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Lester W, Bent C, Alikhan R, Roberts L, Gordon-Walker T, Trenfield S, White R, Forde C, Arachchillage DJ. A British Society for Haematology guideline on the assessment and management of bleeding risk prior to invasive procedures. Br J Haematol 2024; 204:1697-1713. [PMID: 38517351 DOI: 10.1111/bjh.19360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 02/12/2024] [Accepted: 02/13/2024] [Indexed: 03/23/2024]
Affiliation(s)
- Will Lester
- Department of Haematology, University Hospitals Birmingham, Birmingham, UK
| | - Clare Bent
- Department of Radiology, University Hospitals Dorset, Dorset, UK
| | - Raza Alikhan
- Department of Haematology, University Hospitals of Cardiff, Cardiff, UK
| | - Lara Roberts
- Department of Haematology, King College London, London, UK
| | - Tim Gordon-Walker
- Scottish Liver Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Sarah Trenfield
- Department of Anaesthesia and Critical Care, Royal Brompton Hospital, London, UK
| | - Richard White
- Department of Radiology, Cardiff and Vale UHB, Cardiff, UK
| | - Colm Forde
- Department of Radiology, University Hospitals Birmingham, Birmingham, UK
| | - Deepa J Arachchillage
- Department of Immunology and Inflammation, Centre for Haematology, Imperial College London, London, UK
- Department of Haematology, Imperial College Healthcare NHS Trust, London, UK
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Majumdar M, Waller D, Poyant J, McElroy I, Lella S, Feldman ZM, Levine E, Kim Y, Nuzzolo K, Kirshkaln A, DeCarlo C, Dua A. Variability of antiplatelet response in patients with peripheral artery disease. J Vasc Surg 2023; 77:208-215.e3. [PMID: 36028157 DOI: 10.1016/j.jvs.2022.08.015] [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: 06/02/2022] [Revised: 08/09/2022] [Accepted: 08/17/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Antiplatelet therapy has been a pillar of management for peripheral artery disease (PAD). However, a significant subset of patients with PAD will be resistant to certain antiplatelet medications and, therefore, have an increased risk of graft and/or stent thrombosis unknown to the surgeon. At present, no point-of-care testing to identity which patients will experience benefit from these medications has been incorporated into the treatment guidelines. Thromboelastography with platelet mapping affords an opportunity to evaluate real-time coagulation dynamics and platelet function. In the present prospective, observational study, we aimed to delineate the variation in response to antiplatelet therapy in patients with PAD undergoing revascularization. METHODS All patients who were undergoing named vessel revascularization during December 2020 through April 2022 were prospectively enrolled. Platelet mapping assays were performed in three clinical phases: preoperative, postoperative inpatient, and postoperative outpatient. The distribution of platelet reactivity within patients receiving mono- vs dual antiplatelet therapy was assessed, and a between-group inferential analysis was performed. The effect of comorbidities and intervention subtype on platelet inhibition was also analyzed. RESULTS A total of 521 platelet mapping samples from 143 individual patients were analyzed using thromboelastography with platelet mapping. We found wide variability in the distribution of platelet inhibition, with a range of 0 to 100 and an interquartile range of 37.6. Although platelet inhibition with clopidogrel 75 mg was higher on average (44.8 ± 30.2) than that with aspirin 81 mg (24.6 ± 23.7) or aspirin 325 mg (27.1 ± 26.4; P = .001), clopidogrel at 75 mg demonstrated the highest variability in response. CONCLUSIONS These data have demonstrated significant variability in the response to both mono- and dual antiplatelet therapy in PAD patients undergoing lower extremity revascularization. Future research on the effect of this variability in response on the clinical outcomes could provide invaluable understanding of the perioperative thrombotic risk.
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Affiliation(s)
- Monica Majumdar
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | - Davis Waller
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | - Janelle Poyant
- Department of Pharmacy, Tufts Medical Center, Boston, MA
| | - Imani McElroy
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | - Srihari Lella
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | - Zach M Feldman
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | - Emma Levine
- Larner College of Medicine, University of Vermont Medical Center, Burlington, VT
| | - Young Kim
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | - Kathryn Nuzzolo
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | - Amanda Kirshkaln
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | - Charles DeCarlo
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA.
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Racine-Brzostek SE, Asmis LM. Assessment of platelet function utilizing viscoelastic testing. Transfusion 2021; 60 Suppl 6:S10-S20. [PMID: 33089932 DOI: 10.1111/trf.16081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 08/29/2020] [Accepted: 08/29/2020] [Indexed: 12/19/2022]
Affiliation(s)
- Sabrina E Racine-Brzostek
- Department of Pathology and Laboratory Medicine, New York-Presbyterian Hospital, Weill Cornell Medicine, New York, New York, USA
| | - Lars M Asmis
- Centre for Perioperative Thrombosis and Haemostasis, Zurich, Switzerland
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Viscoelastic Hemostatic Assays and Platelet Function Testing in Patients with Atherosclerotic Vascular Diseases. Diagnostics (Basel) 2021; 11:diagnostics11010143. [PMID: 33478051 PMCID: PMC7835760 DOI: 10.3390/diagnostics11010143] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/14/2021] [Accepted: 01/18/2021] [Indexed: 11/16/2022] Open
Abstract
Platelets play crucial role in acute vascular atherosclerotic diseases, including myocardial infarction and stroke. Additionally, platelet aggregation is a key target of antiplatelet agents, forming the keystone of pharmacotherapy of various atherosclerotic cardiovascular diseases. Thromboelastography and thromboelastometry, representing currently available viscoelastic hemostatic assays (VHA), are designed as whole blood, real-time analyzers of clot formation and clot resolution. These assays could, in theory, overcome some limitations of currently available platelet function testing assays. This article reviews the current experience with the use of VHA for platelet function testing and for monitoring of the response to antiplatelet therapy.
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Matkovic M, Novakovic T, Bilbija I, Lazovic JM, Tutus V, Cubrilo M, Aleksic N, Mikic A, Petrovic E, Peric V, Milojevic A, Putnik S. The routine use of platelet function tests in elective coronary artery bypass grafting: A prospective observational trial. J Card Surg 2021; 36:629-636. [PMID: 33403686 DOI: 10.1111/jocs.15284] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/30/2020] [Accepted: 12/16/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Preoperative use of platelet function tests contributes to the decrease of re-intervention rate due to bleeding and the necessity of transfusion in coronary artery bypass grafting (CABG) patients. The aim was to investigate the predictive value and to justify routine preoperative use of multiple electrode aggregometry in these patients. METHODS A prospective observational trial which included 416 consecutive patients subjected to elective isolated CABG was conducted. The Multiplate® test was used to assess platelet function. Platelet function test results, postoperative blood loss, and transfusion requirements were compared between high and low bleeding risk patients. Receiver operating characteristic analysis was performed to assess the sensitivity and specificity of the arachidonic acid (ASPI) and adenosine di-phosphate high sensitive (ADPHS) tests. RESULTS ADPHS and ASPI test results significantly predicted total bleeding > 1000 ml (AUC, 0.685, p < .001; 0.695, p = .039). Sensitivity and specificity were 62.9% and 40.0%, for ADPHS ≤602, and 70.8% and 41.8%, for ASPI ≤ 453. The sensitivity and specificity of cut-off values recommended by the manufacturer were 84.2% and 40.0% for ADPHS ≤ 500, while for ASPI < 600 the values were 54.7% and 62.2%. More platelets and cryoprecipitate were transfused in patients with ADPHS ≤ 602.5 (p < .001; p = .035). Patients with ADPHS ≤ 500 had a higher rate of red blood count, platelet and cryoprecipitate transfusion (p<.001p<.001; p = .013). The manufacturer's ASPI test cut-off values showed no statistically significant prediction for a higher transfusion rate. CONCLUSION Preoperative platelet function tests should be conducted systematically for all elective CABG patients who were on dual antiplatelet therapy after adjusting test cut-off values for each population.
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Affiliation(s)
- Milos Matkovic
- Department for Cardiac Surgery, Clinical Center of Serbia, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Tina Novakovic
- Department for Biostatistics, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Ilija Bilbija
- Department for Cardiac Surgery, Clinical Center of Serbia, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Jelena Milin Lazovic
- Department for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Vladimir Tutus
- Department for Anesthesiology and Intensive Care, Clinical Center of Serbia, Belgrade, Serbia
| | - Marko Cubrilo
- Department for Cardiac Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Nemanja Aleksic
- Department for Cardiac Surgery, Clinical Center of Serbia, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Aleksandar Mikic
- Department for Cardiac Surgery, Clinical Center of Serbia, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Emilija Petrovic
- Department for Cardiac Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Valerija Peric
- Department for Cardiac Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | | | - Svetozar Putnik
- Department for Cardiac Surgery, Clinical Center of Serbia, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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Tian L, Gao X, Yang J, Yao Y, Ji H. Association of Adenosine Diphosphate-Induced Platelet Maximum Amplitude With Postoperative Bleeding and Blood Transfusions in Patients Undergoing Coronary Artery Bypass Grafting. J Cardiothorac Vasc Anesth 2020; 35:421-428. [PMID: 32758409 DOI: 10.1053/j.jvca.2020.07.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 06/29/2020] [Accepted: 07/01/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To investigate the association of adenosine diphosphate (ADP)-induced platelet maximum amplitude (MAADP) with postoperative bleeding and blood product transfusions in patients undergoing coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB). DESIGN This single-center observational study recruited 200 patients who underwent elective, first-time, isolated CABG with CPB. A rapid thromboelastography with platelet mapping test was conducted for all patients before the surgery. Patients were categorized by the preoperative MAADP into ≤50 mm (MAADP ≤50 group [n = 87]) and MAADP >50 mm (MAADP >50 group [n = 113]). The primary outcome was postoperative bleeding at 6 and 24 hours as measured by chest tube drainage volume. The perioperative blood product transfusions, postoperative complications, postoperative time course, and in-hospital mortality also were evaluated. SETTING University hospital. PARTICIPANTS Adult patients scheduled to undergo isolated primary CABG with CPB. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The study included 200 patients who underwent CABG with CPB. MAADP was >50 mm in 113 (56.5%) patients (MAADP >50 group). Compared with the MAADP >50 group, the postoperative chest tube drainage volume at 6 and 24 hours was significantly greater in the patients with MAADP ≤50 mm (476.90 ± 156.36 mL v 403.36 ± 133.24 mL; p < 0.001 and 935.86 ± 318.43 mL v 667.21 ± 222.75 mL; p < 0.001, respectively). The consumption of blood products in patients with MAADP ≤50 mm was significantly more than those with MAADP >50 mm. The durations of intensive care unit stay and length of postoperative hospital stay were markedly longer in the MAADP ≤50 group than in the MAADP >50 group (p = 0.001 and p = 0.005; respectively). There were no significant differences in adverse outcomes between the 2 groups except for the postoperative atrial fibrillation, which occurred more in the MAADP ≤50 group than in the MAADP >50 group (8.05% v 1.77%; p = 0.043). MAADP (area under the receiver operating characteristic curve of 0.767; p < 0.001) was demonstrated to have significant ability to predict bleeding tendency, with a sensitivity of 76.2% and a specificity of 69.0%. CONCLUSIONS Preoperative MAADP may play a potential role in the prediction of postoperative bleeding and allogeneic blood transfusions and guide clinicians in perioperative management of patients undergoing CABG with CPB.
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Affiliation(s)
- Lijuan Tian
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xurong Gao
- Department of Transfusion Medicine, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing Yang
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuntai Yao
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongwen Ji
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; Department of Transfusion Medicine, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Wang L, Valencia O, Phillips S, Sharma V. Implementation of Perioperative Point-of-Care Platelet Function Analyses Reduces Transfusion Requirements in Cardiac Surgery: A Retrospective Cohort Study. Thorac Cardiovasc Surg 2020; 69:710-718. [DOI: 10.1055/s-0040-1710582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Abstract
Background Platelet dysfunction is a common cause of bleeding, perioperative blood transfusion, and surgical re-exploration in cardiac surgical patients. We evaluated the effect of incorporating a platelet function analyzer utilizing impedance aggregometry (Multiplate, Roche, Munich, Germany) into our local transfusion algorithm on the rate of platelet transfusion and postoperative blood loss in patients undergoing coronary artery bypass grafting (CABG) surgery.
Methods Data were collected on patients undergoing CABG surgery from January 2015 to April 2017. Patients who underwent surgery before and after introduction of this algorithm were classified into prealgorithm and postalgorithm groups, respectively. The primary outcome was the rate of platelet transfusion before and after implementation of the Multiplate-based transfusion algorithm. Secondary outcomes included transfusion rate of packed red blood cells, postoperative blood loss at 12 and 24 hours, length of stay in the intensive care unit, and the hospital and mortality.
Results A total of 726 patients were included in this analysis with 360 and 366 patients in the pre- and postalgorithm groups, respectively. Transfusion rates of platelets (p = 0.01) and packed red blood cells (p = 0.0004) were significantly lower following introduction of the algorithm in patients (n = 257) who had insufficient time to withhold antiplatelet agents. Receiver operating characteristic curves defined optimal cutoff points of arachidonic acid and adenosine diphosphate assays on the Multiplate to predict future platelet transfusion were 23AU and 43AU, respectively.
Conclusions The introduction of a Multiplate-based platelet transfusion algorithm showed a statistically significant reduction in the administration of platelets to patients undergoing urgent CABG surgery.
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Affiliation(s)
- Lihui Wang
- Department of Clinical Perfusion, St George's Hospital, London, United Kingdom
| | - Oswaldo Valencia
- Department of Cardiac Surgery, St George's Hospital, London, United Kingdom
| | - Simon Phillips
- Department of Clinical Perfusion, St George's Hospital, London, United Kingdom
| | - Vivek Sharma
- Department of Anaesthesia, St George's Hospital, London, United Kingdom
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Reduction of Preoperative Waiting Time before Urgent Surgery for Patients on P2Y 12 Inhibitors Using Multiple Electrode Aggregometry: A Retrospective Study. J Clin Med 2020; 9:jcm9020424. [PMID: 32033153 PMCID: PMC7074528 DOI: 10.3390/jcm9020424] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 01/30/2020] [Accepted: 01/31/2020] [Indexed: 12/18/2022] Open
Abstract
P2Y12 inhibitor discontinuation is essential before most surgical interventions to limit bleeding complications. Based on pharmacodynamic data, fixed discontinuation durations have been recommended. However, as platelet function recovery is highly variable among patients, a more individualized approach based on platelet function testing (PFT) has been proposed. The aim of this retrospective single-centre study was to determine whether PFT using whole blood adenosine diphosphate–multiple electrode aggregometry (ADP–MEA) was associated with a safe reduction of preoperative waiting time. Preoperative ADP–MEA was performed for 29 patients on P2Y12 inhibitors. Among those, 17 patients underwent a coronary artery bypass graft. Twenty one were operated with an ADP–MEA ≥ 19 U (quantification of the area under the aggregation curve), and the waiting time was shorter by 1.6 days (median 1.8 days, IQR 0.5–2.9), by comparison with the current recommendations (five days for clopidogrel and ticagrelor, seven days for prasugrel). Platelet function recovery was indeed highly variable among individuals. With the 19 U threshold, high residual platelet inhibition was associated with perioperative platelet transfusion. These results suggest that preoperative PFT with ADP–MEA could help reduce waiting time before urgent surgery for patients on P2Y12 inhibitors.
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Ranucci M, Baryshnikova E. Sensitivity of Viscoelastic Tests to Platelet Function. J Clin Med 2020; 9:E189. [PMID: 32284512 PMCID: PMC7019879 DOI: 10.3390/jcm9010189] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 12/28/2019] [Accepted: 01/07/2020] [Indexed: 12/02/2022] Open
Abstract
Viscoelastic tests provide a dynamic assessment of coagulation, by exploring the time to clot formation and the clot strength. Using specific activators or inhibitors, additional factors can be explored, like the fibrinogen contribution to clot strength. Since the early days, various attempts have been done to measure platelet function with viscoelastic test. In general, the difference between the maximum clot strength and the fibrinogen contribution is considered an index of platelet contribution. However, this parameter does not clearly split platelet count from function; additionally, the extensive thrombin generation of standard activated viscoelastic tests activates platelet through the protease activated receptors, bypassing the other pathways. For this reason, standard viscoelastic tests cannot be used to assess platelet reactivity under the effects of aspirin or P2Y12 inhibitors. To overcome this limitation, a specific test was developed (thromboelastography platelet mapping). This test has been compared with the gold standard of light transmission aggregometry and with other point-of-care tests, with conflicting results. In general, the use of viscoelastic tests to assess the effects of antiplatelet agents is still limited. Conversely, platelet contribution to clot strength in the setting of coagulopathic bleeding is considered an important parameter to trigger platelet transfusion or desmopressin.
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Affiliation(s)
- Marco Ranucci
- Department of Cardiothoracic, Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, 20097 Milan, Italy;
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Kammerer T, Hulde N, Speck E, Hübner M, Crispin A, Zwissler B, Conzen P, von Dossow V, Schäfer ST, Hofmann-Kiefer K, Rehm M. Effects of balanced hydroxyethyl starch 6% (130/0.4) and albumin 5% on clot formation and glycocalyx shedding: Subgroup analysis of a prospective randomized trial. Thromb Res 2019; 183:111-118. [DOI: 10.1016/j.thromres.2019.10.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 09/13/2019] [Accepted: 10/21/2019] [Indexed: 12/22/2022]
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Opheim EN, Apelseth TO, Stanworth SJ, Eide GE, Hervig T. Multiple electrode aggregometry and thromboelastography in thrombocytopenic patients with haematological malignancies. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2019; 17:181-190. [PMID: 30747706 PMCID: PMC6596372 DOI: 10.2450/2018.0140-18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 11/07/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND In thrombocytopenic patients better assessment of bleeding risk than that provided by platelet count alone is required. Multiplate® aggregometry and thromboelastography (TEG) could be used, but information on their role in such patients is limited. The primary aim of this study was to investigate the feasibility of Multiplate® analyses in patients with haematological malignancies. A secondary aim was to explore whether a multiple logistic regression model combining Multiplate®, TEG, clinical and laboratory variables was associated with risk of bleeding. MATERIALS AND METHODS This was an exploratory, prospective observational study of thrombocytopenic patients with haematological malignancies. Total platelet count (TPC), white blood cell count, C-reactive protein (CRP) level, temperature and bleeding status were recorded daily. TEG and Multiplate® analyses with four agonists were performed on weekdays. RESULTS Ten patients were enrolled into the study. The median number of days in a study period was 21. Bleeding was observed on 64 of 298 study days. TPC <20×109/L and <10×109/L occurred on 119 and 25 days, respectively. When TPC was <33×109/L, many samples showed no aggregation, regardless of bleeding status. Despite this, the odds of World Health Organization (WHO) grade 2 bleeding decreased significantly as aggregation increased and Multiplate® had a negative predictive value (NPV) of 96% and a positive predictive value (PPV) of 19% for significant bleeding. In the multiple logistic regression model collagen-activated Multiplate® aggregation, TEG angle, TEG reaction time and CRP significantly affected the odds of WHO grade 2 bleeding. The combined model had a NPV of 99% and a PPV of 19%. DISCUSSION Our findings suggest that the markers of platelet function and haemostasis provided by Multiplate® aggregometry and TEG may add information to support prediction of bleeding, although platelet count still remains the most accessible analysis for routine testing.
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Affiliation(s)
- Elin N. Opheim
- Department of Clinical Science, University of Bergen, Norway
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
| | - Torunn O. Apelseth
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
- Laboratory of Clinical Biochemistry, Haukeland University Hospital, Bergen, Norway
| | - Simon J. Stanworth
- NHS Blood and Transplant/Oxford University Hospitals NHS Trust, “John Radcliffe” Hospital, Oxford, United Kingdom
| | - Geir E. Eide
- Department of Global Public Health and Primary Care, University of Bergen, Norway
- Centre for Clinical Research, Haukeland University Hospital, Bergen, Norway
| | - Tor Hervig
- Department of Clinical Science, University of Bergen, Norway
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
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13
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Kruger P, Chan N, Eikelboom JW. Platelet Transfusion for Ticagrelor Reversal. Circ Cardiovasc Interv 2017; 10:CIRCINTERVENTIONS.117.005579. [DOI: 10.1161/circinterventions.117.005579] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Paul Kruger
- From the Population Health Research Institute (P.K., J.W.E.); Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada (N.C., J.W.E.); and Hamilton Health Science Corporation and McMaster University, Ontario, Canada (P.K., N.C., J.W.E.)
| | - Noel Chan
- From the Population Health Research Institute (P.K., J.W.E.); Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada (N.C., J.W.E.); and Hamilton Health Science Corporation and McMaster University, Ontario, Canada (P.K., N.C., J.W.E.)
| | - John W. Eikelboom
- From the Population Health Research Institute (P.K., J.W.E.); Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada (N.C., J.W.E.); and Hamilton Health Science Corporation and McMaster University, Ontario, Canada (P.K., N.C., J.W.E.)
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Sivapalan P, Bäck AC, Ostrowski SR, Ravn HB, Johansson PI. Transfusion requirements in elective cardiopulmonary bypass surgery patients: predictive value of Multiplate and Thromboelastography (TEG) Platelet Mapping Assay. Scandinavian Journal of Clinical and Laboratory Investigation 2017; 77:345-351. [PMID: 28537454 DOI: 10.1080/00365513.2017.1325000] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Managing haemostasis in patients undergoing cardiopulmonary bypass (CPB) surgery remains a challenge. There is no established laboratory test to predict transfusion requirements in cardiac surgery. We investigated whether preoperative Thromboelastography (TEG) with Platelet Mapping Assay (PMA) or Multiple Electrode Aggrometry (MEA) could predict transfusion requirements in patients undergoing elective coronary artery bypass grafting (CABG) or combined CABG with aortic or mitral valve replacement. We prospectively investigated 199 patients undergoing elective CABG or combined procedures. PMA and MEA were performed at baseline (after anaesthesia induction), upon arrival at the intensive care unit and on the first postoperative day. Patients receiving fresh frozen plasma and/or platelets (FFP/PLT) had a lower PMA maximum amplitude (MA) for adenosine diphosphate (PMA-ADP) and arachidonic acid (PMA-AA) at baseline, at arrival in the intensive care unit and the first postoperative day compared to non-transfused patients. Receiver operating characteristic curves on PMA showed that lower values predicted FFP/PLT transfusion: PMA-ActF 0.64 (p = 0.04), PMA-ADP 0.69 (p = 0.01) and PMA-AA 0.71 (p = 0.002). In contrast, MEA values were not able to predict FFP/PLT transfusions. This study shows that preoperative PMA potentially is a better screening tool for platelet inhibition associated with transfusion requirements in patients undergoing CABG or combined procedures.
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Affiliation(s)
- Praleene Sivapalan
- a Department of Cardiothoracic Anaesthesiology , Copenhagen University Hospital , Copenhagen , Denmark
| | - Anne Caroline Bäck
- b Department of Cardiothoracic Surgery , Copenhagen University Hospital , Copenhagen , Denmark
| | - Sisse Rye Ostrowski
- c Section for Transfusion Medicine, Capital Region Blood Bank , Copenhagen University Hospital , Copenhagen , Denmark
| | - Hanne Berg Ravn
- a Department of Cardiothoracic Anaesthesiology , Copenhagen University Hospital , Copenhagen , Denmark
| | - Pär Ingemar Johansson
- d Department of Surgery , University of Texas Health Medical School , Houston , TX , USA.,e Center for Systems Biology, The School of Engineering and Natural Sciences , University of Iceland , Reykjavik , Iceland
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