1
|
Velarde-Ruiz Velasco JA, Crespo J, Montaño-Loza A, Aldana-Ledesma JM, Cano-Contreras AD, Cerda-Reyes E, Fernández Pérez NJ, Castro-Narro GE, García-Jiménez ES, Lira-Vera JE, López-Méndez YI, Meza-Cardona J, Moreno-Alcántar R, Pérez-Escobar J, Pérez-Hernández JL, Tapia-Calderón DK, Higuera-de-la-Tijera F. Position paper on perioperative management and surgical risk in the patient with cirrhosis. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2024:S2255-534X(24)00057-4. [PMID: 39003101 DOI: 10.1016/j.rgmxen.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 05/02/2024] [Indexed: 07/15/2024]
Abstract
INTRODUCTION Management of the patient with cirrhosis of the liver that requires surgical treatment has been relatively unexplored. In Mexico, there is currently no formal stance or expert recommendations to guide clinical decision-making in this context. AIMS The present position paper reviews the existing evidence on risks, prognoses, precautions, special care, and specific management or procedures for patients with cirrhosis that require surgical interventions or invasive procedures. Our aim is to provide recommendations by an expert panel, based on the best published evidence, and consequently ensure timely, quality, efficient, and low-risk care for this specific group of patients. RESULTS Twenty-seven recommendations were developed that address preoperative considerations, intraoperative settings, and postoperative follow-up and care. CONCLUSIONS The assessment and care of patients with cirrhosis that require major surgical or invasive procedures should be overseen by a multidisciplinary team that includes the anesthesiologist, hepatologist, gastroenterologist, and clinical nutritionist. With respect to decompensated patients, a nephrology specialist may be required, given that kidney function is also a parameter involved in the prognosis of these patients.
Collapse
Affiliation(s)
- J A Velarde-Ruiz Velasco
- Servicio de Gastroenterología, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
| | - J Crespo
- Servicio de Aparato Digestivo, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - A Montaño-Loza
- División de Gastroenterología y Hepatología, Hospital de la Universidad de Alberta, Alberta, Canada
| | - J M Aldana-Ledesma
- Servicio de Gastroenterología, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
| | - A D Cano-Contreras
- Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, Veracruz, Mexico
| | | | | | - G E Castro-Narro
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - E S García-Jiménez
- Servicio de Gastroenterología, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
| | - J E Lira-Vera
- Servicio de Gastroenterología y Hepatología, Hospital Central «Dr. Ignacio Morones Prieto», San Luis Potosí, San Luis Potosí, Mexico
| | - Y I López-Méndez
- Departamento de Gastroenterología, Medica Sur, Mexico City, Mexico
| | - J Meza-Cardona
- Departamento de Gastroenterología, Hospital Español, Mexico City, Mexico
| | - R Moreno-Alcántar
- Departamento de Gastroenterología, Hospital de Especialidades «Dr. Bernando Sepúlveda», UMAE Centro Médico Nacional Siglo XXI, IMSS, Mexico City, Mexico
| | - J Pérez-Escobar
- Servicio de Gastroenterología y Unidad de Trasplante Hepático, Hospital Juárez de México, Mexico City, Mexico
| | - J L Pérez-Hernández
- Servicio de Gastroenterología y Hepatología, Hospital General de México «Dr. Eduardo Liceaga», Mexico City, Mexico
| | - D K Tapia-Calderón
- Servicio de Gastroenterología, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
| | - F Higuera-de-la-Tijera
- Servicio de Gastroenterología y Hepatología, Hospital General de México «Dr. Eduardo Liceaga», Mexico City, Mexico.
| |
Collapse
|
2
|
Reardon B, Pasalic L, Favaloro EJ. The Role of Viscoelastic Testing in Assessing Hemostasis: A Challenge to Standard Laboratory Assays? J Clin Med 2024; 13:3612. [PMID: 38930139 PMCID: PMC11205135 DOI: 10.3390/jcm13123612] [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: 05/01/2024] [Revised: 06/18/2024] [Accepted: 06/18/2024] [Indexed: 06/28/2024] Open
Abstract
Viscoelastic testing is increasingly being used in clinical and research settings to assess hemostasis. Indeed, there are potential situations in which viscoelastic testing is reportedly superior to standard routine laboratory testing for hemostasis. We report the current testing platforms and terminology, as well as providing a concise narrative review of the published evidence to guide its use in various clinical settings. Notably, there is increasing evidence of the potential utility of viscoelastic testing for assessment of direct oral anticoagulants, and bleeding associated with chronic liver disease, orthotopic liver transplantation, cardiac surgery, trauma, obstetrics and pediatrics.
Collapse
Affiliation(s)
- Benjamin Reardon
- School of Medicine and Public Health, Joint Medical Program, University of Newcastle, Callaghan, NSW 2145, Australia;
- Haematology Department, Calvary Mater Hospital Newcastle, Waratah, NSW 2298, Australia
| | - Leonardo Pasalic
- Haematology Department, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW 2145, Australia;
- Westmead Clinical School, University of Sydney, Westmead, NSW 2145, Australia
- Sydney Centres for Thrombosis and Haemostasis, Westmead Hospital, Westmead, NSW 2145, Australia
| | - Emmanuel J. Favaloro
- Haematology Department, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW 2145, Australia;
- Sydney Centres for Thrombosis and Haemostasis, Westmead Hospital, Westmead, NSW 2145, Australia
- School of Dentistry and Medical Sciences, Faculty of Science and Health, Charles Sturt University, Wagga Wagga, NSW 2650, Australia
- School of Medical Sciences, Faculty of Medicine and Health, University of Sydney, Westmead Hospital, Westmead, NSW 2145, Australia
| |
Collapse
|
3
|
Ghansah H, Orbán-Kálmándi R, Debreceni IB, Katona É, Rejtő L, Váróczy L, Lóczi L, de Laat B, Huskens D, Kappelmayer J, Bagoly Z. Low factor XIII levels and altered fibrinolysis in patients with multiple myeloma. Thromb Res 2024; 234:12-20. [PMID: 38134612 DOI: 10.1016/j.thromres.2023.12.004] [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: 07/24/2023] [Revised: 11/13/2023] [Accepted: 12/11/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND Acquired factor FXIII (FXIII) deficiency can be immune- or non-immune mediated and may cause severe bleeding symptoms. The incidence of acquired FXIII deficiency and its etiology in patients with multiple myeloma (MM) are poorly understood. OBJECTIVES To assess FXIII levels and the balance of fibrinolysis in newly diagnosed, untreated MM and monoclonal gammopathy of undetermined significance (MGUS) patients. METHODS FXIII activity, mixing studies, FXIII-A2B2 antigen, total FXIII-B antigen were measured in platelet-poor plasma from 17 untreated MM patients, 33 untreated MGUS patients, and 30 age and sex-matched healthy controls. Besides routine laboratory measurements, the balance of coagulation and fibrinolysis was evaluated using quantitative fibrin monomer (FM) test, thrombin-antithrombin assay, α2-antiplasmin activity, plasmin-α2-antiplasmin (PAP) complex, D-dimer, plasmin generation assay, clot lysis assay, and ClotPro-TPA test. RESULTS FXIII-A2B2 levels were significantly lower in MM patients compared to controls [median (IQR):14.6 (11.2-19.4) vs. 21.8 (17.1-26.4) mg/L, p = 0.0015], whereas total FXIII-B did not differ between groups. Decrease in FXIII activity was parallel to the decrease in FXIII-A2B2. An immune-mediated inhibitory mechanism was ruled out. Free/total FXIII-B was significantly higher in MM patients compared to MGUS and healthy controls, suggesting an etiology of FXIII-A consumption. In MM and MGUS patients, FM, D-dimer, and PAP complex were significantly elevated compared to controls, indicating hypercoagulability and ongoing fibrinolysis. CONCLUSIONS Low FXIII levels due to consumption were observed in MM patients at diagnosis. Hypercoagulability and ongoing fibrinolysis were detected in MM and MGUS, indicating that a disturbed hemostasis balance is already present in the latter benign condition.
Collapse
Affiliation(s)
- Harriet Ghansah
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary; Kálmán Laki Doctoral School, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Rita Orbán-Kálmándi
- Department of Laboratory Medicine, Faculty of Medicine, Division of Clinical Laboratory Sciences, University of Debrecen, Debrecen, Hungary
| | - Ildikó Beke Debreceni
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Éva Katona
- Department of Laboratory Medicine, Faculty of Medicine, Division of Clinical Laboratory Sciences, University of Debrecen, Debrecen, Hungary
| | - László Rejtő
- Department of Hematology, Jósa András Teaching Hospital, Nyíregyháza, Hungary
| | - László Váróczy
- Department of Internal Medicine, Division of Hematology, University of Debrecen, Debrecen, Hungary
| | - Linda Lóczi
- Department of Laboratory Medicine, Faculty of Medicine, Division of Clinical Laboratory Sciences, University of Debrecen, Debrecen, Hungary
| | - Bas de Laat
- Synapse Research Institute, Maastricht, the Netherlands
| | - Dana Huskens
- Synapse Research Institute, Maastricht, the Netherlands
| | - János Kappelmayer
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Zsuzsa Bagoly
- Department of Laboratory Medicine, Faculty of Medicine, Division of Clinical Laboratory Sciences, University of Debrecen, Debrecen, Hungary; Hungarian Research Network (HUN-REN-DE) Cerebrovascular Research Group, Debrecen, Hungary.
| |
Collapse
|
4
|
Abstract
Viscoelastic testing methods examine the real-time formation of a clot in a whole blood sample, and include thromboelastography (TEG), rotational thromboelastometry (ROTEM), and several other testing platforms. They allow for concurrent assessment of multiple aspects of clotting, including plasmatic coagulation factors, platelets, fibrinogen, and the fibrinolytic pathway. This testing is rapid and may be performed at the point-of-care, allowing for prompt identification of coagulopathies to guide focused and rational administration of blood products as well as the identification of anticoagulant effect. With recent industry progression towards user-friendly, cartridge-based, portable instruments, viscoelastic testing has emerged in the 21st century as a powerful tool to guide blood transfusions in the bleeding patient, and to identify and treat both bleeding and thrombotic conditions in many operative settings, including trauma surgery, liver transplant surgery, cardiac surgery, and obstetrics. In these settings, the use of transfusion algorithms guided by viscoelastic testing data has resulted in widespread improvements in patient blood management as well as modest improvements in select patient outcomes. To address the increasingly wide adoption of viscoelastic methods and the growing number of medical and laboratory personnel tasked with implementing, performing, and interpreting these methods, this chapter provides an overview of the history, physiology, and technology behind viscoelastic testing, as well as a practical review of its clinical utility and current evidence supporting its use. Also included is a review of testing limitations and the contextual role played by viscoelastic methods among all coagulation laboratory testing.
Collapse
Affiliation(s)
- Timothy Carll
- Department of Pathology, University of Chicago, Chicago, IL, United States.
| |
Collapse
|
5
|
Wool GD, Carll T. Viscoelastic testing: Critical appraisal of new methodologies and current literature. Int J Lab Hematol 2023; 45:643-658. [PMID: 37559473 DOI: 10.1111/ijlh.14144] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 07/25/2023] [Indexed: 08/11/2023]
Abstract
United States Food and Drug Administration (FDA)-approved viscoelastic testing (VET) methodologies have significantly changed in the last 10 years, with the availability of cartridge-based VET. Some of these cartridge-based methodologies use harmonic resonance-based clot detection. While VET has always allowed for the evaluation of real-time clot formation, cartridge-based VET provides increased ease of use as well as greater portability and robustness of results in out-of-laboratory environments. Here we review the use of VET in a variety of clinical contexts, including cardiac surgery, trauma, liver transplant, obstetrics, and hypercoagulable states such as COVID-19. As of now, high quality randomized trial evidence for new generation VET (TEG 6s, HemoSonics Quantra, ROTEM sigma) is limited. Nevertheless, the use of VET-guided transfusion algorithms appears to result in reduced blood usage without worsening of patient outcomes. Future work comparing the new generation VET instruments and continuing to validate clinically important cut-offs will help move the field of point-of-care coagulation monitoring forward and increase the quality of transfusion management in bleeding patients.
Collapse
Affiliation(s)
- Geoffrey D Wool
- Department of Pathology, University of Chicago, Chicago, Illinois, USA
| | - Timothy Carll
- Department of Pathology, University of Chicago, Chicago, Illinois, USA
| |
Collapse
|
6
|
Rautou PE, Caldwell SH, Villa E. Bleeding and Thrombotic Complications in Patients With Cirrhosis: A State-of-the-Art Appraisal. Clin Gastroenterol Hepatol 2023; 21:2110-2123. [PMID: 37121529 DOI: 10.1016/j.cgh.2023.04.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 04/02/2023] [Accepted: 04/14/2023] [Indexed: 05/02/2023]
Abstract
Much has evolved over the past 25 years regarding our understanding of the coagulopathy of liver disease. Paradoxically, this form of coagulopathy is relatively hypercoagulability despite the common clinical impression of a hemorrhagic tendency. The latter is largely driven by portal-mesenteric venous pressure (ie, portal hypertension) and has little to do with hemostatic pathways. It cannot be emphasized enough that the INR does not offer a meaningful measure in this situation and may lead to interventions such as fresh frozen plasma that can actually worsen portal pressure and hence pressure-driven bleeding. With regard to procedure-related bleeding, we point out substantial differences in the definition of high-risk procedures and propose a new operational definition dependent on the applicability of local hemostatic measures, although this requires further investigation. The common occurrence of venous thrombosis in these patients requires careful consideration of hemostatic pathways and overall risk and benefit of intervention. The decision regarding anticoagulation therapy needs to be driven not only by a global assessment including history of non-portal hypertensive-related bleeding, but also by fall risk which can result in head trauma in patients prone to encephalopathy. This is probably best estimated by frailty but has yet to be adequately investigated. In the background of these concerns, several superimposed and complex conditions including infections and renal dysfunction should be taken into account. Inherited forms of thrombophilia in the setting of cirrhosis perhaps do not outweigh the thrombophilia inherent to liver disease but warrant further consideration.
Collapse
Affiliation(s)
- Pierre-Emmanuel Rautou
- Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France; Service d'Hépatologie, AP-HP, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
| | - Stephen H Caldwell
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Virginia, Charlottesville, Virginia.
| | - Erica Villa
- Gastroenterology Unit, CHIMOMO Department, University of Modena and Reggio Emilia, Modena, Italy; IRCCS Saverio de Bellis, Castellana Grotte, Italy
| |
Collapse
|
7
|
Stewart E, Nydam TL, Hendrickse A, Pomposelli JJ, Pomfret EA, Moore HB. Viscoelastic Management of Coagulopathy during the Perioperative Period of Liver Transplantation. Semin Thromb Hemost 2023; 49:119-133. [PMID: 36318962 PMCID: PMC10366939 DOI: 10.1055/s-0042-1758058] [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] [Indexed: 02/04/2023]
Abstract
Viscoelastic testing (VET) in liver transplantation (LT) has been used since its origin, in combination with standard laboratory testing (SLT). There are only a few, small, randomized controlled trials that demonstrated a reduction in transfusion rates using VET to guide coagulation management. Retrospective analyses contrasting VET to SLT have demonstrated mixed results, with a recent concern for overtreatment and the increase in postoperative thrombotic events. An oversight of many studies evaluating VET in LT is a single protocol that does not address the different phases of surgery, in addition to pre- and postoperative management. Furthermore, the coagulation spectrum of patients entering and exiting the operating room is diverse, as these patients can have varying anatomic and physiologic risk factors for thrombosis. A single transfusion strategy for all is short sighted. VET in combination with SLT creates the opportunity for personalized resuscitation in surgery which can address the many challenges in LT where patients are at a paradoxical risk for both life-threatening bleeding and clotting. With emerging data on the role of rebalanced coagulation in cirrhosis and hypercoagulability following LT, there are numerous potential roles in VET management of LT that have been unaddressed.
Collapse
Affiliation(s)
- Erin Stewart
- Department of Anesthesia, University of Colorado School of Medicine, Aurora, Colorado
| | - Trevor L. Nydam
- Division of Transplant Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Adrian Hendrickse
- Department of Anesthesia, University of Colorado School of Medicine, Aurora, Colorado
| | - James J. Pomposelli
- Division of Transplant Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Elizabeth A. Pomfret
- Division of Transplant Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Hunter B. Moore
- Division of Transplant Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| |
Collapse
|
8
|
Hartmann J, Hermelin D, Levy JH. Viscoelastic testing: an illustrated review of technology and clinical applications. Res Pract Thromb Haemost 2022; 7:100031. [PMID: 36760779 PMCID: PMC9903681 DOI: 10.1016/j.rpth.2022.100031] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 11/07/2022] [Accepted: 11/12/2022] [Indexed: 01/26/2023] Open
Abstract
Viscoelastic testing (VET), including thromboelastography and thromboelastometry, provides a rapid and comprehensive picture of whole blood coagulation dynamics and hemostasis that can be reviewed and evaluated at the point-of-care. This technology is over 50 years old; however, over the past few years, there has been a significant increase in research examining the use of VET. Best practice guidelines for the use of VET exist in both the United States and Europe, particularly for elective cardiac surgery, although recommendations for implementation are somewhat limited in some clinical areas by the lack of studies constituting high-grade evidence. Other challenges to implementation surround validation of the technology in some care settings as well as lack of training. Nevertheless, there is a wide range of potential clinical applications, such as treating coagulopathies in liver disease and transplant surgery, critical care, as well as within obstetrical hemorrhage. In this illustrated review, we provide an overview of viscoelastic testing technology (also called viscoelastic hemostatic assays) and describe how the assays can be used to provide a broad overview of hemostasis from clot formation to clot lysis, while highlighting the contribution of coagulation factors and platelets. We then summarize the major clinical applications for viscoelastic testing, including more recent applications, such as in COVID-19. Each section describes the clinical context, and key publications, followed by a representative algorithm and key guidelines.
Collapse
Affiliation(s)
- Jan Hartmann
- Haemonetics Corporation, Boston, Massachusetts, USA
- Correspondence Jan Hartmann, Haemonetics Corporation, Boston, MA 02110, USA. @JanHartmannMD
| | - Daniela Hermelin
- Department of Pathology Saint Louis University School of Medicine, Saint Louis, Missouri, USA
- Medical Affairs, ImpactLife, Davenport, Iowa, USA
| | | |
Collapse
|
9
|
Bissonnette J, Riescher‐Tuczkiewicz A, Gigante E, Bourdin C, Boudaoud L, Soliman H, Durand F, Ronot M, Valla D, Vilgrain V, de Raucourt E, Rautou P. Predicting bleeding after liver biopsy using comprehensive clinical and laboratory investigations: A prospective analysis of 302 procedures. J Thromb Haemost 2022; 20:2786-2796. [PMID: 36128757 PMCID: PMC9828241 DOI: 10.1111/jth.15888] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 08/05/2022] [Accepted: 09/15/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND Liver biopsy carries a small risk of bleeding complications. No validated clinical or laboratory tool helps predict liver biopsy-related bleeding. OBJECTIVES To determine whether global hemostasis tests and/or a clinical questionnaire could identify patients at risk of liver biopsy-related bleeding. PATIENTS/METHODS Consecutive patients scheduled for liver biopsy with an overnight hospital stay were prospectively included. Before liver biopsy, routine hemostasis tests, Platelet Function Analyzer 100, thromboelastometry, thrombin generation assay, plasma clot lysis time, and a clinical questionnaire were performed. Bleeding was defined as a liver hematoma or new free fluid on a systematic ultrasound performed 24 h after liver biopsy or a decrease in hemoglobin level of 2 g/dL or more in patients with pre-existing free fluid in the abdominal cavity. RESULTS Three hundred two patients were included: 173 underwent percutaneous and 129 transjugular liver biopsy. There were 21 bleeding episodes (7%); 20 based on ultrasonographic criteria, 1 on laboratory criteria. None of the hemostasis tests and no item of the clinical questionnaire were associated with liver biopsy-related bleeding in the overall study group. Same results were obtained in subgroup analyses focusing on patients who underwent percutaneous liver biopsy, transjugular liver biopsy, or on patients with cirrhosis. Pain 2 h after liver biopsy was more frequent in patients with liver biopsy-related bleeding (55% vs. 23% p = .002). CONCLUSIONS An extensive hemostasis workup, including global hemostasis assays, does not improve prediction of liver biopsy-related bleeding. Pain 2 h after liver biopsy should alert the clinician to the possibility of procedure-related bleeding.
Collapse
Affiliation(s)
- Julien Bissonnette
- AP‐HP, Hôpital Beaujon, Service d’Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE‐LIVER, Centre de recherche sur l’inflammation, Inserm, UMR1149Université Paris CitéParisFrance
| | - Alix Riescher‐Tuczkiewicz
- AP‐HP, Hôpital Beaujon, Service d’Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE‐LIVER, Centre de recherche sur l’inflammation, Inserm, UMR1149Université Paris CitéParisFrance
| | - Elia Gigante
- AP‐HP, Hôpital Beaujon, Service d’Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE‐LIVER, Centre de recherche sur l’inflammation, Inserm, UMR1149Université Paris CitéParisFrance
| | - Carole Bourdin
- Service d’hématologie biologiqueHôpital BeaujonClichyFrance
| | - Larbi Boudaoud
- Service d’hématologie biologiqueHôpital BeaujonClichyFrance
| | - Heithem Soliman
- AP‐HP, Hôpital Beaujon, Service d’Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE‐LIVER, Centre de recherche sur l’inflammation, Inserm, UMR1149Université Paris CitéParisFrance
| | - François Durand
- AP‐HP, Hôpital Beaujon, Service d’Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE‐LIVER, Centre de recherche sur l’inflammation, Inserm, UMR1149Université Paris CitéParisFrance
| | - Maxime Ronot
- 'AP‐HP, Hôpital Beaujon, Service de Radiologie', 'Centre de recherche sur l’inflammation, Inserm, UMR1149'Université Paris CitéParisFrance
| | - Dominique Valla
- AP‐HP, Hôpital Beaujon, Service d’Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE‐LIVER, Centre de recherche sur l’inflammation, Inserm, UMR1149Université Paris CitéParisFrance
| | - Valérie Vilgrain
- 'AP‐HP, Hôpital Beaujon, Service de Radiologie', 'Centre de recherche sur l’inflammation, Inserm, UMR1149'Université Paris CitéParisFrance
| | | | - Pierre‐Emmanuel Rautou
- AP‐HP, Hôpital Beaujon, Service d’Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE‐LIVER, Centre de recherche sur l’inflammation, Inserm, UMR1149Université Paris CitéParisFrance
| |
Collapse
|
10
|
Roberts LN, Lisman T, Stanworth S, Hernandez-Gea V, Magnusson M, Tripodi A, Thachil J. "Periprocedural management of abnormal coagulation parameters and thrombocytopenia in patients with cirrhosis: Guidance from the SSC of the ISTH": Reply. J Thromb Haemost 2022; 20:2713-2714. [PMID: 36271459 DOI: 10.1111/jth.15859] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 08/22/2022] [Indexed: 02/05/2023]
Affiliation(s)
- Lara N Roberts
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital, London, UK
| | - Ton Lisman
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Simon Stanworth
- Transfusion Medicine, NHS Blood and Transplant, Department of Haematology, Oxford University Hospitals, NHS Foundation Trust, Radcliffe Department of Medicine, University of Oxford and NIHR Oxford Biomedical Research Centre (Haematology), Oxford, UK
| | - Virginia Hernandez-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, IDIBAPS, Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), University of Barcelona, Barcelona, Spain
| | - Maria Magnusson
- Clinical Chemistry and Blood Coagulation Research, MMK, Department of Pediatrics, CLINTEC, Karolinska Institutet, Department of Hematology, Karolinska University Hospital, Stockholm, Sweden
| | - Armando Tripodi
- IRCCS Ca' Granda Maggiore Hospital Foundation, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milano, Italy
| | - Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, UK
| |
Collapse
|
11
|
Hartmann J, Dias JD, Garcia-Tsao G, Pivalizza EG. "Periprocedural management of abnormal coagulation parameters and thrombocytopenia in patients with cirrhosis: Guidance from the SSC of the ISTH": Comment from Hartmann et al. J Thromb Haemost 2022; 20:2711-2712. [PMID: 36271460 DOI: 10.1111/jth.15861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 08/03/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Jan Hartmann
- Department of Medical Affairs, Clinical Development and Medical Safety, Haemonetics Corporation, Boston, Massachusetts, USA
| | - Joao D Dias
- Department of Medical Affairs, Clinical Development and Medical Safety, Haemonetics Corporation, Boston, Massachusetts, USA
| | - Guadalupe Garcia-Tsao
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA
- VA CT Healthcare System, West Haven, Connecticut, USA
| | - Evan G Pivalizza
- Department of Anesthesiology, UT Health McGovern Medical School, Houston, Texas, USA
| |
Collapse
|
12
|
Hartmann J, Dias JD, Pivalizza EG, Garcia-Tsao G. Thromboelastography-Guided Therapy Enhances Patient Blood Management in Cirrhotic Patients: A Meta-analysis Based on Randomized Controlled Trials. Semin Thromb Hemost 2022. [DOI: 10.1055/s-0042-1758081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
AbstractPatients with cirrhosis often have abnormal hemostasis, with increased risk of hemorrhage and thrombosis. Thromboelastography provides a rapid assessment of the coagulation status and can guide product transfusions in adult patients with cirrhosis. This study aimed to determine whether the use of thromboelastography in adult patients with cirrhosis decreases blood product use and impacts adverse events or mortality compared with standard practice. A registered (PROSPERO CRD42020192458) systematic review and meta-analysis was conducted for randomized controlled trials (RCTs) comparing thromboelastography-guided hemostatic management versus standard practice (control). Co-primary outcomes were the number of transfused platelet units and fresh frozen plasma (FFP) units. Secondary outcomes were mortality, adverse events, utilization of individual blood products, blood loss or excessive bleeding events, hospital/intensive care unit stay, and liver transplant/intervention outcomes. The search identified 260 articles, with five RCTs included in the meta-analysis. Platelet use was five times lower with thromboelastography versus the control, with a relative risk of 0.17 (95% confidence interval [CI]: [0.03–0.90]; p = 0.04), but FFP use did not differ significantly. Thromboelastography was associated with less blood product (p < 0.001), FFP + platelets (p < 0.001), and cryoprecipitate (p < 0.001) use. No differences were reported in bleeding rates or longer term mortality between groups, with the thromboelastography group having lower mortality at 7 days versus the control (relative risk [95% CI] = 0.52 [0.30–0.91]; p = 0.02). Thromboelastography-guided therapy in patients with cirrhosis enhances patient blood management by reducing use of blood products without increasing complications.
Collapse
Affiliation(s)
- Jan Hartmann
- Department of Medical Affairs, Clinical Development and Medical Safety, Haemonetics Corporation, Boston, Massachusetts
| | - Joao D. Dias
- Department of Medical Affairs, Clinical Development and Medical Safety, Haemonetics Corporation, Boston, Massachusetts
| | - Evan G. Pivalizza
- Department of Anesthesiology, UT Health McGovern Medical School, Houston, Texas
| | - Guadalupe Garcia-Tsao
- Yale University School of Medicine, Department of Internal Medicine, Section of Digestive Diseases, New Haven, Connecticut
- VA CT Healthcare System, West Haven, Connecticut
| |
Collapse
|
13
|
Matkovic E, Lindholm PF. Role of Viscoelastic and Conventional Coagulation Tests for Management of Blood Product Replacement in the Bleeding Patient. Semin Thromb Hemost 2022; 48:785-795. [PMID: 36174609 DOI: 10.1055/s-0042-1756192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
An important aim of viscoelastic testing (VET) is to implement transfusion algorithms based on coagulation test results to help reduce transfusion rates and improve patient outcomes. Establishing a rapid diagnosis and providing timely treatment of coagulopathy is the cornerstone of management of severely bleeding patients in trauma, postpartum hemorrhage, and major surgery. As the nature of acute bleeding and trauma leads to an unstable and tenuous physiologic state, conventional coagulation tests (CCTs) are too slow to diagnose, manage, and also course correct any hemostatic abnormalities that accompany an acute critical illness. Viscoelastic point-of-care tests strongly correlate with results from standard laboratory tests but are designed to enable clinicians to make timely, informed bleeding management decisions when time to intervene is critical. These assays provide an individualized and goal-oriented approach to patient blood management and are increasingly becoming involved in transfusion algorithms. The scope of this review aims to evaluate the current literature on VETs and their impact on actionable outputs in clinical decision making and their relationship to CCT.
Collapse
Affiliation(s)
- Eduard Matkovic
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Paul F Lindholm
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| |
Collapse
|
14
|
Thromboelastography-Guided Therapy Enhances Patient Blood Management in Cirrhotic Patients: A Meta-analysis Based on Randomized Controlled Trials. Semin Thromb Hemost 2022. [PMID: 36063848 DOI: 10.1055/s-0042-1757135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Patients with cirrhosis often have abnormal hemostasis, with increased risk of hemorrhage and thrombosis. Thromboelastography provides a rapid assessment of the coagulation status and can guide product transfusions in adult patients with cirrhosis. This study aimed to determine whether the use of thromboelastography in adult patients with cirrhosis decreases blood product use and impacts adverse events or mortality compared with standard practice. A registered (PROSPERO CRD42020192458) systematic review and meta-analysis was conducted for randomized controlled trials (RCTs) comparing thromboelastography-guided hemostatic management versus standard practice (control). Co-primary outcomes were the number of transfused platelet units and fresh frozen plasma (FFP) units. Secondary outcomes were mortality, adverse events, utilization of individual blood products, blood loss or excessive bleeding events, hospital/intensive care unit stay, and liver transplant/intervention outcomes. The search identified 260 articles, with five RCTs included in the meta-analysis. Platelet use was five times lower with thromboelastography versus the control, with a relative risk of 0.17 (95% confidence interval [CI]: [0.03-0.90]; p = 0.04), but FFP use did not differ significantly. Thromboelastography was associated with less blood product (p < 0.001), FFP + platelets (p < 0.001), and cryoprecipitate (p < 0.001) use. No differences were reported in bleeding rates or longer term mortality between groups, with the thromboelastography group having lower mortality at 7 days versus the control (relative risk [95% CI] = 0.52 [0.30-0.91]; p = 0.02). Thromboelastography-guided therapy in patients with cirrhosis enhances patient blood management by reducing use of blood products without increasing complications.
Collapse
|
15
|
Hartmann J, Dias JD, Pivalizza EG, Garcia-Tsao G. Thromboelastography-Guided Therapy Enhances Patient Blood Management in Cirrhotic Patients: A Meta-analysis Based on Randomized Controlled Trials. Semin Thromb Hemost 2022; 49:162-172. [PMID: 36055266 PMCID: PMC9897960 DOI: 10.1055/s-0042-1753530] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Patients with cirrhosis often have abnormal hemostasis, with increased risk of hemorrhage and thrombosis. Thromboelastography provides a rapid assessment of the coagulation status and can guide product transfusions in adult patients with cirrhosis. This study aimed to determine whether the use of thromboelastography in adult patients with cirrhosis decreases blood product use and impacts adverse events or mortality compared with standard practice. A registered (PROSPERO CRD42020192458) systematic review and meta-analysis was conducted for randomized controlled trials (RCTs) comparing thromboelastography-guided hemostatic management versus standard practice (control). Co-primary outcomes were the number of transfused platelet units and fresh frozen plasma (FFP) units. Secondary outcomes were mortality, adverse events, utilization of individual blood products, blood loss or excessive bleeding events, hospital/intensive care unit stay, and liver transplant/intervention outcomes. The search identified 260 articles, with five RCTs included in the meta-analysis. Platelet use was five times lower with thromboelastography versus the control, with a relative risk of 0.17 (95% confidence interval [CI]: [0.03-0.90]; p = 0.04), but FFP use did not differ significantly. Thromboelastography was associated with less blood product (p < 0.001), FFP + platelets (p < 0.001), and cryoprecipitate (p < 0.001) use. No differences were reported in bleeding rates or longer term mortality between groups, with the thromboelastography group having lower mortality at 7 days versus the control (relative risk [95% CI] = 0.52 [0.30-0.91]; p = 0.02). Thromboelastography-guided therapy in patients with cirrhosis enhances patient blood management by reducing use of blood products without increasing complications.
Collapse
Affiliation(s)
- Jan Hartmann
- Department of Medical Affairs, Clinical Development and Medical Safety, Haemonetics Corporation, Boston, Massachusetts,Address for correspondence Jan Hartmann, MD, Chief Medical Officer Haemonetics Corporation125 Summer Street, Boston, MA 02110
| | - Joao D. Dias
- Department of Medical Affairs, Clinical Development and Medical Safety, Haemonetics Corporation, Boston, Massachusetts
| | - Evan G. Pivalizza
- Department of Anesthesiology, UT Health McGovern Medical School, Houston, Texas
| | - Guadalupe Garcia-Tsao
- Yale University School of Medicine, Department of Internal Medicine, Section of Digestive Diseases, New Haven, Connecticut,VA CT Healthcare System, West Haven, Connecticut
| |
Collapse
|