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Ismail TI, Mahrous RS. Prophylactic cryoprecipitate transfusion in patients undergoing scoliosis surgery: A randomised-controlled trial. J Perioper Pract 2024; 34:60-69. [PMID: 36416379 DOI: 10.1177/17504589221132393] [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] [Indexed: 06/16/2023]
Abstract
BACKGROUND Scoliosis surgeries in adults often have a high risk of massive blood loss and significant transfusion of blood products during and after surgery. It is not known whether early cryoprecipitate therapy is useful in reducing blood loss and transfusion requirements. The objective of this randomised, prospective placebo control study was to evaluate whether prophylactic administration of cryoprecipitate would reduce blood loss and transfusion requirements during scoliosis surgery. METHODS Eighty adult patients scheduled to undergo elective scoliosis correction were randomly assigned to receive either ten units of cryoprecipitate before incision (cryo group) or an equivalent volume of 0.9% saline (placebo group). Blood loss, transfusion requirements, coagulation parameters and complications were assessed. RESULTS No significant differences were found in the volume of transfused blood products, intraoperative estimated blood loss between the intervention and placebo groups. Postoperative blood loss was significantly lower in the cry group when compared to the other group. During adult surgical correction of scoliosis, prophylactic administration of cryoprecipitate did not diminish the amount of transfused blood products or decrease intraoperative blood loss. CONCLUSION It could be concluded that the prophylactic administration of cryoprecipitate shows no differences in intraoperative blood loss and transfusion requirements during scoliosis surgery.
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Affiliation(s)
- Tarek I Ismail
- Department of Anaesthesia and Surgical Intensive Care, Helwan University, Cairo, Egypt
| | - Rabab Ss Mahrous
- Department of Anaesthesia and Surgical Intensive Care, Alexandria University, Alexandria, Egypt
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2
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Curry N, Davenport R, Lucas J, Deary A, Benger J, Edwards A, Evans A, Foley C, Green L, Morris S, Thomas H, Brohi K, Stanworth SJ. The CRYOSTAT2 trial: The rationale and study protocol for a multi-Centre, randomised, controlled trial evaluating the effects of early high-dose cryoprecipitate in adult patients with major trauma haemorrhage requiring major haemorrhage protocol activation. Transfus Med 2023; 33:123-131. [PMID: 36321753 DOI: 10.1111/tme.12932] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 09/05/2022] [Accepted: 10/03/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVES To describe the protocol for a multinational randomised, parallel, superiority trial, in which patients were randomised to receive early high-dose cryoprecipitate in addition to standard major haemorrhage protocol (MHP), or Standard MHP alone. BACKGROUND Blood transfusion support for trauma-related major bleeding includes red cells, plasma and platelets. The role of concentrated sources of fibrinogen is less clear and has not been evaluated in large clinical trials. Fibrinogen is a key pro-coagulant factor that is essential for stable clot formation. A pilot trial had demonstrated that it was feasible to deliver cryoprecipitate as a source of fibrinogen within 90 min of admission. METHODS Randomisation was via opaque sealed envelopes held securely in participating Emergency Departments or transfusion laboratories. Early cryoprecipitate, provided as 3 pools (equivalent to 15 single units of cryoprecipitate or 6 g fibrinogen supplementation), was transfused as rapidly as possible, and started within 90 min of admission. Participants in both arms received standard treatment defined in the receiving hospital MHP. The primary outcome measure was all-cause mortality at 28 days. Symptomatic thrombotic events including venous thromboembolism and arterial thrombotic events (myocardial infarction, stroke) were collected from randomisation up to day 28 or discharge from hospital. EQ5D-5Land Glasgow Outcome Score were completed at discharge and 6 months. All analyses will be performed on an intention to treat basis, with per protocol sensitivity analysis. RESULTS The trial opened for recruitment in June 2017 and the final patient completed follow-up in May 2022. DISCUSSION This trial will provide firmer evidence to evaluate the effectiveness and cost-effectiveness of early high-dose cryoprecipitate alongside the standard MHP in major traumatic haemorrhage.
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Affiliation(s)
- Nicola Curry
- Oxford UniversityHospitals NHS Foundation Trust, Nuffield Orthopaedic Hospital, Oxford, UK
| | - Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Joanne Lucas
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Alison Deary
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Jonathan Benger
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Antoinette Edwards
- Trauma Audit and Research Network, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Amy Evans
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Claire Foley
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Laura Green
- Blizard Institute, Queen Mary University of London, London, UK
- NHS Blood and Transplant and Bart's Health NHS Trust, London, UK
| | - Stephen Morris
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Helen Thomas
- NHS Blood and Transplant Clinical Trials Unit, Bristol, UK
| | - Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Simon J Stanworth
- NHS Blood and Transplant and Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
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Gyi R, Cho BC, Hensley NB. Patient Blood Management in Vascular Surgery. Anesthesiol Clin 2022; 40:605-625. [PMID: 36328618 DOI: 10.1016/j.anclin.2022.08.007] [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] [Indexed: 06/16/2023]
Abstract
Patient blood management (PBM) is an evidence-based, multidisciplinary approach aimed at appropriately allocating blood products to patients requiring transfusion while simultaneously minimizing inappropriate transfusions. The 3 pillars of patient blood management are optimizing erythropoiesis, minimizing blood loss, and optimizing physiological reserve of anemia. Benefits seen from PBM include limiting hospital costs and mitigating harm from numerous risks of transfusion.
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Affiliation(s)
- Richard Gyi
- Department of Anesthesiology, Johns Hopkins Hospital, 1800 Orleans Avenue, Zayed Tower 6212, Baltimore, MD 21287, USA
| | - Brian C Cho
- Department of Anesthesiology, Johns Hopkins Hospital, 1800 Orleans Avenue, Zayed Tower 6212, Baltimore, MD 21287, USA; Division of Cardiothoracic Anesthesiology, Johns Hopkins University School of Medicine, 1800 Orleans Avenue, Zayed Tower 6212, Baltimore, MD 21287, USA
| | - Nadia B Hensley
- Division of Cardiothoracic Anesthesiology, Johns Hopkins University School of Medicine, 1800 Orleans Avenue, Zayed Tower 6212, Baltimore, MD 21287, USA.
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Dumitrescu G, Januszkiewicz A, Ågren A, Magnusson M, Sparrelid E, Rooyackers O, Wernerman J. Fibrinogen and albumin synthesis rates in major upper abdominal surgery. PLoS One 2022; 17:e0276775. [PMID: 36301906 PMCID: PMC9612515 DOI: 10.1371/journal.pone.0276775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 10/13/2022] [Indexed: 11/22/2022] Open
Abstract
Plasma fibrinogen and albumin concentrations initially decrease after abdominal surgery. On postoperative days 3-5 fibrinogen concentration returns to the preoperative level or even higher, while albumin stays low. It is not known if these altered plasma concentrations reflect changes in synthesis rate, utilization, or both. In particular a low albumin plasma concentration has often been attributed to a low synthesis rate, which is not always the case. The objective of this study was to determine fibrinogen and albumin quantitative synthesis rates in patients undergoing major upper abdominal surgery with and without intact liver size. Patients undergoing liver or pancreatic resection (n = 9+6) were studied preoperatively, on postoperative days 1 and 3-5. De novo synthesis of fibrinogen and albumin was determined; in addition, several biomarkers indicative of fibrinogen utilization were monitored. After hemihepatectomy, fibrinogen synthesis was 2-3-fold higher on postoperative day 1 than preoperatively. On postoperative days 3-5 the synthesis level was still higher than preoperatively. Following major liver resections albumin synthesis was not altered postoperatively compared to preoperative values. After pancreatic resection, on postoperative day 1 fibrinogen synthesis was 5-6-fold higher than preoperatively and albumin synthesis 1.5-fold higher. On postoperative days 3-5, synthesis levels returned to preoperative levels. Despite decreases in plasma concentrations, de novo synthesis of fibrinogen was markedly stimulated on postoperative day 1 after both hemihepatectomies and pancreatectomies, while de novo albumin synthesis remained grossly unchanged. The less pronounced changes seen following hepatectomies were possibly related to the loss of liver tissue.
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Affiliation(s)
- Gabriel Dumitrescu
- Division of Anaesthesia, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- * E-mail:
| | - Anna Januszkiewicz
- Division of Anaesthesia, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Anna Ågren
- Department of Molecular Medicine and Surgery, MMK, Clinical Chemistry and Coagulation, Karolinska Institutet, Stockholm, Sweden
| | - Maria Magnusson
- Department of Molecular Medicine and Surgery, MMK, Clinical Chemistry and Coagulation, Karolinska Institutet, Stockholm, Sweden
- Division of Paediatrics, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Ernesto Sparrelid
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Olav Rooyackers
- Division of Anaesthesia, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Jan Wernerman
- Division of Anaesthesia, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
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5
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Cryoprecipitate use during massive transfusion: A propensity score analysis. Injury 2022; 53:1972-1978. [PMID: 35241286 DOI: 10.1016/j.injury.2022.02.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 02/15/2022] [Accepted: 02/17/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Cryoprecipitate is frequently administered as an adjunct to balanced transfusion in the setting of traumatic hemorrhage. However, civilian studies have not demonstrated a clear survival advantage, and prior observational studies noted selection bias when analyzing cryoprecipitate use. Additionally, due to the logistics involved in cryoprecipitate administration, it is inconsistently implemented alongside standardized massive transfusion protocols. This study aims to evaluate the effects of early cryoprecipitate administration on inpatient mortality in the setting of massive transfusion for exsanguinating trauma and to use propensity score analysis to minimize selection bias. METHODS The registry of an urban level 1 trauma center was queried for adult patients who received at least 6 units of packed red blood cells within 4 h of presentation. Univariate analysis, multiple logistic regression, and propensity score matching were performed. RESULTS 562 patients were identified. Patients with lower median RTS (6.86 (IQR 4.09-7.84) vs 7.6 (IQR 5.97-7.84), P<0.01), decreased Glasgow coma scale (12 (IQR 4-15) vs 15 (IQR 10-15), P<0.01), and increased lactate (7.5 (IQR 4.3-10.2) vs 4.9 (IQR 3.1-7.2), P<0.01) were more commonly administered cryoprecipitate. Mortality was greater among those who received cryoprecipitate (40.2% vs 23.7%, p<0.01) on univariate analysis. Neither multiple logistic regression (OR 0.917; 95% confidence interval 0.462-1.822; p = 0.805) nor propensity score matching (average treatment effect on the treated 2.3%, p = 0.77) revealed that cryoprecipitate administration was associated with a difference in inpatient mortality. CONCLUSIONS Patients receiving cryoprecipitate within 4 h of presentation were more severely injured at presentation and had increased inpatient mortality. Multivariable logistic regression and propensity score analysis failed to show that early administration of cryoprecipitate was associated with survival benefit for exsanguinating trauma patients. The prospect of definitively assessing the utility of cryoprecipitate in exsanguinating hemorrhage warrants prospective investigation.
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Prophylactic fibrinogen concentrate administration in surgical correction of paediatric craniosynostosis: A double-blind placebo-controlled trial. Eur J Anaesthesiol 2021; 38:908-915. [PMID: 33009187 DOI: 10.1097/eja.0000000000001332] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Surgical craniosynostosis repair in children is associated with massive blood loss and significant transfusion of blood products. Fibrinogen concentrate is claimed to be useful in reducing blood loss and transfusion requirements. OBJECTIVE We investigated whether prophylactic administration of fibrinogen concentrate will reduce blood loss and transfusion requirements during paediatric craniofacial surgery. DESIGN Randomised, placebo-controlled, double-blind clinical trial. SETTING University medical centre. PATIENTS A total of 114 infants and children up to 25 months of age (median age 10 months). INTERVENTION Surgical craniosynostosis repair by calvarial remodelling was performed in each patient. Patients were randomised to receive prophylactic fibrinogen concentrate (Haemocomplettan P) at a mean dose of 79 mg kg-1 body weight or placebo. MAIN OUTCOME MEASURES Primary outcome was the volume of transfused blood products. Secondary outcomes were peri-operative blood loss, duration of surgery, length of stay in the paediatric ICU, length of hospital stay, postoperative complications and adverse effects of fibrinogen concentrate infusion. RESULTS No significant differences (P < 0.05) were found in the volume of transfused blood products (median 29 ml kg-1 body weight vs. 29 ml kg-1 body weight), intra-operative estimated blood loss (45 vs. 46 ml kg-1), calculated blood loss (57 vs. 53 ml kg-1), or postoperative blood loss (24 vs. 24 ml kg-1) between the intervention and placebo groups. In addition, duration of surgery, length of stay in the paediatric ICU, hospital stay and complications were not significantly different between the two groups. CONCLUSION During surgical craniosynostosis repair in young children, prophylactic administration of high-dose fibrinogen concentrate did not reduce the amount of transfused blood products or decrease peri-operative blood loss. TRIAL REGISTRATION National Trial Register (NTR2975) and EudraCT (2011-002287-24).
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Fibrinogen prophylaxis for reducing perioperative bleeding in patients undergoing radical cystectomy: A double-blind placebo-controlled randomized trial. J Clin Anesth 2021; 73:110373. [PMID: 34098395 DOI: 10.1016/j.jclinane.2021.110373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 04/28/2021] [Accepted: 04/30/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Excessive bleeding is an important complication of radical cystectomy. We aimed to assess whether preoperative administration of fibrinogen decreases perioperative bleeding and improves the outcome of radical cystectomy. DESIGN Double-blinded randomized trial with two parallel arms. SETTING The study was conducted in the department of surgery at a teaching hospital affiliated with a University of Medical Sciences. PATIENTS In total, 70 men undergoing radical cystectomy were randomized to fibrinogen (n = 35) and placebo-control groups. Mean (SD) age was 64.7 (7.4) years. INTERVENTIONS The intervention group received 2 g fibrinogen concentrate diluted in 100 ml distilled water, and the control group received 100 ml normal saline; both intravenously 15 ̶ 30 min before the start of the surgery. OUTCOME MEASURES The primary outcome was the amount of perioperative blood loss. The secondary outcomes were hemodynamic features and vital signs. MAIN RESULTS Fibrinogen significantly decreased the volume of blood loss (p < 0.001) and the total number of transfused packed-cell units per group (38 vs. 115 units); and compensated the decrease of HCO3 (p = 0.030), the mean arterial pressure (p < 0.001), hemoglobin O2 saturation (p = 0.001), heart rate (p < 0.001), and temperature (p < 0.001) throughout the surgery compared with the placebo. Patients in the fibrinogen group had shorter Intensive Care Unit (p = 0.001) and hospital (p < 0.001) stay. We did not find any adverse reaction in our patients receiving fibrinogen concentrate. CONCLUSION Fibrinogen concentrate reduces perioperative bleeding and the need for blood transfusion in radical cystectomy. It improves the outcomes of the surgery and decreases patients' length of stay in the healthcare system following radical cystectomy. REGISTRATION Iranian Registry of Clinical Trials (IRCT) http://www.irct.ir/, reference number: IRCT20191013045091N1. ETHICS CODE Shahid Beheshti University of Medical Sciences, reference number: IR.SBMU.RETECH.REC.1398.033.
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Barimani B, Moisan P, Santaguida C, Weber M. Therapeutic Application of Fibrinogen in Spine Surgery: A Review Article. Int J Spine Surg 2021; 15:549-561. [PMID: 33963032 PMCID: PMC8176831 DOI: 10.14444/8075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The aim of this review is to investigate current uses of fibrinogen as a tool to reduce operative and postoperative blood loss in different surgical fields especially orthopedic spine surgery. This is a systematic review. METHODS MEDLINE (via Ovid 1946 to June 1, 2020) and Embase (via Ovid 1947 to June 1, 2020) were searched using the keywords "fibrinogen", "surgery", and "spine" for relevant studies. The search strategy used text words and relevant indexing to identify articles discussing the use of fibrinogen to control surgical blood loss. RESULTS The original literature search yielded 407 articles from which 68 duplications were removed. Three hundred thirty-nine abstracts and titles were screened. Results were separated by surgical specialties. CONCLUSIONS Multiple studies have looked at the role of fibrinogen for acute bleeding in the operative setting. The current evidence regarding the use of fibrinogen concentrate in spine surgery is promising but limited, even though this is a field with the potential for severe hemorrhage. Further trials are required to understand the utility of fibrinogen concentrate as a first-line therapy in spine surgery and to understand the importance of target fibrinogen levels and subsequent dosing and administration to allow recommendations to be made in this field.
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Affiliation(s)
- Bardia Barimani
- Division of Orthopedic Surgery, McGill University, Montreal, Quebec, Canada
| | - Philippe Moisan
- Division of Orthopedic Surgery, McGill University, Montreal, Quebec, Canada
| | - Carlos Santaguida
- Department of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada
| | - Michael Weber
- Department of Surgery, McGill University, Montreal, Quebec, Canada
- Montreal General Hospital, Montreal, Quebec, Canada
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Ziegler B, Bachler M, Haberfellner H, Niederwanger C, Innerhofer P, Hell T, Kaufmann M, Maegele M, Martinowitz U, Nebl C, Oswald E, Schöchl H, Schenk B, Thaler M, Treichl B, Voelckel W, Zykova I, Wimmer C, Fries D. Efficacy of prehospital administration of fibrinogen concentrate in trauma patients bleeding or presumed to bleed (FIinTIC): A multicentre, double-blind, placebo-controlled, randomised pilot study. Eur J Anaesthesiol 2021; 38:348-357. [PMID: 33109923 PMCID: PMC7969176 DOI: 10.1097/eja.0000000000001366] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Trauma-induced coagulopathy (TIC) substantially contributes to mortality in bleeding trauma patients. OBJECTIVE The aim of the study was to administer fibrinogen concentrate in the prehospital setting to improve blood clot stability in trauma patients bleeding or presumed to bleed. DESIGN A prospective, randomised, placebo-controlled, double-blinded, international clinical trial. SETTING This emergency care trial was conducted in 12 Helicopter Emergency Medical Services (HEMS) and Emergency Doctors' vehicles (NEF or NAW) and four trauma centres in Austria, Germany and Czech Republic between 2011 and 2015. PATIENTS A total of 53 evaluable trauma patients aged at least 18 years with major bleeding and in need of volume therapy were included, of whom 28 received fibrinogen concentrate and 25 received placebo. INTERVENTIONS Patients were allocated to receive either fibrinogen concentrate or placebo prehospital at the scene or during transportation to the study centre. MAIN OUTCOME MEASURES Primary outcome was the assessment of clot stability as reflected by maximum clot firmness in the FIBTEM assay (FIBTEM MCF) before and after administration of the study drug. RESULTS Median FIBTEM MCF decreased in the placebo group between baseline (before administration of study treatment) and admission to the Emergency Department, from a median of 12.5 [IQR 10.5 to 14] mm to 11 [9.5 to 13] mm (P = 0.0226), but increased in the FC Group from 13 [11 to 15] mm to 15 [13.5 to 17] mm (P = 0.0062). The median between-group difference in the change in FIBTEM MCF was 5 [3 to 7] mm (P < 0.0001). Median fibrinogen plasma concentrations in the fibrinogen concentrate Group were kept above the recommended critical threshold of 2.0 g l-1 throughout the observation period. CONCLUSION Early fibrinogen concentrate administration is feasible in the complex and time-sensitive environment of prehospital trauma care. It protects against early fibrinogen depletion, and promotes rapid blood clot initiation and clot stability. TRIAL REGISTRY NUMBERS EudraCT: 2010-022923-31 and ClinicalTrials.gov: NCT01475344.
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Affiliation(s)
- Bernhard Ziegler
- From the Department of Anaesthesiology, Perioperative Medicine and General Intensive Care Medicine, Paracelsus Medical University, Salzburg (BZ), Department of General and Surgical Critical Care Medicine, (MB, BS, DF ), Department of Anaesthesiology and Intensive Care Medicine (HH, PI, MK, EO, MT, BT), Department of Pediatrics, Pediatrics I, Intensive Care Unit, Medical University of Innsbruck, Innsbruck (CN), Department of Mathematics, Faculty of Mathematics, Computer Science and Physics, University of Innsbruck, Technikerstrasse, Austria (TH), Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center (CMMC), University Witten/Herdecke (UW/H), Campus Cologne-Merheim, Cologne, Germany (MM), Institute of Thrombosis and Haemostasis and the National Haemophilia Centre, The Chaim Sheba Medical Centre, Tel Hashomer, Israel (UM), Sportclinic Zillertal GmbH, Mayrhofen, Austria (CN), Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Salzburg, Austria (HS, WV), Department of Anesthesiology and Intensive Care, Liberec Regional Hospital, Liberec, Czech Republic (IZ), Christophorus 14, Niederöblarn, Austria (CW)
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Efficacy of resuscitation with fibrinogen concentrate and platelets in traumatic hemorrhage swine model. J Trauma Acute Care Surg 2021; 89:S137-S145. [PMID: 32301889 DOI: 10.1097/ta.0000000000002736] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND This study compared the resuscitation effects of platelets and fibrinogen concentrate (FC) on coagulation and hemodynamics in pigs with traumatic hemorrhage and reduced platelet counts. METHODS Thirty pigs (40 ± 3 kg) were anesthetized and catheterized with an apheresis catheter to remove platelets using the Haemonetics 9000 (Haemonetics, Braintree, MA). Afterward, a femur fracture was induced, followed by hemorrhage of 35% the estimated blood volume. Pigs were then randomized to be resuscitated with 5% human albumin (12.5 mL/kg), FC (250 mg/kg, 12.5 mL/kg), or platelets collected from apheresis (11.0 ± 0.5 mL/kg). Animals were monitored for 2 hours or until death. Blood samples were collected before (baseline [BL]) and after apheresis, after hemorrhage, and after resuscitation to assess changes in hemodynamics and coagulation using Rotem. RESULTS No change in mean arterial pressure (MAP) or heart rate (HR) was observed by platelet apheresis. Hemorrhage reduced MAP to 57% ± 5% and elevated HR to 212% ± 20% of BL (both p < 0.05). Resuscitation with albumin, FC, or platelets did not revert MAP or HR to BL. Platelet counts were reduced by apheresis from BL 383 ± 20 × 10/μL to 141 ± 14 × 10/μL and were reduced further after resuscitation with albumin (88 ± 18 × 10/μL) or FC (97 ± 13 × 10/μL, all p < 0.05), but improved with platelet resuscitation (307 ± 24 × 10/μL). Fibrinogen concentration was reduced by apheresis from BL 225 ± 9 mg/dL to 194 ± 8 mg/dL, fell after albumin infusion (134 ± 11 mg/dL), increased to 269 ± 10 mg/dL after FC resuscitation (all p < 0.05), and was not affected by platelet resuscitation. Rotem α-angle decreased from 79 ± 2 degrees to 69 ± 1 degrees by apheresis and hemorrhage (p < 0.05), and recovered similarly by resuscitation with FC (87 ± 1 degrees) or platelets (78 ± 2 degrees), but not by albumin (63 ± 3 degrees). Similar responses were observed in Rotem maximum clot firmness. CONCLUSION In this traumatic hemorrhage swine model, low-volume resuscitation with FC or platelets was similarly effective in restoring coagulation.
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Almeida ND, Lee R, Wei C, Lee D, Asif U, Almeida NC, Klein AL, Hogan E, Sack K, Sherman JH. Coagulation Profile as a Significant Risk Factor for Short-Term Complications and Mortality after Anterior Cervical Discectomy and Fusion. World Neurosurg 2020; 148:e74-e86. [PMID: 33307267 DOI: 10.1016/j.wneu.2020.12.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 11/30/2020] [Accepted: 12/01/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Cervical degenerative disc disease is the most common indication for anterior cervical discectomy and fusion. Given the possible complications, patients are stratified before anterior cervical discectomy and fusion by preoperative risk factors to optimize treatment. One preoperative factor is a patient's coagulation profile. METHODS The American College of Surgeons-National Surgical Quality Improvement Database was used to identify patient preoperative coagulation profile and postoperative complications. By generating binary logistic regression models, each of the 4 abnormal coagulation categories (bleeding disorder, low platelet count, high partial thromboplastin time, and high international normalized ratio [INR]) were analyzed for their independent impact on increased risk for complications compared with the control cohort. RESULTS A total of 61,977 patients were assessed. The most common abnormal coagulation was abnormal platelet count (n = 2149). The most common postoperative outcome was an extended length of hospital stay among patients with an abnormal coagulation profile relative to the control cohort. After multivariate analysis, patients with an abnormal INR (odds ratio, 2.2 [1.3-3.8]; P = 0.003) or abnormal platelet count (odds ratio, 1.5 [1.2-2.1]; P = 0.003) had a higher chance of having an extended length of hospital stay relative to patients having a normal coagulation profile. Having an abnormal INR was found to be associated with an increased risk for having "Any complication." CONCLUSIONS Our results show significant differences in the incidence rates of a multitude of complications among the 5 groups based on univariate analysis. Patients with any abnormal coagulation disorder had increased rates of developing any complication or having an extended length of hospital stay.
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Affiliation(s)
- Neil D Almeida
- George Washington University School of Medicine and Health Sciences, George Washington University in Washington, Washington, District of Columbia, USA
| | - Ryan Lee
- George Washington University School of Medicine and Health Sciences, George Washington University in Washington, Washington, District of Columbia, USA
| | - Chapman Wei
- George Washington University School of Medicine and Health Sciences, George Washington University in Washington, Washington, District of Columbia, USA
| | - Danny Lee
- George Washington University School of Medicine and Health Sciences, George Washington University in Washington, Washington, District of Columbia, USA
| | - Usman Asif
- George Washington University School of Medicine and Health Sciences, George Washington University in Washington, Washington, District of Columbia, USA
| | - Nyle C Almeida
- University of Oklahoma College of Medicine, University of Oklahoma in Oklahoma City, Oklahoma, USA
| | - Andrea L Klein
- George Washington University School of Medicine and Health Sciences, George Washington University in Washington, Washington, District of Columbia, USA
| | - Elizabeth Hogan
- Department of Neurosurgery, George Washington University Hospital in Washington, Washington, District of Columbia, USA
| | - Kenneth Sack
- Department of Neurosurgery, George Washington University Hospital in Washington, Washington, District of Columbia, USA
| | - Jonathan H Sherman
- Department of Neurological Surgery, West Virginia University, Berkeley Medical Center, Martinsburg, West Virginia, USA.
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Ng KT, Yap JLL, Kwok PE. The effect of fibrinogen concentrate on postoperative blood loss: A systematic review and meta-analysis of randomized controlled trials. J Clin Anesth 2020; 63:109782. [DOI: 10.1016/j.jclinane.2020.109782] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 02/01/2020] [Accepted: 03/07/2020] [Indexed: 12/29/2022]
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Leal-Noval SR, Fernández Pacheco J, Casado Méndez M, Cuenca-Apolo D, Múñoz-Gómez M. Current perspective on fibrinogen concentrate in critical bleeding. Expert Rev Clin Pharmacol 2020; 13:761-778. [PMID: 32479129 DOI: 10.1080/17512433.2020.1776608] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION . Massive hemorrhage continues to be a treatable cause of death. Its management varies from prefixed ratio-driven administration of blood components to goal-directed therapy based on point-of-care testing and administration of coagulation factor concentrates. AREAS COVERED . We review the current role of fibrinogen concentrate (FC) for the management of massive hemorrhage, either administered without coagulation testing in life-threatening hemorrhage, or within an algorithm based on viscoelastic hemostatic assays and plasma fibrinogen level. We identified relevant guidelines, meta-analyzes, randomized controlled trials, and observational studies that included indications, dosage, and adverse effects of FC, especially thromboembolic events. EXPERT OPINION . Moderate- to high-grade evidence supports the use of FC for the treatment of severe hemorrhage in trauma and cardiac surgery; a lower grade of evidence is available for its use in postpartum hemorrhage and end-stage liver disease. Pre-emptive FC administration in non-bleeding patients is not recommended. FC should be administered early, in a goal-directed manner, guided by early amplitude of clot firmness parameters (A5- or A10-FIBTEM) or hypofibrinogenemia. Further investigation is required into the early use of FC, as well as its potential advantages over cryoprecipitate, and whether or not its administration at high doses leads to a greater risk of adverse events.
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Affiliation(s)
- Santiago R Leal-Noval
- Neuro Critical Care Department, University Hospital "Virgen Del Rocío" and Institute of Biomedicine "IBIS" , 41013, Seville, Spain
| | - Jose Fernández Pacheco
- Pharmacy and Statistics and Design, University Hospital "Virgen Del Rocío" and Institute of Biomedicine "IBIS" , 41013, Seville, Spain
| | - Manuel Casado Méndez
- Critical Care Department, University Hospital "Virgen Del Rocío" and Institute of Biomedicine "IBIS" , 41013, Seville, Spain
| | - Diego Cuenca-Apolo
- Critical Care Department, University Hospital "Virgen Del Rocío" and Institute of Biomedicine "IBIS" , 41013, Seville, Spain
| | - Manuel Múñoz-Gómez
- Department of Surgical Specialties, Biochemistry and Immunology, University of Málaga , 29071, Málaga, Spain
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Is Fresh Frozen Plasma Still Necessary for Management of Acute Traumatic Coagulopathy? CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00397-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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15
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Modified ROTEM for the detection of rivaroxaban and apixaban anticoagulant activity in whole blood. Eur J Anaesthesiol 2019; 36:449-456. [DOI: 10.1097/eja.0000000000000903] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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16
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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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Fabes J, Brunskill SJ, Curry N, Doree C, Stanworth SJ. Pro-coagulant haemostatic factors for the prevention and treatment of bleeding in people without haemophilia. Cochrane Database Syst Rev 2018; 12:CD010649. [PMID: 30582172 PMCID: PMC6517302 DOI: 10.1002/14651858.cd010649.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Some hospital patients may be at risk of or may present with major bleeding. Abnormalities of clotting (coagulation) are often recorded in these people, and the traditional management has been with transfusions of blood components, either to prevent bleeding (prophylactic) or to treat bleeding (therapeutic). There is growing interest in the use of targeted therapies with specific pro-coagulant haemostatic (causing bleeding to stop and to keep blood within a damaged blood vessel) factor concentrates in place of plasma. OBJECTIVES To assess the effects and safety of pro-coagulant haemostatic factors and factor concentrates in the prevention and treatment of bleeding in people without haemophilia. SEARCH METHODS We searched for randomised controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (2018, issue 3), MEDLINE (from 1948), Embase (from 1974), CINAHL (from 1938), PubMed (publications in process to 18 April 2018), PROSPERO, Transfusion Evidence Library (from 1950), LILACS (from 1980), IndMED (from 1985), KoreaMed (from 1934), Web of Science Conference Proceedings Citation Index (from 1990) and ongoing trial databases to 18 April 2018. SELECTION CRITERIA We included RCTs that compared intravenous administration of a pro-coagulant haemostatic factor concentrate, either with placebo, current best or standard treatment, or another pro-coagulant haemostatic factor concentrate for prevention or treatment of bleeding. There was no restriction on the types of participants. We excluded studies of desmopressin, tranexamic acid and aminocaproic acid and use of pro-coagulant haemostatic factors for vitamin K over-anticoagulation. DATA COLLECTION AND ANALYSIS We followed standard Cochrane methodological procedures. MAIN RESULTS We identified 31 RCTs with 2392 participants and 22 ongoing trials. There were 13 therapeutic RCTs that randomised 1057 participants (range from 20 to 249 participants) and 18 prophylactic trials that randomised 1335 participants (range 20 to 479 participants). The pro-coagulant haemostatic factor concentrate was fibrinogen in 23 trials, Factor XIII in seven trials and pro-thrombin complex concentrates (PCC) in one trial.Seventeen trials had industrial funding or support, eight studies either did not declare their funding or were unclear about their source of funding and six studies declared non-industrial funding sources.Certainty in the evidence and included study biasOur certainty in the evidence, using GRADE criteria, ranged from very low to high across all outcomes. We assessed most outcomes as being of low certainty. Risks of bias were a concern in many of the RCTs; randomisation methodology was unclear in 15 RCTs, with allocation concealment unclear in 14 RCTs and at high risk of bias in five RCTs. The blinding status of outcome assessors was unclear in 13 RCTs and at high risk of bias in five RCTs, although most outcomes in these trials were objective and not prone to observer bias. Study personnel were often unblinded or insufficient information was available to assess their level of blinding (five RCTs were at unclear risk and seven at high risk of bias).Primary outcomesAll-cause mortality was reported by 21 RCTs, arterial thromboembolic events by 22 RCTs, and venous thromboembolic events by 21 RCTs.Fibrinogen concentrate: prophylactic trials with inactive comparator (nine RCTs)The trials had heterogeneous clinical settings and outcome time points, so we did not pool the data. Compared to placebo, there was no evidence that prophylactic fibrinogen concentrate reduced all-cause mortality (4 RCTs; 248 participants). Compared to inactive comparators there was low- to moderate-quality evidence that prophylactic fibrinogen concentrate did not increase the risk of arterial or venous thromboembolic complications (7 RCTs; 398 participants).Fibrinogen concentrate: prophylactic trials with active comparator (two RCTs)There was no mortality or incidence of thromboembolic events in these two RCTs (with 57 participants).Fibrinogen concentrate: therapeutic trials with inactive comparator (eight RCTs)The trials had heterogeneous surgical settings and outcome time points, so we pooled data for subgroups only. Compared to an inactive comparator, there was no evidence (quality ranging from low to high) that fibrinogen concentrate reduced all-cause mortality in actively bleeding participants (7 RCTs; 724 participants). Compared to inactive comparators there was no evidence that the use of fibrinogen concentrate in active bleeding increased arterial (7 RCTs; 607 participants) or venous (6 RCTs; 562 participants) thromboembolic events.Fibrinogen concentrate: therapeutic trials with active comparator (four RCTs)We did not pool the outcome data, as they were not measured at comparable time points. Compared to other active pro-coagulant agents, there was no evidence (very low to moderate quality) that fibrinogen concentrate reduced all-cause mortality in actively bleeding participants (4 RCTs; 220 participants). There was no evidence that fibrinogen concentrate increased the risk of arterial (3 RCTs; 126 participants) or venous (4 RCTs; 220 participants) thromboembolic events.FactorXIII: Prophylactic trials with inactive comparator (six trials)The trials were heterogeneous in their surgical settings and time points for outcome analysis, so we pooled data for subgroups only. Compared to an inactive comparator, there was no evidence that prophylactic Factor XIII reduced all-cause mortality (5 RCTs; 414 participants). There was no evidence (very low to low quality) of a difference in the arterial or venous event rate between Factor XIII and inactive comparators (4 trials; 354 participants).FactorXIII: therapeutic trials with inactive comparator (one trial)There was no mortality or incidence of thromboembolic events in this trial.Prothrombin complex concentrate (PCC): prophylactic trials with inactive comparator (one trial)There was no evidence (moderate quality) that PCC reduced all-cause mortality (1 trial; 78 participants). No thromboembolic complications were reported in this trial. AUTHORS' CONCLUSIONS The paucity of good-quality comparable evidence precludes the drawing of conclusions for clinical practice. Further research is required to determine the risk-to-benefit ratio of these interventions. The sample sizes of future RCTs would need to be greatly increased to detect a reduction in mortality or thromboembolic events between treatment arms. To improve consistency in outcome reporting, the development of core outcome sets is essential and may help address a number of the limitations identified in this review.
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Affiliation(s)
- Jez Fabes
- John Radcliffe HospitalOxfordUKOX3 9DU
| | - Susan J Brunskill
- NHS Blood and TransplantSystematic Review InitiativeLevel 2, John Radcliffe HospitalHeadingtonOxfordOxonUKOX3 9BQ
| | - Nicola Curry
- Churchill HospitalOxford Haemophilia & Thrombosis CentreOld RoadHeadingtonOxfordUKOX3 7LE
| | - Carolyn Doree
- NHS Blood and TransplantSystematic Review InitiativeLevel 2, John Radcliffe HospitalHeadingtonOxfordOxonUKOX3 9BQ
| | - Simon J Stanworth
- Oxford University Hospitals NHS Foundation Trust and University of OxfordNational Institute for Health Research (NIHR) Oxford Biomedical Research CentreJohn Radcliffe Hospital, Headley WayHeadingtonOxfordUKOX3 9BQ
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18
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Deng Q, Hao F, Wang Y, Guo C. Rotation thromboelastometry (ROTEM) enables improved outcomes in the pediatric trauma population. J Int Med Res 2018; 46:5195-5204. [PMID: 30200794 PMCID: PMC6300942 DOI: 10.1177/0300060518794092] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Objective We evaluated the role of rotation thromboelastometry (ROTEM) in managing acute traumatic coagulopathy in pediatric patients with trauma. Methods A retrospective cohort of pediatric patients with trauma from six institutes was studied during a 10-year period from 2007 to 2017. The associations between ROTEM-guided, goal-directed coagulation therapy and clinical outcomes were determined. Results Three hundred thirty-two pediatric patients (age < 15 years) who were treated with ROTEM-guided, goal-directed coagulation therapy were matched to 332 control pediatric patients with conventional plasmatic coagulation tests. The ROTEM protocol was associated with a significant reduction in the interval for admission to acute traumatic coagulopathy treatment, less plasma transfusions in the first 24 hours of admission, and a favorable coagulopathy recovery. Furthermore, the median number of total hospital days was significantly shorter for patients who had the ROTEM protocol than for control patients. Conclusions There are significant favorable outcomes, including rapid acute traumatic coagulopathy treatment and a lower 24-hour blood product requirement, following ROTEM-guided, goal-directed coagulation therapy among pediatric patients with blunt trauma.
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Affiliation(s)
- Qin Deng
- 1 Department of Pediatric General Surgery and Liver Transplantation, Children's Hospital, Chongqing Medical University, Chongqing, China
| | - Fabao Hao
- 1 Department of Pediatric General Surgery and Liver Transplantation, Children's Hospital, Chongqing Medical University, Chongqing, China.,2 Department of Neonatology, Children's Hospital, Chongqing Medical University, Chongqing, China
| | - Yongming Wang
- 1 Department of Pediatric General Surgery and Liver Transplantation, Children's Hospital, Chongqing Medical University, Chongqing, China.,2 Department of Neonatology, Children's Hospital, Chongqing Medical University, Chongqing, China
| | - Chunbao Guo
- 1 Department of Pediatric General Surgery and Liver Transplantation, Children's Hospital, Chongqing Medical University, Chongqing, China.,3 Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital, Chongqing Medical University, Chongqing, China
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19
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Samama CM, Ickx B, Ozier Y, Steib A, Susen S, Godier A. The place of fibrinogen concentrates in the management of perioperative bleeding: A position paper from the Francophone Working Group on Perioperative Haemostasis (GIHP). Anaesth Crit Care Pain Med 2018; 37:355-365. [DOI: 10.1016/j.accpm.2018.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Accepted: 04/02/2018] [Indexed: 01/05/2023]
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20
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Curry N, Foley C, Wong H, Mora A, Curnow E, Zarankaite A, Hodge R, Hopkins V, Deary A, Ray J, Moss P, Reed MJ, Kellett S, Davenport R, Stanworth S. Early fibrinogen concentrate therapy for major haemorrhage in trauma (E-FIT 1): results from a UK multi-centre, randomised, double blind, placebo-controlled pilot trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:164. [PMID: 29914530 PMCID: PMC6006766 DOI: 10.1186/s13054-018-2086-x] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 05/28/2018] [Indexed: 12/16/2022]
Abstract
Background There is increasing interest in the timely administration of concentrated sources of fibrinogen to patients with major traumatic bleeding. Following evaluation of early cryoprecipitate in the CRYOSTAT 1 trial, we explored the use of fibrinogen concentrate, which may have advantages of more rapid administration in acute haemorrhage. The aims of this pragmatic study were to assess the feasibility of fibrinogen concentrate administration within 45 minutes of hospital admission and to quantify efficacy in maintaining fibrinogen levels ≥ 2 g/L during active haemorrhage. Methods We conducted a blinded, randomised, placebo-controlled trial at five UK major trauma centres with adult trauma patients with active bleeding who required activation of the major haemorrhage protocol. Participants were randomised to standard major haemorrhage therapy plus 6 g of fibrinogen concentrate or placebo. Results Twenty-seven of 39 participants (69%; 95% CI, 52–83%) across both arms received the study intervention within 45 minutes of admission. There was some evidence of a difference in the proportion of participants with fibrinogen levels ≥ 2 g/L between arms (p = 0.10). Fibrinogen levels in the fibrinogen concentrate (FgC) arm rose by a mean of 0.9 g/L (SD, 0.5) compared with a reduction of 0.2 g/L (SD, 0.5) in the placebo arm and were significantly higher in the FgC arm (p < 0.0001) at 2 hours. Fibrinogen levels were not different at day 7. Transfusion use and thromboembolic events were similar between arms. All-cause mortality at 28 days was 35.5% (95% CI, 23.8–50.8%) overall, with no difference between arms. Conclusions In this trial, early delivery of fibrinogen concentrate within 45 minutes of admission was not feasible. Although evidence points to a key role for fibrinogen in the treatment of major bleeding, researchers need to recognise the challenges of timely delivery in the emergency setting. Future studies must explore barriers to rapid fibrinogen therapy, focusing on methods to reduce time to randomisation, using ‘off-the-shelf’ fibrinogen therapies (such as extended shelf-life cryoprecipitate held in the emergency department or fibrinogen concentrates with very rapid reconstitution times) and limiting the need for coagulation test-based transfusion triggers. Trial registration ISRCTN67540073. Registered on 5 August 2015.
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Affiliation(s)
- Nicola Curry
- Department of Haematology, Oxford Haemophilia & Thrombosis Centre, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK. .,NIHR BRC Blood Theme, Oxford University, Oxford, UK.
| | - Claire Foley
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, Bristol, UK
| | - Henna Wong
- Department of Haematology, Oxford Haemophilia & Thrombosis Centre, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK.,NIHR BRC Blood Theme, Oxford University, Oxford, UK.,Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Ana Mora
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, Bristol, UK
| | - Elinor Curnow
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, Bristol, UK
| | - Agne Zarankaite
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, Bristol, UK
| | - Renate Hodge
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, Bristol, UK
| | - Valerie Hopkins
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, Bristol, UK
| | - Alison Deary
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, Bristol, UK
| | - James Ray
- Department of Emergency Medicine, John Radcliffe Hospital, Oxford, UK
| | - Phil Moss
- Department of Emergency Medicine, St. George's Hospital, London, UK
| | - Matthew J Reed
- Emergency Medicine Research Group Edinburgh (EMERGE), Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Suzanne Kellett
- Department of Anaesthetics, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Simon Stanworth
- Department of Haematology, Oxford Haemophilia & Thrombosis Centre, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK.,NIHR BRC Blood Theme, Oxford University, Oxford, UK.,Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK.,NHS Blood and Transplant, John Radcliffe Hospital, Oxford, UK
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21
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Martini WZ, Guzman RD, Dubick MA. Stability of Fibrinogen Concentrate in Human Blood Samples: An In Vitro Study. Mil Med 2018; 183:183-188. [DOI: 10.1093/milmed/usx176] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Indexed: 01/24/2023] Open
Affiliation(s)
- Wenjun Z Martini
- U.S. Army Institute of Surgical Research, Joint Base San Antonio, 3650 Chambers Pass, Fort Sam Houston, TX 78234-6135
| | - Rodolfo de Guzman
- U.S. Army Institute of Surgical Research, Joint Base San Antonio, 3650 Chambers Pass, Fort Sam Houston, TX 78234-6135
| | - Michael A Dubick
- U.S. Army Institute of Surgical Research, Joint Base San Antonio, 3650 Chambers Pass, Fort Sam Houston, TX 78234-6135
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The use of viscoelastic haemostatic assays in non-cardiac surgical settings: a systematic review and meta-analysis. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2018. [PMID: 29517964 DOI: 10.2450/2018.0040-18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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23
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Shabanova EM, Drozdov AS, Fakhardo AF, Dudanov IP, Kovalchuk MS, Vinogradov VV. Thrombin@Fe 3O 4 nanoparticles for use as a hemostatic agent in internal bleeding. Sci Rep 2018; 8:233. [PMID: 29321571 PMCID: PMC5762673 DOI: 10.1038/s41598-017-18665-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 12/05/2017] [Indexed: 12/21/2022] Open
Abstract
Bleeding remains one of the main causes of premature mortality at present, with internal bleeding being the most dangerous case. In this paper, magnetic hemostatic nanoparticles are shown for the first time to assist in minimally invasive treatment of internal bleeding, implying the introduction directly into the circulatory system followed by localization in the bleeding zone due to the application of an external magnetic field. Nanoparticles were produced by entrapping human thrombin (THR) into a sol-gel derived magnetite matrix followed by grinding to sizes below 200 nm and subsequent colloidization. Prepared colloids show protrombotic activity and cause plasma coagulation in in vitro experiments. We also show here using a model blood vessel that the THR@ferria composite does not cause systematic thrombosis due to low activity, but being concentrated by an external magnetic field with simultaneous fibrinogen injection accelerates local hemostasis and stops the bleeding. For instance, a model vessel system with circulating blood at the puncture of the vessel wall and the application of a permanent magnetic field yielded a hemostasis time by a factor of 6.5 shorter than that observed for the control sample. Biocompatibility of composites was tested on HELF and HeLa cells and revealed no toxic effects.
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Affiliation(s)
- Emiliya M Shabanova
- ITMO University, Laboratory of Solution Chemistry of Advanced Materials and Technologies, Lomonosova St. 9, 191002, St. Petersburg, Russian Federation
| | - Andrey S Drozdov
- ITMO University, Laboratory of Solution Chemistry of Advanced Materials and Technologies, Lomonosova St. 9, 191002, St. Petersburg, Russian Federation.
| | - Anna F Fakhardo
- ITMO University, Laboratory of Solution Chemistry of Advanced Materials and Technologies, Lomonosova St. 9, 191002, St. Petersburg, Russian Federation
| | - Ivan P Dudanov
- ITMO University, Laboratory of Solution Chemistry of Advanced Materials and Technologies, Lomonosova St. 9, 191002, St. Petersburg, Russian Federation
- Mariinsky Hospital, Regional Cardiovascular Center, Liteyny Ave. 56, 191054, St. Petersburg, Russian Federation
| | - Marina S Kovalchuk
- Mariinsky Hospital, Regional Cardiovascular Center, Liteyny Ave. 56, 191054, St. Petersburg, Russian Federation
| | - Vladimir V Vinogradov
- ITMO University, Laboratory of Solution Chemistry of Advanced Materials and Technologies, Lomonosova St. 9, 191002, St. Petersburg, Russian Federation.
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Rieg A, Rossaint R, Braunschweig T, Spronk H, ten Cate H, van Oerle R, Tolba R, Honickel M, Grottke O. Prothrombin complex concentrate reduces blood loss and enhances thrombin generation in a pig model with blunt liver injury under severe hypothermia. Thromb Haemost 2017; 106:724-33. [DOI: 10.1160/th11-02-0101] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2011] [Accepted: 07/18/2011] [Indexed: 01/05/2023]
Abstract
SummaryAlthough prothrombin complex concentrate (PCC) is increasingly used for the treatment of trauma-induced coagulopathy, few studies have investigated the impact and safety of PCC for this indication. The present study was performed to assess PCC for treatment of coagulopathy after blunt liver injury under severe hypothermia. Coagulopathy in 14 anaesthetised pigs was induced by haemodilution. Subsequently, standardised blunt liver injury was induced under severe hypothermia (32.8–33.2°C). Animals were randomised to receive either PCC (35 IU kg-1) or saline (control). Coagulation was assessed over the following 2 hours by thromboelastometry and thrombin generation. Internal organs were examined to determine presence of emboli. The administration of PCC showed a significant reduction in blood loss (p=0.002 vs. controls) and a significant increase in the rate of survival (p=0.022 vs. controls). Plasma thrombin generation in the PCC group increased considerably above baseline levels, with significant increases in peak thrombin levels and endogenous thrombin potential versus controls throughout the follow-up period. In addition, PT decreased significantly in the PCC group versus the control group. However, only slight improvements in thromboelastometry variables were observed. Histology showed an equal degree of liver injury in both groups, and no thromboembolism. In severely hypothermic pigs, the application of PCC corrected trauma-induced coagulopathy and reduced blood loss. Thus, the infusion of PCC might be a reasonable approach to reduce the need for blood cell transfusion in trauma. Furthermore, the impact and safety of PCC application can be monitored through thrombin generation and thromboelastometry under hypothermia.Note: This study was performed at the RWTH Aachen University Hospital, Pauwelsstrasse 30, D-52074 Aachen, Germany.
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Holck MH, Christensen TD, Hvas AM. Influence of selected antithrombotic treatment on thromboelastometric results. Scandinavian Journal of Clinical and Laboratory Investigation 2017; 78:11-17. [DOI: 10.1080/00365513.2017.1403038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Mia Hammer Holck
- Department of Clinical Biochemistry, Centre of Haemophilia and Thrombosis, Aarhus University Hospital, Aarhus, Denmark
- Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Thomas Decker Christensen
- Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Anne-Mette Hvas
- Department of Clinical Biochemistry, Centre of Haemophilia and Thrombosis, Aarhus University Hospital, Aarhus, Denmark
- Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Christensen TD, Vad H, Pedersen S, Licht PB, Nybo M, Hornbech K, Zois NE, Hvas AM. Coagulation profile in open and video-assisted thoracoscopic lobectomies: a cohort study. Interact Cardiovasc Thorac Surg 2017; 26:382-388. [DOI: 10.1093/icvts/ivx328] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 09/06/2017] [Indexed: 11/14/2022] Open
Affiliation(s)
- Thomas Decker Christensen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik Vad
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Søren Pedersen
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Peter B Licht
- Department of Cardiothoracic and Vascular Surgery, Odense University Hospital, Odense, Denmark
| | - Mads Nybo
- Department of Clinical Biochemistry, Odense University Hospital, Odense, Denmark
| | - Kåre Hornbech
- Department of Cardiothoracic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Nora Elisabeth Zois
- Department of Clinical Biochemistry, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Anne-Mette Hvas
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
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Balendran CA, Henderson N, Olsson M, Lövgren A, Hansson KM. Preclinical evaluation of point-of-care prothrombin time as a biomarker test to guide prothrombin replacement therapy in coagulopathic bleeding. Res Pract Thromb Haemost 2017; 1:252-258. [PMID: 30046694 PMCID: PMC6058266 DOI: 10.1002/rth2.12027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 06/13/2017] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Hemorrhage is still a common cause of death in trauma. Central lab measured prothrombin time (lab PT) is predictive of low prothrombin concentration and clinical outcome in trauma patients, however, treatment guidance is limited by slow turnaround times. Here, we have preclinically evaluated the potential of a point-of-care prothrombin time test (POC PT) as a faster alternative to identify patients with low prothrombin concentration. METHODS Human whole blood was serially diluted and prothrombin time measured by POC PT (CoaguChek XS Pro, Roche) and lab PT. Recombinant human prothrombin (MEDI8111) was added to human whole blood with or without depletion of prothrombin by pretreatment with prothrombin neutralizing antibodies. RESULTS There was no observable difference in the sensitivity of either test to dilution at blood volumes of 60-100%. At blood volumes of ≤55% (equivalent to 47 mg/L prothrombin), PT sharply increased, with greater dilutional sensitivity observed in the POC test. Both tests were insensitive to prothrombin up to 194 mg/L added MEDI8111 (equivalent to 328 mg/L prothrombin versus endogenous concentration of 129 mg/L). Depletion of endogenous prothrombin inversely correlated with an increase in PT which returned to baseline following addition of 97 mg/L MEDI8111 or above. Both assays correlated well above 48.5 mg/L added MEDI8111 (65.9 mg/L prothrombin). CONCLUSIONS Our data supports that POC PT tests, such as the CoaguChek XS Pro, are fit for purpose to confirm a coagulopathic threshold for prothrombin and provide a fast, simple, and mobile method to guide MEDI8111 therapy in bleeding trauma patients.
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Affiliation(s)
- Clare A. Balendran
- Personalised Healthcare & BiomarkersInnovative Medicines and Early Biotech UnitAstraZenecaMölndalSweden
| | - Neil Henderson
- Personalised Healthcare & BiomarkersInnovative Medicines and Early Biotech UnitAstraZenecaMölndalSweden
| | - Marita Olsson
- Early Clinical Development, Innovative Medicines and Early Development Biotech UnitAstraZenecaMölndalSweden
| | | | - Kenny M. Hansson
- Cardiovascular and Metabolic DiseasesInnovative Medicines and Early Development Biotech UnitAstraZenecaMölndalSweden
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Wong H, Curry N. Do we need cryoprecipitate in the era of fibrinogen concentrate and other specific factor replacement options? ACTA ACUST UNITED AC 2017. [DOI: 10.1111/voxs.12376] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- H. Wong
- Department of Haematology; University of Oxford; Oxford UK
- Oxford Haemophilia & Thrombosis Centre; Oxford University Hospitals NHS Foundation Trust and Oxford NIHR BRC Blood Theme; Oxford UK
| | - N. Curry
- Oxford Haemophilia & Thrombosis Centre; Oxford University Hospitals NHS Foundation Trust and Oxford NIHR BRC Blood Theme; Oxford UK
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Influences of limited resuscitation with plasma or plasma protein solutions on hemostasis and survival of rabbits with noncompressible hemorrhage. J Trauma Acute Care Surg 2017; 81:42-9. [PMID: 27120325 DOI: 10.1097/ta.0000000000001091] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Plasma infusion with or without red blood cells is the current military standard of care for prehospital resuscitation of combat casualties. We examined possible advantages of early and limited resuscitation with fresh plasma compared with a single plasma protein or crystalloid solutions in an uncontrolled hemorrhage model in rabbits. METHODS Anesthetized spontaneously breathing rabbits (3.3 ± 0.1 kg) were instrumented and subjected to a splenic uncontrolled hemorrhage. Rabbits in shock were resuscitated at 15 minutes with Plasma-Lyte (PAL; 30 mL/kg), PAL + fibrinogen (PAL + F; 30 mL + 100 mg/kg), fresh rabbit plasma (15 mL/kg), or 25% albumin (ALB; 5 mL/kg) solution, all given in two bolus intravenous injections (15 minutes apart) to achieve a mean arterial pressure of 65 mm Hg, n = 8 to 9/group. Animals were monitored for 2 hours or until death, and blood loss was measured. Blood samples and tissues were collected and analyzed. RESULTS There were no differences among groups in baseline measures and their initial bleeding volume at 15 minutes. At 60 minutes after injury, mean arterial pressure was higher with ALB than with crystalloids (PAL or PAL + F), but shock indices were not different despite the large differences in resuscitation volumes. Fibrinogen addition to PAL only increased clot strength. Plasma resuscitation increased survival rate (75%) without significant improvement in coagulation measures. Albumin administration replenished total plasma protein and increased survival rate to 100% (p < .05 vs. crystalloids). No histological adverse events were identified in the vital organs. CONCLUSIONS Fibrinogen administration added to a compatible crystalloid did not improve hemostatic outcomes. Plasma resuscitation increased survival rate; however, its effects did not differ from those obtained with 25% ALB at one-third of the volume. The ALB advantage was consistent with our previous findings in which 5% ALB was used at a volume equal to plasma. The benefit of plasma for resuscitation may be mostly due to its ALB content rather than its coagulation proteins.
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Maegele M. Coagulation factor concentrate-based therapy for remote damage control resuscitation (RDCR): a reasonable alternative? Transfusion 2017; 56 Suppl 2:S157-65. [PMID: 27100752 DOI: 10.1111/trf.13526] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 01/06/2016] [Accepted: 01/11/2016] [Indexed: 12/11/2022]
Abstract
The concept of remote damage control resuscitation (RDCR) is still in its infancy and there is significant work to be done to improve outcomes for patients with life-threatening bleeding secondary to injury. The prehospital phase of resuscitation is critical and if shock and coagulopathy can be rapidly minimized before hospital admission this will very likely reduce morbidity and mortality. The optimum transfusion strategy for these patients is still highly debated and the potential implications of the recently published pragmatic, randomize, optimal platelet, and plasma ratios trial (PROPPR) for RDCR have been reviewed. Identifying the appropriate transfusion strategy is mandatory before adopting prehospital hemostatic resuscitation strategies. An alternative approach is based on the early administration of coagulation factor concentrates combined with the antifibrinolytic tranexamic acid (TXA). The three major components to this approach in the context of RDCR target the following steps to achieve hemostasis: 1) stop (hyper)fibrinolysis; 2) support clot formation; and 3) increase thrombin generation. Strong evidence exists for the use of TXA. The data from the prospective fibrinogen in trauma induced coagulopathy (FIinTIC) study will inform on the prehospital use of fibrinogen in bleeding trauma patients. Deficits in thrombin generation may be addressed by the administration of prothrombin complex concentrates. Handheld point-of-care devices may be able to support and guide the prehospital and remote use of intravenous hemostatic agents including coagulation factor concentrates along with clinical presentation, assessment, and the extent of bleeding. Combinations may even be more effective for bleeding control. More studies are urgently needed.
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Affiliation(s)
- Marc Maegele
- Department of Traumatology, Orthopedic Surgery and Sportsmedicine, Cologne-Merheim Medical Center (CMMC) and the Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Cologne, Germany
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Tang M, Fenger-Eriksen C, Wierup P, Greisen J, Ingerslev J, Hjortdal V, Sørensen B. Rational and timely haemostatic interventions following cardiac surgery - coagulation factor concentrates or blood bank products. Thromb Res 2017; 154:73-79. [DOI: 10.1016/j.thromres.2017.04.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 02/18/2017] [Accepted: 04/04/2017] [Indexed: 01/08/2023]
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Jin S, Yu G, Hou R, Shen B, Jiang H. Effect of Hemodilution In Vitro with Hydroxyethyl Starch on Hemostasis. Med Sci Monit 2017; 23:2189-2197. [PMID: 28481865 PMCID: PMC5436429 DOI: 10.12659/msm.901588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background Hydroxyethyl starch (HES) solutions are used for volume expansion during surgery. We aimed to investigate how 6%HES 130/0.4 affects hemostasis. Material/Methods Blood samples were collected from 12 healthy adult volunteers, diluting with 6%HES 130/0.4 (HES group) or Ringer lactate solution (RL control group). The hemodilution ratio (HR) of citrated blood volume to plasma substitute volume was 10: 0 (undiluted), 10: 2, 10: 4, and 10: 6. Clotting factors activity was measured. Thrombin generation was monitored. Platelet function was analyzed. Results 1) Activity of coagulation factor was decreased with increasing HR compared to undiluted baseline, and the activity of FVIII was significantly decreased in HES vs. RL. 2) Calibrated automated thrombography (CAT) results showed HES extended lag time, time to peak (ttpeak), start tail, and decreased peak of thrombin generation. Although lag time and ttpeak were significantly prolonged in HES vs. RL, endogenous thrombin potential (ETP) did not change. 3) Flow cytometric (FCM) analysis showed that HES reduced platelet phospholipids serine (PS) vs. baseline and RL. 4) HES significantly decreased antithrombin activity (AT: A) of the anticoagulant system with increasing HR vs. baseline and RL. 5) For fibrinolytic system, HES did not affect fibrinogen degradation products (FDP) and D-dimers (D-D) vs. baseline, or α2-antiplasmin (α2-AP) vs. RL. Conclusions By reducing FVIII activity and platelet PS expression, HES interfered with PS combining to FXIa, FVIIIa, and FVa, which affected the acceleration and explosion stage of thrombin. The decreased velocity and peak of thrombin generation delays and reduces clot formation. Combined 6%HES 130/0.4 decreased anticoagulant activity and may have clinical utility.
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Affiliation(s)
- Shanliang Jin
- Department of Anesthesiology, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China (mainland)
| | - Guifang Yu
- Department of Anesthesiology, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China (mainland)
| | - Ruijiao Hou
- Department of Anesthesiology, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China (mainland)
| | - Boxiong Shen
- Department of Anesthesiology, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China (mainland)
| | - Hong Jiang
- Department of Anesthesiology, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China (mainland)
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Recombinant human prothrombin reduced blood loss in a porcine model of dilutional coagulopathy with uncontrolled bleeding. Blood Coagul Fibrinolysis 2017; 28:244-253. [PMID: 27428015 DOI: 10.1097/mbc.0000000000000590] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
: Uncontrolled bleeding remains one of the leading causes of trauma-induced death. Treatment recommendations focus on fresh frozen plasma and blood cell transfusions, whereas plasma concentrates or single coagulation factors have been studied in recent years. The effect of recombinant human prothrombin factor II (rhFII, 8 mg/kg), activated recombinant human factor VII (rhFVIIa, 300 μg/kg), plasma-derived human fibrinogen (pdhFib) (200 mg/kg), activated prothrombin complex concentrate (aPCC, 40 IU/kg), a three-factor combination intended as a minimal PCC (8 mg/kg rhFII, 640 μg/kg recombinant human factor X (rhFX), and 12 μg/kg rhFVIIa), and vehicle were investigated in a porcine model of dilutional coagulopathy with uncontrolled bleeding. Survival time and blood loss were determined up to 120 min after induction of liver injury. Rotational thromboelastometry EXTEM coagulation time and maximum clot firmness, prothrombin time, thrombin-antithrombin complex (TAT), thrombin generation (endogenous thrombin potential, ETP) were measured at baseline, after dilution, drug administration, and end of experiment. rhFII, the three-factor combination, and aPCC significantly (P < 0.01) decreased blood loss vs. vehicle and rhFII also vs. fibrinogen (P < 0.05). Survival times increased significantly for rhFII, aPCC, rhFVIIa, and pdhFib vs. vehicle (P < 0.05), and, coagulation time, maximum clot firmness, and prothrombin time improved in all groups. TAT and ETP increased transiently for rhFII and three-factor combination, whereas persistently increased for aPCC. PdhFib and rhFVIIa did not increase TAT and ETP. rhFII decreased blood loss and improved hemostatic markers and survival. In vivo, thrombin generation (TAT) and potential to form thrombin (ETP) were transiently elevated by rhFII. Addition of rhFVIIa and rhFX to rhFII did not further improve hemostatic efficacy.
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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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Christensen TD, Vad H, Pedersen S, Hornbech K, Zois NE, Licht PB, Nybo M, Hvas AM. Coagulation profile in patients undergoing video-assisted thoracoscopic lobectomy: A randomized, controlled trial. PLoS One 2017; 12:e0171809. [PMID: 28199364 PMCID: PMC5310875 DOI: 10.1371/journal.pone.0171809] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 01/24/2017] [Indexed: 11/29/2022] Open
Abstract
Background Knowledge about the impact of Low-Molecular-Weight Heparin (LMWH) on the coagulation system in patients undergoing minimal invasive lung cancer surgery is sparse. The aim of this study was to assess the effect of LMWH on the coagulation system in patients undergoing Video-Assisted Thoracoscopic Surgery (VATS) lobectomy for primary lung cancer. Methods Sixty-three patients diagnosed with primary lung cancer undergoing VATS lobectomy were randomized to either subcutaneous injection with dalteparin (Fragmin®) 5000 IE once daily or no intervention. Coagulation was assessed pre-, peri-, and the first two days postoperatively by standard coagulation blood test, thromboelastometry (ROTEM®) and thrombin generation. Results Patients undergoing potential curative surgery for lung cancer were not hypercoagulable preoperatively. There was no statistically significant difference in the majority of the assessed coagulation parameters after LMWH, except that the no intervention group had a higher peak thrombin and a shorter INTEM clotting time on the first postoperative day and a lower fibrinogen level on the second postoperative day. A lower level of fibrin d-dimer in the LMWH group was found on the 1. and 2.postoperative day, although not statistical significant. No differences were found between the two groups in the amount of bleeding or number of thromboembolic events. Conclusions Use of LMWH administered once daily as thromboprophylaxis did not alter the coagulation profile per se. As the present study primarily evaluated biochemical endpoints, further studies using clinical endpoints are needed in regards of an optimized thromboprophylaxis approach.
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Affiliation(s)
- Thomas Decker Christensen
- Department of Cardiothoracic and Vascular Surgery & Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
- * E-mail:
| | - Henrik Vad
- Department of Cardiothoracic and Vascular Surgery & Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Søren Pedersen
- Department of Anesthesiology and Intensive Care & Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Kåre Hornbech
- Department of Cardio-thoracic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Nora Elisabeth Zois
- Department of Clinical Biochemistry, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Peter B. Licht
- Department of Cardiothoracic and Vascular Surgery, Odense University Hospital, Odense, Denmark
| | - Mads Nybo
- Department of Clinical Biochemistry, Odense University Hospital, Odense, Denmark
| | - Anne-Mette Hvas
- Department of Clinical Biochemistry & Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
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Soleimani M, Masoumi N, Nooraei N, Lashay A, Safarinejad MR. The effect of fibrinogen concentrate on perioperative bleeding in transurethral resection of the prostate: a double-blind placebo-controlled and randomized study. J Thromb Haemost 2017; 15:255-262. [PMID: 27888575 DOI: 10.1111/jth.13575] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Indexed: 11/30/2022]
Abstract
Essentials Perioperative bleeding during prostate surgery is still a common morbidity. Anticoagulant and antiplatelet medications contribute to the risk of hemorrhage and prolonged hospital stay. Multiple pharmacological agents have been proposed, but none of them have been widely accepted. It is crucial to find a safe and effective modality to reduce hemorrhage. SUMMARY Background Hemorrhage during transurethral resection of the prostate (TUR-P) has always been a concern. Several studies have shown preoperative administration of fibrinogen concentrate to have promising results in reducing hemorrhage in cardiac surgery. Objectives To investigate the hemostatic effect of fibrinogen concentrate administration on reducing the amount of bleeding during TUR-P in patients with benign prostatic hyperplasia. Methods Sixty men with benign prostatic hyperplasia, who were chosen to undergo TUR-P, entered this prospective randomized double-blind placebo-controlled study. The participants were randomly assigned to two groups: treatment (n = 31) and placebo (n = 29). They received an infusion of 2 g of fibrinogen concentrate (treatment group) or normal saline (placebo group) before surgery. Data regarding the amount of bleeding, the operation and complications were recorded and analyzed. Results No difference was observed in bleeding between the fibrinogen and placebo groups during (521 mL versus 557 mL, respectively) and after (291 mL versus 341 mL, respectively) surgery. This lack of difference was also seen in operation time (43 min versus 42 min), irrigating fluid volume used during (17 L versus 19 L) and after (29 L versus 28 L) surgery, and resected adenoma volume (19 g versus 19 g). The mean blood pressure was also similar in both groups as a confounding factor for the amount of bleeding. Conclusion Preoperative administration of fibrinogen concentrate had no significant influence on intraoperative and postoperative bleeding in TUR-P surgery.
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Affiliation(s)
- M Soleimani
- Department of Urology, Shahid Modarress Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - N Masoumi
- Department of Urology, Shahid Modarress Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - N Nooraei
- Department of Anesthesiology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - A Lashay
- Department of Urology, Shahid Modarress Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - M R Safarinejad
- Clinical Center for Urological Disease Diagnosis, Private Clinic Specializing in Urological and Andrological Genetics, Tehran, Iran
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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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Toh CH, Alhamdi Y. Role of Coagulation Factor Concentrates in the Operating Room. EUROPEAN MEDICAL JOURNAL 2016. [DOI: 10.33590/emj/10313464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
Abstract
The use of fresh frozen plasma, cryoprecipitate, and platelets has been the mainstay of approaches to correct coagulopathies that can arise in the perioperative setting. Limitations include the time delay from obtaining results of coagulation screens to the availability of thawed fresh frozen plasma and the potential of fluid overload. With advances in both global haemostatic testing and concentrates of coagulation factors, there are increasing opportunities for innovative practice. However, there remains a paucity of studies that can provide good quality, unbiased evidence. These issues are elaborated here to form the basis for future study.
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Affiliation(s)
- Cheng-Hock Toh
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK; Roald Dahl Haemostasis and Thrombosis Centre, Royal Liverpool University Hospital, Liverpool, UK
| | - Yasir Alhamdi
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
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Fibrinogen in the initial resuscitation of severe trauma (FiiRST): a randomized feasibility trial. Br J Anaesth 2016; 117:775-782. [DOI: 10.1093/bja/aew343] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2016] [Indexed: 01/10/2023] Open
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Abstract
Traumatic injury is one of the leading causes of death, with uncontrolled hemorrhage from coagulation dysfunction as one of the main potentially preventable causes of the mortality. Hypothermia, acidosis, and resuscitative hemodilution have been considered as the significant contributors to coagulation manifestations following trauma, known as the lethal triad. Over the past decade, clinical observations showed that coagulopathy may be present as early as hospital admission in some severely injured trauma patients. The hemostatic dysfunction is associated with higher blood transfusion requirements, longer hospital stay, and higher mortality. The recognition of this early coagulopathy has initiated tremendous interest and effort in the trauma community to expand our understanding of the underlying pathophysiology and improve clinical treatments. This review discusses the current knowledge of coagulation complications following trauma.
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Affiliation(s)
- Wenjun Z. Martini
- U.S. Army Institute of Surgical Research, 3698 Chambers Pass, JBSA-Fort Sam Houston, Houston, TX 78234-6315 USA
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Atmaja SP, Khotib J, Rahardjo E, Shinta DW, Rahmadi M, Suprapti B. EFFECT OF HYDROXYETHYL STARCH 200/0.5 ON VON WILLEBRAND FACTOR SERUM LEVEL AND ACTIVATED PARTIAL THROMBOPLASTIN TIME (APTT). FOLIA MEDICA INDONESIANA 2016. [DOI: 10.20473/fmi.v51i4.2848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Hydroxyethyl starch (HES) is a colloid administered frequently for intravascular volume expansion during perioperative period. Impairment of haemostasis have been reported during HES administration, but the volume of solution administered was usually higher than 20 ml.kg-1. The objective of this study was to evaluate the effect of Hydroxyethyl starch 200/0.5 dose less than 20 ml.kg-1 on von Willebrand factor serum level and activated partial thromboplastin time. A prospective, observational study was conducted to evaluate von Willebrand factor and activated partial thromboplastin time of patients receiving Hydroxyethyl starch 200/0.5. Inclusion criteria were patients undergoing elective surgery who were going to receive Hydroxyethyl starch 200/0.5 intraoperatively. Fourty six patients were divided into patients receiving crystalloid only group (n=23 patients) and hydroxyethyl starch (n=23 patients). Coagulation variables were assesed 30 minute after insicion and 60 minute after infusion of crystalloid or colloid. Measurement of von Willebrand within each group after crystalloid or HES 200 infusion showed significant decrease, from (mean±SE) 97.688±15.219 ng/ml to 31.611±10.058 ng/ml (p< 0.001) in crystalloid group and 92.884±15.208 ng/ml to 27.378±6.399 ng/ml (p<0.001) in HES 200 group. Activated partial thromboplastin time change was statistically significant (mean±SE) 31.27±1.39 to 35.61±1.62 in HES group only (p=0.007), but this change was not clinically significant. In conclusion, there was neither significant difference in von Willebrand serum level nor in activated partial thromboplastin time between the two groups. There was no coagulation influence with clinically significant effect in the use of HES 20 ml/kg BW in patients undergoing elective surgery.
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Fominskiy E, Nepomniashchikh VA, Lomivorotov VV, Monaco F, Vitiello C, Zangrillo A, Landoni G. Efficacy and Safety of Fibrinogen Concentrate in Surgical Patients: A Meta-Analysis of Randomized Controlled Trials. J Cardiothorac Vasc Anesth 2016; 30:1196-204. [DOI: 10.1053/j.jvca.2016.04.015] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Indexed: 01/07/2023]
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Winstedt D, Solomon C, Hillarp A, Lundahl T, Schött U. Intraoperative Hydroxyethyl Starch and its Effects on Different Fibrinogen Measurements. Clin Appl Thromb Hemost 2016; 22:641-7. [DOI: 10.1177/1076029616632904] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Intravenous fluids with synthetic colloids such as hydroxyethyl starch (HES) are known to interfere with plasma fibrinogen concentration measurements. The aim of this study was to evaluate the effects of an HES solution on fibrinogen measurements in a clinical setting. Methods: The study was performed in patients who received at least 1 L of HES during intracranial tumor resection surgery. Blood samples were drawn before the start of surgery (baseline), after infusion of 1 L of HES, and at later time points. The fibrinogen concentration was measured using 3 different methods: (a) enzyme-linked immunosorbent assay (ELISA), (b) Clauss method with a photometric readout, and (c) Clauss method with an electromechanical readout. In addition, the fibrin-based clot quality was evaluated with the thromboelastometric FIBTEM test. Results: Forty patients were enrolled, and 25 patients were included in the analysis. The fibrinogen concentrations at baseline were 2.2, 2.3, and 2.6 g/L and after 1 L of HES 1.6, 1.7, and 1.9 g/L as measured by ELISA, the photometric test, and the electromechanical test, respectively. The electromechanical Clauss test measured significantly higher concentrations at these time points. The relative decrease, however, was comparable between methods (31%, 29%, and 25%, respectively) but significantly lower than the 44% relative decrease with FIBTEM maximum clot firmness. Conclusion: Despite providing different fibrinogen concentration values at baseline, the relative decrease in fibrinogen concentration after HES infusion was comparable among the 3 tests. In contrast, fibrin-based clot quality was more affected than fibrinogen concentration tests by HES infusion.
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Affiliation(s)
- Dag Winstedt
- Department of Anaesthesia and Intensive Care, Skåne University Hospital Lund, Lund, Sweden
- Division of Anaesthesia and Intensive Care, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Cristina Solomon
- Department of Anaesthesiology, Perioperative Medicine and General Intensive Care, Paracelsus Medical University, Salzburg, Austria
- CSL Behring, Marburg, Germany
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Research Centre, Vienna, Austria
| | - Andreas Hillarp
- Division of Anaesthesia and Intensive Care, Department of Clinical Sciences, Lund University, Lund, Sweden
- Clinical Chemistry and Transfusion Medicine, Halland County Hospital, Sweden
| | - Tom Lundahl
- Division of Anaesthesia and Intensive Care, Department of Clinical Sciences, Lund University, Lund, Sweden
- Clinical Chemistry and Transfusion Medicine, Halland County Hospital, Sweden
| | - Ulf Schött
- Department of Anaesthesia and Intensive Care, Skåne University Hospital Lund, Lund, Sweden
- Division of Anaesthesia and Intensive Care, Department of Clinical Sciences, Lund University, Lund, Sweden
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Abstract
Postpartum Haemorrhage (PPH) is a major cause of maternal morbidity and mortality. Treatment of acquired coagulopathy observed in severe PPH is an important part of PPH management, but is mainly based on literature in trauma patients, and data thus should be interpreted with caution. This review describes recent advances in transfusion strategy and in the use of tranexamic acid and fibrinogen concentrates in women with PPH.
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Affiliation(s)
- Marie Pierre Bonnet
- Department of Anaesthesia and Intensive Care Medicine, Paris Descartes University, Paris, France
| | - Dan Benhamou
- Department of Anaesthesia and Intensive Care Medicine, Paris Sud University, Paris, France
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Schlimp CJ, Ponschab M, Voelckel W, Treichl B, Maegele M, Schöchl H. Fibrinogen levels in trauma patients during the first seven days after fibrinogen concentrate therapy: a retrospective study. Scand J Trauma Resusc Emerg Med 2016; 24:29. [PMID: 26969627 PMCID: PMC4788877 DOI: 10.1186/s13049-016-0221-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 03/08/2016] [Indexed: 02/07/2023] Open
Abstract
Background Fibrinogen concentrate (FC) is increasingly used as first line therapy in bleeding trauma patients. It remains unproven whether FC application increases post-traumatic plasma fibrinogen concentration (FIB) in injured patients, possibly constituting a prothrombotic risk. Thus, we investigated the evolution of FIB following trauma in patients with or without FC therapy. Methods At the AUVA Trauma Centre, Salzburg, we performed a retrospective study of patients admitted to the emergency room and whose FIB levels were documented thereafter up to day 7 post-trauma. Patients were categorized into those with (treatment group) or without (control group) FC therapy during the first 24 h after hospital admission. A subgroup analysis was carried out to investigate the influence of the amount of FC given. Results The study enrolled 435 patients: treatment group, n = 242 (56 %); control group, n = 193 (44 %), with median Injury Severity Score of 34 vs. 22 (P < 0.001) and massive transfusion rate of 18.4 % vs. 0.2 % (P < 0.001). In the treatment group (median FC dose 6 g), FIB was lower on admission and up to day 2 compared with the control group. In patients receiving high (≥10 g) doses of FC, FIB was lower up to day 5 as compared to controls. At other timepoints, FIB did not differ significantly between the groups. In the treatment vs. the control group, other coagulation parameters such as prothrombin time index and platelet count were consistently lower, while activated partial thromboplastin time was consistently prolonged at most timepoints. Inflammatory parameters such as C-reactive protein, interleukin-6 and procalcitonin were generally lower in controls. Discussion The rise of FIB levels from day 2 onwards in our study can be attributed to an upregulated fibrinogen synthesis in the liver, occurring in both study groups as part of the acute phase response after tissue injury. Conclusions The treatment of severe trauma patients with FC during bleeding management in the first 24 h after hospital admission does not lead to higher FIB levels post-trauma beyond that occurring naturally due to the acute phase response.
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Affiliation(s)
- Christoph J Schlimp
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Research Centre, Vienna, Austria
| | - Martin Ponschab
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Research Centre, Vienna, Austria
| | - Wolfgang Voelckel
- Department of Anaesthesiology and Intensive Care, AUVA Trauma Centre, Academic Teaching Hospital of the Paracelsus Medical University, Franz Rehrl Platz 5, 5020, Salzburg, Austria
| | - Benjamin Treichl
- Department of Anaesthesiology and Intensive Care, Innsbruck Medical University, Innsbruck, Austria
| | - Marc Maegele
- Department of Traumatology, Orthopedic Surgery and Sports Medicine Cologne-Merheim Medical Center (CMMC), Institute for Research in Operative Medicine (IFOM), Cologne, Germany
| | - Herbert Schöchl
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Research Centre, Vienna, Austria. .,Department of Anaesthesiology and Intensive Care, AUVA Trauma Centre, Academic Teaching Hospital of the Paracelsus Medical University, Franz Rehrl Platz 5, 5020, Salzburg, Austria.
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Hanna JM, Keenan JE, Wang H, Andersen ND, Gaca JG, Lombard FW, Welsby IJ, Hughes GC. Use of human fibrinogen concentrate during proximal aortic reconstruction with deep hypothermic circulatory arrest. J Thorac Cardiovasc Surg 2016; 151:376-82. [PMID: 26428473 PMCID: PMC5429587 DOI: 10.1016/j.jtcvs.2015.08.079] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 08/11/2015] [Accepted: 08/23/2015] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Human fibrinogen concentrate (HFC) is approved by the Food and Drug Administration for use at 70 mg/kg to treat congenital afibrinogenemia. We sought to determine whether this dose of HFC increases fibrinogen levels in the setting of high-risk bleeding associated with aortic reconstruction and deep hypothermic circulatory arrest (DHCA). METHODS This was a prospective, pilot, off-label study in which 22 patients undergoing elective proximal aortic reconstruction with DHCA were administered 70 mg/kg HFC upon separation from cardiopulmonary bypass (CPB). Fibrinogen levels were measured at baseline, just before, and 10 minutes after HFC administration, on skin closure, and the day after surgery. The primary study outcome was the difference in fibrinogen level immediately after separation from CPB, when HFC was administered, and the fibrinogen level 10 minutes following HFC administration. Additionally, postoperative thromboembolic events were assessed as a safety analysis. RESULTS The mean baseline fibrinogen level was 317 ± 49 mg/dL and fell to 235 ± 39 mg/dL just before separation from CPB. After HFC administration, the fibrinogen level rose to 331 ± 41 mg/dL (P < .001) and averaged 372 ± 45 mg/dL the next day. No postoperative thromboembolic complications occurred. CONCLUSIONS Administration of 70 mg/kg HFC upon separation from CPB raises fibrinogen levels by approximately 100 mg/dL without an apparent increase in thrombotic complications during proximal aortic reconstruction with DHCA. Further prospective study in a larger cohort of patients will be needed to definitively determine the safety and evaluate the efficacy of HFC as a hemostatic adjunct during these procedures.
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Affiliation(s)
- Jennifer M Hanna
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Jeffrey E Keenan
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Hanghang Wang
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Nicholas D Andersen
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Jeffrey G Gaca
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Frederick W Lombard
- Division of Cardiac Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Ian J Welsby
- Division of Cardiac Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC.
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
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Williams P, Yang K, Kershaw G, Wong G, Dunkley S, Kam PCA. The effects of haemodilution with hydroxyethyl starch 130/0.4 solution on coagulation as assessed by thromboelastography and platelet receptor function studies in vitro. Anaesth Intensive Care 2016; 43:734-9. [PMID: 26603798 DOI: 10.1177/0310057x1504300611] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study evaluated the effects of haemodilution with either 6% hydroxyethyl starch (HES) 130/0.4 (Voluven(®)) or 0.9% normal saline (NS) on blood coagulation in vitro. Haemodilution with 6% HES 130/0.4 impaired coagulation, as indicated by the changes in thromboelastographic parameters k-time, α-angle and maximum amplitude. Light transmission aggregometry and multiple electrode aggregometry demonstrated that impaired platelet receptor function occurred only at high levels of haemodilution (40%) with both fluids, but there was no significant difference between the two fluids (P=0.05). The thromboelastographic functional fibrinogen assay showed that the fibrinogen component of clot strength was significantly impaired with haemodilution with HES 130/0.4 compared with haemodilution with NS (whole blood [14.4 ± 4.6 mm] versus 40% HES dilution [3.7 ± 1.9], [P=0.001]; versus 40% NS dilution [10.4 ± 4.6], [P=0.129]). These findings suggest that there is little difference between HES or NS in relation to coagulation or platelet function during minor or moderate haemodilution, but at high levels of haemodilution with HES, fibrinogen activity is more impaired compared with NS.
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Affiliation(s)
- P Williams
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, New South Wales
| | - K Yang
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, New South Wales
| | - G Kershaw
- Department of Haematology, Royal Prince Alfred Hospital, Camperdown, New South Wales
| | - G Wong
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, New South Wales
| | - S Dunkley
- Department of Haematology, Royal Prince Alfred Hospital, Camperdown, New South Wales
| | - P C A Kam
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, New South Wales
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Chee Y, Liu S, Irwin M. Management of bleeding in vascular surgery. Br J Anaesth 2016; 117 Suppl 2:ii85-ii94. [DOI: 10.1093/bja/aew270] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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50
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Vaglio S, Prisco D, Biancofiore G, Rafanelli D, Antonioli P, Lisanti M, Andreani L, Basso L, Velati C, Grazzini G, Liumbruno GM. Recommendations for the implementation of a Patient Blood Management programme. Application to elective major orthopaedic surgery in adults. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2016; 14:23-65. [PMID: 26710356 PMCID: PMC4731340 DOI: 10.2450/2015.0172-15] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Stefania Vaglio
- Italian National Blood Centre, National Institute of Health, Rome, Italy
- Department of Clinical and Molecular Medicine, “Sapienza” University of Rome, Rome, Italy
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Gianni Biancofiore
- Liver Transplant Anaesthesia and Critical Care, University Hospital Pisana, Pisa, Italy
| | - Daniela Rafanelli
- Immunohaematology and Transfusion Unit, Pistoia 3 Local Health Authority, Pistoia, Italy
| | - Paola Antonioli
- Department of Infection Prevention Control and Risk Management, Ferrara University Hospital, Ferrara, Italy
| | - Michele Lisanti
- 1 Orthopaedics and Trauma Section, University Hospital Pisana, Pisa, Italy
| | - Lorenzo Andreani
- 1 Orthopaedics and Trauma Section, University Hospital Pisana, Pisa, Italy
| | - Leonardo Basso
- Orthopaedics and Trauma Ward, Cottolengo Hospital, Turin, Italy
| | - Claudio Velati
- Transfusion Medicine and Immunohaematology Department of Bologna Metropolitan Area, Bologna, Italy, on behalf of Italian Society of Transfusion Medicine and Immunohaematology (SIMTI); Italian Society of Italian Society of Orthopaedics and Traumatology (SIOT); Italian Society of Anaesthesia, Analgesia, Resuscitation and Intensive Therapy (S.I.A.A.R.T.I.); Italian Society for the Study of Haemostasis and Thrombosis (SISET), and the National Association of Hospital Medical Directors (ANMDO) working group
| | - Giuliano Grazzini
- Italian National Blood Centre, National Institute of Health, Rome, Italy
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