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Jeppesen AN, Duez C, Kirkegaard H, Grejs AM, Hvas AM. Fibrinolysis in Cardiac Arrest Patients Treated with Hypothermia. Ther Hypothermia Temp Manag 2023; 13:112-119. [PMID: 36473198 DOI: 10.1089/ther.2022.0037] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Hypothermia affects coagulation, but the effect of hypothermia on fibrinolysis is not clarified. Imbalance in the fibrinolytic system may lead to increased risk of bleeding or thrombosis. Our aim was to investigate if resuscitated cardiac arrest patients treated with hypothermia had an unbalanced fibrinolysis. A prospective cohort study, including 82 patients were treated with hypothermia at 33°C ± 1°C after out-of-hospital cardiac arrest. Blood samples were collected at 24 hours (hypothermia) and at 72 hours (normothermia). Samples were analyzed for fibrin D-dimer, tissue plasminogen activator (tPA), plasminogen, plasminogen activator Inhibitor-1 (PAI-1), thrombin-activatable fibrinolysis inhibitor (TAFI), and an in-house dynamic fibrin clot formation and lysis assay.Compared with normothermia, hypothermia significantly increased plasminogen activity (mean difference = 10.4%, 95% confidence interval [CI] 7.9-12.9), p < 0.001), PAI-1 levels (mean difference = 275 ng/mL, 95% CI 203-348, p < 0.001), and tPA levels (mean difference = 1.0 ng/mL, 95% CI 0.2-1.7, p = 0.01). No differences between hypothermia and normothermia were found in TAFI activity (p = 0.59) or in the fibrin D-dimer levels (p = 0.08). The fibrin clot lysis curves showed three different patterns: normal-, flat-, or resistant clot lysis curve. At hypothermia 45 (55%) patients had a resistant clot lysis curve and 33 (44%) patients had a resistant clot lysis curve at normothermia (p = 0.047). Comatose, resuscitated, cardiac arrest patients treated with hypothermia express an inhibited fibrinolysis even after rewarming. This could potentially increase the thromboembolic risk. ClinicalTrials.gov ID: NCT02258360.
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Affiliation(s)
- Anni Nørgaard Jeppesen
- Anesthesia Section, Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus N, Denmark
| | - Christophe Duez
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus N, Denmark
- Department of Otolaryngology, Head and Neck Surgery, and Aarhus University Hospital, Aarhus N, Denmark
| | - Hans Kirkegaard
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - Anders Morten Grejs
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
- Department of Intensive Care Medicine, Aarhus University Hospital, Aarhus N, Denmark
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Wallner B, Schenk B, Paal P, Falk M, Strapazzon G, Martini WZ, Brugger H, Fries D. Hypothermia Induced Impairment of Platelets: Assessment With Multiplate vs. ROTEM—An In Vitro Study. Front Physiol 2022; 13:852182. [PMID: 35422712 PMCID: PMC9002345 DOI: 10.3389/fphys.2022.852182] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 03/09/2022] [Indexed: 11/20/2022] Open
Abstract
Introduction: This experimental in vitro study aimed to identify and characterize hypothermia-associated coagulopathy and to compare changes in mild to severe hypothermia with the quantitative measurement of rotational thromboelastometry (ROTEM) and multiple-electrode aggregometry (MULTIPLATE). Methods: Whole blood samples from 18 healthy volunteers were analyzed at the target temperatures of 37, 32, 24, 18, and 13.7°C with ROTEM (ExTEM, InTEM and FibTEM) and MULTIPLATE using the arachidonic acid 0.5 mM (ASPI), thrombin receptor-activating peptide-6 32 µM (TRAP) and adenosine diphosphate 6.4 µM (ADP) tests at the corresponding incubating temperatures for coagulation assessment. Results: Compared to baseline (37°C) values ROTEM measurements of clotting time (CT) was prolonged by 98% (at 18°C), clot formation time (CFT) was prolonged by 205% and the alpha angle dropped to 76% at 13.7°C (p < 0.001). At 24.0°C CT was prolonged by 56% and CFT by 53%. Maximum clot firmness was only slightly reduced by ≤2% at 13.7°C. Platelet function measured by MULTIPLATE was reduced with decreasing temperature (p < 0.001): AUC at 13.7°C −96% (ADP), −92% (ASPI) and −91% (TRAP). Conclusion: Hypothermia impairs coagulation by prolonging coagulation clotting time and by decreasing the velocity of clot formation in ROTEM measurements. MULTIPLATE testing confirms a linear decrease in platelet function with decreasing temperatures, but ROTEM fails to adequately detect hypothermia induced impairment of platelets.
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Affiliation(s)
- Bernd Wallner
- Department of Anaesthesiology and General Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
- Department of General and Surgical Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
- *Correspondence: Bernd Wallner,
| | | | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, St. John of God Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Markus Falk
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
| | - Giacomo Strapazzon
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
| | - Wenjun Z. Martini
- US Army Institute of Surgical Research, San Antonio, TX, United States
| | - Hermann Brugger
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
| | - Dietmar Fries
- Department of General and Surgical Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
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Keith MT, Chalifoux NV, Buriko Y. The effect of analytical temperature on thromboelastography tracings in dogs. J Vet Diagn Invest 2021; 34:10-14. [PMID: 34515588 DOI: 10.1177/10406387211042922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Viscoelastic testing methods such as thromboelastography (TEG) are becoming increasingly available to veterinarians in a clinical setting. TEG is useful in determining therapeutic transfusion needs and assessing global abnormalities of hemostasis of patients, given that it provides a more comprehensive assessment of coagulation than traditional tests. TEG is standardly performed at 37°C, which is considered a normal body temperature for human patients; however, 37°C is lower than normal body temperature for most canine patients. In an in vitro study, we investigated the potential effect that this difference in body temperature and test temperature might have on TEG results. Citrated blood samples were collected from clinically normal, as well as sick, dogs with various body temperatures. Samples were analyzed concurrently at the patient's body temperature and at 37°C. There was very high correlation between TEG performed at body temperature and at 37°C for R (min) and MA (mm), high correlation for K (min) and alpha angle (deg), and moderate correlation for LY30 (%) and LY60 (%). For canine patients with normal to mildly abnormal body temperatures, performance of TEG at the standard 37°C is acceptable.
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Affiliation(s)
- Marie T Keith
- Department of Clinical Sciences and Advanced Medicine, Veterinary Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Nolan V Chalifoux
- Department of Clinical Sciences and Advanced Medicine, Veterinary Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Yekaterina Buriko
- Department of Clinical Sciences and Advanced Medicine, Veterinary Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Studer KA, Hanzlicek A, Di Girolamo N, Womble W, Pathak D, Maranville R, Kanda I, Brandão J. Effect of rest temperature on rotational thromboelastometry in New Zealand White rabbits. J Vet Diagn Invest 2020; 33:47-51. [PMID: 33155522 DOI: 10.1177/1040638720968536] [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: 11/16/2022] Open
Abstract
With the increasing popularity of viscoelastic coagulation analyzers, such as rotational thromboelastometry [ROTEM] and thromboelastography, the need for standardized methodology for appropriate interpretation has become increasingly important. Viscoelastic analysis is heavily influenced by a multitude of pre-analytic factors, both in vivo and in vitro, leading to a large amount of variation between institutions. We investigated the effect of room temperature during a 30-min sample rest time on ROTEM, which analyzed both intrinsic and extrinsic pathways. We also evaluated the feasibility of using ROTEM to assess coagulation in non-anesthetized domestic rabbits. Rabbits were selected because they are a common companion animal that could benefit from the use of viscoelastic analysis for various disease processes that could lead to coagulopathies. Citrated whole blood was collected from 10 rabbits and allowed to rest upright for 30 min either at room temperature (~ 21°C) or in a tube warmer (37°C) before analysis. There was no significant difference in results between room temperature and warmed samples, which suggests that allowing samples to rest at room temperature is acceptable clinically. Additionally, blood collection and analysis were feasible in all rabbits.
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Affiliation(s)
- Kelsea A Studer
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Oklahoma State University, Stillwater, OK
| | - Andrew Hanzlicek
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Oklahoma State University, Stillwater, OK
| | - Nicola Di Girolamo
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Oklahoma State University, Stillwater, OK
| | - William Womble
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Oklahoma State University, Stillwater, OK
| | - Debosree Pathak
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Oklahoma State University, Stillwater, OK
| | - Rachel Maranville
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Oklahoma State University, Stillwater, OK
| | - Ian Kanda
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Oklahoma State University, Stillwater, OK
| | - João Brandão
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Oklahoma State University, Stillwater, OK
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Wallner B, Schenk B, Hermann M, Paal P, Falk M, Strapazzon G, Martini WZ, Brugger H, Fries D. Hypothermia-Associated Coagulopathy: A Comparison of Viscoelastic Monitoring, Platelet Function, and Real Time Live Confocal Microscopy at Low Blood Temperatures, an in vitro Experimental Study. Front Physiol 2020; 11:843. [PMID: 32765300 PMCID: PMC7381250 DOI: 10.3389/fphys.2020.00843] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 06/23/2020] [Indexed: 12/17/2022] Open
Abstract
Introduction Hypothermia has notable effects on platelets, platelet function, fibrinogen, and coagulation factors. Common laboratory techniques cannot identify those effects, because blood samples are usually warmed to 37°C before analysis and do not fully reflect the in vivo situation. Multiple aspects of the pathophysiological changes in humoral and cellular coagulation remain obscure. This in vitro experimental study aimed to compare the measurements of thromboelastometry (TEM), multiple-electrode aggregometry (MEA) and Real Time Live Confocal Imaging for the purpose of identifying and characterizing hypothermia-associated coagulopathy. Methods Blood samples were drawn from 18 healthy volunteers and incubated for 30 min before being analyzed at the target temperatures (37, 32, 24, 18, and 13.7°C). At each temperature thromboelastometry and multiple-electrode aggregometry were measured. Real Time Live Confocal Imaging was performed at 4, 24, and 37°C. The images obtained by Real Time Live Confocal Imaging were compared with the functional results of thromboelastometry and multiple-electrode aggregometry. Results Thromboelastometry standard parameters were impaired at temperatures below baseline 37°C (ANOVA overall effect, p < 0.001): clotting time was prolonged by 27% at 13.7°C and by 60% at 18°C (p < 0.044); clot formation time was prolonged by 157% (p < 0.001). A reduction in platelet function with decreasing temperatures was observed (p < 0.001); the area under the curve at 13.7°C was reduced by 96% (ADP test), 92% (ASPI test), and 91% (TRAP test) of the baseline values. Temperature-associated changes in coagulation were visualized with Real Time Live Confocal Imaging. Molecular changes such as the temperature-associated decrease in the fibrin network are paralleled by cellular effects like the lesser activity of the platelets as a result of decreased temperature. The maximum clot firmness (MCF) in TEM only changed slightly within the temperature range tested. Conclusion The inhibitory effects of temperature on clot formation were visualized with Real Time Live Confocal Microscopy and compared with standard point-of-care testing. Inhibition of clotting factors and impaired platelet function are probably a result of hypothermia-induced impairment of thrombin. Measurement of MCF in TEM does not fully concur with Real Time Live Confocal Microscopy or MEA in hypothermia.
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Affiliation(s)
- Bernd Wallner
- Department of Anaesthesiology and General Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria.,Department of General and Surgical Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria.,Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
| | - Bettina Schenk
- Department of General and Surgical Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Martin Hermann
- Department of General and Surgical Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospital of the Brothers of St. John of God, Paracelsus Medical University, Salzburg, Austria
| | - Markus Falk
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
| | - Giacomo Strapazzon
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
| | - Wenjun Z Martini
- U.S. Army Institute of Surgical Research, Fort Sam Houston, San Antonio, TX, United States
| | - Hermann Brugger
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
| | - Dietmar Fries
- Department of General and Surgical Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
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Prüller F, Milke OL, Bis L, Fruhwald F, Scherr D, Eller P, Pätzold S, Altmanninger-Sock S, Rainer P, Siller-Matula J, von Lewinski D. Impaired aspirin-mediated platelet function inhibition in resuscitated patients with acute myocardial infarction treated with therapeutic hypothermia: a prospective, observational, non-randomized single-centre study. Ann Intensive Care 2018; 8:28. [PMID: 29468430 PMCID: PMC5821616 DOI: 10.1186/s13613-018-0366-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Accepted: 02/01/2018] [Indexed: 12/20/2022] Open
Abstract
The majority of resuscitated patients present with underlying cardiac disease, and out of these myocardial infarction is most common. Immediate interventional treatment is recommended and routinely requires dual antiplatelet therapy including aspirin and a P2Y12-inhibitor. Therapeutic hypothermia or target temperature management is also recommended in these patients. Cardiogenic shock as well as reduced body temperature impacts platelet reactivity and its medical inhibition. The study aims to quantify aspirin- and P2Y12-mediated platelet inhibition in patients presenting with myocardial infarction and cardiopulmonary resuscitation. Twenty-five resuscitated patients were enrolled in this prospective, observational, non-randomized single-centre study. These patients were compared to 77 matched controls from the ATLANTIS-ACS database of non-resuscitated patients with myocardial infarction. Platelet function testing was performed by light transmittance aggregometry. Aspirin reactivity was monitored by inducing platelet aggregation with collagen and arachidonic acid, respectively. P2Y12 inhibition was recorded by stimulation of platelet aggregation with adenosine diphosphate. To quantify the overall platelet response, thrombin receptor-activated peptide was used. Aspirin-mediated platelet reactivity decreased significantly in resuscitated patients during the first days and was significantly weaker on day 3 (collagen AUC 253.8 (122.7–352.2) vs. 109.0 (73.0–182.0); p = 0.022). P2Y12-mediated platelet inhibition was also impaired in resuscitated patients on day 3 (mean ADP AUC (IQR): CPR 172.1 (46.7−346.5) vs. control 43.9 (18.9–115.2); p < 0.05). Aspirin- and P2Y12-mediated platelet inhibition is impaired in resuscitated patients treated with therapeutic hypothermia. On day 3, we recorded lowest inhibitory effects of both drug types and patients might be at particular risk at that time. Potentially, intravenous aspirin and P2Y12 inhibitors might still supply a more predictable and stable platelet inhibition.
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Affiliation(s)
- Florian Prüller
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, University Hospital Graz, Graz, Austria
| | | | - Lukasz Bis
- Medical University of Graz, Graz, Austria
| | - Friedrich Fruhwald
- Department of Cardiology, Intensive Care Unit, University Hospital Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Daniel Scherr
- Department of Cardiology, Intensive Care Unit, University Hospital Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Philipp Eller
- Department of Internal Medicine, Intensive Care Unit, University Hospital Graz, Graz, Austria
| | - Sascha Pätzold
- Department of Cardiology, Intensive Care Unit, University Hospital Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Siegfried Altmanninger-Sock
- Department of Cardiology, Intensive Care Unit, University Hospital Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Peter Rainer
- Department of Cardiology, Intensive Care Unit, University Hospital Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | | | - Dirk von Lewinski
- Department of Cardiology, Intensive Care Unit, University Hospital Graz, Auenbruggerplatz 15, 8036, Graz, Austria.
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8
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Trąbka-Zawicki A, Tomala M, Zeliaś A, Paszek E, Zajdel W, Stępień E, Żmudka K. Adaptation of global hemostasis to therapeutic hypothermia in patients with out-of-hospital cardiac arrest: Thromboelastography study. Cardiol J 2017; 26:77-86. [PMID: 28695976 DOI: 10.5603/cj.a2017.0080] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 05/11/2017] [Accepted: 05/21/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The use of mild therapeutic hypothermia (MTH) in patients after out-of-hospital cardiac arrest (OHCA) who are undergoing primary percutaneous coronary intervention (pPCI) can protect patients from thromboembolic complications. The aim of the study was to evaluate the adaptive mecha- nisms of the coagulation system in MTH-treated comatose OHCA survivors. METHODS Twenty one comatose OHCA survivors with acute coronary syndrome undergoing imme- diate pPCI were treated with MTH. Quantitative and qualitative analyses of physical clot properties were performed using thromboelastography (TEG). Two analysis time points were proposed: 1) during MTH with in vitro rewarming conditions (37°C) and 2) after restoration of normothermia (NT) under normal (37°C) and in vitro cooling conditions (32°C). RESULTS During MTH compared to NT, reaction time (R) was lengthened, clot kinetic parameter (a) was significantly reduced, but no effect on clot strength (MA) was observed. Finally, the coagulation index (CI) was significantly reduced with clot fibrinolysis attenuated during MTH. The clot lysis time (CLT) was shortened, and clot stability (LY60) was lower compared with those values during NT. In vitro cooling generally influenced clot kinetics and reduced clot stability after treatment. CONCLUSIONS Thromboelastography is a useful method for evaluation of coagulation system dysfunc- tion in OHCA survivors undergoing MTH. Coagulation impairment in hypothermia was associated with a reduced rate of clot formation, increased weakness of clot strength, and disturbances of fibrinoly- sis. Blood sample analyses performed at 32°C during MTH, instead of the standard 37°C, seems to enhance the accuracy of the evaluation of coagulation impairment in hypothermia.
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Affiliation(s)
- Aleksander Trąbka-Zawicki
- Department of Interventional Cardiology, Jagiellonian University, John Paul II Hospital, Krakow, Poland.
| | - Marek Tomala
- Department of Interventional Cardiology, Jagiellonian University, John Paul II Hospital, Krakow, Poland
| | - Aleksander Zeliaś
- Department of Interventional Cardiology, Jagiellonian University, John Paul II Hospital, Krakow, Poland
| | - Elżbieta Paszek
- Department of Interventional Cardiology, Jagiellonian University, John Paul II Hospital, Krakow, Poland
| | - Wojciech Zajdel
- Department of Interventional Cardiology, Jagiellonian University, John Paul II Hospital, Krakow, Poland
| | - Ewa Stępień
- Department of Medical Physics, Marian Smoluchowski Institute of Physiscs, Faculty of Physics, Astronomy, and Applied Computer, Jagiellonian University, Krakow, Poland
| | - Krzysztof Żmudka
- Department of Interventional Cardiology, Jagiellonian University, John Paul II Hospital, Krakow, Poland
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Figueroa SA, Guanci MM, Blissitt PA, Cahoon WD. Clinical Q & A: Translating Therapeutic Temperature Management from Theory to Practice. Ther Hypothermia Temp Manag 2017; 7:61-64. [PMID: 28117626 DOI: 10.1089/ther.2017.29025.mkb] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | | | - Patricia A Blissitt
- 4 Clinical Faculty, University of Washington School of Nursing , Seattle, Washington
| | - William D Cahoon
- 5 Virginia Commonwealth University School of Pharmacy , Richmond, Virginia
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Jeppesen AN, Kirkegaard H, Ilkjær S, Hvas AM. Influence of temperature on thromboelastometry and platelet aggregation in cardiac arrest patients undergoing targeted temperature management. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:118. [PMID: 27129380 PMCID: PMC4851809 DOI: 10.1186/s13054-016-1302-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 04/19/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Coagulation can be visualised using whole blood coagulation analyses such as thromboelastometry and platelet aggregation tests; however, the role of temperature in the analyses is ambiguous. The aim was to examine whether temperature influences the whole blood coagulation tests. METHODS We included 40 patients treated with targeted temperature management (33 ± 1 °C) after out-of-hospital cardiac arrest. The blood samples were obtained on hypothermia and normothermia. Each blood sample was analysed simultaneously at 33 °C and 37 °C by thromboelastography (ROTEM®) employing the assays EXTEM®, INTEM®, FIBTEM® and HEPTEM®, and by Multiplate®Analyzer, using COLtest®, ADPtest®, ASPItest® and TRAPtest® as agonists. Data on antithrombotic drugs were collected systematically from medical records, and data were analysed using repeated measurement analysis of variance (ANOVA). RESULTS The ROTEM® analyses showed increased clotting time, lower maximum velocity and increased time to maximum velocity (all p values <0.02) when performed at 33 °C compared with 37 °C, irrespective of the patients being hypothermic (median 33.1 °C) or normothermic (median 37.5 °C). However, EXTEM® time to maximum velocity showed no difference between the analyses performed at 33 °C and 37 °C when the patients were hypothermic (p = 0.83). No differences were found in maximum clot firmness (all p values >0.09) analysed at 33 °C and 37 °C, independent of the body temperature. In the hypothermic blood sample, no difference was found when using the COLtest®, ASPItest® or TRAPtest® to compare platelet aggregation analysed at 33 °C and 37 °C (all p values >0.19), but platelet aggregation was significantly higher using the ADPtest® (p < 0.001) when analysed at 33 °C. In the normothermic blood sample, the TRAPtest® showed no difference (p = 0.73) when performed at 33 °C; however, significantly lower aggregation was found using the COLtest® and ASPItest® (all p values <0.001), while a higher aggregation at 33 °C was found using the ADPtest® (p = 0.003). CONCLUSION ROTEM® analyses seemed not to be dependent on body temperature but showed a slower initiation of coagulation when analysed at 33 °C compared with 37 °C. The Multiplate®Analyzer results were dependent on the temperature used in the analyses and the body temperature. In whole blood coagulation tests, the temperature used in the analyses should be kept at 37 °C irrespective of the patient's body temperature being 33 °C or 37 °C.
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Affiliation(s)
- Anni Nørgaard Jeppesen
- Research Centre for Emergency Medicine, Aarhus University Hospital, Nørrebrogade 44, Building 30, 8000, Aarhus C, Denmark. .,Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark.
| | - Hans Kirkegaard
- Research Centre for Emergency Medicine, Aarhus University Hospital, Nørrebrogade 44, Building 30, 8000, Aarhus C, Denmark.,Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Susanne Ilkjær
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Anne Mette Hvas
- Center for Haemophilia and Thrombosis, Department of Clinical Biochemistry, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
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Haraji A, Rakhshan V, Hosseini V. Local heating of the wound with dressings soaked in saline at 42°C can reduce postoperative bleeding: a single-blind, split-mouth, randomised controlled clinical trial. Br J Oral Maxillofac Surg 2016; 54:266-9. [DOI: 10.1016/j.bjoms.2016.01.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 01/16/2016] [Indexed: 10/22/2022]
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Jeong SM, Song JG, Seo H, Choi JH, Jang DM, Hwang GS. Quantification of Both Platelet Count and Fibrinogen Concentration Using Maximal Clot Firmness of Thromboelastometry During Liver Transplantation. Transplant Proc 2015; 47:1890-5. [DOI: 10.1016/j.transproceed.2015.02.019] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Accepted: 02/10/2015] [Indexed: 12/20/2022]
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Heparin dose adjustment required to maintain goal-activated partial thromboplastin time during therapeutic hypothermia. J Crit Care 2015; 30:574-8. [DOI: 10.1016/j.jcrc.2015.01.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Revised: 12/30/2014] [Accepted: 01/23/2015] [Indexed: 11/18/2022]
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Durila M, Lukáš P, Astraverkhava M, Vymazal T. Evaluation of fibrinogen concentrates and prothrombin complex concentrates on coagulation changes in a hypothermic in vitro model using thromboelastometry and thromboelastography. Scand J Clin Lab Invest 2015; 75:407-14. [PMID: 25892117 DOI: 10.3109/00365513.2015.1031694] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Hypothermic coagulopathy is very challenging in bleeding trauma patients. Therefore, we decided to evaluate the efficacy of fibrinogen and prothrombin complex in 30°C hypothermia in vitro to investigate if higher levels of fibrinogen and prothrombin complex concentrate can compensate for the hypothermic effect on coagulation as measured by thromboelastometry/thromboelastography. METHODS Blood samples were obtained from 12 healthy volunteers (six men and six women) in our study. Measurements were performed at 37°C and 30°C simultaneously, then at 30°C with adding fibrinogen and prothrombin complex and in the last step samples with added coagulation factors were warmed back to 37°C. RESULTS We found that 30°C hypothermic coagulopathy can be detected both by thromboelastometry and thromboelastography. Hypothermic coagulopathy can be restored by fibrinogen to the point where the results do not significantly differ from 37°C values (p > 0.05). After warming the sample with fibrinogen to 37°C, the thrombodynamic potential index was not significantly different from baseline (p > 0.05), although there was a trend to prothrombotic status. The addition of prothrombin complex concentrate to 30°C hypothermic sample was not able to correct hypothermic coagulopathy in vitro. CONCLUSIONS Coagulopathy caused by the 30°C hypothermia in vitro model can be corrected by fibrinogen concentrate compared to prothrombin complex concentrate. In spite of a tendency to prothrombotic status, this was not significant with the use of the recommended dose of fibrinogen even after warming the blood to 37°C. However, measurement performed at 37°C seems to be safer than at 30°C.
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Affiliation(s)
- Miroslav Durila
- Department of Anaesthesiology and Intensive Care Medicine, Second Faculty of Medicine, Charles University in Prague, Motol University Hospital , Prague , Czech Republic
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Winstedt D, Thomas OD, Nilsson F, Olanders K, Schött U. Correction of hypothermic and dilutional coagulopathy with concentrates of fibrinogen and factor XIII: an in vitro study with ROTEM. Scand J Trauma Resusc Emerg Med 2014; 22:73. [PMID: 25510409 PMCID: PMC4272532 DOI: 10.1186/s13049-014-0073-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Accepted: 11/26/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Fibrinogen concentrate treatment can improve coagulation during massive traumatic bleeding. The aim of this in vitro study was to determine whether fibrinogen concentrate, or a combination of factor XIII and fibrinogen concentrates, could reverse a haemodilution-induced coagulopathy during hypothermia. METHODS Citrated venous blood from 10 healthy volunteers was diluted in vitro by 33% with 130/0.42 hydroxyethyl starch (HES) or Ringer's acetate (RAc). The effects of fibrinogen concentrate corresponding to 4 gram per 70 kg, or a combination of the same dose of fibrinogen with factor XIII (20 IU per kg), were measured using rotational thromboelastometry (ROTEM). The blood was analysed at 33°C or 37°C with ROTEM EXTEM and FIBTEM reagents. Clotting time (CT), clot formation time (CFT), alpha angle (AA) and maximal clot formation (MCF) were recorded. RESULTS Fibrinogen with or without factor XIII improved all ROTEM parameters in either solution irrespective of temperature, with the exception of EXTEM-AA and EXTEM-CFT in HES haemodilution. Fibrinogen increased FIBTEM-MCF more in the samples diluted with RAc than HES, particularly in presence of factor XIII. CONCLUSIONS Fibrinogen improved in vitro haemodilution-induced coagulopathy at both 33°C and 37°C, though more efficiently after crystalloid than HES haemodilution. Factor XIII had an additional effect on FIBTEM-MCF, but only after crystalloid dilution.
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Affiliation(s)
- Dag Winstedt
- Faculty of Medicine, Lund University, Lund, Sweden.
- Department of Anaesthesia and Intensive Care, Skåne University Hospital Lund, Lund, 221 85, Sweden.
| | - Owain D Thomas
- Faculty of Medicine, Lund University, Lund, Sweden.
- Department of Paediatric Anaesthesia and Intensive Care, Skåne University Hospital Lund, Lund, 221 85, Sweden.
| | - Fredrik Nilsson
- Research and Development Centre, Skåne, Skåne University Hospital Lund, Lund, 221 85, Sweden.
| | - Knut Olanders
- Faculty of Medicine, Lund University, Lund, Sweden.
- Department of Anaesthesia and Intensive Care, Skåne University Hospital Lund, Lund, 221 85, Sweden.
| | - Ulf Schött
- Faculty of Medicine, Lund University, Lund, Sweden.
- Department of Anaesthesia and Intensive Care, Skåne University Hospital Lund, Lund, 221 85, Sweden.
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Sulaiman OM, Pabón GA, Cortés CC, Muñoz LA, Reyes LE, Arevalo JJ. Un resumen de la investigación en tromboelastografía. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2014. [DOI: 10.1016/j.rca.2014.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Sulaiman OM, Pabón GA, Cortés CC, Muñoz LA, Reyes LE, Arevalo JJ. An overview of thrombelastography research. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2014. [DOI: 10.1016/j.rcae.2014.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Minimal effects on ex vivo coagulation during mild therapeutic hypothermia in post cardiac arrest patients. Resuscitation 2014; 85:1359-63. [DOI: 10.1016/j.resuscitation.2014.06.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Revised: 05/29/2014] [Accepted: 06/08/2014] [Indexed: 11/21/2022]
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Peng HT, Rhind SG. Thromboelastographic Study of Psychophysiological Stress: A Review. Clin Appl Thromb Hemost 2013; 21:497-512. [PMID: 24254897 DOI: 10.1177/1076029613512415] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Thromboelastography (TEG) is drawing more attention for clinical and laboratory studies of hemostasis. It has been applied to evaluate the effects of both psychological and physiological stress on whole blood coagulation from the onset of the coagulation cascade through clot formation, to the end with fibrinolysis. We conducted a comprehensive review on the applications of TEG for assessment of different stressors, ranging from physical exercise to emotional situations. The methodology is unique in terms of instrumentation, the methods to activate blood coagulation, the type of blood (citrated vs fresh blood), and study settings (in vitro vs in vivo vs clinical trials). Thromboelastography has most often been used to study the effects of physiological stress. The author's own work and future directions are discussed as well. The review would facilitate future development of TEG for evaluating hemostasis and potential pathological pathways in response to various forms of stress.
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Affiliation(s)
- Henry T Peng
- Defence Research and Development Canada, Toronto Research Centre, Toronto, Ontario, Canada
| | - Shawn G Rhind
- Defence Research and Development Canada, Toronto Research Centre, Toronto, Ontario, Canada
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Oncel MY, Erdeve O, Calisici E, Oguz SS, Canpolat FE, Uras N, Dilmen U. The effect of whole-body cooling on hematological and coagulation parameters in asphyxic newborns. Pediatr Hematol Oncol 2013; 30:246-52. [PMID: 23445486 DOI: 10.3109/08880018.2013.771240] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Although moderate therapeutic hypothermia is the only proven neuroprotective therapy in neonatal hypoxic ischemic encephalopathy secondary to perinatal asphyxia (PA), there is lack of data for its effect on hemostasis. To investigate the effect of neonatal asphyxia on hemostasis and to evaluate the effect of whole body cooling on hematological parameters. Hematological parameters evaluated on the first day of patients with PA before start of hypothermia were compared with those of healthy controls. The effects of whole body cooling on the same parameters were also evaluated on the fourth day. A total of 17 neonates with PA and 15 healthy controls were included. Mean values for prothrombin time (PT), international normalized ratio (INR), activated partial thromboplastin time (aPTT), and d-dimer obtained on the first day were significantly higher in the PA group compared to healthy controls (P ≤ .001 for all comparisons), whereas platelet count, levels of fibrinogen, factors II, V, VII, IX, X, and XI were significantly lower (P ≤ .005 for all comparisons). Levels of factor XIII were normal in both groups. In the study group, mean values for PT, INR, aPTT, and d-dimer evaluated on postnatal day 4 were significantly lower compared to values obtained on the first day of birth in PA group (P < .05 for all comparisons), with statistically significant increases in mean levels of fibrinogen, factor II, V, VII, IX, X, and XII (P < .05 for all comparisons). PA results in significant reductions in levels of factors of the extrinsic pathway and has been associated with thrombocytopenia and disseminated intravascular coagulation. Hypothermia may actually improve the clinical picture in such patients rather than aggravating the hemostatic disturbance, particularly with the implementation of supportive treatment.
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Affiliation(s)
- Mehmet Yekta Oncel
- Division of Neonatology, Zekai Tahir Burak Maternity Teaching Hospital, Ankara, Turkey.
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Ahmad FU, Wang MY, Levi AD. Hypothermia for acute spinal cord injury--a review. World Neurosurg 2013; 82:207-14. [PMID: 23298671 DOI: 10.1016/j.wneu.2013.01.008] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2012] [Revised: 10/26/2012] [Accepted: 01/03/2013] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Spinal cord injury (SCI) is a catastrophic neurological event with no proven treatments that protect against its consequences. Potential benefits of hypothermia in preventing/limiting central nervous system injury are now well known. There has been an interest in its potential use after SCI. This article reviews the current experimental and clinical evidence on the use of therapeutic hypothermia in patients with SCI. METHODS Review of literature. RESULTS There are various mechanisms by which hypothermia is known to protect the central nervous system. Modest hypothermia (32°C-34°C) can deliver the potential benefits of hypothermia without incurring the complications associated with deep hypothermia. Several recent experimental studies have repeatedly shown that the use of hypothermia provides the benefit of neuroprotection after SCI. Although older clinical studies were often focused on local cooling strategies and demonstrated mixed results, more recent data from systemic hypothermia use demonstrate its safety and its benefits. Endovascular cooling is a safe and reliable method of inducing hypothermia. CONCLUSIONS There is robust experimental and some clinical evidence that hypothermia is beneficial in acute SCI. Larger, multicenter trials should be initiated to further study the usefulness of systemic hypothermia in SCI.
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Affiliation(s)
- Faiz U Ahmad
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Michael Y Wang
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Allan D Levi
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA.
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Park KH, Lee KH, Kim H. Effect of hypothermia on coagulatory function and survival in Sprague-Dawley rats exposed to uncontrolled haemorrhagic shock. Injury 2013; 44:91-6. [PMID: 22154303 DOI: 10.1016/j.injury.2011.11.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2011] [Revised: 10/25/2011] [Accepted: 11/17/2011] [Indexed: 02/02/2023]
Abstract
BACKGROUND Acute coagulopathy, hypothermia, and acidosis are the lethal triad of conditions manifested by major trauma patients. Recent animal studies have reported that hypothermia improves survival in animals subjected to controlled haemorrhagic shock. The objective of this study was to investigate the effect of hypothermia on coagulation in rats subjected to uncontrolled haemorrhagic shock. METHODS Thirty-two male Sprague-Dawley rats were randomly divided into four groups: normothermia (control, group N), hypothermia (group H), hypothermic haemorrhagic shock (group HS), and normothermic haemorrhagic shock (group NS). Haemorrhagic shock was induced by splenic laceration. Capacity for coagulation was measured by rotation thromboelastometry (ROTEM(®)), and was measured at baseline as well as the end of the shock and resuscitation periods. Survival was observed for 48 h post-trauma. RESULTS Baseline parameters were not different amongst the groups. Rats exposed to hypothermia alone did not differ in coagulation capacity compared to the control group. Clot formation time (CFT) and maximal clot firmness (MCF) in group HS decreased as the experiment progressed. Maximal clot firmness time (MCFt) in groups H and HS was significantly prolonged during shock and resuscitation compared with that in group NS. In group NS, MCF did not change significantly, but MCFt was reduced compared with baseline. Group HS had poor survival when compared with normovolaemic groups. CONCLUSION Blood clotted less firmly in traumatic haemorrhagic shock, and hypothermia prolonged clotting. However, clot firmness maximised rapidly under normothermic haemorrhagic shock. Haemorrhage would continue for a longer time in hypothermic haemorrhagic shock. Survival of hypothermic shock was not significantly different compared to that of normothermic haemorrhagic shock.
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Affiliation(s)
- Kyung Hye Park
- Department of Emergency Medicine, Inje University, Haeundae Paik Hospital, Busan, South Korea.
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Taggart R, Austin B, Hans E, Hogan D. In vitro evaluation of the effect of hypothermia on coagulation in dogs via thromboelastography. J Vet Emerg Crit Care (San Antonio) 2012; 22:219-24. [DOI: 10.1111/j.1476-4431.2012.00729.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Johansson PI, Sølbeck S, Genet G, Stensballe J, Ostrowski SR. Coagulopathy and hemostatic monitoring in cardiac surgery: an update. SCAND CARDIOVASC J 2012; 46:194-202. [PMID: 22375889 DOI: 10.3109/14017431.2012.671487] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES Cardiac surgery with cardiopulmonary bypass (CPB) causes severe derangements in the hemostatic system, which in turn puts the patient at risks of microvascular bleeding. Excessive transfusion and surgical re-exploration after cardiac surgery are potentially associated with a number of adverse outcomes including increased mortality. DESIGN This review describes coagulopathies occurring in cardiac surgery and the monitoring of these. Viscoelastic hemostatic assays (VHA) have routinely been used in cardiac surgery for more than 25 years and at least 16 studies (involving more than 3250 patients, including three randomized controlled trials) have compared VHA to routine coagulation tests (RCoT) with regards to their ability to predict bleeding and re-do surgery and also with regards to transfusion requirements secondary to hemostatic therapy based on VHA vs. RCoT. RESULTS All 16 studies demonstrated superiority with VHA as compared to RCoT both in predicting bleeding and need for re-do surgery and in reducing the total amount of blood transfusions by employing goal-directed administration of blood products based on VHA as compared RCoT based therapy or at the clinicians discretion. CONCLUSIONS The different types of coagulopathies observed in patients undergoing cardiac surgery requires adequate and timely hemostatic therapy and real-time monitoring with WHA such as TEG/ROTEM and whole blood platelet aggregometry.
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Affiliation(s)
- Pär I Johansson
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, University of Copenhagen, Denmark.
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Jiménez Vizuete JM, Pérez Valdivieso JM, Navarro Suay R, Gómez Garrido M, Monsalve Naharro JA, Peyró García R. [Resuscitation damage control in the patient with severe trauma]. ACTA ACUST UNITED AC 2012; 59:31-42. [PMID: 22429634 DOI: 10.1016/j.redar.2011.12.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2011] [Accepted: 12/04/2011] [Indexed: 11/16/2022]
Abstract
Severe trauma is the principle cause of death among young people in developed countries, with the main causes being due to road traffic accidents and accidents at work. The principle cause of death in severe trauma is the massive uncontrolled loss of blood. Most of the severe traumas with a massive haemorrhage develop coagulopathy, with some controversy over what is the best treatment for this. Patients with severe trauma are complex patients; they have a high mortality, they consume a significant amount of sources and can require rapid, intensive and multidisciplinary treatment encompassed within the concept of resuscitation damage control. In this article we attempt to present a current view of the pathophysiology of severe trauma and resuscitation damage control that may be applied to these types of patients.
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Affiliation(s)
- J M Jiménez Vizuete
- Servicio de Anestesiología y Cuidados Críticos, Hospital General Universitario, Albacete, España
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Koenigshof AM, Scott MA, Brown AJ. Effects of delayed anticoagulation and use of evacuated tubes on non-activated thrombelastography in dogs. Vet Clin Pathol 2012; 41:63-70. [DOI: 10.1111/j.1939-165x.2011.00387.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
| | - Michael A. Scott
- Pathobiology and Diagnostic Investigation; College of Veterinary Medicine; Michigan State University; East Lansing MI USA
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Differding JA, Underwood SJ, Van PY, Khaki RA, Spoerke NJ, Schreiber MA. Trauma induces a hypercoagulable state that is resistant to hypothermia as measured by thrombelastogram. Am J Surg 2011; 201:587-91. [PMID: 21545904 DOI: 10.1016/j.amjsurg.2011.01.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2010] [Revised: 01/21/2011] [Accepted: 01/21/2011] [Indexed: 11/28/2022]
Abstract
BACKGROUND The aim of this study was to test the hypothesis that severely injured trauma patients would be hypercoagulable compared with controls measured by thromboelastography and that this hypercoagulability would persist over a broad range of temperatures. METHODS A prospective study evaluating the effects of temperature on coagulation in trauma patients with Injury Severity Scores ≥ 15 and controls was completed. Thromboelastography was performed 24 hours after admission at 4 temperatures ranging from 32°C to 38°C. RESULTS Ninety-two subjects (46 patients) were analyzed. Patients had a median Injury Severity Score of 20 (interquartile range, 16–26). Time to clot formation increased (P < .001) and fibrin cross-linking decreased (P < .01) in both groups as temperature decreased. Between groups, time to clot formation, fibrin cross-linking, and clot strength were significantly different at each temperature (P < .01), with patients being more hypercoagulable. Time to clot formation and fibrin cross-linking were more affected by temperature in controls compared with patients (P < .02). CONCLUSIONS Severely injured patients are more hypercoagulable than controls throughout a broad range of temperature. Decreasing temperature has a greater effect on coagulation in controls compared with patients.
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Affiliation(s)
- Jerome A Differding
- Division of Trauma, Critical Care and Acute Care Surgery, Oregon Health & Science University, Portland, OR, USA
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Contemporary management of traumatic intracranial hypertension: is there a role for therapeutic hypothermia? Neurocrit Care 2011; 11:427-36. [PMID: 19644773 DOI: 10.1007/s12028-009-9256-2] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Intracranial hypertension (ICH) remains the single most difficult therapeutic challenge for the acute management of severe traumatic brain injury (TBI). We reviewed the published trials of therapeutic moderate hypothermia to determine its effect on ICH and compared its efficacy to other commonly used therapies for ICH. METHODS A PubMed database search was done using various combinations of the search terms "brain injury," "therapeutic hypothermia," "intracranial hypertension," "barbiturates," "mannitol," "hypertonic saline," "hyperventilation," "decompressive craniectomy," and "CSF drainage." RESULTS We identified 11 prospective randomized clinical TBI trials comparing hypothermia vs. normothermia treatment for which intracranial pressure (ICP) data was provided, and 6 prospective cohort studies that provided ICP data before and during hypothermia treatment. In addition, we identified 37 clinical TBI studies of lumbar CSF drainage, mannitol, hyperventilation, barbiturates, hypertonic saline, and decompressive craniectomy that provided pre- and posttreatment ICP data. Hypothermia was at least as effective as the traditional therapies for ICH (hyperventilation, mannitol, and barbiturates), but was less effective than hypertonic saline, lumbar CSF drainage, and decompressive craniectomy. Ultimately, however, therapeutic hypothermia does appear to have a favorable risk/benefit profile. CONCLUSION Therapeutic moderate hypothermia is as effective, or more effective, than most other treatments for ICH. If used for 2-3 days or less there is no evidence that it causes clinically significant adverse events. The lack of consistent evidence that hypothermia improves long-term neurologic outcome should not preclude consideration of its use for the primary treatment of ICH since no other ICP therapy is held to this standard.
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Staikou C, Paraskeva A, Drakos E, Anastassopoulou I, Papaioannou E, Donta I, Kontos M. Impact of Graded Hypothermia on Coagulation and Fibrinolysis. J Surg Res 2011; 167:125-30. [PMID: 19932906 DOI: 10.1016/j.jss.2009.07.037] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2009] [Revised: 07/17/2009] [Accepted: 07/21/2009] [Indexed: 10/20/2022]
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Nair SU, Lundbye JB. The Use of Hypothermia Therapy in Cardiac Arrest Survivors. Ther Hypothermia Temp Manag 2011; 1:9-21. [DOI: 10.1089/ther.2010.0002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Sanjeev U. Nair
- Cardiovascular Hospitalist Program, Hartford Hospital, Hartford, Connecticut
| | - Justin B. Lundbye
- Cardiovascular Hospitalist Program, Hartford Hospital, Hartford, Connecticut
- Cardiovascular Fellowship Program (Hartford Hospital), University of Connecticut School of Medicine, Farmington, Connecticut
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Scharbert G, Kalb ML, Essmeister R, Kozek-Langenecker SA. Mild and moderate hypothermia increases platelet aggregation induced by various agonists: a whole blood in vitro study. Platelets 2010; 21:44-8. [PMID: 19954411 DOI: 10.3109/09537100903420269] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The mechanisms causing temperature-dependent bleeding, especially in hypothermic patients, warrant clarification. Therefore the aim of this study was to investigate platelet aggregation at the clinically important temperature range of 30-34 degrees C. After obtaining informed consent citrated whole blood was drawn from 12 healthy adult male volunteers, who had not taken any medication in the previous 14 days. After venipuncture blood samples were incubated at 37 degrees C until platelet testing. Platelet aggregation was performed in whole blood using the impedance aggregometer Multiplate at five different test temperatures between 30 degrees C and 34 degrees C. Aggregation responses at 37 degrees C served as controls. At temperatures of mild and moderate hypothermia (30-34 degrees C), overall platelet aggregation was increased compared to 37 degrees C. Increases were recorded in response to collagen, thrombin receptor activating peptide and ristocetin between 31 degrees C and 34 degrees C and in response to adenosine diphosphate between 30 degrees C and 34 degrees C. Overall platelet aggregation is increased at mild and moderate hypothermia down to 30 degrees C. These results indicate that bleeding complications reported in mildly hypothermic patients are not due to hypothermia-induced platelet inhibition. The pathomechanism of the overall increased platelet aggregation between 30 degrees C and 34 degrees C requires further detailed study.
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Affiliation(s)
- G Scharbert
- Department of Special Anesthesiology and Pain Management, Medical University of Vienna, Vienna, Austria.
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Abstract
OBJECTIVE Hypothermia is an independent predictor of mortality in adult trauma studies. However, the impact of hypothermia on the pediatric trauma population has not been described. The purpose of this study is to evaluate hypothermia as a cofactor to mortality, complications, and among survivors, hospital length of stay parameters in the pediatric trauma population. DESIGN Retrospective review of a prospectively collected database (National Trauma Registry of the American College of Surgeons) over a 5-yr period (July 2002 to June 2007). SETTING A rural, level I trauma center. PATIENTS One thousand six hundred twenty-nine pediatric patients admitted with a traumatic injury. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Multivariate regression models were used to evaluate the association of hypothermia with mortality, infectious complications, organ dysfunction, and among survivors, hospital length of stay parameters. Of 1,629 pediatric trauma patients admitted, 182 (11.1%) patients were hypothermic (temperature below 36 degrees C) on admission. Hypothermia had an adjusted odds ratio (AOR) of 2.41 (95% confidence interval [CI], 1.12-5.22, p = .025) for mortality. After controlling for covariates, hypothermia had associations with developing pneumonia (AOR, 0.185, 95% CI, 0.040-0.853; p = .031) and a bleeding diathesis (AOR, 3.14, 95% CI, 1.04-9.44; p = .042). The median days in the hospital, intensive care unit (ICU), and ventilator were longer in the hypothermic cohort; however, after controlling for covariates, hypothermia was not associated with differences in hospital days, ICU days, or ventilator days. CONCLUSIONS Hypothermia is a common problem at admission among pediatric trauma patients. Hypothermia is associated with an increase in the odds of death and the development of a bleeding diathesis, while having decreased odds for developing pneumonia. While the length of stay indicators were longer in the hypothermic cohort among survivors, no significant association was noted with hypothermia for hospital, ICU, or ventilator days after controlling for confounders.
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Johansson PI, Stissing T, Bochsen L, Ostrowski SR. Thrombelastography and tromboelastometry in assessing coagulopathy in trauma. Scand J Trauma Resusc Emerg Med 2009; 17:45. [PMID: 19775458 PMCID: PMC2758824 DOI: 10.1186/1757-7241-17-45] [Citation(s) in RCA: 199] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2009] [Accepted: 09/23/2009] [Indexed: 11/14/2022] Open
Abstract
Death due to trauma is the leading cause of lost life years worldwide, with haemorrhage being responsible for 30-40% of trauma mortality and accounting for almost 50% of the deaths the initial 24 h. On admission, 25-35% of trauma patients present with coagulopathy, which is associated with a several-fold increase in morbidity and mortality. The recent introduction of haemostatic control resuscitation along with emerging understanding of acute post-traumatic coagulability, are important means to improve therapy and outcome in exsanguinating trauma patients. This change in therapy has emphasized the urgent need for adequate haemostatic assays to monitor traumatic coagulopathy and guide therapy. Based on the cell-based model of haemostasis, there is emerging consensus that plasma-based routine coagulation tests (RCoT), like prothrombin time (PT) and activated partial thromboplastin time (APTT), are inappropriate for monitoring coagulopathy and guide therapy in trauma. The necessity to analyze whole blood to accurately identify relevant coagulopathies, has led to a revival of the interest in viscoelastic haemostatic assays (VHA) such as Thromboelastography (TEG) and Rotation Thromboelastometry (ROTEM). Clinical studies including about 5000 surgical and/or trauma patients have reported on the benefit of using the VHA as compared to plasma-based assays, to identify coagulopathy and guide therapy. This article reviews the basic principles of VHA, the correlation between the VHA whole blood clot formation in accordance with the cell-based model of haemostasis, the current use of VHA-guided therapy in trauma and massive transfusion (haemostatic control resuscitation), limitations of VHA and future perspectives of this assay in trauma.
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Affiliation(s)
- Pär I Johansson
- Section for Transfusion Medicine, Regional Blood Bank, Rigshospitalet, University of Copenhagen, Denmark
| | - Trine Stissing
- Section for Transfusion Medicine, Regional Blood Bank, Rigshospitalet, University of Copenhagen, Denmark
| | - Louise Bochsen
- Section for Transfusion Medicine, Regional Blood Bank, Rigshospitalet, University of Copenhagen, Denmark
| | - Sisse R Ostrowski
- Section for Transfusion Medicine, Regional Blood Bank, Rigshospitalet, University of Copenhagen, Denmark
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Impact of hypothermia (below 36 degrees C) in the rural trauma patient. J Am Coll Surg 2009; 209:580-8. [PMID: 19854397 DOI: 10.1016/j.jamcollsurg.2009.07.021] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2009] [Revised: 07/12/2009] [Accepted: 07/28/2009] [Indexed: 11/22/2022]
Abstract
BACKGROUND Hypothermia is an independent predictor of mortality based on urban studies. But this association has not been described in the rural setting. This study's purpose was to evaluate hypothermia as a cofactor to mortality, complications, and hospital length of stay (LOS) parameters in the rural trauma setting. STUDY DESIGN The National Trauma Registry of the American College of Surgeons database for our rural, Level I trauma center was queried for a 5-year period (July 2002 to June 2007) to identify adult trauma patients. Multivariate regression models were used to evaluate the association of hypothermia with mortality; infectious complications; organ dysfunction; and, among survivors, hospital LOS parameters. RESULTS Of 9,482 adult patients admitted, 1,490 (15.7%) patients were hypothermic. Hypothermia had an adjusted odds ratio of 1.70 for mortality (95% CI, 1.35 to 2.12; p < 0.001). After controlling for covariates, hypothermia was not significantly associated with infectious complications or organ dysfunction, except for arrhythmia (adjusted odds ratio, 1.40; CI, 1.03 to 1.90; p = 0.031). Hypothermia was not associated with a difference in ICU (p = 0.310) or ventilator (p = 0.144) LOS. But a slight increase in hospital days was noted in the hypothermic patient (hazards ratio, 0.890 for discharge; 95% CI, 0.838 to 0.946; p < 0.001). CONCLUSIONS Hypothermia is a common problem at admission in a rural trauma center. It is associated with an increase in hospitalized days but not with increased ICU or ventilator days among survivors. Other than arrhythmias, it was not significantly associated with other National Trauma Registry of the American College of Surgeons infectious or organ dysfunction complications. Hypothermia is an independent risk factor for mortality in the rural trauma patient.
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Abstract
Therapeutic moderate hypothermia has been advocated for use in traumatic brain injury, stroke, cardiac arrest-induced encephalopathy, neonatal hypoxic-ischemic encephalopathy, hepatic encephalopathy, and spinal cord injury, and as an adjunct to aneurysm surgery. In this review, we address the trials that have been performed for each of these indications, and review the strength of the evidence to support treatment with mild/moderate hypothermia. We review the data to support an optimal target temperature for each indication, as well as the duration of the cooling, and the rate at which cooling is induced and rewarming instituted. Evidence is strongest for prehospital cardiac arrest and neonatal hypoxic-ischemic encephalopathy. For traumatic brain injury, a recent meta-analysis suggests that cooling may increase the likelihood of a good outcome, but does not change mortality rates. For many of the other indications, such as stroke and spinal cord injury, trials are ongoing, but the data are insufficient to recommend routine use of hypothermia at this time.
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Affiliation(s)
- Donald Marion
- The Children's Neurobiological Solutions Foundation, Santa Barbara, California, USA.
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Spiel AO, Kliegel A, Janata A, Uray T, Mayr FB, Laggner AN, Jilma B, Sterz F. Hemostasis in cardiac arrest patients treated with mild hypothermia initiated by cold fluids. Resuscitation 2009; 80:762-5. [DOI: 10.1016/j.resuscitation.2009.03.026] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2008] [Revised: 02/10/2009] [Accepted: 03/25/2009] [Indexed: 10/20/2022]
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Francony G, Declety P, Bouzat P, Picard J, Payen JF. Les dangers de l’hypothermie thérapeutique. ACTA ACUST UNITED AC 2009; 28:371-4. [DOI: 10.1016/j.annfar.2009.02.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Effect of 35 degrees C hypothermia on intracranial pressure and clinical outcome in patients with severe traumatic brain injury. ACTA ACUST UNITED AC 2009; 66:166-73. [PMID: 19131820 DOI: 10.1097/ta.0b013e318157dbec] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND From 1994, we have used therapeutic hypothermia in patients with severe traumatic brain injury (Glasgow Coma Scale scores of 5 or less). In 2000, we altered the target temperature to 35 degrees C from the former 33 degrees C, as our findings suggested that cooling to 35 degrees C is sufficient to control intracranial hypertension, and that hypothermia below 35 degrees C may predispose patients to persistent cumulative oxygen debt. We attempted to clarify whether 35 degrees C hypothermia has the same effect as 33 degrees C hypothermia in reducing intracranial hypertension and whether it is associated with fewer complications and improved outcomes. METHODS We compared intracranial pressure (ICP) and biochemical parameters in the 30 patients treated with 35 degrees C hypothermia (January 2000 to June 2005) with those in the 31 patients treated with 33 degrees C hypothermia (July 1994 to December 1999). RESULTS Patient characteristics were similar in the two groups. The mean temperature during hypothermia was 35.1 +/- 0.7 degrees C in the 35 degrees C hypothermia group and 33.4 +/- 0.8 degrees C in the 33 degrees C hypothermia group. Mean ICP was controlled under 20 mm Hg during hypothermia in both the 35 degrees C hypothermia and 33 degrees C hypothermia groups. The incidence of intracranial hypertension and low cerebral perfusion pressure did not differ between the two groups. The 35 degrees C hypothermic patients exhibited a significant improvement in the decline of serum potassium concentrations during hypothermia and in the increment of C-reactive protein after rewarming. The mortality rate and the incidence of systemic complications tended to be lower in the 35 degrees C group. CONCLUSIONS Cooling patients to 35 degrees C is safe and the ICP reduction effects of 35 degrees C hypothermia are similar to those of 33 degrees C hypothermia.
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Rundgren M, Engström M. A Thromboelastometric Evaluation of the Effects of Hypothermia on the Coagulation System. Anesth Analg 2008; 107:1465-8. [DOI: 10.1213/ane.0b013e31817ee955] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Schneider A, Popp E, Teschendorf P, Böttiger BW. [Therapeutic hypothermia]. Anaesthesist 2008; 57:197-206; quiz 207-8. [PMID: 18246320 DOI: 10.1007/s00101-008-1311-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The use of therapeutic hypothermia has been shown to improve survival and neurological outcome following cardiac arrest. Patients with traumatic brain injury or ischemic stroke also responded positively to therapeutic hypothermia, which may be induced by various procedures including surface cooling, endovascular cooling catheter and cold infusion. Possible side effects include infection and hemorrhage, as well as changes in water and electrolyte levels. It is the aim of this article to provide an overview of studies to date, as well as practical guidance for the application of therapeutic hypothermia.
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Affiliation(s)
- A Schneider
- Klinik für Anästhesiologie und Operative Intensivmedizin, Klinikum der Universität zu Köln, Köln.
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Regional cooling of the extracorporeal blood circuit: a novel anticoagulation approach for renal replacement therapy? Intensive Care Med 2008; 35:364-70. [PMID: 18802685 DOI: 10.1007/s00134-008-1271-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2008] [Accepted: 08/25/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To test the hypothesis that cooling of blood in the extracorporeal circuit of continuous veno-venous hemofiltration (CVVH) enables to realize the procedure without the need of anticoagulation. DESIGN Experimental animal study. METHODS We developed the device for selective cooling of extracorporeal circuit (20 degrees C) allowing blood rewarming (38 degrees C) just before returning into the body. Twelve anesthetized and ventilated pigs were randomized to receive either 6 h of CVVH with application of this device (COOL; n = 6) or without it (CONTR; n = 6). MEASUREMENTS Before the procedure and in 15, 60, 180, 360 min after starting hemofiltration variables related to: (1) circuit patency [time to clotting (TC), number of alarm-triggered pump stopping (AS), venous and transmembranous circuit pressures (VP, TMP)], (2) coagulation status in the extracorporeal circuit [thrombin-antithrombin complexes (TAT(circ)), thromboelastography (TEG)] and (3) animal status (hemodynamics, hemolysis and biochemistry) were assessed. RESULTS The patency of all circuits treated with selective cooling was well maintained within the observation period. By contrast, five of six sessions were prematurely clotted in the untreated group. As a result, the number of AS was significantly higher in the CONTR group. In-circuit thrombus generation in CONTR group was associated with a markedly increasing TAT(circ). TEG performed at 180 min of the procedure revealed a tendency to a prolonged initial clotting time and a significant decrease in clotting rate of in-circuit blood in the COOL group. No signs of repeated cooling/rewarming-induced hemolysis were observed in animals treated with "hypothermic circuit" CVVH. CONCLUSION In this porcine model, regional extracorporeal blood cooling proved effective in preventing in-circuit clotting without the need to use any other anticoagulant.
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Damage control resuscitation: A sensible approach to the exsanguinating surgical patient. Crit Care Med 2008; 36:S267-74. [DOI: 10.1097/ccm.0b013e31817da7dc] [Citation(s) in RCA: 185] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Viuff D, Lauritzen B, Pusateri AE, Andersen S, Rojkjaer R, Johansson PI. Effect of haemodilution, acidosis, and hypothermia on the activity of recombinant factor VIIa (NovoSeven). Br J Anaesth 2008; 101:324-31. [PMID: 18565966 PMCID: PMC2517151 DOI: 10.1093/bja/aen175] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background A range of plasma volume expanders is used clinically, often in settings where haemostasis may already be impaired. The haemostatic agent, recombinant activated factor VII (rFVIIa, NovoSeven®), may be used to improve haemostasis but potential interactions with different volume expanders are poorly understood. Methods Clot formation was measured by thromboelastography (TEG) using blood from healthy volunteers. In vitro effects of rFVIIa with haemodilution, acidosis, and hypothermia were examined. Conditions were induced by dilution with NaCl (0.9%), lactated Ringer's solution, albumin 5%, or hydroxyethyl starch (HES) solutions [MW (molecular weight) 130–670 kDa]; by adjusting pH to 6.8 with 1 M HEPES (N-2-hydroxyethylpiperazine-N′-2-ethanesulphonic acid) buffer; or by reducing temperature to 32°C. We also studied the effect of low vs high MW HES (MW 200 vs 600 kDa) and rFVIIa on in vivo bleeding time (BT) in rabbits. Results Haemodilution progressively altered TEG parameters. rFVIIa improved TEG parameters in the presence of acidosis, hypothermia or 20% haemodilution (P<0.05). At 40% haemodilution, the rFVIIa effect was diminished particularly with high MW HES. In vivo, rFVIIa shortened the BT (P<0.05) with low but not high MW HES. Conclusions Efficacy of rFVIIa was affected by the degree of haemodilution and type of volume expander, but not by acidosis or hypothermia.
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Affiliation(s)
- D Viuff
- Hemostasis Pharmacology, Novo Nordisk A/S, Novo Nordisk Park, 2760 Måløv, Denmark.
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Liedl CP, Friedrich TP. Assessing the bleeding patient: factors affecting hemostasis and common coagulation studies. J Contin Educ Nurs 2007; 38:247-8. [PMID: 18050979 DOI: 10.3928/00220124-20071101-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This column discusses the factors affecting hemostasis and the common coagulation studies used to assess patients with bleeding disorders.
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Affiliation(s)
- Chad P Liedl
- Mayo Clinic-Rochester , Rochester, Minnesota, USA
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