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Shimoda T, Liu C, Mathis BJ, Goto Y, Ageyama N, Kato H, Matsubara M, Ohigashi T, Gosho M, Suzuki Y, Hiramatsu Y. Effect of cardiopulmonary bypass on coagulation factors II, VII and X in a primate model: an exploratory pilot study. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2023; 37:ivad194. [PMID: 38015856 PMCID: PMC10701202 DOI: 10.1093/icvts/ivad194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 11/05/2023] [Accepted: 11/27/2023] [Indexed: 11/30/2023]
Abstract
OBJECTIVES The use of cardiopulmonary bypass (CPB) in cardiac surgery is a major risk factor for postoperative bleeding. We hypothesized that consumptive coagulopathy and haemodilution influence the coagulation factors; therefore, we aimed to estimate the activity profiles of coagulation factors II, VII and X during CPB circulation. METHODS A 120-min bypass was surgically established in cynomolgus monkeys (n = 7). Activities of coagulation factors II, VII and X were measured at 6 time points during the experiment (baseline, 0, 30, 60, 120 min of bypass and 60 min after bypass). To assess the influence of consumptive coagulopathy, the values were adjusted for haemodilution using the haematocrit values. Data were expressed as mean (standard deviation). RESULTS Activities of coagulation factors decreased during the experiment. In particular, the activities for II, VII and X were decreased the most by 44.2% (5.0), 61.4% (4.3) and 49.0% (3.7) at 30 min following CPB initiation (P < 0.001, P < 0.001 and P < 0.001, respectively). Following adjustments for haemodilution, change magnitudes lessened but remained significant for factor VII. The adjusted concentration of factor VII was observed to decrease from the baseline to the initiation of bypass circulation. CONCLUSIONS In conclusion, coagulation factor II, VII and X concentrations decreased during CPB. Following adjustment for haemodilution, a decrease in concentration was observed with factor VII.
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Affiliation(s)
- Tomonari Shimoda
- Department of Cardiovascular Surgery, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Chang Liu
- Department of Cardiovascular Surgery, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Bryan J Mathis
- International Medical Center, University of Tsukuba Hospital, Ibaraki, Japan
| | - Yukinobu Goto
- Department of Thoracic Surgery, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Naohide Ageyama
- Tsukuba Primate Research Center, National Institute of Biomedical Innovation, Tsukuba, Ibaraki, Japan
| | - Hideyuki Kato
- Department of Cardiovascular Surgery, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Muneaki Matsubara
- Department of Cardiovascular Surgery, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Tomohiro Ohigashi
- Tsukuba Clinical Research & Development Organization, University of Tsukuba Hospital, Ibaraki, Japan
| | - Masahiko Gosho
- Department of Biostatistics, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Yasuyuki Suzuki
- Department of Cardiovascular Surgery, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Yuji Hiramatsu
- Department of Cardiovascular Surgery, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
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Shaw JR, James T, Douxfils J, Dargaud Y, Levy JH, Brinkman HJM, Shorr R, Siegal D, Castellucci LA, Gross P, Khalife R, Sperling C, Page D, Fergusson D, Carrier M. Thrombin generation, bleeding and hemostasis in humans: Protocol for a scoping review of the literature. PLoS One 2023; 18:e0293632. [PMID: 37910528 PMCID: PMC10619830 DOI: 10.1371/journal.pone.0293632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 10/16/2023] [Indexed: 11/03/2023] Open
Abstract
INTRODUCTION Hemostasis and bleeding are difficult to measure. Thrombin generation assays (TGAs) can measure both procoagulant and anticoagulant contributions to coagulation. TGAs might prove useful for the study of bleeding disorders. There has been much progress in TGA methodology over the past two decades, but its clinical significance is uncertain. We will undertake a scoping review of the literature to synthesize available information on the application of TGAs towards the study of bleeding and hemostasis, TGA methodologies being used and to summarize available literature on associations between TGA parameters, bleeding and hemostatic outcomes. METHODS AND ANALYSIS MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL) will be searched in collaboration with an information specialist. Title/abstract and full-text screening will be carried out independently and in duplicate; eligible study types will include randomized controlled trials, non-randomized studies, systematic reviews, and case series reporting TGA results and bleeding/hemostatic outcomes among humans. Mapping the information identified will be carried out with results presented using qualitative data analytical techniques. ETHICS AND DISSEMINATION This scoping review will use published, publicly available information. Research ethics approval will not be required. We will disseminate our findings using conference presentations, peer-reviewed publications, social media, and engagement with knowledge users. This review will outline knowledge gaps concerning TGAs, better delineate its applicability as a clinically relevant assay for bleeding. and seek to identify ongoing barriers to its widespread adoption in clinical research, and eventually, in the clinical setting. TRAIL REGULATIONS Registration ID with Open Science Framework: osf.io/zp4ge.
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Affiliation(s)
- Joseph R. Shaw
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Canada
- The Ottawa Hospital, Ottawa, Canada
| | - Tyler James
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Canada
- The Ottawa Hospital, Ottawa, Canada
| | - Jonathan Douxfils
- Namur Thrombosis and Hemostasis Center, University of Namur, Namur, Belgium
| | - Yesim Dargaud
- Lyon Hemophilia Center and Clinical Haemostasis Unit, Lyon, France
| | - Jerrold H. Levy
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Herm Jan M. Brinkman
- Department of Molecular Hematology, Sanquin Research, Amsterdam, The Netherlands
| | | | - Deborah Siegal
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Canada
- The Ottawa Hospital, Ottawa, Canada
| | - Lana A. Castellucci
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Canada
- The Ottawa Hospital, Ottawa, Canada
| | - Peter Gross
- Department of Medicine, Division of Hematology and Thromboembolism, McMaster University, Hamilton, Canada
| | - Roy Khalife
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Canada
- The Ottawa Hospital, Ottawa, Canada
| | | | - David Page
- Canadian Hemophilia Society Patient Partner, Montreal, Canada
| | - Dean Fergusson
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Canada
- The Ottawa Hospital, Ottawa, Canada
| | - Marc Carrier
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Canada
- The Ottawa Hospital, Ottawa, Canada
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Erez O, Gotsch F, Jung E, Chaiworapongsa T, Gudicha DW, Suksai M, Gallo DM, Chaemsaithong P, Bosco M, Al Qasem M, Meyyazhagan A, Than NG, Romero R. Perturbations in kinetics of the thrombin generation assay identify women at risk of preeclampsia in the first trimester and provide the rationale for a preventive approach. Am J Obstet Gynecol 2023; 228:580.e1-580.e17. [PMID: 36368431 PMCID: PMC10149548 DOI: 10.1016/j.ajog.2022.11.1276] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 11/03/2022] [Accepted: 11/04/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Activation of the coagulation system and increased thrombin generation have been implicated in the pathophysiology of preeclampsia, and this rationale supports the administration of low-molecular-weight heparin to prevent this syndrome in patients at risk. Yet, randomized trials of this prophylactic measure have yielded contradictory results. A possible explanation is that only a subset of patients with preeclampsia have excessive thrombin generation and would benefit from the administration of low-molecular-weight heparin. Therefore, the key questions are whether and when patients who subsequently develop preeclampsia present evidence of abnormal thrombin generation. OBJECTIVE This study aimed to determine (1) the kinetics of thrombin generation throughout gestation in women with a normal pregnancy and in those with early and late preeclampsia, and (2) the diagnostic performance of in vivo thrombin generation parameters to predict the development of preeclampsia. STUDY DESIGN This retrospective, nested case-control study was based on a prospective longitudinal cohort of singleton gestations. Cases comprised women who developed preeclampsia (n=49), and controls consisted of patients with a normal pregnancy (n=45). Preeclampsia was classified into early-onset (n=24) and late-onset (n=25). Longitudinal changes in the parameters of the thrombin generation assay (lag time, time to peak thrombin concentration, peak thrombin concentration, endogenous thrombin generation, and velocity index) throughout gestation were compared between the study groups, and normal pregnancy percentiles were derived from the control group. We tested whether a single parameter or a combination of parameters, derived from the kinetics of thrombin generation, could identify patients who subsequently developed preeclampsia. Time-related parameters <10th percentile were considered short, and concentration-related parameters >90th percentile were considered high. RESULTS (1) Patients who developed preeclampsia (early- and late-onset) had abnormal thrombin generation kinetics as early as 8 to 16 weeks of pregnancy; (2) patients with a combination of a short lag time and high peak thrombin concentration at 8 to 16 weeks of pregnancy had an odds ratio of 43.87 for the subsequent development of preeclampsia (area under the curve, 0.79; sensitivity, 56.8%; specificity, 92.7%; positive likelihood ratio, 7.76); (3) at 16 to 22 weeks of gestation, patients with a combination of a short lag time and a high velocity index had an odds ratio of 16 for the subsequent development of preeclampsia (area under the curve, 0.78; sensitivity, 62.2%; specificity, 92.5%; positive likelihood ratio, 8.29). CONCLUSION During early pregnancy, the thrombin generation assay can identify the subset of patients at a greater risk for the development of preeclampsia owing to accelerated and enhanced production of thrombin. This observation provides a rationale for testing the efficacy of low-molecular-weight heparin in this subset of patients. We propose that future research on the efficacy of low-molecular-weight heparin and other interventions targeting the coagulation system to prevent preeclampsia should be focused on patients with abnormal kinetics of thrombin generation.
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Affiliation(s)
- Offer Erez
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Obstetrics and Gynecology, Emek Medical Center, Afula, Israel
| | - Francesca Gotsch
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Eunjung Jung
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Tinnakorn Chaiworapongsa
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Dereje W Gudicha
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Manaphat Suksai
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Dahiana M Gallo
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Piya Chaemsaithong
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Obstetrics and Gynecology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Mariachiara Bosco
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Malek Al Qasem
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Arun Meyyazhagan
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Nandor Gabor Than
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Systems Biology of Reproduction Research Group, Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary; Maternity Private Clinic, Budapest, Hungary; First Department of Pathology and Experimental Cancer Research, Semmelweis University, Budapest, Hungary
| | - Roberto Romero
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI; Detroit Medical Center, Detroit, MI.
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Smith MM. Prothrombin Complex Concentrates in Cardiac Surgery-Is it Time to Call the Pharmacy Instead of the Blood Bank? J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00189-1. [PMID: 37030990 DOI: 10.1053/j.jvca.2023.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 03/11/2023] [Indexed: 04/10/2023]
Affiliation(s)
- Mark M Smith
- Department of Anesthesiology and Perioperative Medicine,Mayo Clinic College of Medicine and Science, Rochester, MN.
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Törnudd M, Ramström S, Kvitting JPE, Alfredsson J, Nyberg L, Björkman E, Berg S. Platelet Function is Preserved After Moderate Cardiopulmonary Bypass Times But Transiently Impaired After Protamine. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00180-5. [PMID: 37059638 DOI: 10.1053/j.jvca.2023.03.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 03/05/2023] [Accepted: 03/08/2023] [Indexed: 04/16/2023]
Abstract
OBJECTIVES Previous studies have described impaired platelet function after cardiopulmonary bypass (CPB). Whether this is still valid in contemporary cardiac surgery is unclear. This study aimed to quantify changes in function and number of platelets during CPB in a present-day cardiac surgery cohort. DESIGN Prospective, controlled clinical study. SETTING A single-center university hospital. PARTICIPANTS Thirty-nine patients scheduled for coronary artery bypass graft surgery with CPB. INTERVENTIONS Platelet function and numbers were measured at 6 timepoints in 39 patients during and after coronary artery bypass graft surgery; at baseline before anesthesia, at the end of CPB, after protamine administration, at intensive care unit (ICU) arrival, 3 hours after ICU arrival, and on the morning after surgery. MEASUREMENTS AND MAIN RESULTS Platelet function was assessed with impedance aggregometry and flow cytometry. Platelet numbers are expressed as actual concentration and as numbers corrected for dilution using hemoglobin as a reference marker. There was no consistent impairment of platelet function during CPB with either impedance aggregometry or flow cytometry. After protamine administration, a decrease in platelet function was seen with impedance aggregometry and for some markers of activation with flow cytometry. Platelet function was restored 3 hours after arrival in the ICU. During CPB (85.0 ± 21 min), the number of circulating platelets corrected for dilution increased from 1.73 ± 0.42 × 109/g to 1.91 ± 0.51 × 109/g (p < 0.001). CONCLUSIONS During cardiac surgery with moderate CPB times, platelet function was not impaired, and no consumption of circulating platelets could be detected. Administration of protamine transiently affected platelet function.
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Affiliation(s)
- Mattias Törnudd
- Department of Cardiothoracic and Vascular Surgery and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Sofia Ramström
- Department of Clinical Chemistry and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden; Cardiovascular Research Centre, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - John-Peder Escobar Kvitting
- Department of Cardiothoracic Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Joakim Alfredsson
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Linnea Nyberg
- Department of Cardiothoracic and Vascular Surgery and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden; Department of Clinical Chemistry and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Erik Björkman
- Department of Cardiothoracic and Vascular Surgery and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden; Department of Clinical Chemistry and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Sören Berg
- Department of Cardiothoracic and Vascular Surgery and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.
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Katona H, Dobronte L, Soltesz A, Tamaska E, Fabry S, Csikos G, Szakal-Toth Z, Fule BK, Lang Z, Merkely B, Gal J, Nemeth E. Perioperative Gelatin Use Is Associated With Increased Complication Rates and Does Not Prevent Postoperative Fluid Overload in Patients Undergoing Elective Cardiac Surgery. J Cardiothorac Vasc Anesth 2023; 37:399-406. [PMID: 36621371 DOI: 10.1053/j.jvca.2022.11.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 11/20/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The benefit of using gelatin solution in cardiac surgery is still controversial. Previous data suggested adverse interactions of gelatin infusion with acute kidney injury (AKI) or coagulopathy. The purpose of this study was to evaluate the association between perioperative gelatin use and fluid overload (FO), hemodynamic stability, and outcomes compared to crystalloid-based fluid management. DESIGN A retrospective study design. SETTING At a single-center tertiary university setting. PARTICIPANTS Propensity score-matched cohort study of 191 pairs of patients scheduled for cardiac surgery. INTERVENTIONS Patients received either gelatin + crystalloid or pure crystalloid-based perioperative fluid management. The primary outcomes were the frequency of FO and hemodynamic stability defined by the vasoactive-inotropic score. Postoperative complications and 3-year survival were analyzed also. MEASUREMENTS AND MAIN RESULTS Patients who received gelatin experienced more frequent postoperative FO than controls (11.0% v 3.1%, p = 0.006) despite comparable hemodynamic stability in both groups. Gelatin administration was linked with a higher rate of postoperative complications, including blood loss, AKI, and new-onset postoperative atrial fibrillation. Use of gelatin infusion resulted in an adjusted odds ratio of 1.982 (95% CI 1.051-3.736, p = 0.035) for developing early postoperative AKI. This study confirmed a dose-dependent relationship between gelatin infusion and AKI. Thirty-day mortality and 3-year survival were similar in the groups. CONCLUSIONS Gelatin administration versus crystalloid fluid management showed a significant association with a higher rate of FO and an increased risk for early postoperative AKI in a dose-dependent manner.
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Affiliation(s)
- Hajna Katona
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary; Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Laszlo Dobronte
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Adam Soltesz
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary; Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Eszter Tamaska
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary; Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Szabolcs Fabry
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary; Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Gergely Csikos
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary; Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | | | - Balazs Krisztian Fule
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary; Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Zsolt Lang
- Department of Biomathematics and Informatics, University of Veterinary Medicine, Budapest, Hungary
| | - Bela Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Janos Gal
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Endre Nemeth
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary; Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary.
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Bai C, Konings J, Ninivaggi M, Lancé M, de Laat B, de Laat-Kremers R. Assessing the individual roles of FII, FV, and FX activity in the thrombin generation process. Front Cardiovasc Med 2022; 9:1000812. [PMID: 36204573 PMCID: PMC9530111 DOI: 10.3389/fcvm.2022.1000812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 08/26/2022] [Indexed: 12/02/2022] Open
Abstract
Thrombin generation (TG) is known as a physiological approach to assess the hemostatic function. Although it correlates well with thrombosis and bleeding, in the current setup it is not sensitive to the effects of fluctuations in single coagulation factors. We optimized the calibrated automated thrombinography (CAT) method to quantify FII, FV and FX activity within the coagulation system. The CAT assay was fine-tuned for the assessment of FII, FV and FX by diluting the samples in FII-, FV-, or FX-deficient plasma, respectively, and measuring TG. Plasma FII levels correlated linearly with the ETP up to a plasma concentration of 100% FII. FV and FX levels correlated linearly with the peak height up to a plasma level of 2.5% FV and 10% FX, respectively. Sensitized CAT protocols were designed by adding a fixed volume of a pre-diluted patient sample to FII, FV, and FX deficient plasma in TG experiments. This approach makes the TG measurement dependent on the activity of the respective coagulation factor. The ETP or peak height were quantified as readouts for the coagulation factor activity. The intra- and inter-assay variation coefficients varied from 5.0 to 8.6%, and from 3.5 to 5.9%, respectively. Reference values were determined in 120 healthy subjects and the assays were clinically validated in 60 patients undergoing coronary artery bypass grafting (CABG). The sensitized CAT assays revealed that the contribution of FII, FV, and FX to the TG process was reduced after CABG surgery, leading to reduced prothrombin conversion and subsequently, lower TG.
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Affiliation(s)
- Cuicui Bai
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, Netherlands
- Department of Protein Engineering, Synapse Research Institute, Maastricht, Netherlands
| | - Joke Konings
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, Netherlands
- Department of Platelet Pathophysiology, Synapse Research Institute, Maastricht, Netherlands
| | - Marisa Ninivaggi
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, Netherlands
| | - Marcus Lancé
- Department of Anesthesiology, Aga Khan University Hospital, Nairobi, Kenya
| | - Bas de Laat
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, Netherlands
- Department of Data Analysis and Artificial Intelligence, Synapse Research Institute, Maastricht, Netherlands
| | - Romy de Laat-Kremers
- Department of Data Analysis and Artificial Intelligence, Synapse Research Institute, Maastricht, Netherlands
- *Correspondence: Romy de Laat-Kremers
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Li H, Bartoszko J, Serrick C, Rao V, Karkouti K. Titrated versus conventional anticoagulation management for thrombin generation in cardiac surgery: a randomized controlled trial. Can J Anaesth 2022; 69:1117-1128. [PMID: 35799088 DOI: 10.1007/s12630-022-02278-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 02/17/2022] [Accepted: 02/23/2022] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Optimal heparin titration during cardiopulmonary bypass (CPB) may reduce coagulation system activation and preserve hemostatic function post-CPB. Our objective was to assess if the Heparin Management System (HMS) Plus improves heparin titration, thereby leading to higher thrombin generation post-CPB compared with activated clotting time (ACT)-guided management. METHODS We conducted a randomized controlled trial of 100 patients undergoing cardiac surgery with CPB at a single center. A total of 50 patients were randomized to conventional ACT-guided management, and 50 to the HMS Plus system. The primary outcome was change in thrombin generation post-CPB compared with baseline, as assessed by calibrated automated thrombography. Secondary outcomes included intraoperative blood loss, chest drain output up to 72 hr, and transfusions. In an exploratory analysis, we compared the quintile of patients with the highest average heparin concentration on CPB (≥ 4.0 mg⋅kg-1) with the rest of the cohort. RESULTS A total of 100 patients were included in an intent-to-treat analysis. We observed no difference in post-CPB thrombin generation or secondary outcomes. However, patients in the HMS Plus group had higher average heparin concentrations while on CPB than patients in the conventional management group did (mean difference, -0.21; 95% confidence interval, -0.42 to -0.01). The quintile of patients with the highest average heparin concentration (4.0 mg⋅kg-1) had higher thrombin generation post-CPB than the rest of the cohort did. CONCLUSIONS The HMS Plus system did not show significant benefits in thrombin generation, bleeding outcomes, or transfusion in patients undergoing cardiac surgery with CPB. Higher average heparin concentrations on CPB were associated with higher post-CPB thrombin generation. STUDY REGISTRATION www. CLINICALTRIALS gov (NCT03347201); first submitted 12 October 2017.
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Affiliation(s)
- Han Li
- Perfusion Services, University Health Network, Toronto, ON, Canada
| | - Justyna Bartoszko
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Cyril Serrick
- Perfusion Services, University Health Network, Toronto, ON, Canada
| | - Vivek Rao
- Cardiovascular Surgery, University Health Network and University of Toronto, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Keyvan Karkouti
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
- Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, ON, Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
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9
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Ma HP, Fu M, Masula M, Xing CS, Zhou Q, Tan JT, Wang J. miR-3064-5p and miR-4745-5p affect heparin sensitivity in patients undergoing cardiac surgery by regulating AT-III and factor X mRNA levels. Front Physiol 2022; 13:914333. [PMID: 36035472 PMCID: PMC9412912 DOI: 10.3389/fphys.2022.914333] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 06/28/2022] [Indexed: 11/13/2022] Open
Abstract
Subject: Perioperative regulation of coagulation function through heparin in patients undergoing cardiac surgery with cardiopulmonary bypass is an important part of performing cardiac surgery, and postoperative bleeding due to abnormal coagulation function caused by differences in heparin sensitivity in different individuals is an independent risk factor for postoperative complications and death.Method: Using an online database, 10 miRNAs interacting with AT-III and FX genes were predicted. Patients were divided into three groups according to the difference in activated clotting time (ACT) after the first dose of heparin (2.5 mg kg−1): group A: hyposensitive group (ACT < 480 s); group B: sensitive group (480 s ≤ ACT ≤ 760 s); and group C: hypersensitive group (ACT > 760 s). Perioperative and 24 h postoperative blood loss and other clinical data of patients in the three groups were recorded. Blood samples were collected before surgery, and RT-PCR was used to detect the levels of AT-III and FX gene mRNA and the levels of predicted 10 miRNAs.Result: Heparin sensitivity was positively correlated with AT-III mRNA levels and negatively correlated with FX gene mRNA levels in the three groups, and the blood loss in group B was significantly lower than that in groups A and C, which was statistically significant (p < 0.05). miR-3064-5p and miR-4745-5p expression levels were significantly different among group A, group B, and group C (p < 0.05) and were closely correlated with AT-III and FX gene mRNA expression levels, respectively.Conclusion: Differences in heparin sensitivity in patients undergoing cardiac surgery were associated with the mRNA expression of AT-III and FX genes, and the expression levels of miR-3064-5p and miR-4745-5p were found to be closely related to the AT-III and FX gene mRNA, respectively, indicating that miR-3064-5p and miR-4745-5p affect the differences in heparin sensitivity among different individuals by regulating the mRNA expression levels of AT-III and FX genes.Clinical Trial Registration:http://www.chictr.org.cn/abouten.aspx, identifier registration number: ChiCTR-2100047348
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10
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Chen J, Ye Y, Huang D, Pan D, Qiu X, Lei L, Luo X, Li J, Wu K, Xiao S, Liu S, Zeng X. The mediating role of coagulation function on the association of prenatal exposure to aflatoxin B1 and postpartum hemorrhage in Guangxi, China. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2022; 29:37543-37555. [PMID: 35066843 DOI: 10.1007/s11356-021-18186-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 12/14/2021] [Indexed: 06/14/2023]
Abstract
Pregnant women are vulnerable to certain environmental agents, one of which is aflatoxin. As one of the most popular aflatoxins, Aflatoxin B1 (AFB1) has recently garnered increased attention concerning its potential association between exposure and adverse pregnancy outcomes. The aims of the study were to examine the associations between prenatal exposure to AFB1 and postpartum hemorrhage (PPH), and whether coagulation function has a mediating effect on their relationship. A total of 379 mother-infant pairs were included in the present study. Prenatal serum AFB1 albumin (AFB1-Alb) adduct levels in peripheral venous blood were detected by using an ELISA kit. Multiple linear and logistics regression models were applied to analyze the relationship between AFB1-Alb levels and PPH. We found mothers with high levels of AFB1-Alb adduct levels had significantly increased postpartum blood loss (partial regression coefficient (β) = 50.71, 95% confidence interval (CI) 3.48, 97.95). Mothers with high levels of AFB1-Alb adduct levels also had significantly increased risk of PPH (odds ratio (OR) = 4.81, 95% CI 1.01, 22.98). Moreover, concentrations of AFB1-Alb were positively associated with activated partial thromboplastin time (APTT) while negatively associated with fibrinogen (FIB). One-unit increase in APTT was correlated with a 6.62-ml (95% CI 3.04, 10.20) increase in postpartum blood loss. Mediation analysis suggested that the maternal blood APTT levels had a positive mediating effect in the association between AFB1-Alb adduct levels and postpartum blood loss (β = 0.32, 95% CI 0.04, 0.68). These results indicated that prenatal exposure to AFB1 was associated with increased postpartum blood loss, possibly by interfering with maternal APTT levels.
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Affiliation(s)
- Jiehua Chen
- Department of Epidemiology and Health Statistics, School of Public Health, Guangxi Medical University, No. 22 Shuangyong Road, Nanning, 530021, Guangxi, China
| | - Ye Ye
- Guangxi Liuzhou Iron & Steel Group Co. Ltd Center for Disease Control and Prevention, Liuzhou, 545002, Guangxi, China
| | - Dongping Huang
- Department of Sanitary Chemistry, School of Public Health, Guangxi Medical University, Nanning, 530021, Guangxi, China
| | - Dongxiang Pan
- Department of Epidemiology and Health Statistics, School of Public Health, Guangxi Medical University, No. 22 Shuangyong Road, Nanning, 530021, Guangxi, China
| | - Xiaoqiang Qiu
- Department of Epidemiology and Health Statistics, School of Public Health, Guangxi Medical University, No. 22 Shuangyong Road, Nanning, 530021, Guangxi, China
| | - Lei Lei
- Department of Epidemiology and Health Statistics, School of Public Health, Guangxi Medical University, No. 22 Shuangyong Road, Nanning, 530021, Guangxi, China
| | - Xingxi Luo
- Department of Epidemiology and Health Statistics, School of Public Health, Guangxi Medical University, No. 22 Shuangyong Road, Nanning, 530021, Guangxi, China
| | - Jinxiu Li
- Department of Epidemiology and Health Statistics, School of Public Health, Guangxi Medical University, No. 22 Shuangyong Road, Nanning, 530021, Guangxi, China
| | - Kaili Wu
- Department of Epidemiology and Health Statistics, School of Public Health, Guangxi Medical University, No. 22 Shuangyong Road, Nanning, 530021, Guangxi, China
| | - Suyang Xiao
- Department of Epidemiology and Health Statistics, School of Public Health, Guangxi Medical University, No. 22 Shuangyong Road, Nanning, 530021, Guangxi, China
| | - Shun Liu
- Department of Maternal, Child and Adolescent Health, School of Public Health, Guangxi Medical University, No. 22 Shuangyong Road, Nanning, 530021, Guangxi, China.
| | - Xiaoyun Zeng
- Department of Epidemiology and Health Statistics, School of Public Health, Guangxi Medical University, No. 22 Shuangyong Road, Nanning, 530021, Guangxi, China.
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11
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Ericksen WL, Levy JH, Kim ES, Nie L, Senzel LB, Bennett-Guerrero E. Thrombin Generation in Cardiac Versus Noncardiac Surgical Cohorts. Anesth Analg 2022; 134:606-614. [PMID: 35180177 DOI: 10.1213/ane.0000000000005840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Bleeding can be a significant problem after cardiac surgery. As a result, venous thromboembolism (VTE) or anticoagulation or both following mechanical valve implantation are often delayed in these patients. The calibrated automated thrombin (CAT) generation assay has become the gold standard to evaluate thrombin generation, a critical step in clot formation independent of other hemostatic processes (eg, platelet activation, fibrin cross-linking, and fibrinolysis), and is increasingly used to examine thrombotic and hemorrhagic outcomes. No study has currently used this assay to compare the thrombin generation profiles of cardiac surgical patients to noncardiac surgical patients. We hypothesize that noncardiac patients may be less prone to postoperative changes in thrombin generation. METHODS A prospective, observational, cohort study was undertaken using blood samples from 50 cardiac and 50 noncardiac surgical patients preoperatively, immediately postoperatively, and on postoperative days 1 to 4. Platelet-poor plasma samples were obtained from patients preoperatively, on arrival to the postanesthesia care unit (PACU) or intensive care unit (ICU), and daily on postoperative days 1 to 4 if patients remained inpatient. Samples were evaluated for CAT measurements. Patient and surgical procedure characteristics were obtained from the electronic medical record. RESULTS The primary outcome variable, median endogenous thrombin potential (ETP), measured in nanomolar × minutes (nM × min), was decreased 100% in cardiac surgical versus 2% in noncardiac patients (P < .001). All parameters of thrombin generation were similarly depressed. Cardiac (versus noncardiac) surgical type was associated with -76.5% difference of percent change in ETP on multivariable regression analysis (95% confidence interval [CI], -87.4 to -65.5; P value <.001). CONCLUSIONS Cardiac surgical patients exhibit a profound decrease in thrombin generation postoperatively compared with noncardiac surgical patients evaluated by this study. Hemodilution and coagulation factor depletion likely contribute to this decreased thrombin generation after cardiac surgery.
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Affiliation(s)
- W Leif Ericksen
- From the Department of Anesthesiology, Stony Brook University, Stony Brook, New York
| | - Jerrold H Levy
- Departments of Anesthesiology and Surgery, Duke University, Durham, North Carolina
| | - Ethan S Kim
- From the Department of Anesthesiology, Stony Brook University, Stony Brook, New York
| | - Lizhou Nie
- Department of Applied Mathematics and Statistics, Stony Brook University, Stony Brook, New York
| | - Lisa B Senzel
- Department of Pathology, Stony Brook University, Stony Brook, New York
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12
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Thrombin Generation in Trauma Patients: How Do we Navigate Through Scylla and Charybdis? CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-021-00502-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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13
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Jeong D, Kim SY, Gu JY, Kim HK. Assessment of Rotational Thromboelastometry and Thrombin Generation Assay to Identify Risk of High Blood Loss and Re-Operation After Cardiac Surgery. Clin Appl Thromb Hemost 2022; 28:10760296221123310. [PMID: 36124381 PMCID: PMC9490460 DOI: 10.1177/10760296221123310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Introduction: We aimed to investigate parameters for prediction of post-operative blood loss and re-operation in patients who underwent cardiopulmonary bypass. Methods: Thrombin generation assay, activated partial thromboplastin time, activated clotting time and rotational thromboelastometry (ROTEM) tests were performed at 4 time points in 65 patients: before skin incision (T1), after heparin injection (T2), after protamine reversal (T3) and before skin closure (T4). Results: Pre-operative endogenous thrombin potential (ETP) and peak thrombin levels were significantly lower in patients with high post-operative blood loss (≥ 800 mL) within 24 h than in those with low blood loss (< 800 mL). Clotting time (CT), maximal clotting firmness, clotting firmness time and alpha angle values of ROTEM measured at T2, T3 or T4 were significant predictors for high post-operative blood loss. An increase in CT-EXTEM over 4 time points was significant in patients who had a re-operation within 48 h compared to their counterparts. Conclusions: This study indicates that pre-operative ETP could predict high post-operative blood loss and that intra-operative ROTEM also helps to stratify risks of high post-operative blood loss and re-operation.
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Affiliation(s)
- Dajeong Jeong
- Department of Laboratory Medicine, Seoul National University Hospital, Seoul, Korea
| | - Seon Young Kim
- Department of Laboratory Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Ja-Yoon Gu
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun Kyung Kim
- Department of Laboratory Medicine, Seoul National University Hospital, Seoul, Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
- Hyun Kyung Kim, MD, PhD, Department of Laboratory Medicine and Cancer Research Institute, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Korea.
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14
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The association of thrombin generation with bleeding outcomes in cardiac surgery: a prospective observational study. Can J Anaesth 2021; 69:311-322. [PMID: 34939141 DOI: 10.1007/s12630-021-02165-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 09/15/2021] [Accepted: 10/04/2021] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Cardiac surgery with cardiopulmonary bypass (CPB) is associated with coagulopathic bleeding. Impaired thrombin generation may be an important cause of coagulopathic bleeding but is poorly measured by existing hemostatic assays. We examined thrombin generation during cardiac surgery, using calibrated automated thrombography, and its association with bleeding outcomes. METHODS We conducted a prospective observational study in 100 patients undergoing cardiac surgery with CPB. Calibrated automated thrombography parameters were expressed as a ratio of post-CPB values divided by pre-CPB values. The association of thrombin generation parameters for bleeding outcomes was compared with conventional tests of hemostasis, and the outcomes of patients with the most severe post-CPB impairment in thrombin generation (≥ 80% drop from baseline) were compared with the rest of the cohort. RESULTS All 100 patients were included in the final analysis, with a mean age of 63 (12) yr, 31 (31%) female, and 94 (94%) undergoing bypass and/or valve surgery. Post-CPB, peak thrombin decreased by a median of 73% (interquartile range [IQR], 49-91%) (P < 0.001) and total thrombin generation, expressed as the endogenous thrombin potential (ETP), decreased 56% [IQR, 30-83%] (P < 0.001). In patients with ≥ 80% decrease in ETP, 21% required re-exploration for bleeding compared with 7% in the rest of the cohort (P = 0.04), and 48% required medical or surgical treatment for hemostasis compared with 27% in the rest of the cohort (P = 0.04). CONCLUSIONS Thrombin generation is significantly impaired by CPB and associated with higher bleeding severity. Clinical studies aimed at the identification and treatment of patients with impaired thrombin generation are warranted.
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15
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Binder NB, Depasse F, Mueller J, Wissel T, Schwers S, Germer M, Hermes B, Turecek PL. Clinical use of thrombin generation assays. J Thromb Haemost 2021; 19:2918-2929. [PMID: 34592058 PMCID: PMC9292855 DOI: 10.1111/jth.15538] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 09/24/2021] [Accepted: 09/28/2021] [Indexed: 11/29/2022]
Abstract
Determining patient's coagulation profile, i.e. detecting a bleeding tendency or the opposite, a thrombotic risk, is crucial for clinicians in many situations. Routine coagulation assays and even more specialized tests may not allow a relevant characterization of the hemostatic balance. In contrast, thrombin generation assay (TGA) is a global assay allowing the dynamic continuous and simultaneous recording of the combined effects of both thrombin generation and thrombin inactivation. TGA thus reflects the result of procoagulant and anticoagulant activities in blood and plasma. Because of this unique feature, TGA has been widely used in a wide array of settings from both research, clinical and pharmaceutical perspectives. This includes diagnosis, prognosis, prophylaxis, and treatment of inherited and acquired bleeding and thrombotic disorders. In addition, TGA has been shown to provide relevant information for the diagnosis of coagulopathies induced by infectious diseases, comprising also disturbance of the coagulation system in COVID-19, or for the assessment of early recurrence in breast cancer. This review article aims to document most clinical applications of TGA.
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Affiliation(s)
| | | | | | | | | | | | - Björn Hermes
- DIN e.V. – DIN Standards Committee Medicine (NAMed)
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16
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Bartoszko J, Callum J, Karkouti K. The association of prothrombin complex concentrates with postoperative outcomes in cardiac surgery: an observational substudy of the FIBRES randomized controlled trial. Can J Anaesth 2021; 68:1789-1801. [PMID: 34523108 PMCID: PMC8563600 DOI: 10.1007/s12630-021-02100-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 07/09/2021] [Accepted: 07/22/2021] [Indexed: 12/03/2022] Open
Abstract
Purpose The mainstay of therapy for coagulation factor deficiency in cardiac surgical patients is frozen plasma (FP); however, prothrombin complex concentrates (PCCs) may offer logistical and safety advantages. As there is limited comparative evidence, we conducted this study to explore the association of comparable PCC or FP doses with transfusion and outcomes. Methods This was a post hoc analysis of a multicentre randomized trial comparing fibrinogen concentrate with cryoprecipitate (FIBRES trial) in bleeding cardiac surgical patients. This analysis included 415 patients who received only PCC (n = 72; 17%) or only FP (n = 343; 83%) for factor replacement. The main outcomes of interest were red blood cell (RBC) and platelet transfusion within 24 hr of cardiopulmonary bypass. Secondary outcomes included postoperative adverse events. Associations were examined by hierarchical generalized estimating equation models adjusted for demographic and surgical characteristics. Results The median [interquartile range (IQR)] PCC dose was 1,000 [1,000–2,000] units, while the median [IQR] FP dose was 4 [2–6] units. Each unit of FP was independently associated with increased adjusted odds of RBC (1.60; 95% confidence interval [CI], 1.36 to 1.87; P < 0.01) and platelet transfusion (1.40; 95% CI, 1.15 to 1.69; P < 0.01) while each 500 units of PCC was independently associated with reduced adjusted odds of RBC (0.67; 95% CI, 0.50 to 0.90; P < 0.01) and platelet transfusion (0.80; 95% CI, 0.70 to 0.92; P < 0.01). Adverse event rates were comparable. Conclusions In cardiac surgical patients with post-cardiopulmonary bypass bleeding, PCC use was associated with lower RBC and platelet transfusion than FP use was. Prospective, randomized clinical trials comparing FP with PCC in this setting are warranted. Supplementary Information The online version contains supplementary material available at 10.1007/s12630-021-02100-4.
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Affiliation(s)
- Justyna Bartoszko
- Department of Anesthesia and Pain Management, Toronto General Hospital - University Health Network, Sinai Health System, Women's College Hospital,, University of Toronto, 200 Elizabeth Street, 3EN-464, Toronto, ON, M5G 2C4, Canada.
- Peter Munk Cardiac Centre and Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada.
| | - Jeannie Callum
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre, Toronto, ON, Canada
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
| | - Keyvan Karkouti
- Department of Anesthesia and Pain Management, Toronto General Hospital - University Health Network, Sinai Health System, Women's College Hospital,, University of Toronto, 200 Elizabeth Street, 3EN-464, Toronto, ON, M5G 2C4, Canada
- Peter Munk Cardiac Centre and Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
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17
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Abstract
The serine protease thrombin, a naturally derived enzyme, plays a key role in hemostasis by converting fibrinogen to fibrin and activating coagulation factor XIII whereby the fibrin clot is stabilized. Furthermore, thrombin activates platelets through protease-activated receptors on the platelet surface. Conversely, thrombin also exerts anticoagulant effects, enhancing the protein C activity while complexed with thrombomodulin. During recent years, it has become evident that thrombin has significant effects beyond hemostasis, as it contributes also to modulation of the endothelium, promotes inflammation and angiogenesis, and plays a role in tumor progression. Yet, due to the very short half-life and almost immediate inhibition in fluid phase by antithrombin, thrombin itself remains elusive, and only indirect measurement of thrombin generation is possible. This review provides a description of structure and mechanisms of action of thrombin both in physiological and pathological processes. Furthermore, it summarizes laboratory tests that measure in vivo or ex vivo thrombin generation, and presents knowledge on the value of these biomarkers in bleeding disorders, cardiopulmonary bypass surgery, and thromboembolic risk assessment in different patient populations. Finally, this review outlines further perspectives on using thrombin generation biomarkers for research purposes and in clinical practice.
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Affiliation(s)
- Julie Brogaard Larsen
- Department of Clinical Biochemistry, Thrombosis and Hemostasis Research Unit, Aarhus University Hospital, Aarhus, Denmark
| | - Anne-Mette Hvas
- Department of Clinical Biochemistry, Thrombosis and Hemostasis Research Unit, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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18
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Nemeth E, Varga T, Soltesz A, Racz K, Csikos G, Berzsenyi V, Tamaska E, Lang Z, Molnar G, Benke K, Eory A, Merkely B, Gal J. Perioperative Factor Concentrate Use is Associated With More Beneficial Outcomes and Reduced Complication Rates Compared With a Pure Blood Product-Based Strategy in Patients Undergoing Elective Cardiac Surgery: A Propensity Score-Matched Cohort Study. J Cardiothorac Vasc Anesth 2021; 36:138-146. [PMID: 33941446 DOI: 10.1053/j.jvca.2021.03.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/12/2021] [Accepted: 03/22/2021] [Indexed: 01/04/2023]
Abstract
OBJECTIVE The goal of this study was to compare factor concentrate (FC)-based and blood product-based hemostasis management of coagulopathy in cardiac surgical patients in terms of postoperative bleeding, required blood products, and outcome. DESIGN Retrospective, propensity score-matched analysis. SETTING Single, tertiary, academic medical center. PARTICIPANTS One hundred eighteen matched pairs of 433 consecutive patients scheduled for cardiac surgery in two isolated periods with distinct strategies of hemostasis management. INTERVENTIONS Patients received either blood product-based (period I) or FC-based (period II) hemostasis management to treat perioperative coagulopathy. MEASUREMENTS AND MAIN RESULTS Patients treated with FC management experienced less postoperative blood loss (907 v 1,153 mL, p = 0.014) and required less red blood cell and fresh frozen plasma transfusion (2.3 v 3.7 units p < 0.0001, and 2.0 v 3.4 units p < 0.0001, respectively) compared with subjects in the blood product-based management group. The frequency of Stage 3 acute kidney injury and 30-day mortality rate were significantly higher in the blood product-based group than in the FC management group (6.8% v 0.8%, p = 0.016, and 7.2% v 0.8%, p = 0.022, respectively). FC management-related thromboembolic events were not registered. The FC strategy was associated with a 2.19-fold decrease in the odds of massive postoperative bleeding (p < 0.0001), a 2.56-fold decrease in the odds of polytransfusion (p < 0.0001), and a 13.16-fold decrease in the odds of early postoperative death (p = 0.003). CONCLUSIONS FC-based versus blood product-based management is associated with reduced blood product needs and fewer complications, and was not linked to a higher frequency of thromboembolic events or a decrease in long-term survival in cardiac surgical patients developing perioperative coagulopathy and bleeding.
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Affiliation(s)
- Endre Nemeth
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary.
| | - Tamas Varga
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Adam Soltesz
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Kristof Racz
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Gergely Csikos
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Viktor Berzsenyi
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Eszter Tamaska
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Zsolt Lang
- Department of Biomathematics and Informatics, University of Veterinary Medicine, Budapest, Hungary
| | - Gabriella Molnar
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
| | - Kalman Benke
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Ajandek Eory
- Department of Family Medicine, Semmelweis University, Budapest, Hungary
| | - Bela Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Janos Gal
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
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19
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Bartoszko J, Karkouti K. Managing the coagulopathy associated with cardiopulmonary bypass. J Thromb Haemost 2021; 19:617-632. [PMID: 33251719 DOI: 10.1111/jth.15195] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 11/23/2020] [Accepted: 11/24/2020] [Indexed: 12/29/2022]
Abstract
Cardiopulmonary bypass (CPB) has allowed for significant surgical advancements, but accompanying risks can be significant and must be expertly managed. One of the foremost risks is coagulopathic bleeding. Increasing levels of bleeding in cardiac surgical patients at the time of separation from CPB are associated with poor outcomes and mortality. CPB-associated coagulopathy is typically multifactorial and rarely due to inadequate reversal of systemic heparin alone. The components of the bypass circuit induce systemic inflammation and multiple disturbances of the coagulation and fibrinolytic systems. Anticipating coagulopathy is the first step in managing it, and specific patient and procedural risk factors have been identified as predictors of excessive bleeding. Medication management pre-procedure is critical, as patients undergoing cardiac surgery are commonly on anticoagulants or antiplatelet agents. Important adjuncts to avoid transfusion include antifibrinolytics, and perfusion practices such as red cell salvage, sequestration, and retrograde autologous priming of the bypass circuit have varying degrees of evidence supporting their use. Understanding the patient's coagulation status helps target product replacement and avoid larger volume transfusion. There is increasing recognition of the role of point-of-care viscoelastic and functional platelet testing. Common pitfalls in the management of post-CPB coagulopathy include overdosing protamine for heparin reversal, imperfect laboratory measures of thrombin generation that result in normal or near-normal laboratory results in the presence of continued bleeding, and delayed recognition of surgical bleeding. While challenging, the effective management of CPB-associated coagulopathy can significantly improve patient outcomes.
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Affiliation(s)
- Justyna Bartoszko
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, University of Toronto, Toronto, ON, Canada
| | - Keyvan Karkouti
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, University of Toronto, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
- Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, ON, Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
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20
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Lin C, Fu Y, Huang S, Zhou S, Shen C. Rapid thrombelastography predicts perioperative massive blood transfusion in patients undergoing coronary artery bypass grafting: A retrospective study. Medicine (Baltimore) 2020; 99:e21833. [PMID: 32925720 PMCID: PMC7489729 DOI: 10.1097/md.0000000000021833] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Massive blood transfusion (MBT) is a relatively common complication of cardiac surgery, which is independently associated with severe postoperative adverse events. However, the value of using rapid thrombotomography (r-TEG) to predict MBT in perioperative period of cardiac surgery has not been explored. This study aimed to identify the effect of r-TEG in predicting MBT for patients undergoing coronary artery bypass grafting (CABG).This retrospective study included consecutive patients first time undergoing CABG at the Zhongnan Hospital of Wuhan University between March 2015 and November 2017. All the patients had done r-TEG tests before surgery. The MBT was defined as receiving at least 4 units of red blood cells intra-operatively and 5 units postoperatively (1 unit red blood cells from 200 mL whole blood).Lower preoperative hemoglobin level (P = .001) and longer cardiopulmonary bypass time (P = .001) were the independent risk factors for MBT during surgery, and no components of the r-TEG predicted MBT during surgery. Meanwhile, longer activated clotting time (P < .001), less autologous blood transfusion (P = .001), and older age (P = .008) were the independent risk factors for MBT within 24 hours of surgery.Preoperative r-TEG activated clotting time can predict the increase of postoperative MBT in patients undergoing CABG. We recommend the careful monitoring of coagulation system with r-TEG, which allows rapid diagnosis of coagulation abnormalities even before the start of surgery.
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Affiliation(s)
- Chenyao Lin
- Department of Laboratory Mediciney, Ningbo Medical Treatment Center Lihuili Hospital, Ningbo
- Department of Blood Transfusion, ZhongNan Hospital of Wuhan University, Wuhan, China
| | - Yourong Fu
- Department of Blood Transfusion, ZhongNan Hospital of Wuhan University, Wuhan, China
| | - Shuang Huang
- Department of Blood Transfusion, ZhongNan Hospital of Wuhan University, Wuhan, China
| | - Shuimei Zhou
- Department of Blood Transfusion, ZhongNan Hospital of Wuhan University, Wuhan, China
| | - Changxin Shen
- Department of Blood Transfusion, ZhongNan Hospital of Wuhan University, Wuhan, China
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21
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Ashikhmina E, Johnson PM, Aganga DO, Nuttall GA, Lahr BD, Schaff HV, Dearani JA. Thrombin Generation and Antithrombin Activity in Infants Undergoing Cardiopulmonary Bypass—An Exploratory Study. J Cardiothorac Vasc Anesth 2020; 34:2083-2090. [DOI: 10.1053/j.jvca.2019.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 12/05/2019] [Accepted: 12/07/2019] [Indexed: 11/11/2022]
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22
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Modrau IS, Halle DR, Nielsen PH, Kimose HH, Greisen JR, Kremke M, Hvas AM. Impact of minimally invasive extracorporeal circulation on coagulation-a randomized trial. Eur J Cardiothorac Surg 2020; 57:1145-1153. [PMID: 32011717 PMCID: PMC7239600 DOI: 10.1093/ejcts/ezaa010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 12/12/2019] [Accepted: 12/25/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Minimally invasive extracorporeal circulation (MiECC) is suggested to have favourable impact on blood loss compared to conventional extracorporeal circulation. We aimed to compare the impact of both systems on coagulation. METHODS Randomized trial comparing endogenous thrombin-generating potential early after elective coronary surgery employing either MiECC group (n = 30) or conventional extracorporeal circulation group (n = 30). Secondary outcomes were in vivo thrombin generation, bleeding end points and haemodilution, as well as morbidity and mortality up to 30-day follow-up. RESULTS Compared to the conventional extracorporeal circulation group, the MiECC group showed (i) a trend towards a higher early postoperative endogenous thrombin-generating potential (P = 0.06), (ii) lower intraoperative levels of thrombin-antithrombin complex and prothrombin fragment 1 + 2 (P < 0.001), (iii) less haemodilution early postoperatively as measured by haematocrit and weight gain, but without correlation to coagulation factors or bleeding end points. Moreover, half as many patients required postoperative blood transfusion in the MiECC group (17% vs 37%, P = 0.14), although postoperative blood loss did not differ between groups (P = 0.84). Thrombin-antithrombin complex levels (rs = 0.36, P = 0.005) and prothrombin fragment 1 + 2 (rs = 0.45, P < 0.001), but not early postoperative endogenous thrombin-generating potential (rs = 0.05, P = 0.72), showed significant correlation to increased transfusion requirements. The MiECC group demonstrated significantly lower levels of creatine kinase-MB, lactate dehydrogenase and free haemoglobin indicating superior myocardial protection, less tissue damage and less haemolysis, respectively. Perioperative morbidity and 30-day mortality did not differ between groups. CONCLUSIONS Conventional but not MiECC is associated with significant intraoperative thrombin generation despite full heparinization. No correlation between coagulation factors or bleeding end points with the degree of haemodilution could be ascertained. CLINICALTRIALS.GOV IDENTIFIER NCT03216720.
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Affiliation(s)
- Ivy Susanne Modrau
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Debbie Richards Halle
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Per Hostrup Nielsen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Hans Henrik Kimose
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jacob Raben Greisen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Michael Kremke
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Anne-Mette Hvas
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
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23
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Thrombin generation and bleeding in cardiac surgery: a clinical narrative review. Can J Anaesth 2020; 67:746-753. [PMID: 32133581 DOI: 10.1007/s12630-020-01609-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 01/20/2020] [Accepted: 01/21/2020] [Indexed: 12/27/2022] Open
Abstract
This narrative review discusses the role of thrombin generation in coagulation and bleeding in cardiac surgery, the laboratory methods for clinical detection of impaired thrombin generation, and the available hemostatic interventions that can be used to improve thrombin generation. Coagulopathy after cardiopulmonary bypass (CPB) is associated with excessive blood loss and adverse patient outcomes. Thrombin plays a crucial role in primary hemostasis, and impaired thrombin generation can be an important cause of post-CPB coagulopathy. Existing coagulation assays have significant limitations in assessing thrombin generation, but whole-blood assays designed to measure thrombin generation at the bed-side are under development. Until then, clinicians may need to institute therapy empirically for non-surgical bleeding in the setting of normal coagulation measures. Available therapies for impaired thrombin generation include administration of plasma, prothrombin complex concentrate, and bypassing agents (recombinant activated factor VII and factor eight inhibitor bypassing activity). In vitro experiments have explored the relative potency of these therapies, but clinical studies are lacking. The potential incorporation of thrombin generation assays into clinical practice and treatment algorithms for impaired thrombin generation must await further clinical development.
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24
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Heparin sensitivity and postoperative blood loss in patients undergoing cardiac surgery with cardiopulmonary bypass. Eur J Anaesthesiol 2020; 37:162-169. [PMID: 31895135 DOI: 10.1097/eja.0000000000001148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Heparin-associated coagulation disorder is an important factor related to postoperative bleeding in patients undergoing cardiac surgery with cardiopulmonary bypass. Currently, the relationship between heparin sensitivity and postoperative bleeding is unknown. OBJECTIVE To investigate the relationship between individual heparin sensitivity and postoperative blood loss in patients undergoing cardiac surgery. DESIGN Prospective controlled study. SETTING Tertiary teaching hospital, Urumqi, Xinjiang, PR China. The study was conducted from January 2016 to August 2018. PATIENTS A total of 195 adult patients undergoing cardiac valve replacement surgery were included. INTERVENTION After initial heparin dosing (2.5 mg kg), patients were divided into three groups according to the whole blood activated clotting time (ACT): group A, insensitive group (ACT < 480 s); group B, sensitive group (480 s < ACT < 750 s); group C, hypersensitive group (ACT > 750 s). MAIN OUTCOME MEASURES First, intra-operative and 24-h postoperative blood loss. Second, antithrombin (AT) and factor X mRNA levels. Third, the plasma levels of AT-III and factor X. Fourth, heparin sensitivity index. RESULTS Blood loss was approximately 20 to 25% lower in group B than in groups A and C, which was statistically significant (P < 0.01). The AT-III mRNA levels increased from groups A to C and was positively associated with heparin sensitivity; the factor X mRNA levels changed in the opposite direction; a significant difference was observed between groups A and C (P < 0.05). The factor X plasma level showed the same trend as its mRNA. The AT-III plasma level was significantly lower in group B than in groups A and C (P < 0.05). CONCLUSION Postoperative blood loss is related to heparin sensitivity in patients undergoing cardiac surgery, and the moderately sensitive patients have the least postoperative bleeding. Individual variation in heparin sensitivity is related to the mRNA and plasma levels of AT-III and factor X. TRIAL REGISTRATION Registration number ChiCTR-RPC-17012259.
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25
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Nam K, Jeon Y, Kim TK, Jo WY, Yoon S, Kwak J, Cho YJ. The velocity curve of the clotting waveform of rotational thromboelastometry predicts bleeding after cardiac surgery but conventional rotational thromboelastometric parameters do not. Minerva Anestesiol 2018; 85:505-513. [PMID: 30394063 DOI: 10.23736/s0375-9393.18.12960-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Early detection of a risk of postoperative bleeding is essential in cardiac surgery patients. The aim of the present study was to evaluate the utility of the first derivative curve (the V-curve) of the clotting waveform of rotational thromboelastometry (ROTEM) in terms of predicting bleeding after cardiac surgery. METHODS We retrospectively analysed 534 cardiac surgery patients. We used the chest tube output during the stay in the intensive care unit to divide patients into a higher blood loss group (HBL group; the fourth quartile) and a lower blood loss group (LBL group; the lower quartiles). We performed multivariable logistic regression using the V-curve parameters and potential confounders including conventional ROTEM parameters. RESULTS In the multivariable model, the adjusted odds ratios for HBL of patients with a lower maximum clotting velocity (MaxVel ≤9 mm*100 s-1) as revealed by extrinsically activated ROTEM (EXTEM), and the area under the velocity curve (AUC ≤988 mm*100) of the fibrin-based extrinsically activated ROTEM (FIBTEM), both measured at skin closure in the end of surgery, were 1.78 (95% CI 1.03 to 3.07) and 2.14 (95% CI 1.20 to 3.82), respectively. However, conventional ROTEM parameters were not included in the final model. Additionally, lower EXTEM MaxVel and FIBTEM AUC values were associated with the need for a higher transfusion volume, longer postoperative intensive care unit and hospital stays, and more frequent re-exploration to control bleeding. CONCLUSIONS The ROTEM V-curve parameters can predict postoperative bleeding and clinical outcomes after cardiac surgery.
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Affiliation(s)
- Karam Nam
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Yunseok Jeon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Tae K Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Woo Y Jo
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Sehee Yoon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Jooah Kwak
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Youn J Cho
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea -
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26
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Boyle G, Kuffel A, Parmar K, Gibson K, Smith M, Grehan A, Hunt BJ, Chambers DJ. A comparison of haemostatic biomarkers during low-risk patients undergoing cardiopulmonary bypass using either conventional centrifugal cell salvage or the HemoSep device. Perfusion 2018; 34:76-83. [PMID: 30067140 DOI: 10.1177/0267659118789051] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Cardiac surgery using cardiopulmonary bypass (CPB) is associated with a coagulopathy due to haemodilution, thrombocytopenia and platelet dysfunction and the activation of coagulation and fibrinolysis, despite the use of large doses of unfractionated heparin. Conventional red cell salvage may exacerbate post-operative bleeding as plasma containing haemostatic factors is discarded. We hypothesized that a novel cell salvage device (HemoSep) may attenuate haemostatic changes associated with red cell salvage. We studied haemostatic markers following autologous transfusion from conventional cell salvage or the HemoSep device. METHODS This randomised, controlled trial compared haemostatic markers in patients undergoing coronary artery bypass grafting or aortic valve replacement who received autologous blood returned from cell salvage (control) or HemoSep (study). Blood samples were taken pre-operatively, end of CPB, post-transfusion of salvaged blood and 3 hours post-operatively and analysed for full blood count (FBC), prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen, D-dimer and endogenous thrombin potential (ETP). RESULTS Fifty-four patients were recruited (n=28 control, n=26 study). Processed blood volume for transfusion was significantly (p<0.001) higher in the HemoSep group. In the HemoSep group, the PT was shorter (18.7±0.3 vs 19.9±0.3 sec; p<0.05) post-operatively and the aPTT was longer (48.6±3.8 vs 37.3±1.0 sec; p<0.01) following autologous transfusion. In the control group, D-dimer and ETP levels were higher (1903±424 vs.1088±151; p<0.05 and 739±46 vs. 394±60; p<0.001, respectively) following autologous transfusion. CONCLUSIONS Although centrifuged cell salvage is known to adequately haemoconcentrate and remove unwanted substrates and bacteriological contamination, the process can exacerbate coagulopathy. The HemoSep device demonstrated some increase in haemostatic markers when used in low-risk cardiac surgery patients.
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Affiliation(s)
- Gethin Boyle
- 1 Clinical Perfusion Department, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, UK
| | | | - Kiran Parmar
- 2 Thrombosis & Vascular Biology Group, The Rayne Institute, UK
| | - Kirsty Gibson
- 3 Cardiovascular Research, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, UK
| | - Megan Smith
- 3 Cardiovascular Research, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, UK
| | - Aidan Grehan
- 1 Clinical Perfusion Department, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, UK
| | - Beverley J Hunt
- 2 Thrombosis & Vascular Biology Group, The Rayne Institute, UK.,4 Thrombosis & Haemophilia, Guy's & St Thomas' NHS Foundation Trust, St Thomas' Hospital, UK
| | - David J Chambers
- 5 Cardiothoracic Surgery/Cardiac Surgical Research, The Rayne Institute, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, UK
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27
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Zwaveling S, Bloemen S, de Laat B, ten Cate H, ten Cate-Hoek A. Calibrated Automated Thrombinography (CAT), a Tool to Identify Patients at Risk of Bleeding during Anticoagulant Therapy: A Systematic Review. TH OPEN 2018; 2:e291-e302. [PMID: 31249953 PMCID: PMC6524885 DOI: 10.1055/s-0038-1672183] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 08/01/2018] [Indexed: 12/14/2022] Open
Abstract
Background Bleeding is a feared adverse event during anticoagulant treatment. In patients on vitamin K antagonists, most bleedings occur with the international normalized ratio (INR) in the therapeutic range. Currently, identification of high-risk patients via laboratory methods is not reliable. In this systematic review, we assessed the ability of calibrated automated thrombin generation (CAT-TG) to predict bleeding in patients on anticoagulant treatment. Methods A systematic search was executed in three databases: Medline, Embase, and Cochrane. Results Seven studies were included; two were of good methodological quality. One study showed that patients on warfarin with INRs in range (2-3) admitted for hemorrhage ( n = 28), had lower CAT-TG levels (endogenous thrombin potential [ETP]: 333 ± 89 nM/min) than patients on warfarin admitted for other reasons (ETP: 436 ± 207 nM/min; p < 0.001). Another study found no difference in ETP or peak levels between bleeding and nonbleeding patients in PPP or PRP. When measured in whole blood, both levels were significantly lower in patients with bleeding compared with nonbleeding patients (median [interquartile range, IQR] ETP: 182.5 [157.2-2,847 nM/min] vs. median [IQR] ETP: 256.2 [194.9-344.2 nM/min]; p < 0.001) and median [IQR] peak: 23.9 [19.6-41.8 nM] vs. median [IQR] peak: 39.1 [24.9-53.2 nM]; p < 0.05). From the remaining studies, four suggested that CAT-TG is more sensitive in detecting hemostatic abnormalities than INR and one article found ETP and INR to be equally useful. However, insufficient data were provided to validate these conclusions. Conclusion Studies investigating the direct association between decreased CAT-TG values and hemorrhagic events are rare. Therefore, the clinical consequences of low CAT-TG values remain to be further investigated.
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Affiliation(s)
- Suzanne Zwaveling
- Laboratory for Clinical Thrombosis and Hemostasis, Internal Medicine and Biochemistry, Maastricht University, Maastricht, The Netherlands
- Synapse Research Institute, Maastricht, The Netherlands
| | | | - Bas de Laat
- Synapse Research Institute, Maastricht, The Netherlands
| | - Hugo ten Cate
- Laboratory for Clinical Thrombosis and Hemostasis, Internal Medicine and Biochemistry, Maastricht University, Maastricht, The Netherlands
| | - Arina ten Cate-Hoek
- Laboratory for Clinical Thrombosis and Hemostasis, Internal Medicine and Biochemistry, Maastricht University, Maastricht, The Netherlands
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28
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Dimberg A, Alström U, Ståhle E, Christersson C. Higher Preoperative Plasma Thrombin Potential in Patients Undergoing Surgery for Aortic Stenosis Compared to Surgery for Stable Coronary Artery Disease. Clin Appl Thromb Hemost 2018; 24:1282-1290. [PMID: 29768939 PMCID: PMC6714769 DOI: 10.1177/1076029618776374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aortic stenosis (AS) and coronary artery disease (CAD) influence the coagulation system, potentially affecting hemostasis during cardiac surgery. Our aim was to evaluate 2 preoperative global hemostasis assays, plasma thrombin potential and thromboelastometry, in patients with severe aortic valve stenosis compared to patients with CAD. A secondary aim was to test whether the assays were associated with postoperative bleeding. Calibrated automated thrombogram (CAT) in platelet-poor plasma and rotational thromboelastometry (ROTEM) in whole blood were analyzed in patients scheduled for elective surgery due to severe AS (n = 103) and stable CAD (n = 68). Patients with AS displayed higher plasma thrombin potential, both thrombin peak with median 252 nmol/L (interquartile range 187-319) and endogenous thrombin potential (ETP) with median 1552 nmol/L/min (interquartile range 1340-1838), when compared to patients with CAD where thrombin peak was median 174 nmol/L (interquartile range 147-229) and ETP median 1247 nmol/L/min (interquartile range 1034-1448; both P < .001). Differences persisted after adjustment for age, gender, comorbidity, and antithrombotic treatment. Differences observed in thromboelastometry between the groups did not persist after adjustment for baseline characteristics. Bleeding amount showed no relationship with plasma thrombin potential but weakly to thromboelastometry (R2 = .064, P = .001). Patients with AS exhibited preoperatively increased plasma thrombin potential compared to patients with CAD. Plasma thrombin potential was not predictive for postoperative bleeding in patients scheduled for elective surgery.
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Affiliation(s)
- Axel Dimberg
- 1 Section of Thoracic Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Ulrica Alström
- 1 Section of Thoracic Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Elisabeth Ståhle
- 1 Section of Thoracic Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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29
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Fitzgerald J, Lenihan M, Callum J, McCluskey S, Srinivas C, van Rensburg A, Karkouti K. Use of prothrombin complex concentrate for management of coagulopathy after cardiac surgery: a propensity score matched comparison to plasma. Br J Anaesth 2018; 120:928-934. [DOI: 10.1016/j.bja.2018.02.017] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Revised: 02/01/2018] [Accepted: 02/18/2018] [Indexed: 12/25/2022] Open
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30
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Slatter DA, Percy CL, Allen-Redpath K, Gajsiewicz JM, Brooks NJ, Clayton A, Tyrrell VJ, Rosas M, Lauder SN, Watson A, Dul M, Garcia-Diaz Y, Aldrovandi M, Heurich M, Hall J, Morrissey JH, Lacroix-Desmazes S, Delignat S, Jenkins PV, Collins PW, O'Donnell VB. Enzymatically oxidized phospholipids restore thrombin generation in coagulation factor deficiencies. JCI Insight 2018; 3:98459. [PMID: 29563336 PMCID: PMC5926910 DOI: 10.1172/jci.insight.98459] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 02/16/2018] [Indexed: 12/11/2022] Open
Abstract
Hemostatic defects are treated using coagulation factors; however, clot formation also requires a procoagulant phospholipid (PL) surface. Here, we show that innate immune cell–derived enzymatically oxidized phospholipids (eoxPL) termed hydroxyeicosatetraenoic acid–phospholipids (HETE-PLs) restore hemostasis in human and murine conditions of pathological bleeding. HETE-PLs abolished blood loss in murine hemophilia A and enhanced coagulation in factor VIII- (FVIII-), FIX-, and FX-deficient human plasma . HETE-PLs were decreased in platelets from patients after cardiopulmonary bypass (CPB). To explore molecular mechanisms, the ability of eoxPL to stimulate individual isolated coagulation factor/cofactor complexes was tested in vitro. Extrinsic tenase (FVIIa/tissue factor [TF]), intrinsic tenase (FVIIIa/FIXa), and prothrombinase (FVa/FXa) all were enhanced by both HETE-PEs and HETE-PCs, suggesting a common mechanism involving the fatty acid moiety. In plasma, 9-, 15-, and 12-HETE-PLs were more effective than 5-, 11-, or 8-HETE-PLs, indicating positional isomer specificity. Coagulation was enhanced at lower lipid/factor ratios, consistent with a more concentrated area for protein binding. Surface plasmon resonance confirmed binding of FII and FX to HETE-PEs. HETE-PEs increased membrane curvature and thickness, but not surface charge or homogeneity, possibly suggesting increased accessibility to cations/factors. In summary, innate immune-derived eoxPL enhance calcium-dependent coagulation factor function, and their potential utility in bleeding disorders is proposed. Innate immune-derived enzymatically oxidized phospholipids enhance calcium-dependent coagulation factor function.
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Affiliation(s)
- David A Slatter
- Systems Immunity Research Institute and Division of Infection and Immunity, Cardiff University, Cardiff, United Kingdom
| | - Charles L Percy
- Systems Immunity Research Institute and Division of Infection and Immunity, Cardiff University, Cardiff, United Kingdom
| | - Keith Allen-Redpath
- Systems Immunity Research Institute and Division of Infection and Immunity, Cardiff University, Cardiff, United Kingdom
| | - Joshua M Gajsiewicz
- Departments of Biological Chemistry and Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Nick J Brooks
- Faculty of Natural Science, Department of Chemistry, Imperial College London, London, United Kingdom
| | - Aled Clayton
- Institute of Cancer and Genetics, Velindre Cancer Centre, School of Medicine, and
| | - Victoria J Tyrrell
- Systems Immunity Research Institute and Division of Infection and Immunity, Cardiff University, Cardiff, United Kingdom
| | - Marcela Rosas
- Systems Immunity Research Institute and Division of Infection and Immunity, Cardiff University, Cardiff, United Kingdom
| | - Sarah N Lauder
- Systems Immunity Research Institute and Division of Infection and Immunity, Cardiff University, Cardiff, United Kingdom
| | - Andrew Watson
- Systems Immunity Research Institute and Division of Infection and Immunity, Cardiff University, Cardiff, United Kingdom
| | - Maria Dul
- School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Cardiff, United Kingdom
| | - Yoel Garcia-Diaz
- School of Chemistry, Vanderbilt University, Nashville, Tennessee, USA
| | - Maceler Aldrovandi
- Systems Immunity Research Institute and Division of Infection and Immunity, Cardiff University, Cardiff, United Kingdom
| | - Meike Heurich
- Systems Immunity Research Institute and Division of Infection and Immunity, Cardiff University, Cardiff, United Kingdom
| | - Judith Hall
- Systems Immunity Research Institute and Division of Infection and Immunity, Cardiff University, Cardiff, United Kingdom
| | - James H Morrissey
- Departments of Biological Chemistry and Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | | | | | - P Vincent Jenkins
- Haematology Department, University Hospital of Wales, Cardiff, United Kingdom
| | - Peter W Collins
- Systems Immunity Research Institute and Division of Infection and Immunity, Cardiff University, Cardiff, United Kingdom
| | - Valerie B O'Donnell
- Systems Immunity Research Institute and Division of Infection and Immunity, Cardiff University, Cardiff, United Kingdom
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31
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Chowdary P, Tang A, Watson D, Besser M, Collins P, Creagh MD, Qureshi H, Rokicka M, Nokes T, Diprose P, Gill R. Retrospective Review of a Prothrombin Complex Concentrate (Beriplex P/N) for the Management of Perioperative Bleeding Unrelated to Oral Anticoagulation. Clin Appl Thromb Hemost 2018; 24:1159-1169. [PMID: 29415562 PMCID: PMC6714747 DOI: 10.1177/1076029617753537] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
A multicenter, retrospective, observational study of 4-factor prothrombin complex concentrate (PCC) and/or fresh frozen plasma (FFP) use within routine clinical care unrelated to vitamin K antagonists was conducted. The PCC was administered preprocedure for correction of coagulopathy (prophylactic cohort) and treatment of bleeding postsurgery (treatment cohort). Of the 445 patients included, 40 were in the prophylactic cohort (PCC alone [n = 16], PCC and FFP [n = 5], FFP alone [n = 19]) and 405 were in the treatment cohort (PCC alone [n = 228], PCC and FFP [n = 123], FFP alone [n = 54]). Cardiovascular surgery was the most common setting. PCC doses ranged between 500 and 5000 IU. Effectiveness (assessed retrospectively) was reported as effective in 93.0% in the PCC-only group (95% confidence interval, 89.1% to 95.9%), 78.9% (70.8% to 85.6%) with PCC and FFP, and 86.3% (76.2% to 93.2%) with FFP alone. In the treatment cohort, international normalized ratio was significantly reduced in all 3 groups. In patients who received PCC, the rate of thromboembolic events (1.9%) was below rates in the literature for similar procedures. PCCs offer a potential alternative to FFP in the management of perioperative bleeding unrelated to oral anticoagulant therapy.
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Affiliation(s)
- Pratima Chowdary
- 1 Katharine Dormandy Haemophilia Centre and Thrombosis Unit, Royal Free Hospital, London, United Kingdom
| | - Augustine Tang
- 2 Lancashire Cardiac Centre, Blackpool Teaching Hospital FT, Blackpool, United Kingdom.,3 Faculty of Health and Medicine, Lancaster University, Lancaster, United Kingdom.,Deceased
| | - Dale Watson
- 2 Lancashire Cardiac Centre, Blackpool Teaching Hospital FT, Blackpool, United Kingdom
| | - Martin Besser
- 4 Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Peter Collins
- 5 Arthur Bloom Haemophilia Centre, University Hospital of Wales, Cardiff, United Kingdom
| | | | - Hafiz Qureshi
- 7 Department of Transfusion Medicine, Glenfield Hospital, Leicester, United Kingdom
| | | | - Tim Nokes
- 9 Derriford Hospital, Plymouth, United Kingdom
| | - Paul Diprose
- 10 Department of Anaesthesia, University Hospital Southampton, Southampton, United Kingdom
| | - Ravi Gill
- 10 Department of Anaesthesia, University Hospital Southampton, Southampton, United Kingdom
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Meesters MI, Burtman D, van de Ven PM, Boer C. Prediction of Postoperative Blood Loss Using Thromboelastometry in Adult Cardiac Surgery: Cohort Study and Systematic Review. J Cardiothorac Vasc Anesth 2018; 32:141-150. [DOI: 10.1053/j.jvca.2017.08.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Indexed: 12/22/2022]
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Boer C, Meesters MI, Milojevic M, Benedetto U, Bolliger D, von Heymann C, Jeppsson A, Koster A, Osnabrugge RL, Ranucci M, Ravn HB, Vonk AB, Wahba A, Pagano D. 2017 EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery. J Cardiothorac Vasc Anesth 2018; 32:88-120. [DOI: 10.1053/j.jvca.2017.06.026] [Citation(s) in RCA: 203] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Indexed: 01/28/2023]
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Ichikawa J, Osada Y, Kodaka M, Nishiyama K, Komori M. Association Between Platelet Count and Postoperative Blood Loss in Patients Undergoing Cardiac Surgery With Cardiopulmonary Bypass and Fresh Frozen Plasma Administration Guided by Thromboelastometry. Circ J 2018; 82:677-683. [DOI: 10.1253/circj.cj-17-0712] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Junko Ichikawa
- Department of Anesthesiology, Tokyo Women’s Medical University Medical Center East
| | - Yoshiko Osada
- Department of Anesthesiology, Tokyo Women’s Medical University Medical Center East
| | - Mitsuharu Kodaka
- Department of Anesthesiology, Tokyo Women’s Medical University Medical Center East
| | - Keiko Nishiyama
- Department of Anesthesiology, Tokyo Women’s Medical University Medical Center East
| | - Makiko Komori
- Department of Anesthesiology, Tokyo Women’s Medical University Medical Center East
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Rizza A, Di Felice G, Luciano R, Porzio O, Panizzon O, Muraca M, Cogo P. Calibrated automated thrombogram values in infants with cardiac surgery before and after cardiopulmonary bypass. Thromb Res 2017; 160:91-96. [DOI: 10.1016/j.thromres.2017.09.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 07/29/2017] [Accepted: 09/20/2017] [Indexed: 10/18/2022]
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Pagano D, Milojevic M, Meesters MI, Benedetto U, Bolliger D, von Heymann C, Jeppsson A, Koster A, Osnabrugge RL, Ranucci M, Ravn HB, Vonk ABA, Wahba A, Boer C. 2017 EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery. Eur J Cardiothorac Surg 2017; 53:79-111. [DOI: 10.1093/ejcts/ezx325] [Citation(s) in RCA: 192] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Ashikhmina E, Said S, Smith MM, Rodriguez V, Oliver WC, Nuttall GA, Dearani JA, Schaff HV. Prothrombin Complex Concentrates in Pediatric Cardiac Surgery: The Current State and the Future. Ann Thorac Surg 2017. [PMID: 28648539 DOI: 10.1016/j.athoracsur.2017.04.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND After decades of practice of pediatric cardiac surgery, postoperative bleeding due to the immaturity of hemostasis, hemodilution, and hypothermia remains a concern. Recently, a new approach for adult coagulopathy after bypass has emerged. Prothrombin complex concentrates (PCCs), designed to treat bleeding in hemophilia patients, are safely and efficiently used off label for hemorrhage after bypass. However, optimal dosing, indications and contraindications, and laboratory tests to assess the efficacy of PCC use in children have not yet been established. This literature review outlines the challenges of bypass-related coagulopathy, the pharmacology, and the experience in use of PCCs, with a focus on their potential in pediatric cardiac surgery. METHODS After a thorough literature search of MEDLINE, Scopus, and Ovid databases using the term "prothrombin complex concentrate AND pediatric," 23 relevant articles were selected. RESULTS The data supporting successful use of PCCs in acquired coagulopathy after cardiac surgery in adults have been increasing. Although small volume, low immunogenicity, efficiency, and speed in correcting coagulopathy are attractive qualities of PCCs for pediatric practice, current evidence is only anecdotal. The main concerns are unknown dosing regimens, the inability to closely monitor the effects of PCCs in real time, and a possibility of thrombotic complications, which can be particularly devastating in young congenital cardiac patients whose lives frequently depend upon the patency of artificial shunts. CONCLUSIONS Extensive, high-quality research is warranted to fill in the gaps of knowledge regarding using PCCs in pediatric cardiac practice.
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Affiliation(s)
- Elena Ashikhmina
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota.
| | - Sameh Said
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Mark M Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Vilmarie Rodriguez
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - William C Oliver
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Gregory A Nuttall
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
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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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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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Ghadimi K, Levy JH, Welsby IJ. Prothrombin Complex Concentrates for Bleeding in the Perioperative Setting. Anesth Analg 2016; 122:1287-300. [PMID: 26983050 DOI: 10.1213/ane.0000000000001188] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Prothrombin complex concentrates (PCCs) contain vitamin K-dependent clotting factors (II, VII, IX, and X) and are marketed as 3 or 4 factor-PCC formulations depending on the concentrations of factor VII. PCCs rapidly restore deficient coagulation factor concentrations to achieve hemostasis, but like with all procoagulants, the effect is balanced against thromboembolic risk. The latter is dependent on both the dose of PCCs and the individual patient prothrombotic predisposition. PCCs are approved by the US Food and Drug Administration for the reversal of vitamin K antagonists in the setting of coagulopathy or bleeding and, therefore, can be administered when urgent surgery is required in patients taking warfarin. However, there is growing experience with the off-label use of PCCs to treat patients with surgical coagulopathic bleeding. Despite their increasing use, there are limited prospective data related to the safety, efficacy, and dosing of PCCs for this indication. PCC administration in the perioperative setting may be tailored to the individual patient based on the laboratory and clinical variables, including point-of-care coagulation testing, to balance hemostatic benefits while minimizing the prothrombotic risk. Importantly, in patients with perioperative bleeding, other considerations should include treating additional sources of coagulopathy such as hypofibrinogenemia, thrombocytopenia, and platelet disorders or surgical sources of bleeding. Thromboembolic risk from excessive PCC dosing may be present well into the postoperative period after hemostasis is achieved owing to the relatively long half-life of prothrombin (factor II, 60-72 hours). The integration of PCCs into comprehensive perioperative coagulation treatment algorithms for refractory bleeding is increasingly reported, but further studies are needed to better evaluate the safe and effective administration of these factor concentrates.
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Affiliation(s)
- Kamrouz Ghadimi
- From the Divisions of Cardiothoracic Anesthesiology and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina
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Kelchtermans H, Pelkmans L, Bouwhuis A, Schurgers E, Lindhout T, Huskens D, Miszta A, Hemker HC, Lancé MD, de Laat B. Simultaneous measurement of thrombin generation and fibrin formation in whole blood under flow conditions. Thromb Haemost 2016; 116:134-45. [PMID: 27074907 DOI: 10.1160/th15-10-0801] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 03/28/2016] [Indexed: 11/05/2022]
Abstract
Assays based on the formation of thrombin and fibrin are frequently used, and results are considered exchangeable in research/clinical settings. However, thrombin generation and fibrin formation do not always go hand in hand and flow profoundly influences thrombus formation. We describe the technical/clinical evaluation of an assay to simultaneously measure thrombin generation and fibrin formation under conditions of flow. Introduction of a fluorometer into a 'cone and base principle'-based rheometer allowed the measurement of thrombin generation (using a thrombin-sensitive substrate) and fibrin formation (changes in viscosity), while applying a linear shear flow. Increasing shear rates inversely related with thrombin generation and fibrin formation. Increasing fibrinogen concentrations in defibrinated plasma resulted in increased thrombin generation and fibrin formation. In pre-operative samples of 70 patients undergoing cardiothoracic surgery, fibrin formation and thrombin generation parameters correlated with fibrinogen content, rotational thromboelastometry (ROTEM) and whole blood Calibrated Automated Thrombinography (CAT) parameters, respectively. Upon dividing patients into two groups based on the median clot strength, a significant difference in perioperative/total blood loss was established. In conclusion, we clinically evaluated a method capable of simultaneously measuring thrombin generation and fibrin formation in plasma/whole blood under continuous flow, rendering our method one step closer to physiology. Importantly, our test proved to be indicative for the amount of blood loss during/after cardiothoracic surgery.
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Affiliation(s)
- Hilde Kelchtermans
- Hilde Kelchtermans, Oxfordlaan 70, Maastricht 6229EV, The Netherlands, Tel.: +31 43 388 58 94, Fax: +31 43 388 45 70, E-mail:
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Changes in thrombin generation in children after cardiac surgery and ex-vivo response to blood products and haemostatic agents. Blood Coagul Fibrinolysis 2016; 27:24-30. [DOI: 10.1097/mbc.0000000000000379] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Purpose of review To provide an overview of acquired coagulopathies that can occur in various perioperative clinical settings. Also described are coagulation disturbances linked to antithrombotic medications and currently available strategies to reverse their antithrombotic effects in situations of severe hemorrhage. Recent findings Recent studies highlight the link between low fibrinogen and decreased fibrin polymerization in the development of acquired coagulopathy. Particularly, fibrin(ogen) deficits are observable after cardiopulmonary bypass in cardiac surgery, on arrival at the emergency room in trauma patients, and with ongoing bleeding after child birth. Regarding antithrombotic therapy, although new oral anticoagulants offer the possibility of efficacy and relative safety compared with vitamin K antagonists, reversal of their anticoagulant effect with nonspecific agents, including prothrombin complex concentrate, has provided conflicting results. Specific antidotes, currently being developed, are not yet licensed for clinical use, but initial results are promising. Summary Targeted hemostatic therapy aims to correct coagulopathies in specific clinical settings, and reduce the need for allogeneic transfusions, thus preventing massive transfusion and its deleterious outcomes. Although there are specific guidelines for reversing anticoagulation in patients treated with antiplatelet agents or warfarin, there is currently little evidence to advocate comprehensive recommendations to treat drug-induced coagulopathy associated with new oral anticoagulants.
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Radulovic V, Laffin A, Hansson KM, Backlund E, Baghaei F, Jeppsson A. Heparin and Protamine Titration Does Not Improve Haemostasis after Cardiac Surgery: A Prospective Randomized Study. PLoS One 2015; 10:e0130271. [PMID: 26134993 PMCID: PMC4489911 DOI: 10.1371/journal.pone.0130271] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Accepted: 05/18/2015] [Indexed: 11/18/2022] Open
Abstract
Background Bleeding complications are common in cardiac surgery. Perioperative handling of heparin and protamine may influence the haemostasis. We hypothesized that heparin and protamine dosing based on individual titration curves would improve haemostasis in comparison to standard dosing. Subjects and Methods Sixty patients scheduled for first time elective coronary artery bypass grafting or valve surgery were included in a prospective randomized study. The patients were randomized to heparin and protamine dosing with Hepcon HMS Plus device or to standard weight and activated clotting time (ACT) based dosing. Blood samples were collected before and 10 minutes, 2 hours and 4 hours after cardiopulmonary bypass. Primary endpoint was endogenous thrombin potential in plasma 2 hours after surgery as assessed by calibrated automated thrombography. Secondary endpoints included total heparin and protamine doses, whole blood clot formation (thromboelastometry) and post-operative bleeding volume and transfusions. Heparin effect was assessed by measuring anti-Xa activity. Results Endogenous thrombin potential and clot formation deteriorated in both groups after surgery without statistically significant intergroup difference. There were no significant differences between the groups in total heparin and protamine doses, heparin effect, or postoperative bleeding and transfusions at any time point. Significant inverse correlations between anti-Xa activity and endogenous thrombin potential were observed 10 min (r = -0.43, p = 0.001), 2 hours (r = -0.66, p<0.001) and 4 hours after surgery (r = -0.58, p<0.001). Conclusion In conclusion, the results suggest that perioperative heparin and protamine dosing based on individual titration curves does not improve haemostasis after cardiac surgery. Postoperative thrombin generation capacity correlates to residual heparin effect. Trial Registration www.isrctn.comISRCTN14201041.
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Affiliation(s)
- Vladimir Radulovic
- Department of Medicine/Hematology and Coagulation Disorders, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anna Laffin
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Erika Backlund
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Fariba Baghaei
- Department of Medicine/Hematology and Coagulation Disorders, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anders Jeppsson
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- * E-mail:
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Ortmann E, Rubino A, Altemimi B, Collier T, Besser MW, Klein AA. Validation of viscoelastic coagulation tests during cardiopulmonary bypass. J Thromb Haemost 2015; 13:1207-16. [PMID: 25903995 DOI: 10.1111/jth.12988] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 04/13/2015] [Indexed: 08/31/2023]
Abstract
BACKGROUND Viscoelastic point-of-care tests such as thromboelastography (TEG) and rotational thromboelastometry (ROTEM) are increasingly used to guide hemostatic therapy after cardiac surgery. The aim of this study was to assess their clinical utility during cardiopulmonary bypass to predict postbypass coagulation status and to guide therapy. METHODS In this prospective study, TEG and ROTEM tests were performed in 52 adult patients undergoing elective cardiac surgery at two time points: near the end of cardiopulmonary bypass and after heparin reversal with protamine. The 95% confidence intervals of the mean difference were compared with a prespecified clinically relevant limit of ± 20% of the value after protamine. RESULTS Both viscoelastic fibrinogen assays were well within the prespecified clinically relevant limit (≥ 79% of patients). The laboratory Clauss fibrinogen was much lower during cardiopulmonary bypass than after protamine (mean difference 1.2 g L(-1) , 95% CI 1.03-1.4, which was outside a clinically acceptable difference. For intrinsically activated tests, clotting times (CT) were different and outside the prespecified limit on TEG (mean difference -1.2 min, 95% CI -1.8 to -0.6) but not on ROTEM (mean difference 2.3 sec, 95% CI -8.6 to 13.2), while clot strength was well within the clinical limit on both devices (≥ 94% of patients). For extrinsically activated tests, clot strength on both TEG and ROTEM was within the pre-specified limit in 98% of patients. CONCLUSIONS Results from TEG and ROTEM tests performed toward the end of cardiopulmonary bypass are similar to results after reversal of heparin. Amplitudes indicating clot strength were the most stable parameters across all tests, whereas CT showed more variability. In contrast, laboratory testing of fibrinogen using the Clauss assay was essentially invalid during cardiopulmonary bypass.
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Affiliation(s)
- E Ortmann
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, UK
| | - A Rubino
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, UK
| | - B Altemimi
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, UK
| | - T Collier
- London School of Hygiene and Tropical Medicine, London, UK
| | - M W Besser
- Department of Haematology, Addenbrooke's Hospital, Cambridge University Hospitals Foundation Trust, Cambridge, UK
| | - A A Klein
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, UK
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Faraoni D, Fenger-Eriksen C, Gillard S, Willems A, Levy JH, Van der Linden P. Evaluation of dynamic parameters of thrombus formation measured on whole blood using rotational thromboelastometry in children undergoing cardiac surgery: a descriptive study. Paediatr Anaesth 2015; 25:573-9. [PMID: 25585839 DOI: 10.1111/pan.12570] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/17/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Total thrombus formation velocity calculated using amplitude parameters obtained at different times could be used to estimate the amplification and the propagation phases observed during coagulation processes, and therefore might be useful to predict postoperative hemostatic products administration in pediatric patients. METHODS We retrospectively analyzed data from 49 children <3 months of age who underwent cardiac surgery. Children ≤1 month of age routinely received fresh frozen plasma during bypass while children >1 month of age did not. The EXTEM parameters were used to calculate velocity curves using amplitudes obtained at different times, the area under the curve called total thrombus formation and the maximum rate of thrombus formation. These parameters were compared between children who received fresh frozen plasma and those who did not. Receiver operating characteristics curves were used to define variables that could be used to predict postoperative fresh frozen plasma transfusion. RESULTS Total thrombus formation and maximum rate of thrombus formation significantly increased in children who received fresh frozen plasma compared to those who did not. Both total thrombus formation and maximum rate of thrombus formation have a better specificity to predict postoperative fresh frozen plasma transfusion compared to clotting time or maximal clot firmness. CONCLUSION Based on this descriptive study, dynamic ROTEM(®) parameters of total thrombus formation could be used to estimate the amplification and the propagation phases of coagulation in children. These parameters might be used in further well-designed study to predict the need for hemostatic products in children undergoing cardiac surgery with cardiopulmonary bypass.
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Affiliation(s)
- David Faraoni
- Department of Anaesthesiology, Centre Hospitalier Universitaire Brugmann - Queen Fabiola Children's University Hospital, Free University of Brussels, Brussels, Belgium; Department of Anesthesiology, Peri-operative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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Percy CL, Hartmann R, Jones RM, Balachandran S, Mehta D, Dockal M, Scheiflinger F, O’Donnell VB, Hall JE, Collins PW. Correcting thrombin generation ex vivo using different haemostatic agents following cardiac surgery requiring the use of cardiopulmonary bypass. Blood Coagul Fibrinolysis 2015; 26:357-67. [PMID: 25928274 PMCID: PMC4888920 DOI: 10.1097/mbc.0000000000000243] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Revised: 09/10/2014] [Accepted: 11/03/2014] [Indexed: 11/25/2022]
Abstract
Recently, lower thrombin generation has been associated with excess bleeding post-cardiopulmonary bypass (CPB). Therefore, treatment to correct thrombin generation is a potentially important aspect of management of bleeding in this group of patients. The objective of the present study was to investigate the effects of fresh frozen plasma (FFP), recombinant factor VIIa (rFVIIa), prothrombin complex concentrate (PCC) and tissue factor pathway inhibitor (TFPI) inhibition on thrombin generation when added ex vivo to the plasma of patients who had undergone cardiac surgery requiring CPB. Patients undergoing elective cardiac surgery were recruited. Blood samples were collected before administration of heparin and 30 min after its reversal. Thrombin generation was measured in the presence and absence of different concentrations of FFP, rFVIIa, PCC and an anti-TFPI antibody. A total of 102 patients were recruited. Thrombin generation following CPB was lower compared with pre-CPB (median endogenous thrombin potential pre-CPB 339 nmol/l per min, post-CPB 155 nmol/l per min, P < 0.0001; median peak thrombin pre-CPB 35 nmol/l, post-CPB 11 nmol/l, P < 0.0001). Coagulation factors and anticoagulants decreased, apart from total TFPI, which increased (55-111 ng/ml, P < 0.0001), and VWF (144-170 IU/dl, P < 0.0001). Thrombin generation was corrected to pre-CPB levels by the equivalent of 15 ml/kg FFP, 45 μg/kg rFVIIa and 25 U/kg of PCC. Inhibition of TFPI resulted in an enhancement of thrombin generation significantly beyond pre-CPB levels. This study shows that FFP, rFVIIa, PCC and inhibition of TFPI correct thrombin generation in the plasma of patients who have undergone surgery requiring CPB. Inhibition of TFPI may be a further potential therapeutic strategy for managing bleeding in this group of patients.
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Affiliation(s)
- Charles L. Percy
- Institute of Infection and Immunity, Cardiff University School of Medicine, Heath Park, Cardiff, UK
| | | | - Rhidian M. Jones
- Institute of Infection and Immunity, Cardiff University School of Medicine, Heath Park, Cardiff, UK
| | | | - Dheeraj Mehta
- Department of Cardiothoracic Surgery, University Hospital of Wales, Heath Park, Cardiff, UK
| | | | | | - Valerie B. O’Donnell
- Institute of Infection and Immunity, Cardiff University School of Medicine, Heath Park, Cardiff, UK
| | - Judith E. Hall
- Institute of Infection and Immunity, Cardiff University School of Medicine, Heath Park, Cardiff, UK
| | - Peter W. Collins
- Institute of Infection and Immunity, Cardiff University School of Medicine, Heath Park, Cardiff, UK
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Herpers R, van Rossum AP, van Beem RT, Michel WM, Strijbis VJF, Strengers PFW, Castel A, Brinkman HJM. INR vs. thrombin generation assays for guiding VKA reversal: a retrospective comparison. Clin Chem Lab Med 2015; 53:1227-36. [PMID: 25720079 DOI: 10.1515/cclm-2014-0877] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 12/15/2014] [Indexed: 11/15/2022]
Abstract
BACKGROUND Prothrombin complex concentrate (PCC) is used to reverse vitamin K antagonist (VKA)-induced anticoagulation. Prothrombin time-derived international normalized ratio (INR) measurements are widely used in determining the required PCC dose, but this approach requires reappraisal. The aim of the present study was to determine the added value of the thrombin generation assay (TGA) compared with the INR in guidance of VKA reversal by PCC. METHODS In an open, observational study, INR and TGA measurements were carried out on plasma samples from phenprocoumon-treated patients receiving VKA reversal. Following both analytical methods, PCC dosing correlates were calculated and compared retrospectively. Alternatively, in vitro PCC spiking experiments were performed. RESULTS As expected, an exponential relationship between PCC dose and INR was found. For the TGA parameters peak thrombin and endogenous thrombin potential (ETP), however, this relationship was found to be linear throughout the full therapeutic range. Additional computational analysis showed a positive correlation (r²=0.7) between the initial INR and PCC dose required for a target INR of 2.1, which was completely lost at a lower target INR. In contrast, a positive correlation (r²=0.8) between initial ETP as well as peak height and PCC dose required to obtain parameter normalization was found. These correlates appeared useful for calculating PCC dose. CONCLUSIONS Our results support the current debate questioning the rationale for the use of the INR in the management of anticoagulation by VKA. Compared with INR, TGA-based calculations may enable a more accurate PCC dosing regimen for patients requiring VKA reversal.
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Ghavidel AA, Toutounchi Z, Shahandashti FJ, Mirmesdagh Y. Rotational thromboelastometry in prediction of bleeding after cardiac surgery. Asian Cardiovasc Thorac Ann 2015; 23:525-9. [DOI: 10.1177/0218492314566330] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Reexploration and its associated complications significantly affect hospital mortality and morbidity. Therefore, to prevent postoperative bleeding and its related complications, using an appropriate modality is essential during cardiac surgery. Methods Four hundred patients (296 males and 104 females, mean age 60.8 ± 9 years) scheduled for first-time coronary artery bypass graft surgery were prospectively enrolled. Blood samples were obtained for ROTEM testing before surgery and 30 min after heparin reversal. The patients were divided into 2 groups: group 1 was patients with no abnormal postoperative bleeding and group 2 was patients who required reexploration for abnormal postoperative bleeding. Group 2 patients were divided into 2 subgroups: 2a was patients with surgical bleeding and group 2b was patients with nonsurgical bleeding. Variables were compared between groups. Results Among the 400 patients, 42 were reexplored. Hospital stay was significantly longer and hospital deaths more frequent in group 2 patients ( p < 0.001 and p = 0.010, respectively). Ten (2.8%) patients had abnormal preoperative results of ROTEM in group 1 compared to 14 (33.3%) in group 2 ( p < 0.001). After surgery, the number of patients with abnormal ROTEM results was significantly different between the 2 groups: 6 (1.7%) in group 1 vs. 14 (33.3%) in group 2 ( p < 0.001). Four (12.5%) patients in group 2a had abnormal preoperative ROTEM results compared to 10 (100%) in group 2a ( p < 0.001). Conclusion Measuring coagulation factors by ROTEM both before surgery and after heparin reversal can identify patients at increased risk of postoperative bleeding.
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Affiliation(s)
- Alireza Alizadeh Ghavidel
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Zia Toutounchi
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | | | - Yalda Mirmesdagh
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
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Jy W, Gómez-Marín O, Salerno TA, Panos AL, Williams D, Horstman LL, Ahn YS. Presurgical levels of circulating cell-derived microparticles discriminate between patients with and without transfusion in coronary artery bypass graft surgery. J Thorac Cardiovasc Surg 2015; 149:305-11. [DOI: 10.1016/j.jtcvs.2014.10.042] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Revised: 08/29/2014] [Accepted: 10/06/2014] [Indexed: 11/25/2022]
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