treatment of fibrinogen deficiency is crucial in maintaining haemostasis in bleeding patients. Further studies are needed to better understand the association between fibrinogen levels, bleeding, and fibrinogen supplementation and their impacts on patient outcomes in different clinical settings.
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10
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Yamamoto Y, Sato Y, Takahashi M, Yamamoto H, Echizen M, Uchida T. TEG6s Platelet Mapping assay for the estimation of plasma fibrinogen concentration during cardiovascular surgery: a single-center prospective observational study. J Anesth 2021; 36:79-88. [PMID: 34643817 PMCID: PMC8807459 DOI: 10.1007/s00540-021-03009-4] [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: 05/04/2021] [Accepted: 09/30/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE The Activator F (ActF) test on the TEG6s Platelet Mapping assay system is a means of quantifying blood viscoelasticity caused by fibrin network formation, triggered by reptilase and factor XIII, while platelets are inhibited. This unique methodology enables the measurement of blood viscoelasticity, even in highly heparinized blood. Here, we investigated whether fibrinogen concentration could be estimated using the ActF test in blood samples obtained during cardiopulmonary bypass (CPB) and after CPB in patients undergoing cardiovascular surgery. METHODS We performed a single-center prospective observational study at a university hospital. Forty patients aged ≥ 18 years who underwent elective cardiovascular surgery with CPB were enrolled. Blood samples were drawn after the induction of anesthesia, after declamping of the aorta during CPB, and after the reversal of heparinization using protamine (after CPB). Coagulation profiles were evaluated using the Platelet Mapping assay and standard laboratory tests. RESULTS There were strong correlations between the maximal amplitude of clot strength (MA) in the ActF test and fibrinogen concentration in samples drawn during CPB (R = 0.84, 95% confidence interval [CI] 0.72-0.91; P < 0.001) and after CPB (R = 0.83, 95% CI 0.70-0.91; P < 0.001). The areas under the receiver-operating characteristic curve for the ActF MA for fibrinogen concentrations < 150 mg/dL were 0.86 (95% CI 0.73-1.0) during CPB and 0.98 (95% CI 0.94-1.0) after CPB. CONCLUSION TEG6s Platelet Mapping ActF MA values strongly correlated with plasma fibrinogen concentration in highly heparinized blood during CPB and yielded highly accurate measurements of low fibrinogen concentrations.
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Affiliation(s)
- Yudai Yamamoto
- Department of Anesthesiology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan.
| | - Yunosuke Sato
- Department of Anesthesiology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Miri Takahashi
- Department of Anesthesiology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Hiroto Yamamoto
- Department of Anesthesiology, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Mayumi Echizen
- Department of Anesthesiology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Tokujiro Uchida
- Department of Anesthesiology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
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11
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Rotational thromboelastometry and conventional coagulation tests in patients undergoing major cardiac or aortic surgery: a retrospective single-center cohort study. J Thromb Thrombolysis 2021; 53:149-157. [PMID: 34232454 PMCID: PMC8791921 DOI: 10.1007/s11239-021-02519-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/24/2021] [Indexed: 11/05/2022]
Abstract
Algorithms for treatment of diffuse bleeding in cardiac surgery are based on intervention thresholds of coagulation tests, such as rotational thromboelastometry (ROTEM) or conventional laboratory tests. The relationship between these two approaches is unclear in patients with increased risk of coagulation abnormalities. We retrospectively analyzed the data of 248 patients undergoing major cardiac and/or aortic surgery. ROTEM and conventional laboratory tests were performed simultaneously after termination of cardiopulmonary bypass and protamine administration to investigate the extrinsic and intrinsic system, and to determine deficiencies in platelets and fibrinogen. We evaluated the association between ROTEM and conventional tests by linear regression analysis and compared the frequency of exceeding established thresholds for clinical intervention. Significant linear associations between ROTEM 10 min after the start of coagulation, and plasma fibrinogen concentration or platelet count (FIBTEM A10, R2 = 0.67, p < 0.001; EXTEM A10, R2 = 0.47, p < 0.001) were obtained. However, the 95% prediction intervals exceeded clinically useful ranges (92–233 mg/dL fibrinogen at the intervention threshold of FIBTEM A10 = 10 mm; 14 × 103–122 × 103/µL platelets at the intervention threshold of EXTEM A10 = 40 mm). The association between EXTEM and INR (R2 = 0.23), and INTEM and aPTT (R2 = 0.095) was poor. The frequency of exceeding intervention thresholds and, consequently, of triggering treatment, varied markedly between ROTEM and conventional tests (p < 0.001 for all comparisons). The predictability of conventional coagulation test results by ROTEM is limited, thus hampering the interchangeability of methods in clinical practice.
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12
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Mitrovic M, Sabljic N, Cvetkovic Z, Pantic N, Zivkovic Dakic A, Bukumiric Z, Libek V, Savic N, Milenkovic B, Virijevic M, Vucinic V, Milosevic I, Pravdic Z, Suvajdzic N, Fareed J, Antic D. Rotational thromboelastometry (ROTEM) profiling of COVID-19 patients. Platelets 2021; 32:690-696. [PMID: 33561381 DOI: 10.1080/09537104.2021.1881949] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
We evaluated coagulation abnormalities via traditional tests and rotational thromboelastometry (ROTEM) in a group of 94 patients with confirmed SARS-CoV-2 infection and different severity of pneumonia (34 moderate, 25 severe, 35 critical) with the hypothesis that ROTEM parameters differed by coronavirus disease 2019 (COVID-19) severity. Shorter than normal clotting time (CT) and higher than normal maximum clot firmness (MCF) in extrinsic rotational thromboelastometry (EXTEM) and fibrinogen rotational thromboelastometry (FIBTEM), shorter than normal EXTEM clot formation time (CFT), and higher than normal α-angle were classified as markers of hypercoagulable state. Increment in the number of patients with ≥2 hypercoagulable parameters, higher EXTEM (P = .0001), FIBTEM MCF (P = .0001) and maximum lysis decrement (P = .002) with increment in disease severity was observed (P = .0001). Significant positive correlations between IL6 and CT EXTEM (P = .003), MCF EXTEM (P = .033), MCF FIBTEM (P = .01), and negative with ML EXTEM (P = .006) were seen. Our findings based on analysis of different disease severity groups confirmed that a hypercoagulable ROTEM pattern characterized by clot formation acceleration, high clot strength, and reduced fibrinolysis was more frequent in advanced disease groups and patients with high IL6. These results supported the need for different thromboprophylaxis approaches for different severity groups.
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Affiliation(s)
- Mirjana Mitrovic
- Clinic of Hematology, Clinical Center of Serbia, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Nikica Sabljic
- Clinic of Hematology, Clinical Center of Serbia, Belgrade, Serbia
| | - Zorica Cvetkovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Clinical Hospital Center Zemun, Zemun, , Serbia
| | - Nikola Pantic
- Clinic of Hematology, Clinical Center of Serbia, Belgrade, Serbia
| | | | - Zoran Bukumiric
- Institute for Medical Statistics and Informatics, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Vesna Libek
- Clinical Hospital Center Zemun, Zemun, , Serbia
| | - Nebojsa Savic
- Clinic of Vascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Branislava Milenkovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Clinic of Pulmology, Clinical Center of Serbia, Belgrade, Serbia
| | - Marijana Virijevic
- Clinic of Hematology, Clinical Center of Serbia, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Violeta Vucinic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Clinic of Pulmology, Clinical Center of Serbia, Belgrade, Serbia
| | - Ivana Milosevic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Clinic for Infectious and Tropical Disease, Clinical Center of Serbia, Belgrade, Serbia
| | - Zlatko Pravdic
- Clinic of Hematology, Clinical Center of Serbia, Belgrade, Serbia
| | - Nada Suvajdzic
- Clinic of Hematology, Clinical Center of Serbia, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Jawed Fareed
- Departments of Pathology and Pharmacology, Loyola University Center, Maywood, Illinois, USA
| | - Darko Antic
- Clinic of Hematology, Clinical Center of Serbia, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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Viscoelastic Hemostatic Assays and Platelet Function Testing in Patients with Atherosclerotic Vascular Diseases. Diagnostics (Basel) 2021; 11:diagnostics11010143. [PMID: 33478051 PMCID: PMC7835760 DOI: 10.3390/diagnostics11010143] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/14/2021] [Accepted: 01/18/2021] [Indexed: 11/16/2022] Open
Abstract
Platelets play crucial role in acute vascular atherosclerotic diseases, including myocardial infarction and stroke. Additionally, platelet aggregation is a key target of antiplatelet agents, forming the keystone of pharmacotherapy of various atherosclerotic cardiovascular diseases. Thromboelastography and thromboelastometry, representing currently available viscoelastic hemostatic assays (VHA), are designed as whole blood, real-time analyzers of clot formation and clot resolution. These assays could, in theory, overcome some limitations of currently available platelet function testing assays. This article reviews the current experience with the use of VHA for platelet function testing and for monitoring of the response to antiplatelet therapy.
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Naik BI, Tanaka K, Sudhagoni RG, Viola F. Prediction of hypofibrinogenemia and thrombocytopenia at the point of care with the Quantra® QPlus® System. Thromb Res 2021; 197:88-93. [DOI: 10.1016/j.thromres.2020.11.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 10/03/2020] [Accepted: 11/01/2020] [Indexed: 01/21/2023]
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15
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Gibbs NM, Weightman WM. Diagnostic accuracy of viscoelastic point-of-care identification of hypofibrinogenaemia in cardiac surgical patients: A systematic review. Anaesth Intensive Care 2020; 48:339-353. [DOI: 10.1177/0310057x20948868] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Hypofibrinogenaemia during cardiac surgery may increase blood loss and bleeding complications. Viscoelastic point-of-care tests provide more rapid diagnosis than laboratory measurement, allowing earlier treatment. However, their diagnostic test accuracy for hypofibrinogenaemia has never been reviewed systematically. We aimed to systematically review their diagnostic test accuracy for the identification of hypofibrinogenaemia during cardiac surgery. Two reviewers assessed relevant articles from seven electronic databases, extracted data from eligible articles and assessed quality. The primary outcomes were sensitivity, specificity and positive and negative predictive values. A total of 576 articles were screened and 81 full texts were assessed, most of which were clinical agreement or outcome studies. Only 10 diagnostic test accuracy studies were identified and only nine were eligible (ROTEM delta 7; TEG5000 1; TEG6S 1, n = 1820 patients) (ROTEM, TEM International GmbH, Munich, Germany; TEG, Haemonetics, Braintree, MA, USA). None had a low risk of bias. Four ROTEM studies with a fibrinogen threshold less than 1.5–1.6 g/l and FIBTEM threshold A10 less than 7.5–8 mm had point estimates for sensitivity of 0.61–0.88; specificity 0.54–0.94; positive predictive value 0.42–0.70; and negative predictive value 0.74–0.98 (i.e. false positive rate 30%–58%; false negative rate 2%–26%). Two ROTEM studies with higher thresholds for both fibrinogen (<2 g/l) and FIBTEM A10 (<9.5 mm) had similar false positive rates (25%–46%), as did the two TEG studies (15%–48%). This review demonstrates that there have been few diagnostic test accuracy studies of viscoelastic point-of-care identification of hypofibrinogenaemia in cardiac surgical patients. The studies performed so far report false positive rates of up to 58%, but low false negative rates. Further diagnostic test accuracy studies of viscoelastic point-of-care identification of hypofibrinogenaemia are required to guide their better use during cardiac surgery.
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Affiliation(s)
- Neville M Gibbs
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Nedlands, Australia
- The University of Western Australia, Nedlands, Australia
| | - William M Weightman
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Nedlands, Australia
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16
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Bolliger D, Tanaka KA. More Is Not Always Better: Effects of Cell Salvage in Cardiac Surgery on Postoperative Fibrinogen Concentrations. J Cardiothorac Vasc Anesth 2020; 34:2383-2385. [DOI: 10.1053/j.jvca.2020.03.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 03/19/2020] [Indexed: 12/25/2022]
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17
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Son K, Yamada T, Tarao K, Kitamura Y, Okazaki J, Sato Y, Isono S. Effects of Cardiac Surgery and Salvaged Blood Transfusion on Coagulation Function Assessed by Thromboelastometry. J Cardiothorac Vasc Anesth 2020; 34:2375-2382. [DOI: 10.1053/j.jvca.2020.02.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 02/01/2020] [Accepted: 02/05/2020] [Indexed: 12/13/2022]
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18
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Buell TJ, Taylor DG, Chen CJ, Dunn LK, Mullin JP, Mazur MD, Yen CP, Shaffrey ME, Shaffrey CI, Smith JS, Naik BI. Rotational thromboelastometry-guided transfusion during lumbar pedicle subtraction osteotomy for adult spinal deformity: preliminary findings from a matched cohort study. Neurosurg Focus 2020; 46:E17. [PMID: 30933918 DOI: 10.3171/2019.1.focus18572] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 01/24/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVESignificant blood loss and coagulopathy are often encountered during adult spinal deformity (ASD) surgery, and the optimal intraoperative transfusion algorithm is debatable. Rotational thromboelastometry (ROTEM), a functional viscoelastometric method for real-time hemostasis testing, may allow early identification of coagulopathy and improve transfusion practices. The objective of this study was to investigate the effect of ROTEM-guided blood product management on perioperative blood loss and transfusion requirements in ASD patients undergoing correction with pedicle subtraction osteotomy (PSO).METHODSThe authors retrospectively reviewed patients with ASD who underwent single-level lumbar PSO at the University of Virginia Health System. All patients who received ROTEM-guided blood product transfusion between 2015 and 2017 were matched in a 1:1 ratio to a historical cohort treated using conventional laboratory testing (control group). Co-primary outcomes were intraoperative estimated blood loss (EBL) and total blood product transfusion volume. Secondary outcomes were perioperative transfusion requirements and postoperative subfascial drain output.RESULTSThe matched groups (ROTEM and control) comprised 17 patients each. Comparison of matched group baseline characteristics demonstrated differences in female sex and total intraoperative dose of intravenous tranexamic acid (TXA). Although EBL was comparable between ROTEM versus control (3200.00 ± 2106.24 ml vs 3874.12 ± 2224.22 ml, p = 0.36), there was a small to medium effect size (Cohen's d = 0.31) on EBL reduction with ROTEM. The ROTEM group had less total blood product transfusion volume (1624.18 ± 1774.79 ml vs 2810.88 ± 1847.46 ml, p = 0.02), and the effect size was medium to large (Cohen's d = 0.66). This difference was no longer significant after adjusting for TXA (β = -0.18, 95% confidence interval [CI] -1995.78 to 671.64, p = 0.32). More cryoprecipitate and less fresh frozen plasma (FFP) were transfused in the ROTEM group patients (cryoprecipitate units: 1.24 ± 1.20 vs 0.53 ± 1.01, p = 0.03; FFP volume: 119.76 ± 230.82 ml vs 673.06 ± 627.08 ml, p < 0.01), and this remained significant after adjusting for TXA (cryoprecipitate units: β = 0.39, 95% CI 0.05 to 1.73, p = 0.04; FFP volume: β = -0.41, 95% CI -772.55 to -76.30, p = 0.02). Drain output was lower in the ROTEM group and remained significant after adjusting for TXA.CONCLUSIONSFor ASD patients treated using lumbar PSO, more cryoprecipitate and less FFP were transfused in the ROTEM group compared to the control group. These preliminary findings suggest ROTEM-guided therapy may allow early identification of hypofibrinogenemia, and aggressive management of this may reduce blood loss and total blood product transfusion volume. Additional prospective studies of larger cohorts are warranted to identify the appropriate subset of ASD patients who may benefit from intraoperative ROTEM analysis.
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Affiliation(s)
| | | | | | - Lauren K Dunn
- 2Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - Jeffrey P Mullin
- 3Department of Neurosurgery, University of Buffalo, New York; and
| | - Marcus D Mazur
- 4Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | | | | | | | | | - Bhiken I Naik
- Departments of1Neurosurgery and.,2Anesthesiology, University of Virginia, Charlottesville, Virginia
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19
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Toffaletti JG, Buckner KA. Use of Earlier-Reported Rotational Thromboelastometry Parameters to Evaluate Clotting Status, Fibrinogen, and Platelet Activities in Postpartum Hemorrhage Compared to Surgery and Intensive Care Patients. Anesth Analg 2019; 128:414-423. [PMID: 29944523 DOI: 10.1213/ane.0000000000003499] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Rotational thromboelastometry (ROTEM) can provide clinical information in 10-20 minutes for guiding administration of fibrinogen, platelets, and fresh frozen plasma products. While ROTEM testing is well established for cardiac and other surgeries, it is less characterized for use in postpartum hemorrhage (PPH) patients. We wanted to determine if the earlier-measured ROTEM parameters (α-angle and amplitude at 10 minutes [A10]) could replace the later parameters (amplitude at 20 minutes and maximum amplitude [maximum clot firmness {MCF}]) in all patient groups studied. We also correlated the A10 and α-angle of the EXTEM and FIBTEM tests to the fibrinogen levels and platelet counts in these patients. METHODS We retrospectively analyzed 100 sets of EXTEM and FIBTEM results ordered on patients undergoing operations for PPH, patients in intensive care units (ICU), and those undergoing cardiothoracic surgery (cardiothoracic operating room [C/T OR]). We determined if the correlations among the various parameters were similar among the PPH, ICU, and C/T OR patients. RESULTS As expected, the EXTEM A10 (A10EX) and FIBTEM A10 (A10FIB) correlated highly to the EXTEM MCF and FIBTEM MCF in all patient groups. The A10EX parameter correlated significantly to both fibrinogen and platelet levels, and the A10FIB correlated to the fibrinogen levels. The difference between the A10EX and the A10FIB (PLTEM) is related to platelet activity, and we found that the PLTEM and platelet count correlated highly for all 100 PPH patients (r = 0.80), C/T OR patients (r = 0.70), and ICU patients (r = 0.66), despite 4 high platelet counts with relatively low PLTEM values in the ICU group. The earlier-reported parameter EXTEM α angle (α-EX) is an excellent indicator of the A10EX, with an α-EX ≥65° (ie, normal) giving a >96% probability that the A10EX was ≥44 mm, and an α-EX value below 65 mm giving an 86% probability that the A10EX was <44 mm. CONCLUSIONS The correlations among the ROTEM parameters for the PPH comparisons were equivalent to the C/T OR patients studied, and the A10EX and A10FIB could replace the MCF results in all patient groups. Also, the α-EX was an early indicator of the A10EX and had good correlations to the A10FIB and the fibrinogen in all patient groups. Finally, in a separate group of 62 comparisons, the FIBTEM α angle showed promise as an early indicator of the A10FIB and the fibrinogen levels.
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Affiliation(s)
- John G Toffaletti
- From the Department of Pathology/Clinical Laboratories, Duke University Health System, Durham, North Carolina
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20
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Iwata S, Hirasaki Y, Nomura M, Ozaki M. Thromboelastometric evaluation of coagulation profiles of cold-stored autologous whole blood: A prospective observational study. Medicine (Baltimore) 2019; 98:e17357. [PMID: 31574880 PMCID: PMC6775353 DOI: 10.1097/md.0000000000017357] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Preoperative autologous blood donation is a well-established procedure to reduce the need for allogeneic blood transfusion. We hypothesized that coagulation activity is maintained in cold-stored whole blood, because the fundamental polymerization properties of fibrin are preserved.Fifty adult patients who underwent elective cardiothoracic surgery were enrolled.Autologous whole blood collected 2 to 4 times at almost 1-week intervals before surgery was stored at approximately 4°C until reinfusion at the time of surgery. Blood samples were drawn just before reinfusion, and rotational thromboelastometry variables and fibrinogen levels were measured.A total of 158 samples were analyzed. The mean duration of cold storage was 16.7 ± 7.4 days (range: 6-33 days). Platelet counts were very low due to collection through a leukoreduction filter. The mean fibrinogen level was 2.3 ± 0.6 g/L. Amplitude at 10 minutes after CT (A10), amplitude at 20 minutes after CT (A20), and maximum clot firmness (MCF) values as determined by FIBTEM analysis were 10.8 ± 3.8, 12.2 ± 4.2, and 13.1 ± 4.7 mm, respectively. Fibrinogen levels were strongly correlated with A10, A20, and FIBTEM-MCF values (ρ = 0.83, P < .0001, ρ = 0.84, P < .0001, ρ = 0.85, P < .0001, respectively). Fibrinogen levels were not correlated with the duration of cold storage (ρ = 0.06, P = .43).The results of the present study demonstrate that fibrin polymerization occurs in cold-stored autologous whole blood, and that such activity is strongly correlated with fibrinogen levels. Furthermore, our data suggest that cold-stored leukoreduced autologous whole blood retains fibrin polymerization properties throughout 33 days.
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Affiliation(s)
- Shihoko Iwata
- Department of Anesthesiology, Tokyo Women's Medical University Hospital
| | - Yuji Hirasaki
- Department of Anesthesia, IMS Tokyo-Katsushika General Hospital, Tokyo, Japan
| | - Minoru Nomura
- Department of Anesthesiology, Tokyo Women's Medical University Hospital
| | - Makoto Ozaki
- Department of Anesthesiology, Tokyo Women's Medical University Hospital
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21
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Tirotta CF, Lagueruela RG, Salyakina D, Wang W, Taylor T, Ojito J, Kubes K, Lim H, Hannan R, Burke R. Interval changes in ROTEM values during cardiopulmonary bypass in pediatric cardiac surgery patients. J Cardiothorac Surg 2019; 14:139. [PMID: 31331371 PMCID: PMC6647318 DOI: 10.1186/s13019-019-0949-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 06/24/2019] [Indexed: 11/18/2022] Open
Abstract
Introduction Rotational thromboelastometry (ROTEM) has been shown to reduce the need for transfused blood products in adult and pediatric cardiac surgery patients. However, similar evidence in newborns, neonates, and young infants is lacking. We quantified ROTEM value changes in pediatric patients on cardiopulmonary bypass (CPB) before, during and after blood product transfusion. Methods Each surgery had at least four interventions: initiating CPB; platelet administration during rewarming phase; post-CPB and following protamine and human fibrinogen concentrate (HFC) administration; and further component therapy if bleeding persisted and ROTEM indicated a deficiency. ROTEM assays were performed prior to surgery commencement, on CPB prior to platelet administration and following 38 mL/kg platelets, and post-CPB after protamine and HFC administration. ROTEM assays were also performed in the post-CPB period after further blood component therapy administration. Results Data from 161 patients were analyzed. Regression models suggested significant changes in HEPTEM clotting time after all interventions. PLT administration during CPB improved HEPTEM α by 22.1° (p < 0.001) and FIBTEM maximum clot firmness (MCF) by 2.9 mm (p < 0.001). HFC administration after CPB termination significantly improved FIBTEM MCF by 2.6 mm (p < 0.001). HEPTEM MCF significantly increased after 3/4 interventions. HEPTEM α significantly decreased after two interventions and significantly increased after two interventions. Greatest perturbances in coagulation parameters occurred in patients ≤90 days of age. Conclusion CPB induced profound perturbations in ROTEM values in pediatric cardiac surgery patients. ROTEM values improved following PLT and HFC administration. This study provides important clinical insights into ROTEM changes in pediatric patients after distinct interventions.
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Affiliation(s)
- Christopher F Tirotta
- Department of Anesthesia, The Heart Program, Nicklaus Children's Hospital, 3100 S.W. 62nd Street, Miami, FL, 33155, USA.
| | - Richard G Lagueruela
- Department of Anesthesia, The Heart Program, Nicklaus Children's Hospital, 3100 S.W. 62nd Street, Miami, FL, 33155, USA
| | - Daria Salyakina
- Research Institute, Nicklaus Children's Hospital, Miami, FL, USA
| | - Weize Wang
- Research Institute, Nicklaus Children's Hospital, Miami, FL, USA
| | - Thomas Taylor
- Research Institute, Nicklaus Children's Hospital, Miami, FL, USA
| | - Jorge Ojito
- Department of Cardiac Surgery, The Heart Program, Nicklaus Children's Hospital, 3100 S.W. 62nd Street, Miami, FL, 33155, USA
| | - Kathleen Kubes
- Department of Cardiac Surgery, The Heart Program, Nicklaus Children's Hospital, 3100 S.W. 62nd Street, Miami, FL, 33155, USA
| | - Hyunsoo Lim
- Department of Cardiac Surgery, The Heart Program, Nicklaus Children's Hospital, 3100 S.W. 62nd Street, Miami, FL, 33155, USA
| | - Robert Hannan
- Department of Cardiac Surgery, The Heart Program, Nicklaus Children's Hospital, 3100 S.W. 62nd Street, Miami, FL, 33155, USA
| | - Redmond Burke
- Department of Cardiac Surgery, The Heart Program, Nicklaus Children's Hospital, 3100 S.W. 62nd Street, Miami, FL, 33155, USA
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Using α-Angle and A10 ROTEM Parameters for Earlier Information on Clotting Status in Surgery, Postpartum Hemorrhage, and ICU Patients. POINT OF CARE 2019. [DOI: 10.1097/poc.0000000000000188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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23
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Miyata S, Itakura A, Ueda Y, Usui A, Okita Y, Ohnishi Y, Katori N, Kushimoto S, Sasaki H, Shimizu H, Nishimura K, Nishiwaki K, Matsushita T, Ogawa S, Kino S, Kubo T, Saito N, Tanaka H, Tamura T, Nakai M, Fujii S, Maeda T, Maeda H, Makino S, Matsunaga S. TRANSFUSION GUIDELINES FOR PATIENTS WITH MASSIVE BLEEDING. ACTA ACUST UNITED AC 2019. [DOI: 10.3925/jjtc.65.21] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Shigeki Miyata
- Department of Clinical Laboratory Medicine, National Cerebral and Cardiovascular Center
| | - Atsuo Itakura
- Department of Obstetrics and Gynecology, Faculty of Medicine, Juntendo University
| | - Yuichi Ueda
- Nara Prefectural Hospital Organization, Nara Prefecture General Medical Center
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Yutaka Okita
- Department of Cardiovascular Surgery, Kobe University
| | - Yoshihiko Ohnishi
- Operation Room, Anesthesiology, National Cerebral and Cardiovascular Center
| | - Nobuyuki Katori
- Department of Anesthesiology, Keio University School of Medicine
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine
| | - Hiroaki Sasaki
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | | | - Kunihiro Nishimura
- Department of Statistics and Data Analysis, Dept of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center
| | | | | | - Satoru Ogawa
- Department of Anesthesiology, Kyoto Prefectural University of Medicine
| | | | | | - Nobuyuki Saito
- Shock and Trauma Center, Nippon Medical School Chiba Hokusoh Hospital
| | - Hiroshi Tanaka
- Department of Surgery, Division of Minimum Invasive Surgery, Kobe University
| | | | - Michikazu Nakai
- Department of Statistics and Data Analysis, Dept of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center
| | - Satoshi Fujii
- Department of Laboratory Medicine, Asahikawa Medical University
| | - Takuma Maeda
- Division of Transfusion Medicine, National Cerebral and Cardiovascular Center
| | - Hiroo Maeda
- Transfusion Medicine and Cell Therapy, Saitama Medical Center/Saitama Medical University
| | - Shintaro Makino
- Department of Obstetrics and Gynecology, Faculty of Medicine, Juntendo University
| | - Shigetaka Matsunaga
- Department of Obstetrics and Gynecology, Saitama Medical Center/Saitama Medical University
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24
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Hashir A, Singh SA, Krishnan G, Subramanian R, Gupta S. Correlation of early ROTEM parameters with conventional coagulation tests in patients with chronic liver disease undergoing liver transplant. Indian J Anaesth 2019; 63:21-25. [PMID: 30745608 PMCID: PMC6341893 DOI: 10.4103/ija.ija_334_18] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background and Aims: Viscoelastic tests such as rotational thromboelastometry (ROTEM) provide a quick and holistic assessment of coagulation status to guide transfusion during liver transplant (LT). Conventional coagulation tests (CCTs) measure single parameters in isolation, and also the results are delayed hampering management of patients during surgery. We evaluated the correlation of early ROTEM-derived parameters with CCTs and also assessed the ability of ROTEM-derived parameters to predict thrombocytopaenia and hypofibrinogenaemia during LT in patients with end-stage liver disease (ESLD). Methods: This retrospective study was carried out in 100 patients with decompensated ESLD undergoing LT. Correlation between CCTs and ROTEM parameters was analyzed. Receiver operating characteristic curves with area under the curve were used to determine the cut-off values of A5 andA10 on EXTEM and FIBTEM. Results: The values of A5EXTEM and A10EXTEM highly correlated with fibrinogen levels and platelet count, whereas A5FIBTEM and A10FIBTEM correlated well with fibrinogen levels. A5EXTEM<21 mm and A10EXTEM<28 mm correlated with a platelet count <75,000 mm−3, whereas A5EXTEM<18 mm and A10EXTEM<25 mm correlated with a platelet count <50,000 mm−3. Fibrinogen levels <100 mg/dL better correlated with A5FIBTEM<5 mm, A10FIBTEM<6 mm, A5EXTEM<21 mm and A10EXTEM<30 mm. Conclusion: Early ROTEM parameters A5 and A10 of both EXTEM and FIBTEM had an excellent correlation with thrombocytopaenia and hypofibrinogenaemia and may potentially guide early transfusion of relevant blood products during LT.
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Affiliation(s)
- A Hashir
- Center for Liver and Biliary Sciences, Max Super Speciality Hospital, New Delhi, India
| | - Shweta A Singh
- Center for Liver and Biliary Sciences, Max Super Speciality Hospital, New Delhi, India
| | - Gopi Krishnan
- Center for Liver and Biliary Sciences, Max Super Speciality Hospital, New Delhi, India
| | - Rajkumar Subramanian
- Center for Liver and Biliary Sciences, Max Super Speciality Hospital, New Delhi, India
| | - Subhash Gupta
- Center for Liver and Biliary Sciences, Max Super Speciality Hospital, New Delhi, India
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25
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Tirotta CF, Lagueruela RG, Madril D, Salyakina D, Wang W, Taylor T, Ojito J, Kubes K, Lim H, Hannan R, Burke R. Correlation Between ROTEM FIBTEM Maximum Clot Firmness and Fibrinogen Levels in Pediatric Cardiac Surgery Patients. Clin Appl Thromb Hemost 2018; 25:1076029618816382. [PMID: 30518238 PMCID: PMC6714911 DOI: 10.1177/1076029618816382] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This study evaluated whether rotational thromboelastometry (ROTEM; Tem International
GmbH, Munich, Germany) FIBTEM maximum clot firmness (MCF) can be used to predict plasma
fibrinogen level in pediatric patients undergoing cardiac surgery. Linear regression was
conducted to predict plasma fibrinogen level using FIBTEM MCF (0.05 level of
significance). Scatter plot with the regression line for the model fit was created. Fifty
charts were retrospectively reviewed, and 87 independent measurements of FIBTEM MCF paired
with plasma fibrinogen levels were identified for analysis. Linear regression analysis
suggested a significant positive linear relationship (P < .0001)
between plasma fibrinogen levels and MCF. Both MCF intercept and slope were significantly
correlated with fibrinogen level (P < .0001). The estimated regression
equation (predicted fibrinogen = 78.6 + 12.4 × MCF) indicates that a 1-mm increase in MCF
raises plasma fibrinogen level by an average of 12.4 mg/dL. The statistically significant
positive linear relationship observed between MCF and fibrinogen levels
(P < .001) suggests that MCF can be used as a surrogate for
fibrinogen level. This relationship is of clinical relevance in the calculation of
patient-specific dosing of fibrinogen supplementation in this setting.
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Affiliation(s)
- Christopher F Tirotta
- 1 Department of Anesthesia, The Heart Program, Nicklaus Children's Hospital, Miami, FL, USA
| | - Richard G Lagueruela
- 1 Department of Anesthesia, The Heart Program, Nicklaus Children's Hospital, Miami, FL, USA
| | - Danielle Madril
- 1 Department of Anesthesia, The Heart Program, Nicklaus Children's Hospital, Miami, FL, USA
| | - Daria Salyakina
- 2 Nicklaus Children's Health System Research Institute, Miami, FL, USA
| | - Weize Wang
- 2 Nicklaus Children's Health System Research Institute, Miami, FL, USA
| | - Thomas Taylor
- 2 Nicklaus Children's Health System Research Institute, Miami, FL, USA
| | - Jorge Ojito
- 3 The Heart Program, Nicklaus Children's Hospital, Miami, FL, USA
| | - Kathleen Kubes
- 3 The Heart Program, Nicklaus Children's Hospital, Miami, FL, USA
| | - Hyunsoo Lim
- 3 The Heart Program, Nicklaus Children's Hospital, Miami, FL, USA
| | - Robert Hannan
- 3 The Heart Program, Nicklaus Children's Hospital, Miami, FL, USA
| | - Redmond Burke
- 3 The Heart Program, Nicklaus Children's Hospital, Miami, FL, USA
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Matzelle SA, Weightman WM, Gibbs NM. An Audit of the Diagnostic Accuracy of Rotational Thromboelastometry for the Identification of Hypofibrinogenaemia and Thrombocytopenia during Cardiopulmonary Bypass. Anaesth Intensive Care 2018; 46:620-626. [DOI: 10.1177/0310057x1804600614] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We audited the diagnostic accuracy of ROTEM® (TEM Innovations, GmbH, Munich, Germany) measurements of hypofibrinogenaemia (fibrinogen <1.5 g/l) and thrombocytopenia (platelet count <100 × 109/l) in 200 adult non-transplant patients during cardiopulmonary bypass (CPB). Blood samples were obtained for FIBTEM (assay for the fibrin part of the clot), PLTEM (calculated platelet-specific component), and laboratory measurements simultaneously. Our thresholds for FIBTEM and PLTEM were A10 (clot firmness 10 minutes after clotting time) ≤8 mm, and <35 mm respectively. We also calculated the accuracy of smaller thresholds and earlier indices. We found that FIBTEM A10 ≤8 mm had low sensitivity (0.62) for hypofibrinogenaemia. With the 13% hypofibrinogenaemia prevalence in our sample, the positive predictive value (PPV) was 0.47. In contrast, FIBTEM A10 ≤8 mm had higher specificity (0.90) (negative predictive value [NPV] 0.94). Of the other FIBTEM values analysed, only A5 ≤6 mm had similar or superior accuracy. The PLTEM results were less encouraging (sensitivity 0.81, specificity 0.62). With our prevalence of thrombocytopenia (also 13%), the PPV was only 0.24. However, the NPV was high (0.96). Of the other PLTEM values analysed, only A5 <25 mm had similar or superior accuracy. These findings indicate that during CPB FIBTEM A10 ≤8 mm and PLTEM A10 <35 mm have greater accuracy in identifying the absence of hypofibrinogenaemia and thrombocytopenia respectively than their presence. On the basis of these results we would be reassured by FIBTEM A10 values >8 mm and PLTEM A10 values ≥35 mm, but would continue to use laboratory measurements for confirmation. We would not use FIBTEM A10 ≤8 mm or PLTEM A10 <35 mm values alone to guide replacement therapy unless clinical conditions warranted an immediate decision before laboratory measurements were available.
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Affiliation(s)
- S. A. Matzelle
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Perth, Western Australia
| | - W. M. Weightman
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Perth, Western Australia
| | - N. M. Gibbs
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Perth, Western Australia
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Rocha RV, Tam DY, Fremes SE. Rotational thromboelastometry for perioperative blood conservation? It is all in the bloody details. J Thorac Cardiovasc Surg 2018; 157:1055-1057. [PMID: 30180980 DOI: 10.1016/j.jtcvs.2018.07.080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 07/27/2018] [Indexed: 11/17/2022]
Affiliation(s)
- Rodolfo V Rocha
- Division of Cardiac Surgery, Schulich Heart Centre, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Derrick Y Tam
- Division of Cardiac Surgery, Schulich Heart Centre, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Stephen E Fremes
- Division of Cardiac Surgery, Schulich Heart Centre, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
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28
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Curry NS, Davenport R, Pavord S, Mallett SV, Kitchen D, Klein AA, Maybury H, Collins PW, Laffan M. The use of viscoelastic haemostatic assays in the management of major bleeding: A British Society for Haematology Guideline. Br J Haematol 2018; 182:789-806. [PMID: 30073664 DOI: 10.1111/bjh.15524] [Citation(s) in RCA: 113] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Nicola S Curry
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,NIHR BRC, Blood Theme, Oxford University, Oxford, UK
| | - Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Sue Pavord
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,NIHR BRC, Blood Theme, Oxford University, Oxford, UK
| | - Susan V Mallett
- Department of Anaesthesia, Royal Free London NHS Foundation Trust, London, UK
| | | | - Andrew A Klein
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
| | - Helena Maybury
- Department of Obstetrics, Leicester Royal Infirmary, Leicester, UK
| | - Peter W Collins
- Department of Haematology, School of Medicine, Cardiff University, Cardiff, UK
| | - Mike Laffan
- Department of Haematology, Imperial College and Hammersmith Hospital, London, UK
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29
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Okabayashi S, Ogawa S, Tanaka KA, Nishiyama T, Takeshita S, Nakayama Y, Nakajima Y, Sawa T, Mizobe T. A Comparative Study of Point-of-Care Prothrombin Time in Cardiopulmonary Bypass Surgery. J Cardiothorac Vasc Anesth 2018; 32:1609-1614. [DOI: 10.1053/j.jvca.2017.12.044] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Indexed: 11/11/2022]
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30
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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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31
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Akay OM. The Double Hazard of Bleeding and Thrombosis in Hemostasis From a Clinical Point of View: A Global Assessment by Rotational Thromboelastometry (ROTEM). Clin Appl Thromb Hemost 2018; 24:850-858. [PMID: 29758989 PMCID: PMC6714726 DOI: 10.1177/1076029618772336] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Hemostasis is a complex dynamic process involving bleeding and thrombosis as two end-points. Conventional coagulation tests which are measured in plasma examine only isolated portions of the coagulation cascade, thereby giving no information on important interactions essential to the clinical evaluation of hemostatic function. Thromboelastography (TEG), originally described in 1948 has improved over the decades and become a valuable tool of coagulation testing because of the limitations of standard coagulation tests. TEG is a technique that provides data about the entire coagulation system, from the beginning of clot formation to fibrinolysis, involving both cellular and plasma components of hemostasis. Rotational thromboelastometry (ROTEM) which evolved from TEG technology overcome several limitations of classical TEG while maintaining a good correlation with conventional TEG determination. ROTEM analyses are useful for rapid assessment of global clotting function in various clinical situations including liver transplantation, cardiac surgery, obstetrics, trauma, hemophilia and idiopathic thrombocytopenic purpura. ROTEM has been also reported to be useful in identifying various hypercoagulable conditions including major surgery, malignancy, Behcet’s disease and apheresis. Further developments in ROTEM based transfusion strategies may also reduce transfusion requirements and improve clinical outcomes by optimizing the administration of blood components. This is a literature review of ROTEM including its technique, interpretation and specially clinical applications in different scenarios of bleeding and thrombotic disorders.
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Affiliation(s)
- Olga Meltem Akay
- 1 Department of Hematology, Koç University Medical School, İstanbul, Turkey
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32
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Fabbro M, Patel PA. The DRIHEMATO PT-S Test in Cardiac Surgery, a Tulip Mania Problem? J Cardiothorac Vasc Anesth 2018; 32:1615-1617. [PMID: 29506895 DOI: 10.1053/j.jvca.2018.01.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Michael Fabbro
- University of Miami, Miller School of Medicine, Miami, FL
| | - Prakash A Patel
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
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Bhardwaj V, Malhotra P, Hasija S, Chowdury UK, Pangasa N. Coagulopathies in cyanotic cardiac patients: An analysis with three point - of - care testing devices (Thromboelastography, rotational thromboelastometry, and sonoclot analyzer). Ann Card Anaesth 2017; 20:212-218. [PMID: 28393783 PMCID: PMC5408528 DOI: 10.4103/aca.aca_4_17] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Introduction: In the last few years, viscoelastic point-of-care (POC) coagulation devices such as thromboelastography (TEG), rotational thromboelastometry (ROTEM), and Sonoclot (SON) analyzer have been increasingly used in major surgeries for timely assessment and management of coagulopathies. The aim of the present study was to evaluate coagulation profile of cyanotic cardiac patients with TEG, ROTEM, and SON analyzer. In addition, we assessed the correlation of standard laboratory coagulation tests and postoperative chest drain output (CDO) with the parameters of POC testing devices. Materials and Methods: Thirty-five patients of either gender, belonging to the American Society of Anesthesiologists Grade I–III, and undergoing elective cardiac surgery on cardiopulmonary bypass for cyanotic congenital heart disease were included in this study. To identify possible coagulation abnormalities, blood samples for TEG, ROTEM, SON, and standard laboratory coagulation were collected after induction of anesthesia. The correlations between variables were assessed using Pearson's correlation coefficient. P < 0.05 was considered statistically significant. Results and Discussion: EXTEM clot time (CT) and clot formation time (CFT) were prolonged in 87% and 45% patients whereas INTEM CT and CFT were prolonged in 36% and 73% patients, respectively. FIBTEM maximum clot firmness (MCF) was decreased in 30% patients. We observed significant correlation between fibrinogen concentration and ROTEM FIBTEM MCF (r = 0.94, P < 0.001). The SON platelet function (SON PF) showed good correlation with platelet count (r = 0.85, P < 0.001). We also found significant correlation between preoperative FIBTEM MCF and CDO in first 4 postoperative hours (r = 0.49, P = 0.004) and 24 postoperative hours (r = 0.52, P = 0.005). Receiver operating characteristic analysis demonstrated that SON PF and TEG maximum amplitude are highly predictive of thrombocytopenia below 100 × 109/L (area under the curve [AUC] - 0.97 and 0.92, respectively), while FIBTEM-MCF is highly predictive of hypofibrinogenemia (fibrinogen <150 mg/dL (AUC, 0.99). Conclusion: Cyanotic cardiac patients have preoperative coagulation abnormalities in ROTEM, TEG, and SON parameters. ROTEM FIBTEM is highly predictive of hypofibrinogenemia while SON PF is highly predictive of thrombocytopenia. ROTEM FIBTEM can be studied as a marker of increased postoperative CDO.
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Affiliation(s)
- Vandana Bhardwaj
- Department of Cardiac Anaesthesia, Cardio Thoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Poonam Malhotra
- Department of Cardiac Anaesthesia, Cardio Thoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Suruchi Hasija
- Department of Cardiac Anaesthesia, Cardio Thoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Ujjwal Kumar Chowdury
- Department of Cardio Thoracic Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Neha Pangasa
- Department of Cardiac Anaesthesia, Cardio Thoracic Centre, All India Institute of Medical Sciences, New Delhi, India
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Kvint S, Schuster J, Kumar MA. Neurosurgical applications of viscoelastic hemostatic assays. Neurosurg Focus 2017; 43:E9. [DOI: 10.3171/2017.8.focus17447] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Patients taking antithrombotic agents are very common in neurosurgical practice. The perioperative management of these patients can be extremely challenging especially as newer agents, with poorly defined laboratory monitoring and reversal strategies, become more prevalent. This is especially true with emergent cases in which rapid reversal of anticoagulation is required and the patient’s exact medical history is not available. With an aging patient population and the associated increase in diseases such as atrial fibrillation, it is expected that the use of these agents will continue to rise in coming years. Furthermore, thromboembolic complications such as deep venous thrombosis, pulmonary embolism, and myocardial infarction are common complications of major surgery. These trends, in conjunction with a growing understanding of the hemostatic process and its contribution to the pathophysiology of disease, stress the importance of the complete evaluation of a patient’s hemostatic profile in guiding management decisions. Viscoelastic hemostatic assays (VHAs), such as thromboelastography and rotational thromboelastometry, are global assessments of coagulation that account for the cellular and plasma components of coagulation. This FDA-approved technology has been available for decades and has been widely used in cardiac surgery and liver transplantation. Although VHAs were cumbersome in the past, advances in software and design have made them more accurate, reliable, and accessible to the neurosurgeon. VHAs have demonstrated utility in guiding intraoperative blood product transfusion, identifying coagulopathy in trauma, and managing postoperative thromboprophylaxis. The first half of this review aims to evaluate and assess VHAs, while the latter half seeks to appraise the evidence supporting their use in neurosurgical populations.
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Affiliation(s)
| | | | - Monisha A. Kumar
- Departments of 1Neurosurgery and
- 2Neurology, University of Pennsylvania, Philadelphia, Pennsylvania
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35
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Fabbro M, Jain P. Hemodilution on Cardiopulmonary Bypass and Its Impact on TEG Patterns and Coagulation: Is the Evidence Dilute? J Cardiothorac Vasc Anesth 2017; 31:1564-1566. [DOI: 10.1053/j.jvca.2017.06.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Indexed: 01/12/2023]
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36
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Fabbro M, Winkler AM, Levy JH. Technology: Is There Sufficient Evidence to Change Practice in Point-of-Care Management of Coagulopathy? J Cardiothorac Vasc Anesth 2017; 31:1849-1856. [DOI: 10.1053/j.jvca.2017.05.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Indexed: 01/30/2023]
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37
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Soh S, Kwak YL, Song JW, Yoo KJ, Kim HJ, Shim JK. Rotational Thromboelastometry Predicts Increased Bleeding After Off-Pump Coronary Bypass Surgery. Ann Thorac Surg 2017; 104:1318-1324. [DOI: 10.1016/j.athoracsur.2017.02.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Revised: 01/13/2017] [Accepted: 02/13/2017] [Indexed: 01/09/2023]
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38
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Gozdzik W, Adamik B, Wysoczanski G, Gozdzik A, Rachwalik M, Skalec T, Kübler A. Preoperative thromboelastometry for the prediction of increased chest tube output in cardiac surgery: A retrospective study. Medicine (Baltimore) 2017; 96:e7669. [PMID: 28746233 PMCID: PMC5627859 DOI: 10.1097/md.0000000000007669] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Bleeding following cardiac surgery is a serious event with potentially life-threatening consequences. Preoperative recognition of coagulation abnormalities and detection of cardiopulmonary bypass (CPB) related coagulopathy could aid in the start of preventive treatment strategies that minimize perioperative blood loss. Most algorithms that analyze thromboelastometry coagulation tests in elective cardiac surgery do not include test results performed before surgery. We evaluated preoperative rotational thromboelastometry test results for their ability to predict blood loss during and after cardiac surgery.A total of 114 adult patients undergoing cardiac surgery with CPB were included in this retrospective analysis. Each patient had thromboelastometry tests done twice: preoperatively, before the induction of anesthesia and postoperatively, 10 minutes after heparin reversal with protamine after decannulation.Patients were placed into 1 of 2 groups depending on whether preoperative thromboelastometry parameters deviated from reference ranges: Group 1 [N = 29; extrinsically activated test (EXTEM) or INTEM results out of normal range] or Group 2 (N = 85; EXTEM and INTEM results within the normal range). We observed that the total amount of chest tube output was significantly greater in Group 1 than in Group 2 (700 mL vs 570 mL, P = .03). At the same time, the preoperative values of standard coagulation tests such as platelet count, aPTT, and INR did not indicate any abnormalities of coagulation.Preoperative coagulation abnormalities diagnosed with thromboelastometry can predict increased chest tube output in the early postoperative period in elective adult cardiac surgery. Monitoring of the coagulation system with thromboelastometry allows rapid diagnosis of coagulation abnormalities even before the start of the surgery. These abnormalities could not always be detected with routine coagulation tests.
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Affiliation(s)
| | | | | | - Anna Gozdzik
- Department and Clinic of Cardiac Surgery, Wroclaw Medical University
| | - Maciej Rachwalik
- Department and Clinic of Cardiac Surgery, Wroclaw Medical University
| | | | - Andrzej Kübler
- Centre of Pain Therapy and Palliative Care, University Hospital, Wroclaw, Poland
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Abstract
Hemorrhage is a major contributor to morbidity and mortality during the perioperative period. Current methods of diagnosing coagulopathy have various limitations including long laboratory runtimes, lack of information on specific abnormalities of the coagulation cascade, lack of in vivo applicability, and lack of ability to guide the transfusion of blood products. Viscoelastic testing offers a promising solution to many of these problems. The two most-studied systems, thromboelastography (TEG) and rotational thromboelastometry (ROTEM), offer similar graphical and numerical representations of the initiation, formation, and lysis of clot. In systematic reviews on the clinical efficacy of viscoelastic tests, the majority of trials analyzed were in cardiac surgery patients. Reviews of the literature suggest that transfusions of packed red blood cells (pRBC), plasma, and platelets are all decreased in patients whose transfusions were guided by viscoelastic tests rather than by clinical judgement or conventional laboratory tests. Mortality appears to be lower in the viscoelastic testing groups, despite no difference in surgical re-intervention rates and massive transfusion rates. Cost-effectiveness studies also seem to favor viscoelastic testing. Viscoelastic testing has also been investigated in small studies in other clinical contexts, such as sepsis, obstetric hemorrhage, inherited bleeding disorders, perioperative thromboembolism risk assessment, and management of anticoagulation for patients on mechanical circulatory support systems or direct oral anticoagulants (DOACs). While the results are intriguing, no systematic, larger trials have taken place to date. Viscoelastic testing remains a relatively novel method to assess coagulation status, and evidence for its use appears favorable in reducing blood product transfusions, especially in cardiac surgery patients.
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Affiliation(s)
- Liang Shen
- Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Sheida Tabaie
- Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Natalia Ivascu
- Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
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40
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Introduction of thromboelastometry-guided administration of fresh-frozen plasma is associated with decreased allogeneic blood transfusions and post-operative blood loss in cardiopulmonary-bypass surgery. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2017; 16:244-252. [PMID: 28488956 DOI: 10.2450/2017.0265-16] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 01/11/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND Cardiac surgery is frequently associated with excessive blood loss requiring multiple blood transfusions which are, in turn, associated with increased morbidity and mortality. We evaluated the effectiveness of rotational thromboelastometry (ROTEM®)-guided administration of fresh-frozen plasma (FFP) with regards to blood loss, transfusion requirements, and major post-operative complications. MATERIALS AND METHODS Coagulation management in 68 prospective patients undergoing cardiac surgery with cardiopulmonary bypass was based on a treatment algorithm guided by ROTEM® measurements. The primary end-point was blood loss at 24 hours after surgery. Secondary end-points were: (i) need for allogeneic blood products after cardiopulmonary bypass and 24 hours post-operatively, and (ii) post-operative complications until discharge. The results were compared with those of a retrospective, control group of 69 patients who received empirical coagulation management before implementation of the ROTEM®-guided algorithm. RESULTS Although patients with significantly lower haemoglobin levels received less packed red blood cells (PRBC) (840 vs 1,120 mL; p=0.031) and FFP (480 vs 720 mL; p=0.007) after introduction of the ROTEM® algorithm, the intra-operative blood loss and post-operative haemoglobin levels were similar in the ROTEM® and the retrospective control groups. In addition to significantly reduced blood loss and decreased requirements for PRBC (30.8 vs 62.3%; p<0.001) and FFP (25.0 vs 56.5%; p<0.001), the amounts of PRBC (315 vs 840 mL; p<0.001) and FFP (480 vs 840 mL; p=0.001) received during the first 24 hours after surgery were significantly reduced in the ROTEM® group, as was the duration of post-operative hospitalisation. DISCUSSION Compared with empirical treatment, timely ROTEM®-guided FFP administration during cardiac surgery can reduce not only overall blood product use and blood loss but also the duration of hospitalisation.
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41
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Gorlinger K, Bhardwaj V, Kapoor PM. Simulation in coagulation testing using rotational thromboelastometry: A fast emerging, reliable point of care technique. Ann Card Anaesth 2017; 19:516-20. [PMID: 27397458 PMCID: PMC4971982 DOI: 10.4103/0971-9784.185546] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Computer simulations can come in handy to train medical personnel with necessary skills to face the clinical scenarios involving various coagulopathies. Now a days, point of care (POC) devices such as thromboelastography, Sonoclot analyzer and newly approved rotational thromboelastometry (ROTEM) with faster results to assess coagulopathies are available on bedside of patients. ROTEM is emerging as a quick, portable, and well-validated device to evaluate coagulopathy in critical care and perioperative setup. A novel platelet-aggregometry integrated module enables simultaneous analysis of platelets as well as coagulation tests on the same screen. The entire gamut of POC signature curves obtained with different coagulation defects can be learned with graphical simulations. These simulations can be a valuable strategy to elucidate latent conditions, for which simulation interventions can then be designed to mimic different clinical scenarios.
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Affiliation(s)
- Klaus Gorlinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, Essen, Germany
| | - Vandana Bhardwaj
- Department of Cardiac Anaesthesiology, Cardio Thoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Poonam Malhotra Kapoor
- Department of Cardiac Anaesthesiology, Cardio Thoracic Centre, All India Institute of Medical Sciences, New Delhi, India
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Adler M, Ivic S, Bodmer NS, Ten Cate H, Bachmann LM, Wuillemin WA, Nagler M. Thromboelastometry and Thrombelastography Analysis under Normal Physiological Conditions - Systematic Review. Transfus Med Hemother 2017; 44:78-83. [PMID: 28503123 DOI: 10.1159/000464297] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 02/20/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Studies investigating thromboelastometry or thrombelastography analyses in a physiological context are scattered and not easy to access. OBJECTIVE To systematically retrieve and describe published reports studying healthy subjects and targeting at the correlation of ROTEM® and TEG® measurements with conventional parameters of hemostasis. METHODS Systematic Review: Papers were searched in Medline, Scopus and the Science Citation Index database. Reference lists of included studies and of reviews were screened. To be included papers had to report ROTEM or TEG data on healthy subjects. Two reviewers screened papers for inclusion, read full texts of potentially relevant papers, and extracted data of included papers. RESULTS Searches identified 1,721 records of which 1,713 were either excluded immediately or after reading the full text. The remaining 8 studies enrolled 632 subjects. The association of conventional parameters of hemostasis with ROTEM and with TEG was investigated in one and two studies, respectively. Overall correlation was limited and ranged from 0.0 to 0.40 (total thrombus generation vs. fibrinogen; clotting time INTEM vs. activated partial thromboplastin time). CONCLUSIONS Studies assessing the relationship between thromboelastometry or thromboelastography analyses and conventional parameters of hemostasis in healthy subjects remains scarce, and correlations are limited. Further research is needed to understand the physiology of thromboelastometry and thromboelastography parameters.
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Affiliation(s)
- Marcel Adler
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, and Department of Clinical Research, University of Bern, Bern, Switzerland
| | - Sandra Ivic
- medignition Inc, Research Consultants, Zurich, Switzerland
| | | | - Hugo Ten Cate
- Laboratory of Clinical Thrombosis and Hemostasis, and Cardiovascular Research Institute, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Walter A Wuillemin
- Division of Hematology and Central Hematology Laboratory, Luzerner Kantonsspital, University of Bern, Lucerne, Switzerland
| | - Michael Nagler
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, and Department of Clinical Research, University of Bern, Bern, Switzerland.,Division of Hematology and Central Hematology Laboratory, Luzerner Kantonsspital, University of Bern, Lucerne, Switzerland
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Abstract
Haemorrhage in the setting of severe trauma is associated with significant morbidity and mortality. There is increasing awareness of the important role fibrinogen plays in traumatic haemorrhage. Fibrinogen levels fall precipitously in severe trauma and the resultant hypofibrinogenaemia is associated with poor outcomes. Hence, it has been postulated that early fibrinogen replacement in severe traumatic haemorrhage may improve outcomes, although, to date there is a paucity of high quality evidence to support this hypothesis. In addition there is controversy regarding the optimal method for fibrinogen supplementation. We review the current evidence regarding the role of fibrinogen in trauma, the rationale behind fibrinogen supplementation and discuss current research.
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Williams B, McNeil J, Crabbe A, Tanaka KA. Practical Use of Thromboelastometry in the Management of Perioperative Coagulopathy and Bleeding. Transfus Med Rev 2017; 31:11-25. [DOI: 10.1016/j.tmrv.2016.08.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Revised: 08/23/2016] [Accepted: 08/23/2016] [Indexed: 12/23/2022]
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Moore LJ, Todd SR. Hemorrhage and Transfusions in the Surgical Patient. COMMON PROBLEMS IN ACUTE CARE SURGERY 2017. [PMCID: PMC7120919 DOI: 10.1007/978-3-319-42792-8_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Hemorrhage remains the leading cause of intra-operative deaths and those in the first 24 h. Many cardiovascular and hepatobiliary procedures result in massive hemorrhage and postpartum hemorrhage events in labor and delivery place the patient at a high risk for mortality. Both upper and lower gastrointestinal bleeding (e.g., diverticulosis, esophageal and gastric varices, and peptic ulcer disease) can also result in significant blood loss requiring massive transfusion and resuscitation from hemorrhagic shock. Therefore, safe, timely, and effective transfusion of blood products is critical. The aim of this chapter is to provide clinicians with a discussion of the current literature on the various blood component products, their indications, and unique hemostatic conditions in the surgical patient. While the majority of data concerning optimal management of acquired coagulopathy and hemorrhagic shock resuscitation is based on trauma patients, many of the principles can and should be applied to the surgical patient (or likely any patient) with profound hemorrhage.
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Affiliation(s)
- Laura J. Moore
- Department of Surgery, The University of Texas McGovern Medical School - Houston, Houston, Texas USA
| | - S. Rob Todd
- General Surgery and Trauma Ben Taub Hospital, Houston, Texas USA
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Thomas O, Rein H, Strandberg K, Schött U. Coagulative safety of epidural catheters after major upper gastrointestinal surgery: advanced and routine coagulation analysis in 38 patients. Perioper Med (Lond) 2016; 5:28. [PMID: 27777753 PMCID: PMC5067910 DOI: 10.1186/s13741-016-0053-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 09/26/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The risk of spinal haematoma in patients receiving epidural catheters is estimated using routine coagulation tests, but guidelines are inconsistent in their recommendations on what to do when results indicate slight hypocoagulation. Postoperative patients are prone to thrombosis, and thromboelastometry has previously shown hypercoagulation in this setting. We aimed to better understand perioperative haemostasis by comparing results from routine and advanced tests, hypothesizing that patients undergoing major upper gastrointestinal surgery would be deficient in vitamin K-dependent coagulation factors because of malnutrition, or hypocoagulative because of accumulation of low molecular weight heparin (LMWH). METHODS Thirty-eight patients receiving epidural analgesia for major upper gastrointestinal surgery were included. We took blood at the time of preoperative epidural catheterization and at catheter withdrawal. Prothrombin time-international normalized ratio (PT-INR), activated partial thromboplastin time (aPTT) and platelet count (Plc) were analysed, and also albumin, proteins induced by vitamin K absence (PIVKA-II), rotational thromboelastometry (ROTEM®), multiple electrode aggregometry (Multiplate®) and activities of factors II, VII, IX, X, XI, XII and XIII. RESULTS Postoperative coagulation was characterized by thrombocytosis and hyperfibrinogenaemia. Mean PT-INR increased significantly from 1.0 ± 0.1 to 1.2 ± 0.2 and mean aPTT increased significantly from 27 ± 3 to 30 ± 4 s. Activity of vitamin K-dependent factors did not decrease significantly: FIX and FX activity increased. FXII and FXIII decreased significantly. Mean Plc increased from 213 ± 153 × 106/L while all mean ROTEM-MCFs (maximal clot firmnesses) especially FIBTEM-MCF increased significantly to above the reference interval. All mean ROTEM® clotting times were within their reference intervals both before and after surgery. ROTEM® (HEPTEM minus INTEM) results were spread around 0. There were significant correlations between routine tests and the expected coagulation factors, but not any of the viscoelastic parameters or PIVKA-II. Multiplate® area under curve and EXTEM-MCF correlated significantly to Plc as did EXTEM-MCF to fibrinogen, FIX, FX and FXIII; and FIBTEM-MCF to Plc, FII, FXI and FXIII. CONCLUSIONS The increase in PT-INR may be caused by decreased postoperative FVII while the elevated aPTT may be caused by low FXII. The mild postoperative hypocoagulation indicated by routine tests is not consistent with thromboelastometry. The relevance of ROTEM® and Multiplate® in the context of moderately increased routine tests remains unclear. Trial registration number is not applicable since this is not a clinical trial.
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Affiliation(s)
- Owain Thomas
- Faculty of Medicine, University of Lund, 22100 Lund, Sweden ; Department of Paediatric Anaesthesia and Intensive Care, SUS Lund University Hospital, 22185 Lund, Sweden
| | | | - Karin Strandberg
- Faculty of Medicine, University of Lund, 22100 Lund, Sweden ; Coagulation Laboratory, Department of Clinical Chemistry, Division of Laboratory Medicine, Skåne University Hospital, 21428 Malmö, Sweden
| | - Ulf Schött
- Faculty of Medicine, University of Lund, 22100 Lund, Sweden ; Department of Anaesthesia and Intensive Care, SUS Lund University Hospital, 22185 Lund, Sweden
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Karkouti K, Callum J, Wijeysundera DN, Rao V, Crowther M, Grocott HP, Pinto R, Scales DC. Point-of-Care Hemostatic Testing in Cardiac Surgery: A Stepped-Wedge Clustered Randomized Controlled Trial. Circulation 2016; 134:1152-1162. [PMID: 27654344 DOI: 10.1161/circulationaha.116.023956] [Citation(s) in RCA: 190] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 09/02/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Cardiac surgery is frequently complicated by coagulopathic bleeding that is difficult to optimally manage using standard hemostatic testing. We hypothesized that point-of-care hemostatic testing within the context of an integrated transfusion algorithm would improve the management of coagulopathy in cardiac surgery and thereby reduce blood transfusions. METHODS We conducted a pragmatic multicenter stepped-wedge cluster randomized controlled trial of a point-of-care-based transfusion algorithm in consecutive patients undergoing cardiac surgery with cardiopulmonary bypass at 12 hospitals from October 6, 2014, to May 1, 2015. Following a 1-month data collection at all participating hospitals, a transfusion algorithm incorporating point-of-care hemostatic testing was sequentially implemented at 2 hospitals at a time in 1-month intervals, with the implementation order randomly assigned. No other aspects of care were modified. The primary outcome was red blood cell transfusion from surgery to postoperative day 7. Other outcomes included transfusion of other blood products, major bleeding, and major complications. The analysis adjusted for secular time trends, within-hospital clustering, and patient-level risk factors. All outcomes and analyses were prespecified before study initiation. RESULTS Among the 7402 patients studied, 3555 underwent surgery during the control phase and 3847 during the intervention phase. Overall, 3329 (45.0%) received red blood cells, 1863 (25.2%) received platelets, 1645 (22.2%) received plasma, and 394 (5.3%) received cryoprecipitate. Major bleeding occurred in 1773 (24.1%) patients, and major complications occurred in 740 (10.2%) patients. The trial intervention reduced rates of red blood cell transfusion (adjusted relative risk, 0.91; 95% confidence interval, 0.85-0.98; P=0.02; number needed to treat, 24.7), platelet transfusion (relative risk, 0.77; 95% confidence interval, 0.68-0.87; P<0.001; number needed to treat, 16.7), and major bleeding (relative risk, 0.83; 95% confidence interval, 0.72-0.94; P=0.004; number needed to treat, 22.6), but had no effect on other blood product transfusions or major complications. CONCLUSIONS Implementation of point-of-care hemostatic testing within the context of an integrated transfusion algorithm reduces red blood cell transfusions, platelet transfusions, and major bleeding following cardiac surgery. Our findings support the broader adoption of point-of-care hemostatic testing into clinical practice. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT02200419.
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Affiliation(s)
- Keyvan Karkouti
- From Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Canada (K.K.); Department of Laboratory Medicine and Pathobiology, Sunnybrook Health Sciences Centre, University of Toronto, Canada (J.C.); Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Canada (D.N.W.); Division of Cardiac Surgery, Department of Surgery, Toronto General Hospital, University Health Network, University of Toronto, Canada (V.R.); Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada (M.C.); Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, Canada (H.P.G.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada (R.P.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre and Interdepartmental Division of Critical Care, University of Toronto, Canada (D.C.S.); and the Peter Munk Cardiac Centre, University Health Network, Toronto, Canada (K.K., D.N.W., V.R.).
| | - Jeannie Callum
- From Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Canada (K.K.); Department of Laboratory Medicine and Pathobiology, Sunnybrook Health Sciences Centre, University of Toronto, Canada (J.C.); Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Canada (D.N.W.); Division of Cardiac Surgery, Department of Surgery, Toronto General Hospital, University Health Network, University of Toronto, Canada (V.R.); Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada (M.C.); Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, Canada (H.P.G.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada (R.P.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre and Interdepartmental Division of Critical Care, University of Toronto, Canada (D.C.S.); and the Peter Munk Cardiac Centre, University Health Network, Toronto, Canada (K.K., D.N.W., V.R.)
| | - Duminda N Wijeysundera
- From Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Canada (K.K.); Department of Laboratory Medicine and Pathobiology, Sunnybrook Health Sciences Centre, University of Toronto, Canada (J.C.); Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Canada (D.N.W.); Division of Cardiac Surgery, Department of Surgery, Toronto General Hospital, University Health Network, University of Toronto, Canada (V.R.); Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada (M.C.); Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, Canada (H.P.G.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada (R.P.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre and Interdepartmental Division of Critical Care, University of Toronto, Canada (D.C.S.); and the Peter Munk Cardiac Centre, University Health Network, Toronto, Canada (K.K., D.N.W., V.R.)
| | - Vivek Rao
- From Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Canada (K.K.); Department of Laboratory Medicine and Pathobiology, Sunnybrook Health Sciences Centre, University of Toronto, Canada (J.C.); Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Canada (D.N.W.); Division of Cardiac Surgery, Department of Surgery, Toronto General Hospital, University Health Network, University of Toronto, Canada (V.R.); Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada (M.C.); Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, Canada (H.P.G.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada (R.P.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre and Interdepartmental Division of Critical Care, University of Toronto, Canada (D.C.S.); and the Peter Munk Cardiac Centre, University Health Network, Toronto, Canada (K.K., D.N.W., V.R.)
| | - Mark Crowther
- From Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Canada (K.K.); Department of Laboratory Medicine and Pathobiology, Sunnybrook Health Sciences Centre, University of Toronto, Canada (J.C.); Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Canada (D.N.W.); Division of Cardiac Surgery, Department of Surgery, Toronto General Hospital, University Health Network, University of Toronto, Canada (V.R.); Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada (M.C.); Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, Canada (H.P.G.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada (R.P.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre and Interdepartmental Division of Critical Care, University of Toronto, Canada (D.C.S.); and the Peter Munk Cardiac Centre, University Health Network, Toronto, Canada (K.K., D.N.W., V.R.)
| | - Hilary P Grocott
- From Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Canada (K.K.); Department of Laboratory Medicine and Pathobiology, Sunnybrook Health Sciences Centre, University of Toronto, Canada (J.C.); Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Canada (D.N.W.); Division of Cardiac Surgery, Department of Surgery, Toronto General Hospital, University Health Network, University of Toronto, Canada (V.R.); Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada (M.C.); Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, Canada (H.P.G.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada (R.P.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre and Interdepartmental Division of Critical Care, University of Toronto, Canada (D.C.S.); and the Peter Munk Cardiac Centre, University Health Network, Toronto, Canada (K.K., D.N.W., V.R.)
| | - Ruxandra Pinto
- From Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Canada (K.K.); Department of Laboratory Medicine and Pathobiology, Sunnybrook Health Sciences Centre, University of Toronto, Canada (J.C.); Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Canada (D.N.W.); Division of Cardiac Surgery, Department of Surgery, Toronto General Hospital, University Health Network, University of Toronto, Canada (V.R.); Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada (M.C.); Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, Canada (H.P.G.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada (R.P.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre and Interdepartmental Division of Critical Care, University of Toronto, Canada (D.C.S.); and the Peter Munk Cardiac Centre, University Health Network, Toronto, Canada (K.K., D.N.W., V.R.)
| | - Damon C Scales
- From Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Canada (K.K.); Department of Laboratory Medicine and Pathobiology, Sunnybrook Health Sciences Centre, University of Toronto, Canada (J.C.); Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Canada (D.N.W.); Division of Cardiac Surgery, Department of Surgery, Toronto General Hospital, University Health Network, University of Toronto, Canada (V.R.); Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada (M.C.); Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, Canada (H.P.G.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada (R.P.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre and Interdepartmental Division of Critical Care, University of Toronto, Canada (D.C.S.); and the Peter Munk Cardiac Centre, University Health Network, Toronto, Canada (K.K., D.N.W., V.R.)
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Wikkelsø A, Wetterslev J, Møller AM, Afshari A. Thromboelastography (TEG) or thromboelastometry (ROTEM) to monitor haemostatic treatment versus usual care in adults or children with bleeding. Cochrane Database Syst Rev 2016; 2016:CD007871. [PMID: 27552162 PMCID: PMC6472507 DOI: 10.1002/14651858.cd007871.pub3] [Citation(s) in RCA: 133] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Severe bleeding and coagulopathy are serious clinical conditions that are associated with high mortality. Thromboelastography (TEG) and thromboelastometry (ROTEM) are increasingly used to guide transfusion strategy but their roles remain disputed. This review was first published in 2011 and updated in January 2016. OBJECTIVES We assessed the benefits and harms of thromboelastography (TEG)-guided or thromboelastometry (ROTEM)-guided transfusion in adults and children with bleeding. We looked at various outcomes, such as overall mortality and bleeding events, conducted subgroup and sensitivity analyses, examined the role of bias, and applied trial sequential analyses (TSAs) to examine the amount of evidence gathered so far. SEARCH METHODS In this updated review we identified randomized controlled trials (RCTs) from the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 1); MEDLINE; Embase; Science Citation Index Expanded; International Web of Science; CINAHL; LILACS; and the Chinese Biomedical Literature Database (up to 5 January 2016). We contacted trial authors, authors of previous reviews, and manufacturers in the field. The original search was run in October 2010. SELECTION CRITERIA We included all RCTs, irrespective of blinding or language, that compared transfusion guided by TEG or ROTEM to transfusion guided by clinical judgement, guided by standard laboratory tests, or a combination. We also included interventional algorithms including both TEG or ROTEM in combination with standard laboratory tests or other devices. The primary analysis included trials on TEG or ROTEM versus any comparator. DATA COLLECTION AND ANALYSIS Two review authors independently abstracted data; we resolved any disagreements by discussion. We presented pooled estimates of the intervention effects on dichotomous outcomes as risk ratio (RR) with 95% confidence intervals (CIs). Due to skewed data, meta-analysis was not provided for continuous outcome data. Our primary outcome measure was all-cause mortality. We performed subgroup and sensitivity analyses to assess the effect based on the presence of coagulopathy of a TEG- or ROTEM-guided algorithm, and in adults and children on various clinical and physiological outcomes. We assessed the risk of bias through assessment of trial methodological components and the risk of random error through TSA. MAIN RESULTS We included eight new studies (617 participants) in this updated review. In total we included 17 studies (1493 participants). A total of 15 trials provided data for the meta-analyses. We judged only two trials as low risk of bias. The majority of studies included participants undergoing cardiac surgery.We found six ongoing trials but were unable to retrieve any data from them. Compared with transfusion guided by any method, TEG or ROTEM seemed to reduce overall mortality (7.4% versus 3.9%; risk ratio (RR) 0.52, 95% CI 0.28 to 0.95; I(2) = 0%, 8 studies, 717 participants, low quality of evidence) but only eight trials provided data on mortality, and two were zero event trials. Our analyses demonstrated a statistically significant effect of TEG or ROTEM compared to any comparison on the proportion of participants transfused with pooled red blood cells (PRBCs) (RR 0.86, 95% CI 0.79 to 0.94; I(2) = 0%, 10 studies, 832 participants, low quality of evidence), fresh frozen plasma (FFP) (RR 0.57, 95% CI 0.33 to 0.96; I(2) = 86%, 8 studies, 761 participants, low quality of evidence), platelets (RR 0.73, 95% CI 0.60 to 0.88; I(2) = 0%, 10 studies, 832 participants, low quality of evidence), and overall haemostatic transfusion with FFP or platelets (low quality of evidence). Meta-analyses also showed fewer participants with dialysis-dependent renal failure.We found no difference in the proportion needing surgical reinterventions (RR 0.75, 95% CI 0.50 to 1.10; I(2) = 0%, 9 studies, 887 participants, low quality of evidence) and excessive bleeding events or massive transfusion (RR 0.38, 95% CI 0.38 to 1.77; I(2) = 34%, 2 studies, 280 participants, low quality of evidence). The planned subgroup analyses failed to show any significant differences.We graded the quality of evidence as low based on the high risk of bias in the studies, large heterogeneity, low number of events, imprecision, and indirectness. TSA indicates that only 54% of required information size has been reached so far in regards to mortality, while there may be evidence of benefit for transfusion outcomes. Overall, evaluated outcomes were consistent with a benefit in favour of a TEG- or ROTEM-guided transfusion in bleeding patients. AUTHORS' CONCLUSIONS There is growing evidence that application of TEG- or ROTEM-guided transfusion strategies may reduce the need for blood products, and improve morbidity in patients with bleeding. However, these results are primarily based on trials of elective cardiac surgery involving cardiopulmonary bypass, and the level of evidence remains low. Further evaluation of TEG- or ROTEM-guided transfusion in acute settings and other patient categories in low risk of bias studies is needed.
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Affiliation(s)
- Anne Wikkelsø
- Hvidovre Hospital, University of CopenhagenDepartment of Anaesthesiology and Intensive Care MedicineKettegård Alle 30,HvidovreDenmark2650
| | - Jørn Wetterslev
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Ann Merete Møller
- Herlev and Gentofte Hospital, University of CopenhagenCochrane Anaesthesia, Critical and Emergency Care GroupHerlev RingvejHerlevDenmark2730
| | - Arash Afshari
- Rigshospitalet, Copenhagen University HospitalJuliane Marie Centre ‐ Anaesthesia and Surgical Clinic Department 4013CopenhagenDenmark
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Koami H, Sakamoto Y, Sakurai R, Ohta M, Imahase H, Yahata M, Umeka M, Miike T, Nagashima F, Iwamura T, Yamada KC, Inoue S. The thromboelastometric discrepancy between septic and trauma induced disseminated intravascular coagulation diagnosed by the scoring system from the Japanese association for acute medicine. Medicine (Baltimore) 2016; 95:e4514. [PMID: 27495106 PMCID: PMC4979860 DOI: 10.1097/md.0000000000004514] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The aim of this study is to evaluate the hematological differences between septic and traumatic disseminated intravascular coagulation (DIC) using the rotational thromboelastometry (ROTEM).This retrospective study includes all sepsis or severe trauma patients transported to our emergency department who underwent ROTEM from 2013 to 2014. All patients were divided into 2 groups based on the presence of DIC diagnosed by the Japanese Association for Acute Medicine (JAAM) DIC score. We statistically analyzed the demographics, clinical characteristics, laboratory data, ROTEM findings (EXTEM and FIBTEM), and outcome.Fifty-seven patients (30 sepsis and 27 severe trauma) were included in primary analysis. Sepsis cases were significantly older and had higher systemic inflammatory response syndrome (SIRS) scores, whereas there were no significant differences in other parameters including Acute Physiology and Chronic Health Evaluation (APACHE) II score, sequential organ failure assessment (SOFA) score. Twenty-six patients (14 sepsis and 12 severe trauma) were diagnosed with DIC. The Septic DIC (S-DIC) group was significantly older and had higher DIC scores than the traumatic DIC (T-DIC) group. Hematologic examination revealed significantly higher CRP, fibrinogen, lower FDP, DD, and higher FDP/DD ratio were found in the S-DIC group in comparison with the T-DIC group. ROTEM findings showed that the A10, A20, and MCF in the FIBTEM test were significantly higher in the S-DIC group. However, no statistical differences were confirmed in the LI30, LI45, and ML in EXTEM test.The plasma fibrinogen level and fibrinogen based clot firmness in whole-blood test revealed statistical significance between septic and traumatic DIC patients.
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Affiliation(s)
- Hiroyuki Koami
- Advanced Emergency Care Center, Saga University Hospital, Saga city, Saga, Japan
- Correspondence: Hiroyuki Koami, Advanced Emergency Care Center, Saga University Hospital, 5-1-1, Nabeshima, Saga city, Saga 8498501, Japan (e-mail: )
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Assessment of the Hemostatic Parameters and Platelet Function on Thromboelastometry and Impedance Aggregometry in Hemodialysis Patients Qualified for Kidney Transplantation: Preliminary Report. Transplant Proc 2016; 48:1431-4. [DOI: 10.1016/j.transproceed.2016.02.057] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Revised: 02/04/2016] [Accepted: 02/24/2016] [Indexed: 11/23/2022]
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