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Bishop RC, Jonk KM, Migliorisi A, Austin SM, Mullins EC, Wilkins PA. Increased packed cell volume alters point of care viscoelastic clotting parameters in horses. Equine Vet J 2024. [PMID: 39228098 DOI: 10.1111/evj.14413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 07/30/2024] [Indexed: 09/05/2024]
Abstract
BACKGROUND Polycythaemia and coagulopathy are identified risk factors for non-survival in critically ill horses. Assessment of coagulation is recommended for critical care monitoring but may be affected by concurrent polycythaemia. OBJECTIVE To evaluate the effects of induced polycythaemia on coagulation parameters as measured by a point-of-care viscoelastic coagulation device (VCM Vet™). STUDY DESIGN Prospective interventional study. METHODS Healthy adult horses (n = 7) were given 6 mcg/kg of phenylephrine IV over 15 min to induce transient polycythaemia. Samples for packed cell volume (PCV), total solids (TS), complete blood count (CBC), activated partial thromboplastin time (PTT), prothrombin (PT) and VCM Vet™ viscoelastic testing were collected at baseline (T0), 5 min (T1) and 2 h (T2) post-phenylephrine infusion. Splenic volume was measured by transabdominal ultrasonography. VCM Vet™ and plasma-based coagulation parameters, splenic volume and haematologic values were compared within and between time points. RESULTS Splenic volume decreased from T0 (11.5 ± 4.8 L) to T1 (6.1 ± 2 L, p = 0.04) and returned to baseline volume by T2 (12.1 ± 3.9 L, p = 0.8), consistent with phenylephrine-induced splenic contraction. PCV increased from T0 (37% ± 4%) to T1 (56.3% ± 5.3%; p < 0.001) and returned to baseline at T2 (41.6% ± 3.6%; p = 0.1). A10 and A20 (amplitude at 10 and 20 min, VCM units) were decreased from T0 (12.6 ± 1.6, 18.9 ± 5) to T1 (5.4 ± 1.9, 7.6 ± 2.4; both p < 0.001) and remained lower than baseline at T2 (9.3 ± 2.1, 12.7 ± 3; both p = 0.01). PT and PTT remained within reference ranges with no significant difference over time (p = 0.5 and 0.09, respectively). PCV was negatively correlated with CFT (R = -0.61, p = 0.003), A10 (R = -0.9, p < 0.001) and A20 (R = -0.87, p < 0.001). MAIN LIMITATIONS Small sample size, limited to healthy mares. CONCLUSIONS Phenylephrine-induced polycythaemia was associated with hypocoagulable viscoelastic traces using the VCM Vet™ device without effect on plasma-based coagulation assessments or platelet number. Further investigation of viscoelastic testing is needed in horses with increased PCV due to clinical illness.
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Affiliation(s)
- Rebecca C Bishop
- Department of Veterinary Clinical Medicine, University of Illinois Urbana-Champaign, Urbana, Illinois, USA
| | - Kaitlyn M Jonk
- Department of Veterinary Clinical Medicine, University of Illinois Urbana-Champaign, Urbana, Illinois, USA
| | - Alessandro Migliorisi
- Department of Veterinary Clinical Medicine, University of Illinois Urbana-Champaign, Urbana, Illinois, USA
| | - Scott M Austin
- Department of Veterinary Clinical Medicine, University of Illinois Urbana-Champaign, Urbana, Illinois, USA
| | - Emma C Mullins
- Department of Veterinary Clinical Medicine, University of Illinois Urbana-Champaign, Urbana, Illinois, USA
| | - Pamela A Wilkins
- Department of Veterinary Clinical Medicine, University of Illinois Urbana-Champaign, Urbana, Illinois, USA
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Scarlatescu E, Kim PY, Marchenko SP, Tomescu DR. Validation of the time to attain maximal clot amplitude after reaching maximal clot formation velocity parameter as a measure of fibrinolysis using rotational thromboelastometry and its application in the assessment of fibrinolytic resistance in septic patients: a prospective observational study: communication from the ISTH SSC Subcommittee on Fibrinolysis. J Thromb Haemost 2024; 22:1223-1235. [PMID: 38104723 DOI: 10.1016/j.jtha.2023.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 11/12/2023] [Accepted: 12/04/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND In sepsis, fibrinolysis resistance correlates with worse outcomes. Practically, rotational thromboelastometry (ROTEM) is used to report residual clot amplitude relative to maximum amplitude at specified times after clot formation clot lysis indices (CLIs). However, healthy individuals can exhibit similar CLIs, thus making it challenging to solely diagnose the low fibrinolytic state. Furthermore, CLI does not include the kinetics of clot formation, which can affect overall fibrinolysis. Therefore, a more nuanced analysis, such as time to attain maximal clot amplitude after reaching maximal clot formation velocity (t-AUCi), is needed to better identify fibrinolysis resistance in sepsis. OBJECTIVES To evaluate the correlation between the degree of fibrinolytic activation and t-AUCi in healthy or septic individuals. METHODS Whole blood (n = 60) from septic or healthy donors was analyzed using tissue factor-activated (EXTEM) and nonactivated (NATEM) ROTEM assays. Lysis was initiated with tissue-type plasminogen activator, and CLI and t-AUCi were calculated. Standard coagulation tests and plasma fibrinolysis markers (D-dimer, plasmin-α2-antiplasmin complex, plasminogen activator inhibitor type 1, and plasminogen) were also measured. RESULTS t-AUCi values decreased with increasing fibrinolytic activity and correlated positively with CLI for different degrees of clot lysis both in EXTEM and NATEM. t-AUCi cutoff value of 1962.0 seconds in EXTEM predicted low fibrinolytic activity with 81.8% sensitivity and 83.7% specificity. In addition, t-AUCi is not influenced by clot retraction. CONCLUSION Whole-blood point-of-care ROTEM analyses with t-AUCi offers a more rapid and parametric evaluation of fibrinolytic potential compared with CLI, which can be used for a more rapid and accurate diagnosis of fibrinolysis resistance in sepsis.
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Affiliation(s)
- Ecaterina Scarlatescu
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania; Department of Anesthesia and Intensive Care III, Fundeni Clinical Institute, Bucharest, Romania.
| | - Paul Y Kim
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Sergey P Marchenko
- Department of Cardiac Surgery, Pavlov First St. Petersburg Medical University, St. Petersburg, Russian Federation
| | - Dana R Tomescu
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania; Department of Anesthesia and Intensive Care III, Fundeni Clinical Institute, Bucharest, Romania
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Donkin R, Fung YL, Singh I. Fibrinogen, Coagulation, and Ageing. Subcell Biochem 2023; 102:313-342. [PMID: 36600138 DOI: 10.1007/978-3-031-21410-3_12] [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: 01/06/2023]
Abstract
The World Health Organization estimates that the world's population over 60 years of age will nearly double in the next 30 years. This change imposes increasing demands on health and social services with increased disease burden in older people, hereafter defined as people aged 60 years or more. An older population will have a greater incidence of cardiovascular disease partly due to higher levels of blood fibrinogen, increased levels of some coagulation factors, and increased platelet activity. These factors lead to a hypercoagulable state which can alter haemostasis, causing an imbalance in appropriate coagulation, which plays a crucial role in the development of cardiovascular diseases. These changes in haemostasis are not only affected by age but also by gender and the effects of hormones, or lack thereof in menopause for older females, ethnicity, other comorbidities, medication interactions, and overall health as we age. Another confounding factor is how we measure fibrinogen and coagulation through laboratory and point-of-care testing and how our decision-making on disease and treatment (including anticoagulation) is managed. It is known throughout life that in normal healthy individuals the levels of fibrinogen and coagulation factors change, however, reference intervals to guide diagnosis and management are based on only two life stages, paediatric, and adult ranges. There are no specific diagnostic guidelines based on reference intervals for an older population. How ageing relates to alterations in haemostasis and the impact of the disease will be discussed in this chapter. Along with the effect of anticoagulation, laboratory testing of fibrinogen and coagulation, future directions, and implications will be presented.
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Affiliation(s)
- Rebecca Donkin
- The University of the Sunshine Coast, School of Health and Behavioural Sciences, Sippy Downs, QLD, Australia. .,Griffith University, School of Medicine and Dentistry, Gold Coast, QLD, Australia.
| | - Yoke Lin Fung
- The University of the Sunshine Coast, School of Health and Behavioural Sciences, Sippy Downs, QLD, Australia
| | - Indu Singh
- Griffith University, School of Pharmacy and Medical Science, Gold Coast, QLD, Australia
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Characterization of 2 Different Prothrombin Complex Concentrates by Different Hemostatic Assays in an In Vitro Hemodilution Model. Anesth Analg 2022; 135:1031-1040. [PMID: 35984000 DOI: 10.1213/ane.0000000000006174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Viscoelastically guided coagulation factor concentrate-based algorithms for the treatment of trauma-induced coagulopathy include the administration of prothrombin complex concentrates (PCCs). However, the exact role of PCC preparations in this context is a matter of debate. Particularly, the ideal diagnostic trigger for their administration and potential differences between heparin-containing and heparin-free preparations remain unclear. We investigated the hypothesis that 2 different PCCs might have distinct influences on in vitro blood coagulation. METHODS We conducted a direct comparison of 2 commercially available PCC preparations (the heparin-containing Beriplex P/N and the heparin-free Cofact) in an in vitro hemodilution model. Sole fibrinogen substitution served as the control group. To characterize the hemostatic changes, we utilized conventional coagulation tests, a thrombin generation assay (TGA), and 2 different viscoelastic hemostatic assays (VHAs; ROTEM delta and ClotPro). RESULTS Irrespective of the diagnostic assay used, no significant differences between the 2 PCC groups were observed. Fibrinogen levels remained stable from the baseline throughout every dilution level. The control group already showed an increased endogenous thrombin potential (ETP; nM·L -1 ·min -1 ) at all dilution levels compared to baseline (baseline, 2829.4 (432.8); 40% dilution, 4211.7 (391.6); 60% dilution, 4290.9 (300.8); 80% dilution, 3861.4 (303.5); all P < .001). Spiking with both PCC preparations led to a further-pronounced thrombin elevation in comparison to the control group (ETP at 40% dilution, PCC1: 4913.3 [370.2], PCC2: 4988.1 [265.7]; 60% dilution, PCC1: 5174.5 [234.7], PCC2: 5390.4 [334.9]; 80% dilution, PCC1: 5253.8 [357.9], PCC2: 5392.6 [313.4]; all P < .001). Conventional coagulation tests did not mirror the TGA results. Despite increased thrombin generation, prothrombin time was significantly prolonged at all dilution levels for the control group, and both PCC groups exhibited significant prolongations at the 60% and 80% dilution levels (all P < .001) compared to baseline. Similarly, VHA did not depict the thrombin elevation. Furthermore, descriptive analyses revealed relevant differences between the 2 VHA devices, particularly at baseline. CONCLUSIONS Both PCC preparations (ie, irrespective of heparin content) induced significant elevation of thrombin generation, which was not depicted by conventional coagulation tests or VHA. Our in vitro results suggest that diagnostic assays routinely used to guide PCC administration might not adequately reflect thrombin generation in bleeding patients.
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Mamczak CN, Speybroeck J, Stillson JE, Dynako J, Piscoya A, Peck EE, Aboukhaled M, Cancel E, McDonald M, Garcia D, Lovejoy J, Lubin S, Stanton R, Kutcher ME. Viscoelastic Hemostatic Assays for Orthopedic Trauma and Elective Procedures. J Clin Med 2022; 11:jcm11144029. [PMID: 35887803 PMCID: PMC9323142 DOI: 10.3390/jcm11144029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/07/2022] [Accepted: 07/07/2022] [Indexed: 02/04/2023] Open
Abstract
The application of viscoelastic hemostatic assays (VHAs) (e.g., thromboelastography (TEG) and rotational thromboelastometry (ROTEM)) in orthopedics is in its relative infancy when compared with other surgical fields. Fortunately, several recent studies describe the emerging use of VHAs to quickly and reliably analyze the real-time coagulation and fibrinolytic status in both orthopedic trauma and elective orthopedic surgery. Trauma-induced coagulopathy—a spectrum of abnormal coagulation phenotypes including clotting factor depletion, inadequate thrombin generation, platelet dysfunction, and dysregulated fibrinolysis—remains a potentially fatal complication in severely injured and/or hemorrhaging patients whose timely diagnosis and management are aided by the use of VHAs. Furthermore, VHAs are an invaluable compliment to common coagulation tests by facilitating the detection of hypercoagulable states commonly associated with orthopedic injury and postoperative status. The use of VHAs to identify hypercoagulability allows for an accurate venous thromboembolism (VTE) risk assessment and monitoring of VTE prophylaxis. Until now, the data have been insufficient to permit an individualized approach with regard to dosing and duration for VTE thromboprophylaxis. By incorporating VHAs into routine practice, orthopedic surgeons will be better equipped to diagnose and treat the complete spectrum of coagulation abnormalities faced by orthopedic patients. This work serves as an educational primer and up-to-date review of the current literature on the use of VHAs in orthopedic surgery.
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Affiliation(s)
- Christiaan N. Mamczak
- Department of Orthopaedic Trauma, Florida Orthopaedic Institute, St. Petersburg, FL 33701, USA;
| | - Jacob Speybroeck
- Department of Orthopaedic Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA;
| | - John E. Stillson
- Department of Family Medicine, John Peter Smith Hospital, Fort Worth, TX 76104, USA
- Correspondence:
| | - Joseph Dynako
- Department of Orthopaedic Surgery, University of Mississippi Medical Center, Jackson, MS 39216, USA;
| | - Andres Piscoya
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA;
| | - Ethan E. Peck
- Department of Emergency Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (E.E.P.); (M.A.); (E.C.); (D.G.)
| | - Michael Aboukhaled
- Department of Emergency Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (E.E.P.); (M.A.); (E.C.); (D.G.)
| | - Emily Cancel
- Department of Emergency Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (E.E.P.); (M.A.); (E.C.); (D.G.)
| | - Michael McDonald
- Department of Graduate Medical Education, Naval Medical Readiness and Training Command, Portsmouth, VA 23708, USA;
| | - Diego Garcia
- Department of Emergency Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (E.E.P.); (M.A.); (E.C.); (D.G.)
| | - John Lovejoy
- Department of Orthopaedic Surgery, University of Florida Health Jacksonville, Jacksonville, FL 32209, USA;
| | - Stephanie Lubin
- Department of Orthopaedic Surgery, Hôpital Sacré Coeur, Milot 1230, Haiti;
| | - Robert Stanton
- Department of Pediatric Orthopaedics, Nemours Children’s Health-Florida, Orlando, FL 32827, USA;
| | - Matthew E. Kutcher
- Departments of Surgery and Emergency Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA;
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Rodgers SC, Carter KT, Patki D, O'Brien RC, Kutcher ME. Thromboelastography-Based Evaluation of Gender-Associated Hypercoagulability. Am Surg 2022; 88:2619-2625. [PMID: 35576492 DOI: 10.1177/00031348221087905] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Age, race, and gender differences in coagulation status of healthy volunteers have been reported in previous case series; however, rigorous multivariate analysis adjusting for these factors is lacking. We aimed to investigate the effects of age, race, and gender on baseline coagulation status in healthy volunteers. METHODS Thirty healthy volunteer controls with no history of bleeding or thrombotic events and no previous anticoagulant or antiplatelet use were recruited. Citrated and heparinized blood samples were drawn, and kaolin and platelet-mapping thromboelastography (TEG) assays performed. RESULTS Thirty participants had a mean age of 37, mean body mass index of 29 kg/m2, and were 47% African-American and 70% female. Women were significantly older than men (40 ± 11 y vs 28 ± 7 y, P = .002); there were no significant differences in demographics by race. Multivariate analysis of variance for the effect of age, race, and gender across TEG parameters yielded evidence for gender differences in hypercoagulability (Pillai's trace P = .02), which appear to be driven by differences in K-time, alpha angle, maximal amplitude, and G parameter. Women were hypercoagulable compared to men, as manifested by shorter K-time, steeper alpha angle, higher maximal amplitude, and larger G parameter. DISCUSSION Women at baseline have relatively hypercoagulable fibrin deposition kinetics, platelet contributions to clot formation, and overall clot strength compared to men, even when adjusted for age and race. Additional research is needed to specifically detail the key patient-level factors, clinical implications, and opportunities for tailored therapy related to gender-associated hypercoagulability.
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Affiliation(s)
- Skylar C Rodgers
- Department of Surgery, 21693University of Mississippi Medical Center, Jackson, MS, USA
| | - Kristen T Carter
- Department of Surgery, 21693University of Mississippi Medical Center, Jackson, MS, USA
| | - Deepti Patki
- Department of Surgery, 21693University of Mississippi Medical Center, Jackson, MS, USA
| | - Robert C O'Brien
- Department of Surgery, 21693University of Mississippi Medical Center, Jackson, MS, USA
| | - Matthew E Kutcher
- Department of Surgery, 21693University of Mississippi Medical Center, Jackson, MS, USA
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Duman Güven D, Ulukaya S, Sergin DY, Deniz MN, Fırat Ö. Thromboelastography of Patients Undergoing Bariatric Surgery. Bariatr Surg Pract Patient Care 2020. [DOI: 10.1089/bari.2019.0032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Dilek Duman Güven
- Department of Anesthesiology and Reanimation, Ege University School of Medicine, Izmir, Turkey
| | - Sezgin Ulukaya
- Department of Anesthesiology and Reanimation, Ege University School of Medicine, Izmir, Turkey
| | - Demet Y. Sergin
- Department of Anesthesiology and Reanimation, Ege University School of Medicine, Izmir, Turkey
| | - Mustafa N. Deniz
- Department of Anesthesiology and Reanimation, Ege University School of Medicine, Izmir, Turkey
| | - Özgür Fırat
- Department of General Surgery, Ege University School of Medicine, Izmir, Turkey
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Sun JB, Bian MH, Zhong T, Lu YY, Zhu BQ, Wen HQ, Hu HL. Reference values for kaolin-activated thromboelastography in volunteers of Anhui Province in China. J Clin Lab Anal 2017; 31. [PMID: 28133787 DOI: 10.1002/jcla.22128] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 12/12/2016] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND The assessment of the coagulation status using thromboelastography (TEG) in Chinese population has less been reported. This study aimed to establish reliable reference values for kaolin-activated TEG in Chinese volunteers. METHODS A total of 1681 Chinese adult individuals were recruited for this study. The reference individuals were stratified by gender and age, and the TEG values were measured on the basis of strict quality control. The 95% reference values were determined using nonparametric statistical methods. RESULTS The sex-related 95% reference values were reaction time (R):4.2-8.7 minutes; clotting time (K): 1.2-3.2 minutes; alpha angle (α): 47.0-72.3 degree; maximum amplitude (MA): 49.1-70.5 mm for males, and R: 3.7-9.0 minutes; K: 1.0-3.2 minutes; α: 48.4-74.4 degree; MA: 46.8-72.4 mm for females. Also, the TEG parameters indicated a relatively more hypercoagulable profile in both female and elder groups. CONCLUSIONS This study established the reference values for kaolin-activated TEG in the target Chinese population, which might provide a reference for both clinical and laboratory studies.
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Affiliation(s)
- Jun-Bo Sun
- Department of Blood Transfusion, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China.,Department of Blood Transfusion, The Second Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Mao-Hong Bian
- Department of Blood Transfusion, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Tao Zhong
- Department of Blood Transfusion, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Ying-Yu Lu
- Department of Blood Transfusion, The Second Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Bang-Qiang Zhu
- Department of Blood Transfusion, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Hui-Qin Wen
- Department of Blood Transfusion, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Hai-Liang Hu
- Department of Blood Transfusion, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
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De Pietri L, Bianchini M, Rompianesi G, Bertellini E, Begliomini B. Thromboelastographic reference ranges for a cirrhotic patient population undergoing liver transplantation. World J Transplant 2016; 6:583-593. [PMID: 27683637 PMCID: PMC5036128 DOI: 10.5500/wjt.v6.i3.583] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Revised: 06/21/2016] [Accepted: 08/16/2016] [Indexed: 02/05/2023] Open
Abstract
AIM To describe the thromboelastography (TEG) “reference” values within a population of liver transplant (LT) candidates that underline the differences from healthy patients.
METHODS Between 2000 and 2013, 261 liver transplant patients with a model for end-stage liver disease (MELD) score between 15 and 40 were studied. In particular the adult patients (aged 18-70 years) underwent to a first LT with a MELD score between 15 and 40 were included, while all patients with acute liver failure, congenital bleeding disorders, and anticoagulant and/or antiplatelet drug use were excluded. In this population of cirrhotic patients, preoperative haematological and coagulation laboratory tests were collected, and the pretransplant thromboelastographic parameters were studied and compared with the parameters measured in a previously studied population of 40 healthy subjects. The basal TEG parameters analysed in the cirrhotic population of liver candidates were as follows: Reaction time (r), coagulation time (k), Angle-Rate of polymerization of clot (αAngle), Maximum strenght of clot (MA), Amplitudes of the TEG tracing at 30 min and 60 min after MA is measured (A30 and A60), and Fibrinolysis at 30 and 60 min after MA (Ly30 and Ly60). The possible correlation between the distribution of the reference range and the gender, age, MELD score (higher or lower than 20) and indications for transplantation (liver pathology) were also investigated. In particular, a MELD cut-off value of 20 was chosen to verify the possible correlation between the thromboelastographic reference range and MELD score.
RESULTS Most of the TEG reference values from patients with end-stage liver disease were significantly different from those measured in the healthy population and were outside the suggested normal ranges in up to 79.3% of subjects. Wide differences were found among all TEG variables, including r (41.5% of the values), k (48.6%), α (43.7%), MA (79.3%), A30 (74.4%) and A60 (80.9%), indicating a prevailing trend to hypocoagulability. The differences between the mean TEG values obtained from healthy subjects and the cirrhotic population were statistically significant for r (P = 0.039), k (P < 0.001), MA (P < 0.001), A30 (P < 0.001), A60 (P < 0.001) and Ly60 (P = 0.038), indicating slower and less stable clot formation in the cirrhotic patients. In the cirrhotic population, 9.5% of patients had an r value shorter than normal, indicating a tendency for faster clot formation. Within the cirrhotic patient population, gender, age and the presence of hepatocellular carcinoma or alcoholic cirrhosis were not significantly associated with greater clot firmness or enhanced whole blood clot formation, whereas greater clot strength was associated with a MELD score < 20, hepatitis C virus and cholestatic-related cirrhosis (P < 0.001; P = 0.013; P < 0.001).
CONCLUSION The range and distribution of TEG values in cirrhotic patients differ from those of healthy subjects, suggesting that a specific thromboelastographic reference range is required for liver transplant candidates.
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10
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Gehrie EA, Baine I, Booth GS. Pathology Consultation on Viscoelastic Studies of Coagulopathic Obstetrical Patients. Am J Clin Pathol 2016; 146:149-55. [PMID: 27124951 DOI: 10.1093/ajcp/aqw044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES In obstetrics, the decision to transfuse blood components has historically been driven by traditional laboratory testing in combination with direct observation of bleeding. The adjunctive use of viscoelastic testing, including thromboelastometry and thromboelastography, has gained increasing acceptance in the clinical domain. METHODS We performed a review of the published medical literature by searching the PUBMED database for keywords "viscoelastic" and "obstetric," as well as "viscoelastic" and "postpartum hemorrhage." Additionally, case reports and expert opinion publications that referenced viscoelastic studies in obstetrical patients were evaluated. RESULTS There is very little high-quality evidence currently published in the medical literature to support the notion that viscoelastic testing obviates the need for traditional coagulation testing or improves mortality resulting from major obstetrical hemorrhage. CONCLUSIONS Additional research is needed to further focus the optimum role of viscoelastic tests in major obstetrical hemorrhage.
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Affiliation(s)
- Eric A Gehrie
- From the Department of Laboratory Medicine, Yale University, New Haven, CT;
| | - Ian Baine
- From the Department of Laboratory Medicine, Yale University, New Haven, CT
| | - Garrett S Booth
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN
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11
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Differences between coagulation and cytokine profiles in dogs of different ages. Vet J 2015; 205:410-2. [PMID: 26073287 DOI: 10.1016/j.tvjl.2015.05.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Revised: 04/26/2015] [Accepted: 05/17/2015] [Indexed: 11/22/2022]
Abstract
In human medicine, age is a risk factor for thromboembolic diseases associated with hypercoagulable and antifibrinolytic states, but information in veterinary medicine is limited. This study compared the thromboelastometric (TEM) profiles of two groups of dogs of distinct ages. Ten healthy old (>10 years) Beagles and 10 healthy young (<3 years) Beagles were recruited. White blood cell counts and haematocrit were significantly lower in the old group compared to the young group, and fibrinogen, total proteins, globulins and monocyte chemoattractant protein-1 plasma concentrations were significantly higher in the old group. Comparisons of the TEM profiles indicated a hypercoagulable profile and a decrease in fibrinolytic activity in all old Beagles. The findings support the need to consider age as a possible risk factor for thrombosis in dogs.
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12
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Holli Halset J, Hanssen SW, Espinosa A, Klepstad P. Tromboelastography: variability and relation to conventional coagulation test in non-bleeding intensive care unit patients. BMC Anesthesiol 2015; 15:28. [PMID: 25755628 PMCID: PMC4353683 DOI: 10.1186/s12871-015-0011-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2014] [Accepted: 02/21/2015] [Indexed: 01/23/2023] Open
Abstract
Background Intensive care unit (ICU) patients usually have abnormal biochemical and hematological laboratory test results as a consequence of organ dysfunction and underlying disease. Thromboelastography (TEG®) is a point-of-care laboratory analysis that gives an overview of several aspects of the coagulation process. In order to be able to perform a clinical interpretation of abnormal TEG® results the expected values from non-bleeding ICU patients should be known. The aim of this study is to report the normal variability observed in non-bleeding, non-transfused ICU patients. Methods Adult ICU patients without bleeding in the last 24 hours, who had not received blood products within the last 24 hours, with no hematological diseases and no anticoagulation therapeutic treatment were included. Standard clinical chemistry tests, coagulation tests and TEG® were obtained. All results were reported in relation to standard reference values. TEG® values were compared with routine coagulation measurement using Spearman correlations. Results We observed that the normal variability observed in non-bleeding, non-transfused ICU patients in this study included abnormally high TEG® values for maximum amplitude (MA) (73%). None of the patients showed MA results corresponding to hypocoagulability. Other coagulation tests were also changed with elevated D-Dimer, fibrinogen and APTT values, and a low ATIII value. Conclusion In unselected ICU patients without bleeding or known factors that influence coagulation, a TEG® value of MA is often elevated suggesting hypercoagulability. This finding should be considered when interpreting TEG® observations obtained in ICU patients.
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Affiliation(s)
- Jørgen Holli Halset
- Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Simon Wøhlert Hanssen
- Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Aurora Espinosa
- Department of Immunology and Transfusion Medicine, St. Olav University Hospital, Trondheim, Norway
| | - Pål Klepstad
- Department of Anesthesiology and Intensive Care Medicine, St. Olav University Hospital, Trondheim, Norway ; Department of Circulation and Medical Imaging, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway ; Department of Intensive Care Medicine, St. Olav University Hospital, P.O. box 3250 Sluppen, N-7006 Trondheim, Norway
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13
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McMichael MA, Smith SA, Galligan A, Swanson KS. In vitro hypercoagulability on whole blood thromboelastometry associated with in vivo reduction of circulating red cell mass in dogs. Vet Clin Pathol 2014; 43:154-63. [DOI: 10.1111/vcp.12127] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Maureen A. McMichael
- Department of Veterinary Clinical Sciences; College of Veterinary Medicine; University of Illinois; Urbana IL USA
| | - Stephanie A. Smith
- Department of Biochemistry; College of Medicine; University of Illinois; Urbana IL USA
| | - Alyssa Galligan
- Department of Veterinary Clinical Sciences; College of Veterinary Medicine; University of Illinois; Urbana IL USA
| | - Kelly S. Swanson
- Department of Veterinary Clinical Sciences; College of Veterinary Medicine; University of Illinois; Urbana IL USA
- Department of Animal Sciences; College of Agricultural, Consumer & Environmental Sciences; University of Illinois; Urbana IL USA
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14
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Park F, Blois S, Abrams-Ogg A, Wood R, Allen D, Nykamp S, Downie A. Hypercoagulability and ACTH-Dependent Hyperadrenocorticism in Dogs. J Vet Intern Med 2013; 27:1136-42. [DOI: 10.1111/jvim.12162] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Revised: 05/23/2013] [Accepted: 07/16/2013] [Indexed: 11/28/2022] Open
Affiliation(s)
- F.M. Park
- Department of Clinical Studies; Ontario Veterinary College; University of Guelph; Guelph ON
| | - S.L. Blois
- Department of Clinical Studies; Ontario Veterinary College; University of Guelph; Guelph ON
| | - A.C.G. Abrams-Ogg
- Department of Clinical Studies; Ontario Veterinary College; University of Guelph; Guelph ON
| | - R.D. Wood
- Department of Pathobiology; Ontario Veterinary College; University of Guelph; Guelph ON
| | - D.G. Allen
- Department of Clinical Studies; Ontario Veterinary College; University of Guelph; Guelph ON
| | - S.G. Nykamp
- Department of Clinical Studies; Ontario Veterinary College; University of Guelph; Guelph ON
| | - A. Downie
- Health Sciences Center (Downie); Ontario Veterinary College; University of Guelph; Guelph ON
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15
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Lennon E, Hanel R, Walker J, Vaden S. Hypercoagulability in Dogs with Protein-Losing Nephropathy as Assessed by Thromboelastography. J Vet Intern Med 2013; 27:462-8. [DOI: 10.1111/jvim.12067] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Revised: 01/14/2013] [Accepted: 02/04/2013] [Indexed: 01/24/2023] Open
Affiliation(s)
- E.M. Lennon
- North Carolina State University College of Veterinary Medicine; Raleigh NC
| | - R.M. Hanel
- North Carolina State University College of Veterinary Medicine; Raleigh NC
| | - J.M. Walker
- North Carolina State University College of Veterinary Medicine; Raleigh NC
| | - S.L. Vaden
- North Carolina State University College of Veterinary Medicine; Raleigh NC
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16
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Sankarankutty A, Nascimento B, Teodoro da Luz L, Rizoli S. TEG® and ROTEM® in trauma: similar test but different results? World J Emerg Surg 2012; 7 Suppl 1:S3. [PMID: 23531394 PMCID: PMC3424963 DOI: 10.1186/1749-7922-7-s1-s3] [Citation(s) in RCA: 89] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Introduction Transfusion in trauma is often empiric or based on traditional lab tests. Viscoelastic tests such as thromboelastography (TEG®) and rotational thromboelastometry (ROTEM®) have been proposed as superior to traditional lab tests. Due to the similarities between the two tests, general opinion seems to consider them equivalent with interchangeable interpretations. However, it is not clear whether the results can be similarly interpreted. This review evaluates the comparability between TEG and ROTEM and performs a descriptive review of the parameters utilized in each test in adult trauma patients. Methods PUBMED database was reviewed using the keywords “thromboelastography” and “compare”, between 2000 and 2011. Original studies directly comparing TEG® with ROTEM® in any area were retrieved. To verify the individual test parameter used in studies involving trauma patients, we further performed a review using the keywords “thromboelastography” and “trauma” in the PUBMED database. Results Only 4 studies directly compared TEG® with ROTEM®. One in liver transplantation found that transfusion practice could differ depending on the device in use. Another in cardiac surgery concluded that all measurements are not completely interchangeable. The third article using commercially available plasma detected clinically significant differences in the results from the two devices. The fourth one was a head-to-head comparison of the technical aspects. The 24 articles reporting the use of viscoelastic tests in trauma patients, presented considerable heterogeneity. Conclusion Both tests are potentially useful as means to rapidly diagnose coagulopathy, guide transfusion and determine outcome in trauma patients. Differences in the activators utilized in each device limit the direct comparability. Standardization and robust clinical trials comparing the two technologies are needed before these tests can be widely recommended for clinical use in trauma.
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Affiliation(s)
- Ajith Sankarankutty
- Departments of Surgery and Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada.
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In-vitro hypocoagulability on whole blood thromboelastometry associated with in-vivo expansion of red cell mass in an equine model. Blood Coagul Fibrinolysis 2011; 22:424-30. [PMID: 21508831 DOI: 10.1097/mbc.0b013e3283464f83] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
In several species, there is a strong correlation between indicators of red cell mass (RCM) and thromboelastometry results. The horse has a reliable, temporary, polycythemia in response to phenylephrine infusion. Our objective was to evaluate the effects of an in-vivo increase in circulating RCM on thromboelastometry results in an equine model of transient polycythemia. Six healthy research horses had whole blood thromboelastometry with contact activator and tissue factor initiation after recalcification of citrated samples. Additional samples were frozen for thrombin-antithrombin (TAT). Complete blood count biochemical analysis, fibrinogen, activated partial thromboplastin time (aPTT), and prothrombin time (PT) were performed. Additional samples were taken at 5 min and 2 h after phenylephrine infusion. Thromboelastometry was performed separately on four horses not receiving phenylephrine with the samples divided and spiked with phenylephrine ex vivo. Red cell count (P<0.001) and hematocrit (P<0.001) were significantly higher at 5 min after phenylephrine compared with baseline and 2 h. There was no change in platelet count, fibrinogen, PT, aPTT, or TAT at any time point. Both ex-tem and in-tem parameters were hypocoagulable at 5 min after phenylephrine compared to baseline and 2 h. There was no effect of phenylephrine in the ex-vivo spiking studies on any of the thromboelastometry parameters. Whole blood thromboelastometry results were hypocoagulable in this equine model of in-vivo transient polycythemia only during the polycythemic phase. All other coagulation parameters were unchanged. In the absence of other indicators of hypocoagulability, this may point to an artifact of thromboelastometry. Alternatively, the data may reflect true in-vivo hypocoagulability in patients with increased circulating RCM.
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Roeloffzen WWH, Kluin-Nelemans HC, Mulder AB, Veeger NJGM, Bosman L, de Wolf JTM. In Normal Controls, Both Age and Gender Affect Coagulability as Measured by Thrombelastography. Anesth Analg 2010; 110:987-94. [DOI: 10.1213/ane.0b013e3181d31e91] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Roeloffzen WWH, Kluin-Nelemans HC, Bosman L, de Wolf JTM. Effects of red blood cells on hemostasis. Transfusion 2010; 50:1536-44. [PMID: 20158685 DOI: 10.1111/j.1537-2995.2010.02586.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Currently there is no sensitive laboratory test to establish the influence of red blood cells (RBCs) on hemostasis. As thromboelastography (TEG) measures hemostasis in whole blood, taking into account the interactions of all cellular elements, we used this instrument to investigate the role that RBCs play in hemostasis. STUDY DESIGN AND METHODS In 29 patients with chemotherapy-induced anemia we studied the effect of progressive anemia on the coagulation profile. In 24 patients with chronic anemia we studied the effect of transfusion of RBCs on coagulation. Finally, in 18 patients we evaluated whether storage time of RBCs has additional effects on hemostasis. RESULTS We observed a significant negative correlation between hemoglobin and TEG variables related to both clot strength and elasticity (p < 0.05). Moreover, anemia was associated with a delay in the initiation of the coagulation cascade. Correction of anemia by RBC transfusion resulted in significant shortening of this initiation phase with now the opposite effect on clot strength and elasticity. The negative effects on clot quality were significantly worse when fresh RBCs were transfused compared to longer-stored RBCs. Furthermore, in contrast to the longer-stored RBCs, fresh RBCs did not enhance initial fibrin formation. CONCLUSIONS In this study we found that anemia was associated with a delay in the initiation of the coagulation cascade with a finally formed clot with superior strength and viscoelastic properties. Transfusion of RBCs was associated with impaired clot quality, with even worse effects on the initial fibrin build-up and clot quality by fresh RBCs.
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Affiliation(s)
- Wilfried W H Roeloffzen
- Department of Hematology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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20
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A comparison of kaolin-activated versus nonkaolin-activated thromboelastography in native and citrated blood. Blood Coagul Fibrinolysis 2008; 19:495-501. [PMID: 18685432 DOI: 10.1097/mbc.0b013e3282f9adf9] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Thromboelastography can be performed with native or citrated blood (a surrogate to native blood in healthy controls, surgical and cirrhotic patients). Activators such as kaolin are increasingly used to reduce the time to trace generation. To compare kaolin-activated thromboelastography with nonkaolin-activated thromboelastography of native and citrated blood in patients with liver disease, patients undergoing treatment with warfarin or low-molecular weight heparin and healthy volunteers. We studied thromboelastography parameters in 21 healthy volunteers (group 1) and 50 patients, including 20 patients with liver cirrhosis with a nonbiliary aetiology (group 2), 10 patients with primary biliary cirrhosis or primary sclerosing cholangitis (group 3), 10 patients on warfarin treatment (group 4) and 10 patients with enoxaparin prophylaxis (group 5). Thromboelastography was performed using four methods: native blood (kaolin-activated and nonkaolin-activated) and citrated blood (kaolin-activated and nonkaolin-activated). For all thromboelastography parameters, correlation was poor (Spearman correlation coefficient < 0.70) between nonkaolin-activated and kaolin-activated thromboelastography, for both citrated and native blood. In healthy volunteers, in patients with liver disease and in those receiving anticoagulant treatment, there was a poor correlation between nonkaolin-activated and kaolin-activated thromboelastography. Kaolin-activated thromboelastography needs further validation before routine clinical use in these settings, and the specific methodology must be considered in comparing published studies.
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21
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Race and sex differences in thrombogenicity: risk of ischemic events following coronary stenting. Blood Coagul Fibrinolysis 2008; 19:268-75. [DOI: 10.1097/mbc.0b013e3282ff76ae] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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22
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Ng KFJ, Lawmin JC, Li CCF, Tsang SF, Tang WM, Chiu KY. Comprehensive preoperative evaluation of platelet function in total knee arthroplasty patients taking diclofenac. J Arthroplasty 2008; 23:424-30. [PMID: 18358383 DOI: 10.1016/j.arth.2007.04.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2006] [Accepted: 04/07/2007] [Indexed: 02/01/2023] Open
Abstract
The severity and variability of platelet dysfunction in preoperative arthritic patients taking nonsteroidal anti-inflammatory drugs (NSAIDs) have not been well studied previously. We evaluate 30 preoperative patients taking diclofenac (group D) by routine coagulation screen, platelet count, fibrinogen concentration, thrombelastography, and PFA-100 (Dade Behring, Inc, Deerfield, IL)) platelet function analyzer. Ten patients (group P) and 30 healthy volunteers (group N) not taking NSAIDs serve as control. Diclofenac causes significant prolongation of mean PFA-100 closure times (P < .0001). However, the prolongation is highly variable; and up to 33% of patients are still having normal platelet function despite diclofenac consumption. Low body weight is a significant predictor of more severe platelet dysfunction (P < .01). Other tests are not useful. We conclude that not all patients taking NSAIDs have similar platelet dysfunction and that preoperative monitoring with PFA-100 is preferable.
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Affiliation(s)
- Kwok F J Ng
- Department of Anaesthesiology, The University of Hong Kong, Hong Kong, China
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Lang T, Bauters A, Braun SL, Pötzsch B, von Pape KW, Kolde HJ, Lakner M. Multi-centre investigation on reference ranges for ROTEM thromboelastometry. Blood Coagul Fibrinolysis 2005; 16:301-10. [PMID: 15870552 DOI: 10.1097/01.mbc.0000169225.31173.19] [Citation(s) in RCA: 380] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Reagent-supported thromboelastometry (TEM) with the ROTEM Whole Blood Haemostasis Analyser is an enhancement of thromboelastography, a method that is increasingly used for the point of care monitoring of acute perioperative bleeding disorders. We investigated the reference ranges of two activated tests (INTEM and EXTEM) and a test analysing specifically the fibrin component of coagulation (FIBTEM) in a multi-centre approach. The reference ranges obtained for the clotting time (CT), clot formation time (CFT), alpha angle (ALP), maximum clot firmness (MCF) and clot lysis parameters were comparable from centre to centre. INTEM: CT equals; 137-246 s, CFT equals; 40-100 s, MCF equals; 52-72 mm. EXTEM: CT equals; 42-74 s, CFT equals; 46-148 s, MCF equals; 49-71 mm. FIBTEM: MCF equals; 9-25 mm. ROTEM whole blood coagulation correlated weakly with a trend towards enhanced coagulation in females compared with males and in advanced age. The repeatability (within-run imprecision) of the results was dependent on the test with the following coefficients of variation: 1-5% (clot firmness, alpha angle), 3-12% (CT, CFT), 6-13% (FIBTEM clot firmness). Citrated blood samples were stable for ROTEM analysis stored within 6 h from drawing. In summary, the data showed that ROTEM thromboelastometry yields consistent values between centres and that providing general orientating reference ranges seems to be possible.
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Affiliation(s)
- Thomas Lang
- Clinical Institute of Medical and Chemical Laboratory Diagnostic, University Clinic of Graz, Austria
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Abstract
The term thrombelastograph (TEG) was used to describe the trace produced from the measurement of the viscoelastic changes associated with fibrin polymerization. Recently the term rotational thromboelastometry has been applied to the output of the ROTEM instrument. Since its first description in 1948, the TEG/ROTEM has been successfully used in the near patient assessment of haemostasis. The greatest use has been the application of TEG-guided transfusion of blood components in hepatic and more widely in cardiac surgery. Recent years have seen a renewed interest in the technology with applications for both pharmaceutical monitoring and patient screening being described. The present review gives a broad overview of the developments and applications related to thrombelastography/thromboelastometry.
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Affiliation(s)
- R J Luddington
- Haematology Department, Addenbrooke's Hospital, Cambridge, UK.
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