1
|
Janko N, Majeed A, Commins I, Gow P, Kemp W, Roberts SK. Rotational thromboelastometry predicts future bleeding events in patients with cirrhosis. Scand J Gastroenterol 2024:1-7. [PMID: 39010734 DOI: 10.1080/00365521.2024.2375591] [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: 02/28/2024] [Accepted: 06/27/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND AND AIMS Patients with cirrhosis of the liver are in a delicate state of rebalanced haemostasis and are at risk of developing both bleeding and thrombotic complications. Conventional haemostatic tests are unable to predict bleeding and thrombosis in these patients. We aimed to explore the role of Rotational Thromboelastometry (ROTEM) in predicting bleeding and thrombotic events in patients with cirrhosis. METHODS We conducted a prospective cohort study of patients with cirrhosis at two metropolitan hospitals. All patients underwent ROTEM analysis and were then followed to record any bleeding and thrombotic events. Univariate and multivariate logistic regression analyses were performed to explore associations with bleeding and thrombotic events. RESULTS Nineteen of the 162 patients recruited experienced a bleeding event within one year of ROTEM analysis. On univariate analysis, maximum clot firmness (MCF) using both EXTEM and INTEM tests was significantly reduced in patients who had a bleeding event, compared to those who did not (50 mm vs. 57 mm, p < 0.01 and 48 mm vs. 54 mm, p < 0.01, respectively). In addition, on univariate analysis, clotting time (CT) in the INTEM test was prolonged in the bleeding group (214 s vs. 198 s, p = 0.01). On multivariate analysis, only MCFEX was a significant predictor of bleeding events. In contrast, there was no association found between ROTEM parameters and development of thrombosis within a one-year period. CONCLUSIONS ROTEM may provide a useful tool in predicting future bleeding events in patients with cirrhosis. Larger studies are required to further validate this finding and explore its application in clinical practice.
Collapse
Affiliation(s)
- Natasha Janko
- Department of Gastroenterology, Alfred Health, Melbourne, Australia
- Central Clinical School, Monash University, Melbourne, Australia
| | - Ammar Majeed
- Department of Gastroenterology, Alfred Health, Melbourne, Australia
- Central Clinical School, Monash University, Melbourne, Australia
| | - Isabella Commins
- Department of Gastroenterology, Alfred Health, Melbourne, Australia
- Central Clinical School, Monash University, Melbourne, Australia
| | - Paul Gow
- Victorian Liver Transplant Unit, Austin Health, Heidelberg, Australia
- Department of Medicine, Austin Academic Centre, University of Melbourne, Melbourne, Australia
| | - William Kemp
- Department of Gastroenterology, Alfred Health, Melbourne, Australia
- Central Clinical School, Monash University, Melbourne, Australia
| | - Stuart K Roberts
- Department of Gastroenterology, Alfred Health, Melbourne, Australia
- Central Clinical School, Monash University, Melbourne, Australia
| |
Collapse
|
2
|
Lahvic NK, Schauer SG, Higgins SS, Johannigman JA, Grathwohl KW. An Analysis of the Association of Arrival Hemoglobin With Overtransfusion at 24 Hours in a Trauma Population. Mil Med 2024:usae293. [PMID: 38913448 DOI: 10.1093/milmed/usae293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 03/20/2024] [Accepted: 06/10/2024] [Indexed: 06/26/2024] Open
Abstract
BACKGROUND Hemorrhage control and resuscitative concepts have evolved in recent years, leading to aggressive use of blood products in trauma patients. There is subsequently a potential risk for overtransfusion, adverse effects, and waste associated with unnecessary transfusion. Methods for conserving blood products are of particular importance in future large-scale combat operations where supply chains are likely to be strained. This study examined the association of emergency department (ED) arrival hemoglobin (HGB) with overtransfusion among survivors at 24 hours after major trauma at a military trauma center. MATERIALS AND METHODS We performed a retrospective cohort study of patients who had a "major trauma" activation and received any red blood cells. Overtransfusion was defined as a HGB level ≥11.0 g/dL at 24 hours (outcome variable). Multivariable logistic regression statistics were used to compare groups and adjust for confounders (injury severity score, arrival modified shock index, injury type, age, and gender). A receiver operating characteristic was constructed with overtransfusion at 24 hours as the outcome (binary) and arrival HGB (continuous) as the independent variable. RESULTS A total of 382 patients met inclusion criteria. Overtransfusion occurred in 30.4% (n = 116) of patients, with mean ED HGB levels of 13.2 g/dL (12.9 to 13.6) versus 11.6 g/dL (11.3 to 11.8, P < .001). Receiver operating characteristic analysis showed that ED HGB was highly sensitive (0.931) for predicting 24-hour overtransfusion. In our multivariable logistic regression analysis, when adjusting for injury severity score, arrival modified shock index, injury type, age, and gender, we found that the ED HGB value had a per-unit odds ratio of 1.60 (95% CI, 1.38 to 1.86) for 24-hour overtransfusion. Hospital and intensive care unit length of stay, mechanical ventilator days, and mortality did not increase. CONCLUSION We found that the arrival HGB value was associated with overtransfusion among 24-hour survivors in a civilian trauma setting. Our findings will inform future prospective studies that investigate blood sparing clinical practice guidelines.
Collapse
Affiliation(s)
| | - Steven G Schauer
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78234, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Sophie S Higgins
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
| | | | - Kurt W Grathwohl
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
| |
Collapse
|
3
|
Gruneberg D, Hofer S, Schöchl H, Zipperle J, Oberladstätter D, Decker SO, Von der Forst M, Tourelle KM, Dietrich M, Weigand MA, Schmitt FCF. Comparison of Two Viscoelastic Testing Devices in a Parturient Population. J Clin Med 2024; 13:692. [PMID: 38337386 PMCID: PMC10856714 DOI: 10.3390/jcm13030692] [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: 12/23/2023] [Revised: 01/20/2024] [Accepted: 01/22/2024] [Indexed: 02/12/2024] Open
Abstract
Background: Viscoelastic hemostatic assays (VHAs) have become an integral diagnostic tool in guiding hemostatic therapy, offering new opportunities in personalized hemostatic resuscitation. This study aims to assess the interchangeability of ClotPro® and ROTEM® delta in the unique context of parturient women. Methods: Blood samples from 217 parturient women were collected at three timepoints. A total of 631 data sets were eligible for our final analysis. The clotting times were analyzed via extrinsic and intrinsic assays, and the clot firmness parameters A5, A10, and MCF were analyzed via extrinsic, intrinsic, and fibrin polymerization assays. In parallel, the standard laboratory coagulation statuses were obtained. Device comparison was assessed using regression and Bland-Altman plots. The best cutoff calculations were used to determine the VHA values corresponding to the established standard laboratory cutoffs. Results: The clotting times in the extrinsic and intrinsic assays showed notable differences between the devices, while the extrinsic and intrinsic clot firmness results demonstrated interchangeability. The fibrinogen assays revealed higher values in ClotPro® compared to ROTEM®. An ROC analysis identified VHA parameters with high predictive values for coagulopathy exclusion and yet low specificity. Conclusions: In the obstetric setting, the ROTEM® and ClotPro® parameters demonstrate a significant variability. Device- and indication-specific transfusion algorithms are essential for the accurate interpretation of measurements and adequate hemostatic therapy.
Collapse
Affiliation(s)
- Daniel Gruneberg
- Department of Anesthesiology, Medical Faculty Heidelberg, Heidelberg University, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (D.G.)
| | - Stefan Hofer
- Department of Anesthesiology, Kaiserslautern Westpfalz Hospital, 67655 Kaiserslautern, Germany
| | - Herbert Schöchl
- Ludwig Boltzmann Institute for Traumatology, The Research Center in Cooperation with AUVA, 1200 Vienna, Austria
| | - Johannes Zipperle
- Ludwig Boltzmann Institute for Traumatology, The Research Center in Cooperation with AUVA, 1200 Vienna, Austria
| | - Daniel Oberladstätter
- Ludwig Boltzmann Institute for Traumatology, The Research Center in Cooperation with AUVA, 1200 Vienna, Austria
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, 5020 Salzburg, Austria
| | - Sebastian O. Decker
- Department of Anesthesiology, Medical Faculty Heidelberg, Heidelberg University, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (D.G.)
| | - Maik Von der Forst
- Department of Anesthesiology, Medical Faculty Heidelberg, Heidelberg University, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (D.G.)
| | - Kevin Michel Tourelle
- Department of Anesthesiology, Medical Faculty Heidelberg, Heidelberg University, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (D.G.)
| | - Maximilian Dietrich
- Department of Anesthesiology, Medical Faculty Heidelberg, Heidelberg University, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (D.G.)
| | - Markus A. Weigand
- Department of Anesthesiology, Medical Faculty Heidelberg, Heidelberg University, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (D.G.)
| | - Felix C. F. Schmitt
- Department of Anesthesiology, Medical Faculty Heidelberg, Heidelberg University, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (D.G.)
| |
Collapse
|
4
|
Kukreja N, Rodriguez IE, Moore HB, LaRiviere W, Crouch C, Stewart E, Nydam TL, Kennealey P, Hendrickse AD, Pomfret EA, Fernandez-Bustamante A. The in-vitro influence of urea concentration on thromboelastrography in patients with and without end stage renal disease. Am J Surg 2023; 226:817-822. [PMID: 37407391 PMCID: PMC10733546 DOI: 10.1016/j.amjsurg.2023.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 05/25/2023] [Accepted: 06/20/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND End stage renal disease (ESRD) is associated with platelet dysfunction but also thromboembolic complications. The specific role of increased blood urea nitrogen (BUN) on coagulation is unclear. We aimed to characterize thromboelastography (TEG) parameters from males and females with ESRD and normal kidney function and evaluate if exogenous urea in vitro reproduced those TEG differences. METHODS We collected blood samples from 20 living kidney donors and 20 kidney recipients. TEG was performed without and with two increasing urea concentrations in vitro. TEG parameters were compared between recipients and donors. RESULTS Blood from kidney recipients showed baseline increased maximum amplitude (MA) and shortened time to maximum amplitude (TMA) compared to donors. These differences were not confirmed in females. In all patients, BUN was inversely correlated with TMA (r = -0.342; p = 0.031). In males, BUN and creatinine concentrations showed a direct correlation with MA (0.583; p = 0.007) and an inverse correlation with TMA (r = -0.520; p = 0.019). Urea in vitro decreased R-time (p = 0.005) and increased LY30 (p = 0.009) in donors but not recipients. CONCLUSIONS ESRD is associated with increased MA and decreased TMA on TEG. No change in MA was observed with increasing urea concentrations in vitro. Gender-specific variability in TEG parameters were observed.
Collapse
Affiliation(s)
- Naveen Kukreja
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Ivan E Rodriguez
- Colorado Center for Transplantation Care, Research, and Education (CCTCARE). Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Hunter B Moore
- Colorado Center for Transplantation Care, Research, and Education (CCTCARE). Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Cara Crouch
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Erin Stewart
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Trevor L Nydam
- Colorado Center for Transplantation Care, Research, and Education (CCTCARE). Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Peter Kennealey
- Colorado Center for Transplantation Care, Research, and Education (CCTCARE). Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Adrian D Hendrickse
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Elizabeth A Pomfret
- Colorado Center for Transplantation Care, Research, and Education (CCTCARE). Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | | |
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
|
Janko N, Majeed A, Kemp W, Hogan C, Nandurkar H, Roberts SK. Rotational ThromboElastometry-guided blood component administration versus standard of care in patients with Cirrhosis and coagulopathy undergoing Invasive ProcEdures (RECIPE): study protocol for a randomised controlled trial. Trials 2023; 24:516. [PMID: 37568228 PMCID: PMC10422802 DOI: 10.1186/s13063-023-07552-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 07/28/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND Patients with cirrhosis often undergo invasive procedures both for management of complications of their advanced liver disease, including treatment for hepatocellular carcinoma, as well as underlying comorbidities. Despite a current understanding that most patients with cirrhosis are in a rebalanced haemostatic state (despite abnormalities in conventional coagulation tests, namely INR and platelet count), patients with cirrhosis are still often given prophylactic blood components based on these conventional parameters, in an effort to reduce procedure-related bleeding. Viscoelastic tests such as Rotational Thromboelastometry (ROTEM) provide a global measurement of haemostasis and have been shown to predict bleeding risk more accurately than conventional coagulation tests, and better guide blood product transfusion in a number of surgical and trauma-related settings. The aim of this study is to assess the utility of a ROTEM-based algorithm to guide prophylactic blood component delivery in patients with cirrhosis undergoing invasive procedures. We hypothesise that ROTEM-based decision-making will lead to a reduction in pre-procedural blood component usage, particularly fresh frozen plasma (FFP), compared with standard of care, whilst maintaining optimal clinical outcomes. METHODS This is a multi-centre randomised controlled trial comparing ROTEM-guided prophylactic blood component administration to standard of care in patients with cirrhosis and coagulopathy undergoing invasive procedures. The primary efficacy outcome of the trial is the proportion of procedures requiring prophylactic transfusion, with the primary safety outcome being procedure-related bleeding complications. Secondary outcomes include the amount of blood products (FFP, platelets, cryoprecipitate) transfused, transfusion-related side effects, procedure-related complications other than bleeding, hospital length of stay and survival. DISCUSSION We anticipate that this project will lead to improved prognostication of patients with cirrhosis, in terms of their peri-procedural bleeding risk. We hope to show that a significant proportion of cirrhotic patients, deemed coagulopathic on the basis of standard coagulation tests such as INR and platelet count, are actually in a haemostatic balance and thus do not require prophylactic blood product, leading to decreased and more efficient blood component use. TRIAL REGISTRATION RECIPE has been prospectively registered with the Australia and New Zealand Clinical Trials Registry on the 30th April 2019 ( ACTRN12619000644167 ).
Collapse
Affiliation(s)
- Natasha Janko
- Department of Gastroenterology, Alfred Health, Melbourne, VIC, Australia.
- Central Clinical School, Monash University, Melbourne, VIC, Australia.
| | - Ammar Majeed
- Department of Gastroenterology, Alfred Health, Melbourne, VIC, Australia
- Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - William Kemp
- Department of Gastroenterology, Alfred Health, Melbourne, VIC, Australia
- Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Chris Hogan
- Department of Laboratory Haematology, Austin Health, Melbourne, VIC, Australia
| | - Harshal Nandurkar
- Department of Haematology, Alfred Health, Melbourne, VIC, Australia
- Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia
| | - Stuart K Roberts
- Department of Gastroenterology, Alfred Health, Melbourne, VIC, Australia
- Central Clinical School, Monash University, Melbourne, VIC, Australia
| |
Collapse
|
7
|
LaCroix IS, Cohen M, Moore EE, Dzieciatkowska M, Silliman CC, Hansen KC, D'Alessandro A. Omics markers of platelet transfusion in trauma patients. Transfusion 2023; 63:1447-1462. [PMID: 37466356 DOI: 10.1111/trf.17472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/26/2023] [Accepted: 05/30/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND Even in the era of the COVID-19 pandemic, trauma remains the global leading cause of mortality under the age of 49. Trauma-induced coagulopathy is a leading driver of early mortality in critically ill patients, and transfusion of platelet products is a life-saving intervention to restore hemostasis in the bleeding patient. However, despite extensive functional studies based on viscoelastic assays, limited information is available about the impact of platelet transfusion on the circulating molecular signatures in trauma patients receiving platelet transfusion. MATERIALS AND METHODS To bridge this gap, we leveraged metabolomics and proteomics approaches to characterize longitudinal plasma samples (n = 118; up to 11 time points; total samples: 759) from trauma patients enrolled in the Control Of Major Bleeding After Trauma (COMBAT) study. Samples were collected in the field, in the emergency department (ED), and at intervals up to 168 h (7 days) post-hospitalization. Transfusion of platelet (PLT) products was performed (n = 30; total samples: 250) in the ED through 24 h post-hospitalization. Longitudinal plasma samples were subjected to mass spectrometry-based metabolomics and proteomics workflows. Multivariate analyses were performed to determine omics markers of transfusion of one, two, three, or more PLT transfusions. RESULTS Higher levels of tranexamic acid (TXA), inflammatory proteins, carnitines, and polyamines were detected in patients requiring PLT transfusion. Correlation of PLT units with omics data suggested sicker patients required more units and partially overlap with the population requiring transfusion of packed red blood cell products. Furthermore, platelet activation was likely increased in the most severely injured patients. Fatty acid levels were significantly lower in PLT transfusion recipients (at time of maximal transfusion: Hour 4) compared with non-recipients, while carnitine levels were significantly higher. Fatty acid levels restore later in the time course (e.g., post-PLT transfusion). DISCUSSION The present study provides the first multi-omics characterization of platelet transfusion efficacy in a clinically relevant cohort of trauma patients. Physiological alterations following transfusion were detected, highlighting the efficacy of mass spectrometry-based omics techniques to improve personalized transfusion medicine. More specialized clinical research studies focused on PLT transfusion, including organized pre and post transfusion sample collection and limitation to PLT products only, are required to fully understand subsequent metabolomic and proteomic alterations.
Collapse
Affiliation(s)
- Ian S LaCroix
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver - Anschutz Medical Campus, Aurora, Colorado, USA
| | - Mitchell Cohen
- Department of Surgery, University of Colorado - Anschutz Medical Campus, Aurora, Colorado, USA
| | - Ernest E Moore
- Department of Surgery, University of Colorado - Anschutz Medical Campus, Aurora, Colorado, USA
- "Ernest E Moore" Trauma Center at Denver Health, Denver, Colorado, USA
| | - Monika Dzieciatkowska
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver - Anschutz Medical Campus, Aurora, Colorado, USA
| | - Christopher C Silliman
- Vitalant Research Institute, Denver, Colorado, USA
- Department of Pediatrics, University of Colorado - Anschutz Medical Campus, Aurora, Colorado, USA
| | - Kirk C Hansen
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver - Anschutz Medical Campus, Aurora, Colorado, USA
| | - Angelo D'Alessandro
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver - Anschutz Medical Campus, Aurora, Colorado, USA
| |
Collapse
|
8
|
Maegele M. [Viscoelasticity-based point of care coagulation diagnostics in the context of resuscitation room management of severely injured and bleeding trauma patients : Diagnostics and treatment of trauma-induced coagulopathy]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2023; 126:542-551. [PMID: 36976344 DOI: 10.1007/s00113-023-01300-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/31/2023] [Indexed: 03/29/2023]
Abstract
Uncontrolled bleeding with associated trauma-induced coagulopathy (TIC) remains the leading cause of preventable death after severe trauma. Meanwhile, TIC is recognized as a separate clinical entity with substantial impact on downstream morbidity and mortality. In clinical practice severely injured and bleeding patients are often still being treated according to established damage control surgery (DCS) procedures with surgical bleeding control and empirical transfusion of classical blood products in predefined ratios in the sense of damage control resuscitation (DCR); however, algorithms are also available, which have been constructed from established viscoelasticity-based point of care (POC) diagnostic procedures and target value-oriented treatments. The latter enables a timely qualitative assessment of coagulation function from whole blood at bedside and provides rapid and clinically useful information on the presence, development and dynamics of the coagulation disorder. The early implementation of viscoelasticity-based POC procedures in the context of resuscitation room management of severely injured and bleeding patients was uniformly associated with reductions in potentially harmful blood products, especially overtransfusions, and an overall improvement in outcome including survival. The present article reviews the clinical questions around the use of viscoelasticity-based procedures as well as recommendations for the early and acute management of bleeding trauma patients taking the current literature into account.
Collapse
Affiliation(s)
- Marc Maegele
- Klinik für Orthopädie, Unfallchirurgie und Sporttraumatologie, Kliniken der Stadt Köln-Merheim, Universität Witten/Herdecke (UW/H), Campus Köln-Merheim, Ostmerheimerstr. 200, 51109, Köln, Deutschland.
- Institut für Forschung in der Operativen Medizin (IFOM), Universität Witten/Herdecke (UW/H), Campus Köln-Merheim, Köln, Deutschland.
| |
Collapse
|
9
|
Rossaint R, Afshari A, Bouillon B, Cerny V, Cimpoesu D, Curry N, Duranteau J, Filipescu D, Grottke O, Grønlykke L, Harrois A, Hunt BJ, Kaserer A, Komadina R, Madsen MH, Maegele M, Mora L, Riddez L, Romero CS, Samama CM, Vincent JL, Wiberg S, Spahn DR. The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition. Crit Care 2023; 27:80. [PMID: 36859355 PMCID: PMC9977110 DOI: 10.1186/s13054-023-04327-7] [Citation(s) in RCA: 108] [Impact Index Per Article: 108.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 01/20/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Severe trauma represents a major global public health burden and the management of post-traumatic bleeding continues to challenge healthcare systems around the world. Post-traumatic bleeding and associated traumatic coagulopathy remain leading causes of potentially preventable multiorgan failure and death if not diagnosed and managed in an appropriate and timely manner. This sixth edition of the European guideline on the management of major bleeding and coagulopathy following traumatic injury aims to advise clinicians who care for the bleeding trauma patient during the initial diagnostic and therapeutic phases of patient management. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma included representatives from six European professional societies and convened to assess and update the previous version of this guideline using a structured, evidence-based consensus approach. Structured literature searches covered the period since the last edition of the guideline, but considered evidence cited previously. The format of this edition has been adjusted to reflect the trend towards concise guideline documents that cite only the highest-quality studies and most relevant literature rather than attempting to provide a comprehensive literature review to accompany each recommendation. RESULTS This guideline comprises 39 clinical practice recommendations that follow an approximate temporal path for management of the bleeding trauma patient, with recommendations grouped behind key decision points. While approximately one-third of patients who have experienced severe trauma arrive in hospital in a coagulopathic state, a systematic diagnostic and therapeutic approach has been shown to reduce the number of preventable deaths attributable to traumatic injury. CONCLUSION A multidisciplinary approach and adherence to evidence-based guidelines are pillars of best practice in the management of severely injured trauma patients. Further improvement in outcomes will be achieved by optimising and standardising trauma care in line with the available evidence across Europe and beyond.
Collapse
Affiliation(s)
- Rolf Rossaint
- Department of Anaesthesiology, University Hospital Aachen, RWTH, Aachen University, Pauwelsstrasse 30, D-52074, Aachen, Germany.
| | - Arash Afshari
- grid.5254.60000 0001 0674 042XDepartment of Paediatric and Obstetric Anaesthesia, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Bertil Bouillon
- grid.412581.b0000 0000 9024 6397Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Vladimir Cerny
- grid.424917.d0000 0001 1379 0994Department of Anaesthesiology, Perioperative Medicine and Intensive Care, Masaryk Hospital, J.E. Purkinje University, Socialni pece 3316/12A, CZ-40113 Usti nad Labem, Czech Republic ,grid.4491.80000 0004 1937 116XDepartment of Anaesthesiology and Intensive Care Medicine, Charles University Faculty of Medicine, Simkova 870, CZ-50003 Hradec Králové, Czech Republic
| | - Diana Cimpoesu
- grid.411038.f0000 0001 0685 1605Department of Emergency Medicine, Emergency County Hospital “Sf. Spiridon” Iasi, University of Medicine and Pharmacy ”Grigore T. Popa” Iasi, Blvd. Independentei 1, RO-700111 Iasi, Romania
| | - Nicola Curry
- grid.410556.30000 0001 0440 1440Oxford Haemophilia and Thrombosis Centre, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Windmill Road, Oxford, OX3 7HE UK ,grid.4991.50000 0004 1936 8948Radcliffe Department of Medicine, Oxford University, Oxford, UK
| | - Jacques Duranteau
- grid.460789.40000 0004 4910 6535Department of Anesthesiology, Intensive Care and Perioperative Medicine, Assistance Publique Hôpitaux de Paris, Paris Saclay University, 78 rue du Général Leclerc, F-94275 Le Kremlin-Bicêtre Cedex, France
| | - Daniela Filipescu
- grid.8194.40000 0000 9828 7548Department of Cardiac Anaesthesia and Intensive Care, “Prof. Dr. C. C. Iliescu” Emergency Institute of Cardiovascular Diseases, Carol Davila University of Medicine and Pharmacy, Sos Fundeni 256-258, RO-022328 Bucharest, Romania
| | - Oliver Grottke
- grid.1957.a0000 0001 0728 696XDepartment of Anaesthesiology, University Hospital Aachen, RWTH, Aachen University, Pauwelsstrasse 30, D-52074 Aachen, Germany
| | - Lars Grønlykke
- grid.5254.60000 0001 0674 042XDepartment of Thoracic Anaesthesiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Anatole Harrois
- grid.460789.40000 0004 4910 6535Department of Anesthesiology, Intensive Care and Perioperative Medicine, Assistance Publique Hôpitaux de Paris, Paris Saclay University, 78 rue du Général Leclerc, F-94275 Le Kremlin-Bicêtre Cedex, France
| | - Beverley J. Hunt
- grid.420545.20000 0004 0489 3985Thrombosis and Haemophilia Centre, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Alexander Kaserer
- grid.412004.30000 0004 0478 9977Institute of Anaesthesiology, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - Radko Komadina
- grid.8954.00000 0001 0721 6013Department of Traumatology, General and Teaching Hospital Celje, Medical Faculty, Ljubljana University, Oblakova ulica 5, SI-3000 Celje, Slovenia
| | - Mikkel Herold Madsen
- grid.5254.60000 0001 0674 042XDepartment of Paediatric and Obstetric Anaesthesia, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Marc Maegele
- grid.412581.b0000 0000 9024 6397Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Lidia Mora
- grid.7080.f0000 0001 2296 0625Department of Anaesthesiology, Intensive Care and Pain Clinic, Vall d’Hebron Trauma, Rehabilitation and Burns Hospital, Autonomous University of Barcelona, Passeig de la Vall d’Hebron 119-129, ES-08035 Barcelona, Spain
| | - Louis Riddez
- grid.24381.3c0000 0000 9241 5705Department of Surgery and Trauma, Karolinska University Hospital, S-171 76 Solna, Sweden
| | - Carolina S. Romero
- grid.106023.60000 0004 1770 977XDepartment of Anaesthesia, Intensive Care and Pain Therapy, Consorcio Hospital General Universitario de Valencia, Universidad Europea of Valencia Methodology Research Department, Avenida Tres Cruces 2, ES-46014 Valencia, Spain
| | - Charles-Marc Samama
- Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP Centre - Université Paris Cité - Cochin Hospital, 27 rue du Faubourg St. Jacques, F-75014 Paris, France
| | - Jean-Louis Vincent
- grid.4989.c0000 0001 2348 0746Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070 Brussels, Belgium
| | - Sebastian Wiberg
- grid.5254.60000 0001 0674 042XDepartment of Thoracic Anaesthesiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Donat R. Spahn
- grid.412004.30000 0004 0478 9977Institute of Anaesthesiology, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| |
Collapse
|
10
|
Determination of reference ranges for the ClotPro® thromboelastometry device in paediatric patients. Br J Anaesth 2023; 130:183-190. [PMID: 36376099 DOI: 10.1016/j.bja.2022.09.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 09/09/2022] [Accepted: 09/24/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND A new thromboelastometry analyser (ClotPro®) was developed with advanced diagnostics. The reference ranges of ClotPro® in children ages 0-16 yr have not been reported. METHODS In this prospective study, venous blood samples from 321 patients were obtained from children undergoing elective surgery after induction of anaesthesia. Reference ranges were defined by calculating the 2.5% and 97.5% percentiles for each age group (0-3 months, 4-12 months, 13-24 months, 2-5 yr, 6-10 yr, and 11-16 yr). RESULTS Reference ranges of the ClotPro® analyser in all age groups demonstrated significant differences in some parameters between age groups. In the first 3 months of life, a significant shortening of the clotting time (CT) in the extrinsically activated test (EX-test) was observed in children aged 0-3 months compared with children of all older age groups (P<0.001), whereas there were no overall differences in the intrinsically activated test (IN-test). In both assays, the clot amplitude 5 and 10 min after CT (A5, A10 value) was significantly higher in the first year of life compared with children older than 1 yr (EX-test and IN-test A5 and A10, respectively; P<0.001). The strength of fibrin polymerisation (FIB-test) was significantly higher in the first 3 months of life (A5 and A10, P<0.003). CONCLUSIONS ClotPro® reference ranges were determined for six paediatric age groups, and show age-dependent differences in specific parameters. These values will be helpful in monitoring haemostasis in paediatric patients and for developing tailored bleeding management protocols. CLINICAL TRIAL REGISTRATION NCT04190615.
Collapse
|
11
|
Andrade R, Yeager M, Concepcion J, Spardy J, Ang D, Kornblith L, Elkbuli A. National analysis of whole blood and component versus component transfusions in civilian trauma patients who underwent a thoracotomy or laparotomy: Toward improving patient outcomes and quality of care. Surgery 2022; 172:1837-1843. [PMID: 36328825 DOI: 10.1016/j.surg.2022.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/19/2022] [Accepted: 09/11/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND This study aimed to investigate the associations of whole blood and component versus component transfusions with in-hospital mortality, complication rates, intensive care unit length of stay, and packed red blood cells transfusion volumes in adult civilian trauma patients. METHODS We performed a retrospective cohort study of the American College of Surgeons Trauma Quality Program Participant Use File 2016 to 2019 dataset. Adult civilian trauma patients (aged >18 years) sustaining injuries of at least moderate severity who received whole blood and component or component within 4 hours of arrival and underwent thoracotomy or laparotomy were included. Multivariable regression analysis was used to compare outcomes between whole blood and component and component groups. RESULTS A total of 37,384 patients met eligibility criteria, of which 218 received whole blood and component and 37,166 received component. There was no significant difference in in-hospital mortality between whole blood and component and component groups for those who underwent thoracotomy (adjusted odds ratio = 0.408, P = .413) or laparotomy (adjusted odds ratio = 1.046, P = .857). Thoracotomy patients who received whole blood and component had no difference in 4-hour or 24-hour pack red blood cell volumes (3336 mL vs 3106 mL, P = .754; 3 658mL vs 3,636mL, P = .982), intensive care unit length of stay (10.68 days vs 8.63 days, P = .542), or complications rates compared to those who received component. Laparotomy patients who received whole blood and component had no difference in 4 hour or 24-hour packed red blood cell volumes (2,758 mL vs 2,721mL, P = .927; 3,538 mL vs 3,385 mL, P = .754), intensive care unit length of stay (11.78 days vs 9.90 days, P = .177), or complications rates compared to those who received component. CONCLUSION Study findings have indicated that a combined resuscitation with whole blood and component transfusion in adult civilian trauma patients is a viable alternative to component transfusion alone.
Collapse
Affiliation(s)
- Ryan Andrade
- School of Osteopathic Medicine, A.T. Still University, Mesa, AZ
| | - Matthew Yeager
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL
| | | | - Jeffrey Spardy
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL
| | - Darwin Ang
- Department of Surgery, Division of Trauma and Surgical Critical Care, Ocala Regional Medical Center, Ocala, FL; Department of Surgery, University of South Florida, Tampa, FL
| | - Lucy Kornblith
- Department of Surgery, Division of Trauma and Surgical Critical Care, Zuckerberg San Francisco General Hospital & Trauma Center, CA; Department of Surgery, University of San Francisco, CA
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Orlando Regional Medical Center, FL; Department of Surgical Education, Orlando Regional Medical Center, FL.
| |
Collapse
|
12
|
Maria A, Lal BB, Khanna R, Sood V, Mukund A, Bajpai M, Alam S. Rotational thromboelastometry-guided blood component use in cirrhotic children undergoing invasive procedures: Randomized controlled trial. Liver Int 2022; 42:2492-2500. [PMID: 35977053 DOI: 10.1111/liv.15398] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 07/28/2022] [Accepted: 08/12/2022] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS This randomized controlled trial (RCT) was conducted with the aim to evaluate the efficacy and safety of using ROTEM-based transfusion strategy in cirrhotic children undergoing invasive procedures. METHODS This was an open-label, RCT which included (i) children under 18 years of age with liver cirrhosis; (ii) INR between 1.5 and 2.5; and/or (iii) platelet count between 20 × 109 /L and 50 × 109 /L (for procedures other than liver biopsy) and between 40 × 109 /L and 60 × 109 /L (for liver biopsy); and (iv) listed for invasive procedures. Stratified randomization was done for children undergoing liver biopsies. Patients randomized to the ROTEM and conventional groups received blood component transfusion using predefined criteria. RESULTS A total of 423 invasive procedures were screened for inclusion of which 60 were randomized (30 in each group with comparable baseline parameters). The volume of total blood components, fresh frozen plasma (FFP) and platelets transfused was significantly lower in ROTEM as compared to conventional group. Only 46.7% of children in ROTEM group received a blood component compared to 100% in conventional group (p < .001). The requirement of FFP (ROTEM: 43.3%, Conventional: 83.3%, p = .001) was significantly lower in the patients receiving ROTEM-guided transfusions. There was no difference in procedure-related bleed and transfusion-related complications between the two groups. ROTEM was cost-effective (p = .002) despite the additional cost of the test. CONCLUSION ROTEM-based transfusion strategies result in lower blood component transfusion in cirrhotic children undergoing invasive procedures without an increase in risk of procedure-related bleed. ROTEM-guided transfusion strategy is cost-effective.
Collapse
Affiliation(s)
- Arjun Maria
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Bikrant B Lal
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Rajeev Khanna
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Vikrant Sood
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Amar Mukund
- Department of Intervention Radiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Meenu Bajpai
- Department of Transfusion Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Seema Alam
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| |
Collapse
|
13
|
CREST: clinical bleeding and risk evaluation in hematology-oncology patients: a systematic review and meta-analysis of thromboelastography's role. Blood Coagul Fibrinolysis 2022; 33:351-363. [PMID: 35946467 PMCID: PMC9594149 DOI: 10.1097/mbc.0000000000001141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Thrombocytopenia and bleeding are common complications of hematologic malignancies. Often, prophylactic platelets are administered to minimize bleeding risk, based on total platelet count (TPC). However, TPC is a poor predictor, and does not provide rapid information. This review presents a novel prospective in the use of point-of-care viscoelastic studies to assess bleeding risk and guide transfusion therapy in a haematological oncological population, where its use can be extended to a ward level as a bedside test. Monitoring TEG maximum amplitude trends may be useful to guide transfusion protocols, especially for patients with total platelet counts ranging 30-100 × 10 9 /l. Fibrinogen assessment in this group of patients may identify other blood components that require replacing to reduce bleeding risk. Normal maximum amplitude parameters for patients with low platelet counts can be a reassuring sign. This meta-analysis serves to remind the reader that absolute platelet quantity does not equate to the quality of clot formation.
Collapse
|
14
|
Miranda SP, Wathen C, Schuster JM, Petrov D. Letter to the Editor Regarding "Viscoelastic Hemostatic Assays and Outcomes in Traumatic Brain Injury: A Systematic Literature Review". World Neurosurg 2022; 166:291-293. [PMID: 36192854 PMCID: PMC9514967 DOI: 10.1016/j.wneu.2022.04.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 04/08/2022] [Indexed: 01/28/2023]
Affiliation(s)
- Stephen P Miranda
- Department of Neurosurgery, Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Connor Wathen
- Department of Neurosurgery, Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - James M Schuster
- Department of Neurosurgery, Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Dmitriy Petrov
- Department of Neurosurgery, Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
15
|
Hindmarsh DD, Rutter CR, Pugnetti VD, Jeffery U. Response of the VCMVet viscoelastic coagulation monitor to veterinary environmental simulation challenges. Vet Clin Pathol 2022; 51:45-50. [PMID: 35191046 DOI: 10.1111/vcp.13041] [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: 01/20/2021] [Revised: 04/05/2021] [Accepted: 05/11/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Traditional viscoelastic clotting tests are significantly impacted by the operator and environmental variation. The VCMVet coagulation monitor could provide a more user-friendly alternative for veterinary practices. OBJECTIVES We aimed to determine if environmental vibration commonly encountered in veterinary practice alters the results of a point-of-care viscoelastic device, the VCMVet. METHODS Nine fresh whole blood samples from healthy dogs were evaluated simultaneously using VCMVet instruments under four environmental conditions: (normal) alone and undisturbed on a raised tabletop, (centrifuge) on a countertop 6 inches from a centrifuge that operated at 12 000 rpm for 10 minutes every 20 minutes, (workspace) on a tabletop workspace in proximity to two heavy-use computers, and (gurney) on a rolling gurney at a walking pace for 10 minutes every 20 minutes. Results were compared between conditions using a Friedman test, and if this was significant (P-value < .05), it was followed by a Wilcoxon test for paired samples. RESULTS Analysis of samples on a rolling gurney created obvious movement artifacts, and this condition was excluded from statistical analysis. The centrifuge condition resulted in a significantly higher alpha angle (median 49 degrees, interquartile range 4) than the normal condition (median 46 degrees, interquartile range 5, P = .0078). Other viscoelastic parameters were not significantly different between the normal, centrifuge, and workspace conditions. CONCLUSIONS The VCMVet is suitable for use in a busy veterinary environment but should be protected from vibration. The instrument does not produce reliable results when operated on a moving gurney, and it should be stationary during sample analysis.
Collapse
Affiliation(s)
- Dalton D Hindmarsh
- Department of Small Animal Clinical Sciences, Texas A&M University, College Station, TX, USA
| | - Christine R Rutter
- Department of Small Animal Clinical Sciences, Texas A&M University, College Station, TX, USA
| | - Viktoria D Pugnetti
- Interdisciplinary Veterinary Medicine, Texas A&M University, College Station, TX, USA
| | - Unity Jeffery
- Department of Veterinary Pathobiology, Texas A&M University, College Station, TX, USA
| |
Collapse
|
16
|
Guo WJ, Chen WY, Yu XR, Shen L, Huang YG. Intraoperative thromboelastography-guided transfusion in a patient with factor XI deficiency: A case report. World J Clin Cases 2022; 10:242-248. [PMID: 35071523 PMCID: PMC8727276 DOI: 10.12998/wjcc.v10.i1.242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 07/12/2021] [Accepted: 11/25/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Factor XI (FXI) deficiency, also known as hemophilia C, is a rare bleeding disorder of unpredictable severity that correlates poorly with FXI coagulation activity. This often poses great challenges in perioperative hemostatic management. Thromboelastography (TEG) is a method for testing blood coagulation using a viscoelastic hemostatic assay of whole blood to assess the overall coagulation status. Here, we present the successful application of intraoperative TEG monitoring in an FXI-deficient patient as an individualized blood transfusion strategy.
CASE SUMMARY A 21-year-old male patient with FXI deficiency was scheduled to undergo reconstructive surgery for macrodactyly of the left foot under general anesthesia. To minimize his bleeding risk, he was scheduled to receive fresh frozen plasma (FFP) as an empirical prophylactic FXI replacement at a dose of 15-20 mL/kg body weight (900-1200 mL) before surgery. Subsequent FFP transfusion was to be adjusted according to surgical need. Instead, TEG assessment was used at the beginning and toward the end of his surgery. According to intraoperative TEG results, the normalization of coagulation function was achieved with an infusion of only 800 mL FFP, and blood loss was minimal. The patient showed an uneventful postoperative course and was discharged on postoperative day 8.
CONCLUSION TEG can be readily applied in the intraoperative period to individualize transfusion needs in patients with rare inherited coagulopathy.
Collapse
Affiliation(s)
- Wen-Juan Guo
- Department of Anesthesiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Wei-Yun Chen
- Department of Anesthesiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Xue-Rong Yu
- Department of Anesthesiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Le Shen
- Department of Anesthesiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Yu-Guang Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| |
Collapse
|
17
|
Blaine KP, Dudaryk R. Pro-Con Debate: Viscoelastic Hemostatic Assays Should Replace Fixed Ratio Massive Transfusion Protocols in Trauma. Anesth Analg 2022; 134:21-31. [PMID: 34908543 DOI: 10.1213/ane.0000000000005709] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Major trauma patients at risk of traumatic coagulopathy are commonly treated with early clotting factor replacement to maintain hemostasis and prevent microvascular bleeding. In the United States, trauma transfusions are often dosed by empiric, low-ratio massive transfusion protocols, which pair plasma and platelets in some ratio relative to the red cells, such as the "1:1:1" combination of 1 units of red cells, 1 unit of plasma, and 1 donor's worth of pooled platelets. Empiric transfusion increases the rate of overtransfusion when unnecessary blood products are administered based on a formula and not on at patient's hemostatic profile. Viscoelastic hemostatic assays (VHAs) are point-of-care hemostatic assays that provided detailed information about abnormal clotting pathways. VHAs are used at many centers to better target hemostatic therapies in trauma. This Pro/Con section will address whether VHA guidance should replace empiric fixed ratio protocols in major trauma.
Collapse
Affiliation(s)
- Kevin P Blaine
- From the Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, Oregon
| | - Roman Dudaryk
- Department of Anesthesiology, Perioperative Medicine, and Pain Management, University of Miami Health System/Ryder Trauma Center, Miami, Florida
| |
Collapse
|
18
|
Willis J, Carroll C, Planz V, Galgano SJ. Thromboelastography: a review for radiologists and implications on periprocedural bleeding risk. Abdom Radiol (NY) 2022; 47:2697-2703. [PMID: 35567618 PMCID: PMC9107068 DOI: 10.1007/s00261-022-03539-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/19/2022] [Accepted: 04/20/2022] [Indexed: 01/18/2023]
Abstract
Thromboelastography (TEG) and rotational thromboelastometry are emerging technologies that are gaining increasing acceptance in the medical field to evaluate the coagulation status of patients on an individual level by assessing dynamic clot formation. TEG has been proven to reduce blood product use as well as improve patient outcomes in a variety of medical settings, including trauma and surgery due to the expediated nature of the test as well as the ability to determine specific deficiencies present in whole blood that are otherwise undetectable with traditional coagulation studies. Currently, no guidelines or recommendations are in place for the utilization of TEG in interventional or diagnostic radiology although access to TEG has become increasingly common in recent years. This manuscript presents a review of prior literature on the technical aspects of TEG as well as its use in various fields and explains the normal TEG-tracing parameters. Common hemodynamic abnormalities and their effect on the TEG tracing are illustrated, and the appropriate treatments for each abnormality are briefly mentioned. TEG has the potential to be a useful tool for determining the hemodynamic state of patients in both interventional and diagnostic radiology, and further research is needed to determine the value of these tests in the periprocedural setting.
Collapse
Affiliation(s)
- Joseph Willis
- grid.265892.20000000106344187University of Alabama at Birmingham School of Medicine, Birmingham, AL USA
| | - Caleb Carroll
- grid.265892.20000000106344187University of Alabama at Birmingham School of Medicine, Birmingham, AL USA
| | - Virginia Planz
- grid.412807.80000 0004 1936 9916Department of Radiology, Vanderbilt University Medical Center, Nashville, TN USA
| | - Samuel J. Galgano
- grid.265892.20000000106344187Department of Radiology, University of Alabama at Birmingham, Birmingham, AL USA
| |
Collapse
|
19
|
Cortesi V, Raffaeli G, Amelio GS, Amodeo I, Gulden S, Manzoni F, Cervellini G, Tomaselli A, Colombo M, Araimo G, Artoni A, Ghirardello S, Mosca F, Cavallaro G. Hemostasis in neonatal ECMO. Front Pediatr 2022; 10:988681. [PMID: 36090551 PMCID: PMC9458915 DOI: 10.3389/fped.2022.988681] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 08/12/2022] [Indexed: 12/14/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a life-saving support for cardio-respiratory function. Over the last 50 years, the extracorporeal field has faced huge technological progress. However, despite the improvements in technique and materials, coagulation problems are still the main contributor to morbidity and mortality of ECMO patients. Indeed, the incidence and survival rates of the main hemorrhagic and thrombotic complications in neonatal respiratory ECMO are relevant. The main culprit is related to the intrinsic nature of ECMO: the contact phase activation. The exposure of the human blood to the non-endothelial surface triggers a systemic inflammatory response syndrome, which chronically activates the thrombin generation and ultimately leads to coagulative derangements. Pre-existing illness-related hemostatic dysfunction and the peculiarity of the neonatal clotting balance further complicate the picture. Systemic anticoagulation is the management's mainstay, aiming to prevent thrombosis within the circuit and bleeding complications in the patient. Although other agents (i.e., direct thrombin inhibitors) have been recently introduced, unfractionated heparin (UFH) is the standard of care worldwide. Currently, there are multiple tests exploring ECMO-induced coagulopathy. A combination of the parameters mentioned above and the evaluation of the patient's underlying clinical context should be used to provide a goal-directed antithrombotic strategy. However, the ideal algorithm for monitoring anticoagulation is currently unknown, resulting in a large inter-institutional diagnostic variability. In this review, we face the features of the available monitoring tests and approaches, mainly focusing on the role of point-of-care (POC) viscoelastic assays in neonatal ECMO. Current gaps in knowledge and areas that warrant further study will also be addressed.
Collapse
Affiliation(s)
- Valeria Cortesi
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Genny Raffaeli
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Giacomo S Amelio
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Ilaria Amodeo
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Silvia Gulden
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesca Manzoni
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Gaia Cervellini
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Andrea Tomaselli
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Marta Colombo
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Gabriella Araimo
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Artoni
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefano Ghirardello
- Neonatal Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Fabio Mosca
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Giacomo Cavallaro
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| |
Collapse
|
20
|
Scarlatescu E, Kietaibl SA, Tomescu DR. The effect of a viscoelastic-guided bleeding algorithm implementation on blood products use in adult liver transplant patients. A propensity score-matched before-after study. Transfus Apher Sci 2021; 61:103322. [PMID: 34799243 DOI: 10.1016/j.transci.2021.103322] [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: 09/13/2021] [Revised: 11/09/2021] [Accepted: 11/13/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Perioperative blood products transfusion is correlated with increased morbidity and mortality in liver transplantation (LTx). The objectives of our study are to assess the effect of a standardized viscoelastic test (VET)-guided bleeding management algorithm implementation on intraoperative bleeding, allogenic blood products and factor concentrates requirements and on early postoperative complications in LTx. METHODS Retrospective before-after study comparing two matched cohorts of patients undergoing LTx before (control cohort) and after (intervention cohort) the implementation of a VET-based bleeding algorithm in a single center academic hospital. RESULTS After propensity score matching, we included 94 patients in each cohort. Patients in intervention cohort received significantly less blood products, fresh frozen plasma (FFP), and cryoprecipitate (p < 0.001 for each), while the amount of fibrinogen concentrate used was significantly higher (p < 0.001). Postoperatively, intervention cohort patients had significantly lower postoperative hemoglobin and fibrinogen levels and longer prothrombin time compared to control cohort. There were no significant differences in red blood cells transfusions, intraoperative bleeding, early postoperative complications, and short term survival. CONCLUSIONS The implementation of a VET-guided bleeding algorithm decreases allogenic blood products requirements, mainly FFP use and allows a more restrictive management of coagulopathy in patients with chronic liver disease undergoing LTx.
Collapse
Affiliation(s)
- Ecaterina Scarlatescu
- Department of Anaesthesia and Intensive Care Medicine III, Fundeni Clinical Institute, Fundeni Street No. 258, Bucharest, 022328, Romania.
| | - Sibylle A Kietaibl
- Evangelical Hospital Vienna, 1180, Vienna, Austria; Sigmund Freud Private University, Medical Faculty, Campus Prater, 1020, Vienna, Austria
| | - Dana R Tomescu
- Department of Anaesthesia and Intensive Care Medicine III, Fundeni Clinical Institute, Fundeni Street No. 258, Bucharest, 022328, Romania; "Carol Davila" University of Medicine and Pharmacy, Dionisie Lupu Street No. 37, Bucharest, 020021, Romania
| |
Collapse
|
21
|
Prophylactic fibrinogen concentrate administration in surgical correction of paediatric craniosynostosis: A double-blind placebo-controlled trial. Eur J Anaesthesiol 2021; 38:908-915. [PMID: 33009187 DOI: 10.1097/eja.0000000000001332] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Surgical craniosynostosis repair in children is associated with massive blood loss and significant transfusion of blood products. Fibrinogen concentrate is claimed to be useful in reducing blood loss and transfusion requirements. OBJECTIVE We investigated whether prophylactic administration of fibrinogen concentrate will reduce blood loss and transfusion requirements during paediatric craniofacial surgery. DESIGN Randomised, placebo-controlled, double-blind clinical trial. SETTING University medical centre. PATIENTS A total of 114 infants and children up to 25 months of age (median age 10 months). INTERVENTION Surgical craniosynostosis repair by calvarial remodelling was performed in each patient. Patients were randomised to receive prophylactic fibrinogen concentrate (Haemocomplettan P) at a mean dose of 79 mg kg-1 body weight or placebo. MAIN OUTCOME MEASURES Primary outcome was the volume of transfused blood products. Secondary outcomes were peri-operative blood loss, duration of surgery, length of stay in the paediatric ICU, length of hospital stay, postoperative complications and adverse effects of fibrinogen concentrate infusion. RESULTS No significant differences (P < 0.05) were found in the volume of transfused blood products (median 29 ml kg-1 body weight vs. 29 ml kg-1 body weight), intra-operative estimated blood loss (45 vs. 46 ml kg-1), calculated blood loss (57 vs. 53 ml kg-1), or postoperative blood loss (24 vs. 24 ml kg-1) between the intervention and placebo groups. In addition, duration of surgery, length of stay in the paediatric ICU, hospital stay and complications were not significantly different between the two groups. CONCLUSION During surgical craniosynostosis repair in young children, prophylactic administration of high-dose fibrinogen concentrate did not reduce the amount of transfused blood products or decrease peri-operative blood loss. TRIAL REGISTRATION National Trial Register (NTR2975) and EudraCT (2011-002287-24).
Collapse
|
22
|
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
| |
Collapse
|
23
|
Tantry US, Hartmann J, Neal MD, Schöechl H, Bliden KP, Agarwal S, Mason D, Dias JD, Mahla E, Gurbel PA. The role of viscoelastic testing in assessing peri-interventional platelet function and coagulation. Platelets 2021; 33:520-530. [PMID: 34369848 DOI: 10.1080/09537104.2021.1961709] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
We carried out a literature search in MEDLINE (PubMed) and EMBASE literature databases to provide a concise review of the role of viscoelastic testing in assessing peri-interventional platelet function and coagulation. The search identified 130 articles that were relevant for the review, covering the basic science of VHA and VHA in clinical settings including cardiac surgery, cardiology, neurology, trauma, non-cardiac surgery, obstetrics, liver disease, and COVID-19. Evidence from these articles is used to describe the important role of VHAs and platelet function testing in various peri-interventional setups. VHAs can help us to comprehensively assess the contribution of platelets and coagulation dynamics to clotting at the site-of-care much faster than standard laboratory measures. In addition to standard coagulation tests, VHAs are beneficial in reducing allogeneic transfusion requirements and bleeding, in predicting ischemic events, and improving outcomes in several peri-interventional care settings. Further focused studies are needed to confirm their utility in the peri-interventional case.
Collapse
Affiliation(s)
- Udaya S Tantry
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Jan Hartmann
- Medical Affairs and Clinical Development, Haemonetics Corporation, Boston, MA, USA
| | - Matthew D Neal
- Department of General Surgery, The University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Herbert Schöechl
- Department of Anesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Salzburg, Austria.,AUVA Trauma Research Centre, Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Vienna, Austria
| | - Kevin P Bliden
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Seema Agarwal
- Department of Anaesthesia, Manchester University Foundation Trust, Manchester, UK
| | - Dan Mason
- Medical Affairs and Clinical Development, Haemonetics Corporation, Boston, MA, USA
| | - Joao D Dias
- Medical Affairs and Clinical Development, Haemonetics Corporation, Boston, MA, USA
| | - Elisabeth Mahla
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Paul A Gurbel
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, USA
| |
Collapse
|
24
|
Al Moosawi M, Trudeau J, Smith T, Lefebvre A, Shih AW. ROTEM in the setting of liver transplant surgery reduces frozen plasma transfusion. Transfus Apher Sci 2021; 60:103125. [PMID: 33775554 DOI: 10.1016/j.transci.2021.103125] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 02/28/2021] [Accepted: 03/19/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND INR is traditionally used as a marker of clinical coagulopathy, but is suboptimal in liver disease patients due to rebalanced hemostasis and its ineffectiveness to predict bleeding. Rotational thromboelastometry (ROTEM) testing evaluates whole blood hemostasis, which may provide more accurate assessments with the EXTEM CT parameter than INR. Thus, in end-stage liver disease (ESLD) patients, we hypothesized that elevated INRs are associated with normal EXTEM CT values. METHODS A retrospective study assessing adult (>18) patients with ESLD and elevated INRs undergoing liver transplantation, was performed to assess correlations between INR and EXTEM CT. This included patients post-ROTEM implementation where all had pre-operative ROTEM testing; and patients up to one year pre-ROTEM implementation to compare transfusion utilization. Data abstracted also included patient demographics, coagulation testing results, liver disease etiology, and MELD score. RESULTS The study included 138 patients in the post-ROTEM group and 59 patients in the pre-ROTEM group. Normal EXTEM CT was observed in 95.3 % and 93 % of patients with INR of 1.3-1.8 and up to 3 respectively. There was no correlation between INR of 1.3-1.8 and EXTEM CT (⍴ = 0.239), and only moderate correlation was observed with higher INRs (⍴ = 0.617 with INRs >1.8). ROTEM-guided transfusion in liver transplant surgeries was associated with reduced plasma transfusion (OR 0.27, 95 % CI 0.12-0.58, p = 0.001) after adjusting for red cell utilization and coagulation testing. CONCLUSION Our study suggests ROTEM may be advantageous for evaluating coagulopathy in patients with liver disease and ROTEM-guided transfusion reduces plasma transfusion.
Collapse
Affiliation(s)
- Muntadhar Al Moosawi
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jacqueline Trudeau
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada; Department of Anesthesiology, Pharmacology, and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Tyler Smith
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada; Centre for Blood Research, University of British Columbia, Vancouver, British Columbia, Canada
| | - Alexandre Lefebvre
- Department of Cardiothoracic Anesthesiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Andrew W Shih
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada; Centre for Blood Research, University of British Columbia, Vancouver, British Columbia, Canada.
| |
Collapse
|
25
|
Lee SH, Lira-Albarrán S, Saadeldin IM. Comprehensive Proteomics Analysis of In Vitro Canine Oviductal Cell-Derived Extracellular Vesicles. Animals (Basel) 2021; 11:ani11020573. [PMID: 33672125 PMCID: PMC7926305 DOI: 10.3390/ani11020573] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/25/2021] [Accepted: 01/26/2021] [Indexed: 11/29/2022] Open
Abstract
Simple Summary As the dog shows unique and peculiar reproductive characteristics, assisted reproductive techniques such as in vitro maturation and in vitro fertilization have not been well-established compared with those of other mammals. Our recent work demonstrated the interplay between in vitro oviductal cell-derived extracellular vesicles (OC-EVs) and cumulus-oocyte complexes in dogs. Here, we provided for the first time a comprehensive proteomic analysis of OC-EVs. A total of 398 proteins were identified in all OC-EVs samples. A functional enrichment analysis indicated that these core proteins were involved in the key cellular metabolic process related to oocyte maturation and embryonic development. The current comprehensive description of the canine OC-EVs proteome would provide a fundamental resource for further understanding canine reproductive physiology, the interaction of sperms with female counterparts during fertilization, early pregnancy, and establishing an efficient system of in vitro embryo production. Abstract Dogs (Canis lupus familiaris) have unique and peculiar reproductive characteristics. While the interplay between in vitro oviductal cell-derived extracellular vesicles (OC-EVs) and cumulus-oocyte complexes in dogs has begun to be elucidated, no study has yet provided extensive information on the biological content and physiological function of OC-EVs and their role in canine oocyte development. Here, we aimed to provide the first comprehensive proteomic analysis of OC-EVs. We identified 398 proteins as present in all OC-EVs samples. The functional enrichment analysis using Gene Ontology terms and an Ingenuity Pathway Analysis revealed that the identified proteins were involved in several cellular metabolic processes, including translation, synthesis, expression, and protein metabolism. Notably, the proteins were also involved in critical canonical pathways with essential functions in oocyte and embryo development, such as ERK/MAPK, EIF2, PI3K/AKT, and mTOR signaling. These data would be an important resource for studying canine reproductive physiology and establishing a successful in vitro embryo production system in dogs.
Collapse
Affiliation(s)
- Seok Hee Lee
- Center for Reproductive Sciences, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, CA 94143, USA;
- Correspondence: (S.H.L.); (I.M.S.); Tel.: +1-4154760932 (S.H.L.); +966-530910740 (I.M.S.)
| | - Saúl Lira-Albarrán
- Center for Reproductive Sciences, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, CA 94143, USA;
| | - Islam M Saadeldin
- Department of Physiology, Faculty of Veterinary Medicine, Zagazig University, Zagazig 44519, Egypt
- Department of Animal Production, College of Food and Agriculture Sciences, King Saud University, Riyadh 11451, Saudi Arabia
- King Faisal Specialist Hospital & Research Centre, Department of Comparative Medicine, Riyadh 11211, Saudi Arabia
- Correspondence: (S.H.L.); (I.M.S.); Tel.: +1-4154760932 (S.H.L.); +966-530910740 (I.M.S.)
| |
Collapse
|
26
|
Lorenzen H, Frøstrup AB, Larsen AS, Fenger MS, Dahdouh S, Zoel-Ghina R, Nielsen LK. Pneumatic tube transport of blood samples affects global hemostasis and platelet function assays. Int J Lab Hematol 2021; 43:1207-1215. [PMID: 33538112 DOI: 10.1111/ijlh.13470] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 12/26/2020] [Accepted: 12/29/2020] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Pneumatic tube systems (PTS) are frequently used for rapid and cost-effective transportation of blood samples to the clinical laboratory. The impact of PTS transport on platelet function measured by the Multiplate system and global hemostasis measured by the TEG 5000 was evaluated. METHODS Paired samples from healthy adult individuals were obtained at two study sites: Rigshospitalet (RH) and Nordsjaellands Hospital (NOH). One sample was transported by PTS and one manually (non-PTS). Platelet function was assessed by platelet aggregation (Multiplate) and global hemostasis was assessed by a variety of thrombelastography (TEG) assays. Multiplate (n = 39) and TEG (n = 32) analysis was performed at site RH, and Multiplate (n = 28) analysis was performed at site NOH. RESULTS A significant higher agonist-induced platelet aggregation was found for PTS samples compared to manual transport at site NOH (P < .02, all agonists). No significant difference was found at site RH (P > .05, all agonists). For Kaolin TEG, samples transported by PTS showed a significant lower R-time and higher Angle (P < .001). No significant differences in MA and LY30 was found (P > .05). ACT of RapidTEG was significantly reduced (P = .001) and MA of Functional Fibrinogen TEG was significantly increased (P < .001) after PTS transport. No significant impact of PTS was observed for TEG assays with heparinase (P > .05). CONCLUSIONS Depending on the type of PTS, transportation by PTS affected platelet aggregation measured by Multiplate. Furthermore, PTS alters TEG parameters possibly reflecting coagulation factors. Clinical laboratories should evaluate the effect of the local PTS on Multiplate and TEG results.
Collapse
Affiliation(s)
| | - Ann-Britt Frøstrup
- Department of Clinical Immunology, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Immunology, Zealand University Hospital, Roskilde, Denmark
| | - Anja S Larsen
- Department of Clinical Immunology, Nordsjaellands Hospital, Hillerød, Denmark
| | - Michelle S Fenger
- Faculty of Health, University College Copenhagen, Copenhagen, Denmark.,Department of Clinical Immunology, Rigshospitalet, Copenhagen, Denmark
| | - Sanne Dahdouh
- Faculty of Health, University College Copenhagen, Copenhagen, Denmark.,Department of Clinical Immunology, Nordsjaellands Hospital, Hillerød, Denmark
| | - Randa Zoel-Ghina
- Department of Clinical Immunology, Rigshospitalet, Copenhagen, Denmark
| | - Leif K Nielsen
- Faculty of Health, University College Copenhagen, Copenhagen, Denmark
| |
Collapse
|
27
|
DeAnda A, Levy G, Kinsky M, Sanjoto P, Garcia M, Avandsalehi KR, Diaz G, Yates SG. Comparison of the Quantra QPlus System With Thromboelastography in Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 35:1030-1036. [PMID: 33384230 DOI: 10.1053/j.jvca.2020.11.058] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 11/24/2020] [Accepted: 11/25/2020] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Use of viscoelastic testing, such as thromboelastography (TEG), is recommended in cardiac surgery to monitor coagulation and to guide the transfusion of blood products. The Quantra QPlus System is a novel point-of-care platform that uses ultrasonic pulses to characterize dynamic changes in viscoelastic properties of a blood sample during coagulation. Despite the ability to assess similar aspects of clot formation, limited studies addressing the interchangeability of viscoelastic testing parameters exist. The primary aim of the present study was to assess the correlation and agreement between Quantra and TEG5000 results using blood samples from cardiac surgery patients. DESIGN Tertiary care, academic medical center. SETTING Prospective observational study. PARTICIPANTS Twenty-eight patients undergoing elective cardiac surgery undergoing cardiopulmonary bypass were evaluated. MEASUREMENTS AND MAIN RESULTS Perioperative blood samples were collected and assessed using Quantra, and results were compared with TEG and conventional coagulation testing. Method comparison analysis demonstrated that Quantra parameters (Quantra clot time, clot stiffness, and fibrinogen contribution to clot stiffness) significantly correlated with TEG R and TEG G after induction of anesthesia, during cardiopulmonary bypass, and after rewarming (rs = 0.83, rs = 0.84, and rs = 0.73, respectively). However, Quantra parameters demonstrated poor agreement compared with equivalent TEG5000 parameters. CONCLUSIONS The Quantra QPlus System significantly correlated with TEG5000, suggesting that this test may be used in a similar clinical context. Despite the strength of correlation between Quantra and TEG parameters, measurements are not interchangeable.
Collapse
Affiliation(s)
- Abe DeAnda
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, University of Texas Medical Branch, Galveston, TX
| | - Gal Levy
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, University of Texas Medical Branch, Galveston, TX
| | - Michael Kinsky
- Department of Anesthesiology, Division of Cardiovascular and Thoracic Surgery, University of Texas Medical Branch, Galveston, TX
| | - Peni Sanjoto
- Department of Anesthesiology, Division of Cardiovascular and Thoracic Surgery, University of Texas Medical Branch, Galveston, TX
| | - Mary Garcia
- Department of Pathology, Division of Transfusion Medicine, University of Texas Medical Branch, Galveston, TX
| | - Kurosh R Avandsalehi
- Department of Pathology, Division of Transfusion Medicine, University of Texas Medical Branch, Galveston, TX
| | - Gabriel Diaz
- Department of Pathology, Division of Transfusion Medicine, University of Texas Medical Branch, Galveston, TX
| | - Sean G Yates
- Department of Anesthesiology, Division of Cardiovascular and Thoracic Surgery, University of Texas Medical Branch, Galveston, TX.
| |
Collapse
|
28
|
Huddleston SJ, Jackson S, Kane K, Lemke N, Shaffer AW, Soule M, Hertz M, Shumway S, Qi S, Perry T, Kelly R. Separate Effect of Perioperative Recombinant Human Factor VIIa Administration and Packed Red Blood Cell Transfusions on Midterm Survival in Lung Transplantation Recipients. J Cardiothorac Vasc Anesth 2020; 34:3013-3020. [DOI: 10.1053/j.jvca.2020.05.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 05/18/2020] [Accepted: 05/25/2020] [Indexed: 11/11/2022]
|
29
|
Agarwal S, Abdelmotieleb M. Viscoelastic testing in cardiac surgery. Transfusion 2020; 60 Suppl 6:S52-S60. [PMID: 32955756 DOI: 10.1111/trf.16075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 06/30/2020] [Accepted: 06/30/2020] [Indexed: 11/30/2022]
Abstract
Bleeding complications are common in cardiac surgery and lead to an increase in morbidity and mortality. This is multifactorial in aetiology including the effects of cardiopulmonary bypass, the drugs given to manipulate the coagulation system and the vascular nature of the surgery itself. Viscoelastic tests provide a point of care, rapid assessment of coagulation which offer the advantage of faster turnaround times and a nuanced view of the elements of the coagulation system allowing targeted therapy to be delivered quickly. Both thomboelastography (TEG)and thromboelastometry (ROTEM) have been recommended for use in cardiac surgery, both have shown a reduction in transfusion and bleeding when used as part of a testing algorithm. They are particularly useful in assessing residual heparinisation and fibrinogen levels. Additionally, TEG allows the evaluation of the effects of anti-platelet agents on platelet function. This review discusses the mechanisms by which bleeding occurs in cardiac surgery and explores three uses of viscoelastic testing in cardiac surgery: to predict bleeding, to assess platelet function and peri-operative testing to reduce transfusion.
Collapse
Affiliation(s)
- Seema Agarwal
- Department of Cardiothoracic Anaesthesia and ICM, Manchester University Foundation Trust, Manchester, UK
| | - Mohamed Abdelmotieleb
- Department of Cardiothoracic Anaesthesia and ICM, Manchester University Foundation Trust, Manchester, UK
| |
Collapse
|
30
|
Janko N, Majeed A, Kemp W, Roberts SK. Viscoelastic Tests as Point-of-Care Tests in the Assessment and Management of Bleeding and Thrombosis in Liver Disease. Semin Thromb Hemost 2020; 46:704-715. [PMID: 32932542 DOI: 10.1055/s-0040-1715475] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Viscoelastic point-of-care (VET POC) tests provide a global assessment of hemostasis and have an increasing role in the management of bleeding and blood component delivery across several clinical settings. VET POC tests have a rapid turnaround time, provide a better overall picture of hemostasis, predict bleeding more accurately than conventional coagulation tests, and reduce blood component usage and health care costs. Despite commonly having abnormal conventional coagulation tests, most patients with chronic liver disease have a "rebalanced" hemostasis. However, this hemostatic balance is delicate and these patients are predisposed to both bleeding and thromboembolic events. Over recent years, VET POC tests have been increasingly studied for their potential as better functional tests of hemostasis in liver disease patients. This review provides a background on the most common VET POC tests (thromboelastography and rotational thromboelastometry) and discusses the current evidence for these tests in the prediction and management of bleeding and thrombosis in patients with chronic liver disease, and in liver resection and transplant. With the recent publication of several randomized controlled trials, there is growing evidence that VET POC tests may be used to improve bleeding risk assessment and reduce blood product use in liver disease patients outside of the transplant setting. However, consensus is still lacking regarding the VET POC tests' thresholds that should be used to trigger blood product transfusion. VET POC tests also show promise in predicting thrombosis in patients with liver disease, but further research is needed before they can be used to guide anticoagulant therapy.
Collapse
Affiliation(s)
- Natasha Janko
- Department of Gastroenterology, Alfred Health, Melbourne, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Ammar Majeed
- Department of Gastroenterology, Alfred Health, Melbourne, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - William Kemp
- Department of Gastroenterology, Alfred Health, Melbourne, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Stuart K Roberts
- Department of Gastroenterology, Alfred Health, Melbourne, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
| |
Collapse
|
31
|
Sahli SD, Rössler J, Tscholl DW, Studt JD, Spahn DR, Kaserer A. Point-of-Care Diagnostics in Coagulation Management. SENSORS (BASEL, SWITZERLAND) 2020; 20:E4254. [PMID: 32751629 PMCID: PMC7435714 DOI: 10.3390/s20154254] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 07/17/2020] [Accepted: 07/28/2020] [Indexed: 12/15/2022]
Abstract
This review provides a comprehensive and up-to-date overview of point-of-care (POC) devices most commonly used for coagulation analyses in the acute settings. Fast and reliable assessment of hemostasis is essential for the management of trauma and other bleeding patients. Routine coagulation assays are not designed to visualize the process of clot formation, and their results are obtained only after 30-90 m due to the requirements of sample preparation and the analytical process. POC devices such as viscoelastic coagulation tests, platelet function tests, blood gas analysis and other coagulometers provide new options for the assessment of hemostasis, and are important tools for an individualized, goal-directed, and factor-based substitution therapy. We give a detailed overview of the related tests, their characteristics and clinical implications. This review emphasizes the evident advantages of the speed and predictive power of POC clot measurement in the context of a goal-directed and algorithm-based therapy to improve the patient's outcome. Interpretation of viscoelastic tests is facilitated by a new visualization technology.
Collapse
Affiliation(s)
- Sebastian D. Sahli
- Institute of Anesthesiology, University and University Hospital Zurich, 8091 Zurich, Switzerland; (S.D.S.); (J.R.); (D.W.T.); (D.R.S.)
| | - Julian Rössler
- Institute of Anesthesiology, University and University Hospital Zurich, 8091 Zurich, Switzerland; (S.D.S.); (J.R.); (D.W.T.); (D.R.S.)
| | - David W. Tscholl
- Institute of Anesthesiology, University and University Hospital Zurich, 8091 Zurich, Switzerland; (S.D.S.); (J.R.); (D.W.T.); (D.R.S.)
| | - Jan-Dirk Studt
- Division of Hematology, University and University Hospital Zurich, 8091 Zurich, Switzerland;
| | - Donat R. Spahn
- Institute of Anesthesiology, University and University Hospital Zurich, 8091 Zurich, Switzerland; (S.D.S.); (J.R.); (D.W.T.); (D.R.S.)
| | - Alexander Kaserer
- Institute of Anesthesiology, University and University Hospital Zurich, 8091 Zurich, Switzerland; (S.D.S.); (J.R.); (D.W.T.); (D.R.S.)
| |
Collapse
|
32
|
Leal-Noval SR, Fernández Pacheco J, Casado Méndez M, Cuenca-Apolo D, Múñoz-Gómez M. Current perspective on fibrinogen concentrate in critical bleeding. Expert Rev Clin Pharmacol 2020; 13:761-778. [PMID: 32479129 DOI: 10.1080/17512433.2020.1776608] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION . Massive hemorrhage continues to be a treatable cause of death. Its management varies from prefixed ratio-driven administration of blood components to goal-directed therapy based on point-of-care testing and administration of coagulation factor concentrates. AREAS COVERED . We review the current role of fibrinogen concentrate (FC) for the management of massive hemorrhage, either administered without coagulation testing in life-threatening hemorrhage, or within an algorithm based on viscoelastic hemostatic assays and plasma fibrinogen level. We identified relevant guidelines, meta-analyzes, randomized controlled trials, and observational studies that included indications, dosage, and adverse effects of FC, especially thromboembolic events. EXPERT OPINION . Moderate- to high-grade evidence supports the use of FC for the treatment of severe hemorrhage in trauma and cardiac surgery; a lower grade of evidence is available for its use in postpartum hemorrhage and end-stage liver disease. Pre-emptive FC administration in non-bleeding patients is not recommended. FC should be administered early, in a goal-directed manner, guided by early amplitude of clot firmness parameters (A5- or A10-FIBTEM) or hypofibrinogenemia. Further investigation is required into the early use of FC, as well as its potential advantages over cryoprecipitate, and whether or not its administration at high doses leads to a greater risk of adverse events.
Collapse
Affiliation(s)
- Santiago R Leal-Noval
- Neuro Critical Care Department, University Hospital "Virgen Del Rocío" and Institute of Biomedicine "IBIS" , 41013, Seville, Spain
| | - Jose Fernández Pacheco
- Pharmacy and Statistics and Design, University Hospital "Virgen Del Rocío" and Institute of Biomedicine "IBIS" , 41013, Seville, Spain
| | - Manuel Casado Méndez
- Critical Care Department, University Hospital "Virgen Del Rocío" and Institute of Biomedicine "IBIS" , 41013, Seville, Spain
| | - Diego Cuenca-Apolo
- Critical Care Department, University Hospital "Virgen Del Rocío" and Institute of Biomedicine "IBIS" , 41013, Seville, Spain
| | - Manuel Múñoz-Gómez
- Department of Surgical Specialties, Biochemistry and Immunology, University of Málaga , 29071, Málaga, Spain
| |
Collapse
|
33
|
Rimaitis M, Bilskienė D, Tamošuitis T, Vilcinis R, Rimaitis K, Macas A. Implementation of Thromboelastometry for Coagulation Management in Isolated Traumatic Brain Injury Patients Undergoing Craniotomy. Med Sci Monit 2020; 26:e922879. [PMID: 32620738 PMCID: PMC7357252 DOI: 10.12659/msm.922879] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Coagulopathy (CP) is a modifiable factor linked with secondary brain damage and poor outcome of traumatic brain injury (TBI). A shift towards goal-directed coagulation management has been observed recently. We investigated whether rotational thromboelastometry (ROTEM) based management could be successfully implemented in TBI patients and improve outcomes. MATERIAL AND METHODS A prospective, case-control study was performed. Adult patients with isolated TBI requiring craniotomy were included in this study. All patients underwent standard coagulation tests (SCT). Patients were identified as either in control group or in case group. Patients in the case group were additionally tested with ROTEM to specify their coagulation status. Management of the patients in the control group was based on SCT, whereas management of patients in the case group was guided by ROTEM. Outcome measures were as follows: CP rate, protocol adhesion, blood loss, transfusions, progressive hemorrhagic injury (PHI), re-intervention, Glasgow coma score (GCS) and Glasgow outcome score (GOS) at discharge, and in-hospital mortality. RESULTS There were 134 patients enrolled (65 patients in the control group and 69 patients in the case group). Twenty-six patients in the control group (40%) were found to be coagulopathic (control-CP subgroup) and 34 patients in the case group (49.3%) were found to be coagulopathic (case-CP subgroup). Twenty-five case-CP patients had ROTEM abnormalities triggering protocolized intervention, and 24 of them were treated. Overall ROTEM-based protocol adhesion rate was 85.3%. Postoperative ROTEM parameters of case-CP patients significantly improved, and the number of coagulopathic patients decreased. The incidence of PHI (control versus case group) and neurosurgical re-intervention (control-CP versus case-CP subgroup) was in favor of ROTEM guidance (P<0.05). Mortality and GCS and GOS at discharge did not differ significantly between groups. CONCLUSIONS ROTEM led to consistent coagulation management, improved clot quality, and decreased incidence of PHI and neurosurgical re-intervention. Further studies are needed to confirm benefits of ROTEM in cases of TBI.
Collapse
Affiliation(s)
- Marius Rimaitis
- Department of Anesthesiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Diana Bilskienė
- Department of Anesthesiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Tomas Tamošuitis
- Department of Neurosurgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Rimantas Vilcinis
- Department of Neurosurgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Kęstutis Rimaitis
- Department of Anesthesiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Andrius Macas
- Department of Anesthesiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| |
Collapse
|
34
|
Raffaeli G, Tripodi A, Cavallaro G, Cortesi V, Scalambrino E, Pesenti N, Artoni A, Mosca F, Ghirardello S. Thromboelastographic profiles of healthy very low birthweight infants serially during their first month. Arch Dis Child Fetal Neonatal Ed 2020; 105:412-418. [PMID: 31704736 DOI: 10.1136/archdischild-2019-317860] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 09/11/2019] [Accepted: 10/18/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVE We determined thromboelastographic (TEG) profiles of healthy very low birthweight infants (VLBWIs) of the day of birth and at set intervals during their first month. DESIGN Prospective observational study with blinded clinical and laboratory follow-up. SETTING Level III neonatal intensive care unit (June 2015 to June 2018). PATIENTS Consecutive qualifying VLBWIs were enrolled at birth and followed up for 30 days. INTERVENTIONS AND MAIN OUTCOMES MEASURES Laboratory (citrated-native TEG, prothrombin time (PT), activated partial thromboplastin time (APTT), fibrinogen, blood count) and clinical variables were retrieved at birth, 3rd-5th, 10th and 30th day of life. Blood samples temporally related to events with a potential hemostatic impact (sepsis, bleeding, platelets/plasma transfusions, ibuprofen/indomethacin administration) were excluded from analysis. RESULTS We enrolled 201 VLBWIs and 72 full-term neonates. Sixty-seven of the healthy VLBWIs completed the 30-day follow-up. 541 TEG traces were analysed.On day 1, the median (minimum-maximum) TEG values were as follows: reaction time (R), 8.2 min (1-21.8); kinetics (K), 2.8 min (0.8-16); α angle, 51° (14.2-80.6); maximum amplitude (MA), 54.9 mm (23.9-76.8). PT and APTT were 15.9 s (11.7-51.2) and 59 s (37.8-97.5), respectively. The above parameters suggest minor hypocoagulability compared with term infants. On day 30, the median (minimum-maximum) R was 5 (1-16.9), K 1 (0.8-4.1), α 74.7 (41.1-86.7) and MA 70.2 (35.8-79.7). PT and APTT were 12.1 (10.4-16.6) and 38.8 (29.6-51.4), respectively. Those parameters are consistent with a relatively hypercoagulable phenotype, compared with term infants. CONCLUSIONS Healthy VLBWIs have a prolonged PT and APTT, but their TEG profiles suggest a relatively balanced hemostatic system, with slight hypocoagulability initially (compared with term neonates), gradually evolving to a somewhat more procoagulant phenotype over the first month.
Collapse
Affiliation(s)
- Genny Raffaeli
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Armando Tripodi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giacomo Cavallaro
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Valeria Cortesi
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Erica Scalambrino
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicola Pesenti
- Department of Statistics and Quantitative Methods, Division of Biostatistics, Epidemiology and Public Health, University of Milano-Bicocca, Milan, Italy
| | - Andrea Artoni
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Fabio Mosca
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Stefano Ghirardello
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| |
Collapse
|
35
|
Unal D, Senayli Y, Polat R, Spahn DR, Toraman F, Alkis N. Peri-operative blood transfusion in elective major surgery: incidence, indications and outcome - an observational multicentre study. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2020; 18:261-279. [PMID: 32697928 PMCID: PMC7375885 DOI: 10.2450/2020.0011-20] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 04/23/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Patients' demographic and epidemiological characteristics, local variations in clinicians' knowledge and experience and types of surgery can influence peri-operative transfusion practices. Sharing data on transfusion practices and recipients may improve patients' care and implementation of Patient Blood Management (PBM). MATERIALS AND METHODS This was a multicentre, prospective, observational, cross-sectional study that included 61 centres. Clinical and transfusion data of patients undergoing major elective surgery were collected; transfusion predictors and patients' outcomes were analysed. RESULTS Of 6,121 patients, 1,579 (25.8%) received a peri-operative transfusion. A total of 5,812 blood components were transfused: red blood cells (RBC), fresh-frozen plasma and platelets in 1,425 (23.3%), 762 (12.4%) and 88 (1.4%) cases, respectively). Pre-operative anaemia was identified in 2,019 (33%) patients. Half of the RBC units were used by patients in the age group 45-69 years. Specific procedures with the highest RBC use were coronary artery bypass grafting (16.9% of all units) and hip arthroplasty (14.9%). Low haemoglobin concentration was the most common indication for intra-operative RBC transfusion (57%) and plasma and platelet transfusions were mostly initiated for acute bleeding (61.3% and 61.1%, respectively). The RBC transfusion rate in study centres varied from 2% to 72%. RBC transfusion was inappropriate in 99% (n=150/151) of pre-operative, 23% (n=211/926) of intra-operative and 43% (n=308/716) of post-operative RBC transfusion episodes. Pre-operative haemoglobin, increased blood loss, open surgery and duration of surgery were the main independent predictors of intra-operative RBC transfusion. Low pre-operative haemoglobin concentration was independently associated with post-operative pulmonary complications. CONCLUSIONS These findings identified areas for improvement in peri-operative transfusion practice and PBM implementation in Turkey.
Collapse
Affiliation(s)
- Dilek Unal
- Department of Anaesthesiology and Reanimation, University of Health Sciences Diskapi Yildirim Beyazit Teaching Hospital, Ankara, Turkey
| | - Yesim Senayli
- Department of Anaesthesiology and Reanimation, “Ankara Gulhane” Teaching Hospital, Ankara, Turkey
| | - Reyhan Polat
- Department of Anaesthesiology and Reanimation, University of Health Sciences Diskapi Yildirim Beyazit Teaching Hospital, Ankara, Turkey
| | - Donat R. Spahn
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Fevzı Toraman
- Department of Anaesthesiology, “Acibadem Mehmet Ali Aydınlar” University School of Medicine, Istanbul, Turkey
| | - Neslıhan Alkis
- Department of Anaesthesiology and Reanimation, Ankara University Medical Faculty, Ankara, Turkey
| |
Collapse
|
36
|
Windberger U, Dibiasi C, Lotz EM, Scharbert G, Reinbacher-Koestinger A, Ivanov I, Ploszczanski L, Antonova N, Lichtenegger H. The effect of hematocrit, fibrinogen concentration and temperature on the kinetics of clot formation of whole blood. Clin Hemorheol Microcirc 2020; 75:431-445. [PMID: 32390608 DOI: 10.3233/ch-190799] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Dynamic mechanical analysis of blood clots can be used to detect the coagulability of blood. OBJECTIVE We investigated the kinetics of clot formation by changing several blood components, and we looked into the clot "signature" at its equilibrium state by using viscoelastic and dielectric protocols. METHODS Oscillating shear rheometry, ROTEM, and a dielectro-rheological device was used. RESULTS In fibrinogen- spiked samples we found the classical high clotting ability: shortened onset, faster rate of clotting, and higher plateau stiffness. Electron microscopy explained the gain of stiffness. Incorporated RBCs weakened the clots. Reduction of temperature during the clotting process supported the development of high moduli by providing more time for fiber assembly. But at low HCT, clot firmness could be increased by elevating the temperature from 32 to 37°C. In contrast, when the fibrinogen concentration was modified, acceleration of clotting via temperature always reduced clot stiffness, whatever the initial fibrinogen concentration. Electrical resistance increased continuously during clotting; loss tangent (D) (relaxation frequency 249 kHz) decreased when clots became denser: fewer dipoles contributed to the relaxation process. The relaxation peak (Dmax) shifted to lower frequencies at higher platelet count. CONCLUSION Increasing temperature accelerates clot formation but weakens clots. Rheometry and ROTEM correlate well.
Collapse
Affiliation(s)
- U Windberger
- Center for Biomedical Research, Medical University Vienna, Vienna, Austria
| | - Ch Dibiasi
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - E M Lotz
- Center for Biomedical Research, Medical University Vienna, Vienna, Austria
| | - G Scharbert
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - A Reinbacher-Koestinger
- Institute of Fundamentals and Theory in Electrical Engineering, Graz University of Technology, Graz, Austria
| | - I Ivanov
- Institute of Mechanics, Bulgarian Academy of Science, Sofia, Bulgaria
| | - L Ploszczanski
- Department of Material Sciences and Process Engineering, Institute of Physics and Materials Science, University of Natural Resources and Life Sciences, Vienna, Austria
| | - N Antonova
- Institute of Mechanics, Bulgarian Academy of Science, Sofia, Bulgaria
| | - H Lichtenegger
- Department of Material Sciences and Process Engineering, Institute of Physics and Materials Science, University of Natural Resources and Life Sciences, Vienna, Austria
| |
Collapse
|
37
|
Santos AS, Oliveira AJF, Barbosa MCL, Nogueira JLDS. Viscoelastic haemostatic assays in the perioperative period of surgical procedures: Systematic review and meta-analysis. J Clin Anesth 2020; 64:109809. [PMID: 32299044 DOI: 10.1016/j.jclinane.2020.109809] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 02/20/2020] [Accepted: 04/04/2020] [Indexed: 01/23/2023]
Abstract
OBJECTIVE The aim of this study is to evaluate the safety and efficacy of Viscoelastic Haemostatic Assays (VHA) to guide transfusions in patients undergoing surgical procedures. DESIGN Systematic review with meta-analysis of randomized controlled trials up until June 5, 2019. SETTING Hospitalized patients. INTERVENTIONS VHAs compared to the Standard-Of-Care (SOC), which are represented by standard laboratory tests and/or clinical decisions. MEASUREMENTS Primary - Risk of death, acute kidney injury, thrombotic events and reoperation for bleeding; Secondary - Risk of use of red blood cells (RBC), platelets, fresh frozen plasma (FFP), fibrinogen, factor VIIa, prothrombin complex, volume of RBC, platelets and FFP, length of hospital stay, and length of ICU stay. RESULTS VHAs were associated to a statistically significant reduction in mortality (7.3% vs. 12.1%; RR = 0.64, p-value = 0.03), risk of acute kidney injury (10.5% vs. 17.6%; RR = 0.53, p-value = 0.005), volume of red blood cells (RBCs) transfused (MD = -1.63 U, p-value = 0.02), risk of platelet transfusion (23.9% vs. 27.3%; RR = 0.74, p-value = 0.006), risk of fresh frozen plasma (FFP) transfusion (RR = 0.57, p-value = 0.001), and volume of FFP transfused (MD = -0.90, p-value = 0.0003). No significant differences were observed in terms of thrombotic events, reexploration for bleeding, RBC transfusion, volume of platelets transfused, use of fibrinogen, prothrombin complex, or factor VIIa, length of hospitalization and length of ICU stay. CONCLUSION Viscoelastic haemostatic assays are safe and efficacious for coagulation control in patients undergoing surgical procedures, therefore it should be considered for use in practice.
Collapse
Affiliation(s)
- André Soares Santos
- Centre for Health Technology Assessment of the UFMG Teaching Hospital (NATS-HC/UFMG), Universidade Federal de Minas Gerais, Av. Alfredo Balena, 110, Santa Efigênia, 30.130-100 Belo Horizonte, Brazil.; Department of Economical Sciences, School of Economics, Universidade Federal de Minas Gerais, Av. Presidente Antônio Carlos, 6627, Pampulha, 31.270-901 Belo Horizonte, Brazil.
| | - Ananda Jessyla Felix Oliveira
- Centre for Health Technology Assessment of the UFMG Teaching Hospital (NATS-HC/UFMG), Universidade Federal de Minas Gerais, Av. Alfredo Balena, 110, Santa Efigênia, 30.130-100 Belo Horizonte, Brazil.; Department of Health Management, School of Nursing, Universidade Federal de Minas Gerais, Av. Alfredo Balena, 190, Santa Efigênia, 30.130-100 Belo Horizonte, Brazil
| | - Maria Carolina Lage Barbosa
- Centre for Health Technology Assessment of the UFMG Teaching Hospital (NATS-HC/UFMG), Universidade Federal de Minas Gerais, Av. Alfredo Balena, 110, Santa Efigênia, 30.130-100 Belo Horizonte, Brazil.; Collegy of Pharmacy, Universidade Federal de Minas Gerais, Av. Presidente Antônio Carlos, 6627, Pampulha, 31.270-901 Belo Horizonte, Brazil
| | - José Luiz Dos Santos Nogueira
- Centre for Health Technology Assessment of the UFMG Teaching Hospital (NATS-HC/UFMG), Universidade Federal de Minas Gerais, Av. Alfredo Balena, 110, Santa Efigênia, 30.130-100 Belo Horizonte, Brazil
| |
Collapse
|
38
|
Bogdanić D, Bogdanić N, Karanović N. Evaluation of platelet count and platelet function analyzer - 100 testing for prediction of platelet transfusion following coronary bypass surgery. Scandinavian Journal of Clinical and Laboratory Investigation 2020; 80:296-302. [PMID: 32125177 DOI: 10.1080/00365513.2020.1731847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Platelet transfusions are commonly administered to treat bleeding in cardiac surgery. The aim of this study was to compare platelet (PLT) count and values of collagen adenosine diphosphate closure time (cADP-CT) measured by Platelet Function Analyzer (PFA) for prediction of PLT transfusion therapy following coronary bypass surgery. For this prospective observational study, 66 patients scheduled for coronary artery bypass grafting (CABG) who received early PLT transfusions (within 60 min after the operation) were enrolled. To assess changes in platelets, count and function, two time points were selected: 15 min before and 30 - 60 min after the end of PLT transfusion. The patients were divided into transfused and non-transfused with further PLT in the 48 h postoperatively. We used the receiver operating characteristics (ROC) curve to investigate whether the PLT count and cADP-CT values were predictors of PLT transfusion. The positive predictive values (PPV) of PLT count and cADP-CT after PLT transfusion for further PLT transfusion were 33% and 86% respectively, with a PLT count threshold of ≤200 × 109/L and cADP-CT threshold of ≥118 s. The comparison among the ROC curves showed a statistical difference (p = .0002). In multiple regression analysis, cADP-CT was the strongest predictor for the number of PLT transfusion doses in the 48 h postoperatively. In CABG patients, the results of cADP-CT after PLT transfusion have a better predictive capacity for further PLT transfusions than the PLT count.
Collapse
Affiliation(s)
- Dejana Bogdanić
- Department of Transfusion Medicine, University Hospital Center Split, Split, Croatia
| | - Nikolina Bogdanić
- University Hospital for Infectious Diseases "Dr. Fran Mihaljević", Zagreb, Croatia
| | - Nenad Karanović
- Department of Anesthesiology and Intensive Care, University Hospital Center Split, Split, Croatia
| |
Collapse
|
39
|
Abstract
OBJECTIVES Critically ill patients with deranged conventional coagulation tests are often perceived to have an increased bleeding risk. Whether anticoagulant prophylaxis for these patients should be withheld is contentious. This study assessed the ability of using in vitro clot strength, as measured by thromboelastography, to predict thromboembolism in patients with abnormal coagulation profiles. DESIGN Prospective cohort study. SETTING A tertiary ICU. PATIENTS Two-hundred and fifteen critically ill coagulopathic patients with thrombocytopenia and/or a derangement in at least one conventional coagulation test (international normalized ratio or activated partial thromboplastin time) within 48 hours of ICU admission. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Thromboelastography was performed for all study patients, and plasma thrombotic biomarkers were measured in a nested cohort (n = 40). Of the 215 patients included, 34 patients (16%) developed subsequent thromboembolism-predominantly among those with a normal (maximum amplitude, 54-72 mm) or increased (maximum amplitude, > 72 mm) in vitro clot strength on thromboelastography (91%; area under the receiver-operating characteristic curve, 0.74; 95% CI, 0.64-0.83). The ability of the maximum amplitude to predict thromboembolism was comparable to plasma P-selectin concentrations (thromboembolism, 78.3 ng/mL vs no thromboembolism, 59.5 ng/mL; p = 0.031; area under the receiver-operating characteristic curve, 0.73; 95% CI, 0.52-0.95). In addition, patients with an increased maximum amplitude were also less likely to receive blood product transfusions within 24 hours of testing compared with those with a subnormal maximum amplitude (12.8% vs 69.2%, respectively; area under the receiver-operating characteristic curve, 0.74; 95% CI, 0.67-0.80). CONCLUSIONS In patients with abnormal coagulation profiles, an increased in vitro clot strength on thromboelastography was associated with an increased risk of thromboembolism, and a reduced risk of requiring transfusion compared with those with a normal or reduced in vitro clot strength.
Collapse
|
40
|
Dhara S, Moore EE, Yaffe MB, Moore HB, Barrett CD. Modern Management of Bleeding, Clotting, and Coagulopathy in Trauma Patients: What Is the Role of Viscoelastic Assays? CURRENT TRAUMA REPORTS 2020; 6:69-81. [PMID: 32864298 DOI: 10.1007/s40719-020-00183-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Purpose of Review The purpose of this review is to briefly outline the current state of hemorrhage control and resuscitation in trauma patients with a specific focus on the role viscoelastic assays have in this complex management, to include indications for use across all phases of care in the injured patient. Recent Findings Viscoelastic assay use to guide blood-product resuscitation in bleeding trauma patients can reduce mortality by up to 50%. Viscoelastic assays also reduce total blood products transfused, reduce ICU length of stay, and reduce costs. There are a large number of observational and retrospective studies evaluating viscoelastic assay use in the initial trauma resuscitation, but only one randomized control trial. There is a paucity of data evaluating use of viscoelastic assays in the operating room, post-operatively, and during ICU management in trauma patients, rendering their use in these settings extrapolative/speculative based on theory and data from other surgical disciplines and settings. Summary Both hypocoagulable and hypercoagulable states exist in trauma patients, and better indicate what therapy may be most appropriate. Further study is needed, particularly in the operating room and post-operative/ICU settings in trauma patients.
Collapse
Affiliation(s)
- Sanjeev Dhara
- University of Chicago School of Medicine, Chicago, IL
| | - Ernest E Moore
- Department of Surgery, University of Colorado Denver, Denver, CO
| | - Michael B Yaffe
- Koch Institute for Integrative Cancer Research, Center for Precision Cancer Medicine, Massachusetts Institute of Technology, Cambridge, MA
| | - Hunter B Moore
- Department of Surgery, University of Colorado Denver, Denver, CO
| | - Christopher D Barrett
- Koch Institute for Integrative Cancer Research, Center for Precision Cancer Medicine, Massachusetts Institute of Technology, Cambridge, MA
| |
Collapse
|
41
|
Kumar M, Ahmad J, Maiwall R, Choudhury A, Bajpai M, Mitra LG, Saluja V, Mohan Agarwal P, Bihari C, Shasthry SM, Jindal A, Bhardwaj A, Kumar G, Sarin SK. Thromboelastography-Guided Blood Component Use in Patients With Cirrhosis With Nonvariceal Bleeding: A Randomized Controlled Trial. Hepatology 2020; 71:235-246. [PMID: 31148204 DOI: 10.1002/hep.30794] [Citation(s) in RCA: 98] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 05/21/2019] [Indexed: 12/12/2022]
Abstract
Thromboelastography (TEG) provides a more comprehensive global coagulation assessment than routine tests (international normalized ratio [INR] and platelet [PLT] count), and its use may avoid unnecessary blood component transfusion in patients with advanced cirrhosis and significant coagulopathy who have nonvariceal upper gastrointestinal (GI) bleeding. A total of 96 patients with significant coagulopathy (defined in this study as INR >1.8 and/or PLT count < 50 × 109 /L) and nonvariceal upper GI bleed (diagnosed after doing upper gastrointestinal endoscopy, which showed ongoing bleed from a nonvariceal source) were randomly allocated to TEG-guided transfusion strategy (TEG group; n = 49) or standard-of-care (SOC) group (n = 47). In the TEG group, only 26.5% patients were transfused with all three blood components (fresh frozen plasma [FFP], PLTs, and cryoprecipitate) versus 87.2% in the SOC group (P < 0.001). Although 7 (14.3%) patients in the TEG group received no blood component transfusion, there were no such patients in the SOC group (P = 0.012). Also, there was a significantly lower use of blood components (FFP, PLTs, and cryoprecipitate) in the TEG group compared with the SOC group. Failure to control bleed, failure to prevent rebleeds, and mortality between the two groups were similar. Conclusion: In patients with advanced cirrhosis with coagulopathy and nonvariceal upper GI bleeding, TEG-guided transfusion strategy leads to a significantly lower use of blood components compared with SOC (transfusion guided by INR and PLT count), without an increase in failure to control bleed, failure to prevent rebleed, and mortality.
Collapse
Affiliation(s)
- Manoj Kumar
- Department of Hepatology and Liver Transplantation, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Juned Ahmad
- Department of Hepatology and Liver Transplantation, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Rakhi Maiwall
- Department of Hepatology and Liver Transplantation, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Ashok Choudhury
- Department of Hepatology and Liver Transplantation, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Meenu Bajpai
- Department of Transfusion Medicine, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Lalita G Mitra
- Department of Critical Care Medicine, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Vandana Saluja
- Department of Critical Care Medicine, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Prashant Mohan Agarwal
- Department of Critical Care Medicine, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Chhagan Bihari
- Department of Pathology, Institute of Liver & Biliary Sciences, New Delhi, India
| | | | - Ankur Jindal
- Department of Hepatology and Liver Transplantation, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Ankit Bhardwaj
- Department of Clinical Research, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Guresh Kumar
- Department of Biostatistics, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Shiv K Sarin
- Department of Hepatology and Liver Transplantation, Institute of Liver & Biliary Sciences, New Delhi, India
| |
Collapse
|
42
|
Mikhail C, Pennington Z, Arnold PM, Brodke DS, Chapman JR, Chutkan N, Daubs MD, DeVine JG, Fehlings MG, Gelb DE, Ghobrial GM, Harrop JS, Hoelscher C, Jiang F, Knightly JJ, Kwon BK, Mroz TE, Nassr A, Riew KD, Sekhon LH, Smith JS, Traynelis VC, Wang JC, Weber MH, Wilson JR, Witiw CD, Sciubba DM, Cho SK. Minimizing Blood Loss in Spine Surgery. Global Spine J 2020; 10:71S-83S. [PMID: 31934525 PMCID: PMC6947684 DOI: 10.1177/2192568219868475] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
STUDY DESIGN Broad narrative review. OBJECTIVE To review and summarize the current literature on guidelines, outcomes, techniques and indications surrounding multiple modalities of minimizing blood loss in spine surgery. METHODS A thorough review of peer-reviewed literature was performed on the guidelines, outcomes, techniques, and indications for multiple modalities of minimizing blood loss in spine surgery. RESULTS There is a large body of literature that provides a consensus on guidelines regarding the appropriate timing of discontinuation of anticoagulation, aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and herbal supplements prior to surgery. Additionally, there is a more heterogenous discussion the utility of preoperative autologous blood donation facilitated by erythropoietin and iron supplementation for healthy patients slated for procedures with high anticipated blood loss and for whom allogeneic transfusion is likely. Intraoperative maneuvers available to minimize blood loss include positioning and maintaining normothermia. Tranexamic acid (TXA), bipolar sealer electrocautery, and topical hemostatic agents, and hypotensive anesthesia (mean arterial pressure (MAP) <65 mm Hg) should be strongly considered in cases with larger exposures and higher anticipated blood loss. There is strong level 1 evidence for the use of TXA in spine surgery as it reduces the overall blood loss and transfusion requirements. CONCLUSION As the volume and complexity of spinal procedures rise, intraoperative blood loss management has become a pivotal topic of research within the field. There are many tools for minimizing blood loss in patients undergoing spine surgery. The current literature supports combining techniques to use a cost- effective multimodal approach to minimize blood loss in the perioperative period.
Collapse
Affiliation(s)
| | | | - Paul M. Arnold
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | - Norman Chutkan
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - John G. DeVine
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Daniel E. Gelb
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | - Fan Jiang
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Brian K. Kwon
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Thomas E. Mroz
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ahmad Nassr
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - K. Daniel Riew
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Lali H. Sekhon
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | | | | | | | | | - Samuel K. Cho
- Icahn School of Medicine at Mount Sinai, New York, NY, USA,Samuel K. Cho, Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, New York, NY 10029, USA.
| |
Collapse
|
43
|
Managing coagulopathy following PPH. Best Pract Res Clin Obstet Gynaecol 2019; 61:106-120. [DOI: 10.1016/j.bpobgyn.2019.04.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 04/01/2019] [Accepted: 04/17/2019] [Indexed: 12/12/2022]
|
44
|
Terada R, Ikeda T, Mori Y, Yamazaki S, Kashiwabara K, Yamauchi H, Ono M, Yamada Y, Okazaki H. Comparison of two point of care whole blood coagulation analysis devices and conventional coagulation tests as a predicting tool of perioperative bleeding in adult cardiac surgery-a pilot prospective observational study in Japan. Transfusion 2019; 59:3525-3535. [PMID: 31614002 DOI: 10.1111/trf.15523] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 06/10/2019] [Accepted: 08/13/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND It is widely accepted that Point-of Care Test (PoCT) devices are useful in the detection of coagulopathies in situations of massive bleeding such as major cardiac surgery. These devices contribute to the reduction of blood transfusion. However, their implementation remains limited in Japan because of their cost and lack of health insurance support. STUDY DESIGN AND METHODS Conventional coagulation tests and thromboelastography (TEG)/Sonoclot values were measured in 50 consecutive cardiac surgery cases. Clinical background information such as operative procedures was obtained from electronic medical records, and the theoretical perioperative total blood loss was calculated by measuring the hemoglobin content and total red blood cell transfusion volume. The correlation between perioperative total blood loss and the measured laboratory values or clinical parameters was evaluated by a multivariate linear regression analysis. The risk factors of the total amount of platelet transfusion and postoperative drain bleeding volume were similarly evaluated. RESULTS No significant association between the estimated perioperative total blood loss (eTBL) and the laboratory measurements including conventional coagulation tests, TEG and Sonoclot was observed. On the other hand, postoperative drain bleeding volume was significantly associated with postoperative Sonoclot CR (p = 0.039) as well as preoperative use of oral anticoagulants and cell saver treated blood volume. Platelet transfusion amount was significantly associated with post-CBP PF and time to peak value of Sonoclot (p = 0.014 and 0.001, respectively). CONCLUSION Sonoclot measurements may be useful to estimate the risks of postoperative bleeding and platelet transfusion in cardiac surgeries in Japan.
Collapse
Affiliation(s)
- Rui Terada
- Department of Blood Transfusion, The University of Tokyo Hospital, Tokyo, Japan
| | - Toshiyuki Ikeda
- Department of Blood Transfusion, The University of Tokyo Hospital, Tokyo, Japan
| | - Yoshiteru Mori
- Department of Anesthesiology and Pain Relief Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Sho Yamazaki
- Department of Blood Transfusion, The University of Tokyo Hospital, Tokyo, Japan
| | - Kosuke Kashiwabara
- Department of Biostatistics Division, Clinical Research Support Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Haruo Yamauchi
- Department of Cardiac Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Minoru Ono
- Department of Cardiac Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Yoshitsugu Yamada
- Department of Anesthesiology and Pain Relief Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Hitoshi Okazaki
- Department of Blood Transfusion, The University of Tokyo Hospital, Tokyo, Japan
| |
Collapse
|
45
|
Schmidt AE, Israel AK, Refaai MA. The Utility of Thromboelastography to Guide Blood Product Transfusion. Am J Clin Pathol 2019; 152:407-422. [PMID: 31263903 DOI: 10.1093/ajcp/aqz074] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES To provide an overview of the clot viscoelastic testing technology and to describe its utility in guiding blood product transfusions. METHODS A case scenario will be discussed as well as interpretation of thromboelastography (TEG) tracings. In addition, literature examining the utility of viscoelastic testing in guiding patient management and blood product transfusions will be reviewed. RESULTS TEG/rotational thromboelastometry (ROTEM) is useful in evaluating clot kinetics in trauma and acutely bleeding patients. TEG/ROTEM parameters are reflective of values measured using standard coagulation assays; however, TEG/ROTEM parameters are more rapidly available and more costly. TEG and ROTEM are used in three main settings: cardiac surgery, liver transplantation, and trauma to assess global hemostasis and administration of blood products. CONCLUSIONS TEG/ROTEM can be helpful in guiding resuscitation and blood product transfusion. Several studies have demonstrated a reduction in transfusion of blood components with TEG/ROTEM; however, other studies have suggested that TEG/ROTEM is not clinically effective in guiding transfusion.
Collapse
Affiliation(s)
- Amy E Schmidt
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY
| | - Anna Karolina Israel
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY
| | - Majed A Refaai
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY
| |
Collapse
|
46
|
Citrated kaolin thrombelastography (TEG) thresholds for goal-directed therapy in injured patients receiving massive transfusion. J Trauma Acute Care Surg 2019; 85:734-740. [PMID: 30059456 DOI: 10.1097/ta.0000000000002037] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Goal-directed hemostatic resuscitation based on thrombelastography (TEG) has a survival benefit compared with conventional coagulation assays such as international normalized ratio, activated partial thromboplastin time, fibrinogen level, and platelet count. While TEG-based transfusion thresholds for patients at risk for massive transfusion (MT) have been defined using rapid TEG, cutoffs have not been defined for TEG using other activators such as kaolin. The purpose of this study was to develop thresholds for blood product transfusion using citrated kaolin TEG (CK-TEG) in patients at risk for MT. METHODS CK-TEG was assessed in trauma activation patients at two Level 1 trauma centers admitted between 2010 and 2017. Receiver operating characteristic (ROC) curve analyses were performed to test the predictive performance of CK-TEG measurements in patients requiring MT, defined as >10 units of red blood cells or death within the first 6 hours. The Youden Index defined optimal thresholds for CK-TEG-based resuscitation. RESULTS Of the 825 trauma activations, 671 (81.3%) were men, 419 (50.8%) suffered a blunt injury, and 62 (7.5%) received a MT. Patients who had a MT were more severely injured, had signs of more pronounced shock, and more abnormal coagulation assays. CK-TEG R-time was longer (4.9 vs. 4.4 min, p = 0.0084), angle was lower (66.2 vs. 70.3 degrees, p < 0.0001), maximum amplitude was lower in MT (57 vs. 65.5 mm, p < 0.0001), and LY30 was greater (1.8% vs. 1.2%, p = 0.0012) in patients with MT compared with non-MT. To predict MT, R-time yielded an area under the ROC curve (AUROC) = 0.6002 and a cut point of >4.45 min. Angle had an AUROC = 0.6931 and a cut point of <67 degrees. CMA had an AUROC = 0.7425, and a cut point of <60 mm. LY30 had an AUROC = 0.623 with a cut point of >4.55%. CONCLUSION We have identified CK-TEG thresholds that can guide MT in trauma. We propose plasma transfusion for R-time >4.45 min, fibrinogen products for an angle <67 degrees, platelet transfusion for MA <60 mm, and antifibrinolytics for LY30 >4.55%. LEVEL OF EVIDENCE Therapeutic study, level V.
Collapse
|
47
|
Peng HT, Nascimento B, Tien H, Callum J, Rizoli S, Rhind SG, Beckett A. A comparative study of viscoelastic hemostatic assays and conventional coagulation tests in trauma patients receiving fibrinogen concentrate. Clin Chim Acta 2019; 495:253-262. [DOI: 10.1016/j.cca.2019.04.066] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 03/27/2019] [Accepted: 04/15/2019] [Indexed: 12/13/2022]
|
48
|
Dias JD, Sauaia A, Achneck HE, Hartmann J, Moore EE. Thromboelastography-guided therapy improves patient blood management and certain clinical outcomes in elective cardiac and liver surgery and emergency resuscitation: A systematic review and analysis. J Thromb Haemost 2019; 17:984-994. [PMID: 30947389 PMCID: PMC6852204 DOI: 10.1111/jth.14447] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 03/11/2019] [Indexed: 01/19/2023]
Abstract
Essentials TEG-guided therapy has been shown to be valuable in a number of surgical settings. This systematic review and analysis specifically evaluated the effects of TEG-guided therapy. TEG-guided therapy can improve blood product utilization and enhance resource management. Use of TEG improved key patient outcomes, including bleed rate, length of stay and mortality. BACKGROUND Thromboelastography (TEG 5000 and 6s Thrombelastograph Hemostasis Analyzer; Haemonetics) is a point-of-care system designed to monitor and analyze the entire coagulation process in real time. TEG-guided therapy has been shown to be valuable in a variety of surgical settings. OBJECTIVE To conduct an analysis of published clinical trials to evaluate the effects of TEG-guided transfusion for the management of perioperative bleeding on patient outcomes. PATIENTS/METHODS We searched MEDLINE (PubMed) and EMBASE for original articles reporting studies using TEG vs controls in a perioperative setting for inclusion in this systematic review. We identified nine eligible randomized controlled trials (RCTs) in two elective surgery settings (cardiac surgery and liver surgery), but only one RCT in the emergency setting. RESULTS In the elective surgery study meta-analysis, platelet (P = 0.004), plasma (P < 0.001) and red blood cell transfusion (P = 0.14), operating room length of stay (LoS) (P = 0.005), intensive care unit LoS (P = 0.04) and bleeding rate (P = 0.002) were reduced with TEG-guided transfusion vs controls. Although blood product use was reduced, rates of mortality remained comparable between the TEG group and control group. In the emergency setting evaluation, the RCT reported lower mortality in the TEG group than in the control group (P = 0.049). In addition, there were significant reductions in platelet and plasma transfusion (P = 0.04 and P = 0.02, respectively), and the number of ventilator-free days increased, in the TEG group as compared with the control group (P = 0.10). CONCLUSIONS This systematic review and analysis indicate that TEG-guided hemostatic therapy can enhance blood product management and improve key patient outcomes, including LoS, bleeding rate, and mortality.
Collapse
Affiliation(s)
| | - Angela Sauaia
- Department of Health Systems Management and PolicyUniversity of Colorado DenverDenverColorado
| | | | | | - Ernest E. Moore
- Department of SurgeryUniversity of Colorado DenverDenverColorado
| |
Collapse
|
49
|
Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ, Komadina R, Maegele M, Nardi G, Riddez L, Samama CM, Vincent JL, Rossaint R. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:98. [PMID: 30917843 PMCID: PMC6436241 DOI: 10.1186/s13054-019-2347-3] [Citation(s) in RCA: 676] [Impact Index Per Article: 135.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 02/06/2019] [Indexed: 12/24/2022]
Abstract
Background Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources. Methods The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. Results Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group’s belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms. Conclusions A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient. Electronic supplementary material The online version of this article (10.1186/s13054-019-2347-3) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Donat R Spahn
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland
| | - Bertil Bouillon
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Vladimir Cerny
- Department of Anaesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Socialni pece 3316/12A, CZ-40113, Usti nad Labem, Czech Republic.,Centre for Research and Development, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic, Sokolska 581, CZ-50005, Hradec Kralove, Czech Republic.,Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine in Hradec Kralove, Charles University, Simkova 870, CZ-50003, Hradec Kralove, Czech Republic.,Department of Anaesthesia, Pain Management and Perioperative Medicine, QE II Health Sciences Centre, Dalhousie University, Halifax, 10 West Victoria, 1276 South Park St, Halifax, NS, B3H 2Y9, Canada
| | - Jacques Duranteau
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, University of Paris XI, Faculté de Médecine Paris-Sud, 78 rue du Général Leclerc, F-94275, Le Kremlin-Bicêtre Cedex, France
| | - Daniela Filipescu
- Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, RO-022328, Bucharest, Romania
| | - Beverley J Hunt
- King's College and Departments of Haematology and Pathology, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Radko Komadina
- Department of Traumatology, General and Teaching Hospital Celje, Medical Faculty Ljubljana University, SI-3000, Celje, Slovenia
| | - Marc Maegele
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Giuseppe Nardi
- Department of Anaesthesia and ICU, AUSL della Romagna, Infermi Hospital Rimini, Viale Settembrini, 2, I-47924, Rimini, Italy
| | - Louis Riddez
- Department of Surgery and Trauma, Karolinska University Hospital, S-171 76, Solna, Sweden
| | - Charles-Marc Samama
- Hotel-Dieu University Hospital, 1, place du Parvis de Notre-Dame, F-75181, Paris Cedex 04, France
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070, Brussels, Belgium
| | - Rolf Rossaint
- Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, D-52074, Aachen, Germany.
| |
Collapse
|
50
|
The use of thromboelastography (TEG) in massively bleeding patients at Haukeland University Hospital 2008–15. Transfus Apher Sci 2019; 58:117-121. [DOI: 10.1016/j.transci.2018.12.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|