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Coccolini F, Shander A, Ceresoli M, Moore E, Tian B, Parini D, Sartelli M, Sakakushev B, Doklestich K, Abu-Zidan F, Horer T, Shelat V, Hardcastle T, Bignami E, Kirkpatrick A, Weber D, Kryvoruchko I, Leppaniemi A, Tan E, Kessel B, Isik A, Cremonini C, Forfori F, Ghiadoni L, Chiarugi M, Ball C, Ottolino P, Hecker A, Mariani D, Melai E, Malbrain M, Agostini V, Podda M, Picetti E, Kluger Y, Rizoli S, Litvin A, Maier R, Beka SG, De Simone B, Bala M, Perez AM, Ordonez C, Bodnaruk Z, Cui Y, Calatayud AP, de Angelis N, Amico F, Pikoulis E, Damaskos D, Coimbra R, Chirica M, Biffl WL, Catena F. Strategies to prevent blood loss and reduce transfusion in emergency general surgery, WSES-AAST consensus paper. World J Emerg Surg 2024; 19:26. [PMID: 39010099 PMCID: PMC11251377 DOI: 10.1186/s13017-024-00554-7] [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: 04/24/2024] [Accepted: 07/01/2024] [Indexed: 07/17/2024] Open
Abstract
Emergency general surgeons often provide care to severely ill patients requiring surgical interventions and intensive support. One of the primary drivers of morbidity and mortality is perioperative bleeding. In general, when addressing life threatening haemorrhage, blood transfusion can become an essential part of overall resuscitation. However, under all circumstances, indications for blood transfusion must be accurately evaluated. When patients decline blood transfusions, regardless of the reason, surgeons should aim to provide optimal care and respect and accommodate each patient's values and target the best outcome possible given the patient's desires and his/her clinical condition. The aim of this position paper was to perform a review of the existing literature and to provide comprehensive recommendations on organizational, surgical, anaesthetic, and haemostatic strategies that can be used to provide optimal peri-operative blood management, reduce, or avoid blood transfusions and ultimately improve patient outcomes.
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Affiliation(s)
- Federico Coccolini
- General Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia, 56124, Pisa, Italy.
| | - Aryeh Shander
- Anesthesiology and Critical Care, Rutgers University, Newark, NJ, USA
| | - Marco Ceresoli
- General Emergency and Trauma Surgery Department, Monza University Hospital, Monza, Italy
| | - Ernest Moore
- Ernest E. Moore Shock Trauma Center, University of Colorado, Denver, CO, USA
| | - Brian Tian
- General Emergency and Trauma Surgery Department, Cesena Hospital, Cesena, Italy
| | - Dario Parini
- General Surgery Department, Rovigo Hospital, Rovigo, Italy
| | | | - Boris Sakakushev
- General Surgery Department, University Hospital St George, Medical University, Plovdiv, Bulgaria
| | - Krstina Doklestich
- Clinic of Emergency Surgery, University Clinical Center of Serbia, Belgrade, Serbia
| | - Fikri Abu-Zidan
- The Research Office, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Tal Horer
- Vascular and Trauma Surgery, Orebro Hospital, Orebro, Sweden
| | - Vishal Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Timothy Hardcastle
- Department of Trauma and Burns, Inkosi Albert Luthuli Central Hospital and Department of Surgical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Elena Bignami
- Anesthesia Department, Parma University Hospital, Parma, Italy
| | - Andrew Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery Foothills Medical Centre, Calgary, AB, Canada
| | - Dieter Weber
- Department of General Surgery, Royal Perth Hospital, Perth, Australia
| | - Igor Kryvoruchko
- Department of Surgery No. 2, Kharkiv National Medical University, Kharkiv, Ukraine
| | - Ari Leppaniemi
- General Surgery Department, Melahiti Hospital, Helsinki, Finland
| | - Edward Tan
- Emergency Surgery Department, Radboud Medical Centre, Nijmegen, The Netherlands
| | - Boris Kessel
- Hillel Yaffe Medical Center, Rappaport Medical School, Haifa, Israel
| | - Arda Isik
- Division of General Surgery, School of Medicine, Istanbul Medeniyet University, Kadikoy, Istanbul, Turkey
| | - Camilla Cremonini
- General Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia, 56124, Pisa, Italy
| | | | - Lorenzo Ghiadoni
- Emergency Medicine Department, Pisa University Hospital, Pisa, Italy
| | - Massimo Chiarugi
- General Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia, 56124, Pisa, Italy
| | - Chad Ball
- Trauma and Acute Care Surgery, Foothills Medical Center, Calgary, AB, Canada
| | - Pablo Ottolino
- Unidad de Trauma y Urgencias, Hospital Dr. Sótero del Río, Santiago de Chile, Chile
| | - Andreas Hecker
- Department of General, Thoracic and Transplant Surgery, University Hospital of Giessen, Giessen, Germany
| | - Diego Mariani
- General Surgery Department, Legnano Hospital, Legnano, Italy
| | - Ettore Melai
- ICU Department, Pisa University Hospital, Pisa, Italy
| | - Manu Malbrain
- First Department of Anesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland
| | - Vanessa Agostini
- Medicina Trasfusionale, IRCCS-Ospedale Policlinico San Martino, Genoa, Italy
| | - Mauro Podda
- Department of Surgical Science, University of Cagliari, Cagliari, Italy
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Yoram Kluger
- General, Emergency and Trauma Surgery Department, Rambam Medical Centre, Tel Aviv, Israel
| | | | - Andrey Litvin
- Department of Surgical Diseases No. 3, University Clinic, Gomel State Medical University, Gomel, Belarus
| | - Ron Maier
- Harborview Medical Center, University of Washington, Seattle, WA, USA
| | | | - Belinda De Simone
- Department of Digestive and Emergency Surgery, Infermi Hospital, Rimini, Italy
| | - Miklosh Bala
- Trauma and Acute Care Surgery Unit Department of General Surgery, Hadassah Medical Center, Jerusalem, Israel
| | - Aleix Martinez Perez
- Faculty of Health Sciences, Valencian International University (VIU), Valencia, Spain
| | - Carlos Ordonez
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cali, Colombia
| | - Zenon Bodnaruk
- Hospital Information Services for Jehovah's Witnesses, Tuxedo Park, NY, USA
| | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | | | - Nicola de Angelis
- General Surgery Department, Ferrara University Hospital, Ferrara, Italy
| | - Francesco Amico
- Discipline of Surgery, The University of Newcastle, Newcastle, Australia
| | - Emmanouil Pikoulis
- 3rd Department of Surgery, Attikon General Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | | | - Raul Coimbra
- General Surgery Department, Riverside University Health System Medical Center, Loma Linda, CA, USA
| | - Mircea Chirica
- General Surgery Department, Grenoble University Hospital, Grenoble, France
| | - Walter L Biffl
- Division of Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA
| | - Fausto Catena
- General Emergency and Trauma Surgery Department, Cesena Hospital, Cesena, Italy
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Eckers A, Hunsicker O, Spies C, Balzer F, Rubarth K, von Heymann C. In vivo effects of balanced, low molecular 6% and 10% hydroxyethyl starch compared with crystalloid volume replacement on the coagulation system in major pancreatic surgery-a sub-analysis of a prospective double-blinded, randomized controlled trial. PLoS One 2024; 19:e0303165. [PMID: 38991044 PMCID: PMC11239059 DOI: 10.1371/journal.pone.0303165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 04/19/2024] [Indexed: 07/13/2024] Open
Abstract
BACKGROUND The outcome of patients undergoing major surgery treated with HES for hemodynamic optimization is unclear. This post-hoc analysis of a randomized clinical pilot trial investigated the impact of low-molecular balanced HES solutions on the coagulation system, blood loss and transfusion requirements. METHODS The Trial was registered: EudraCT 2008-004175-22 and ethical approval was provided by the ethics committee of Berlin. Patients were randomized into three groups receiving either a 10% HES 130/0.42 solution, a 6% HES 130/0.42 solution or a crystalloid following a goal-directed hemodynamic algorithm. Endpoints were parameters of standard and viscoelastic coagulation laboratory, blood loss and transfusion requirements at baseline, at the end of surgery (EOS) and the first postoperative day (POD 1). RESULTS Fifty-two patients were included in the analysis (HES 10% (n = 15), HES 6% (n = 17) and crystalloid (n = 20)). Fibrinogen decreased in all groups at EOS (HES 10% 338 [298;378] to 192 [163;234] mg dl-1, p<0.01, HES 6% 385 [302;442] to 174 [163;224] mg dl-1, p<0.01, crystalloids 408 [325;458] to 313 [248;370] mg dl-1, p = 0.01). MCF FIBTEM was decreased for both HES groups at EOS (HES 10%: 20.5 [16.0;24.8] to 6.5 [5.0;10.8] mm, p = <0.01; HES 6% 27.0 [18.8;35.2] to 7.0 [5.0;19.0] mm, p = <0.01). These changes did not persist on POD 1 for HES 10% (rise to 16.0 [13.0;24.0] mm, p = 0.88). Blood loss was not different in the groups nor transfusion requirements. CONCLUSION Our data suggest a stronger but transient effect of balanced, low-molecular HES on the coagulation system. Despite the decline of the use of artificial colloids in clinical practice, these results may help to inform clinicians who use HES solutions.
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Affiliation(s)
- Alexander Eckers
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Campus Virchow-Klinikum, Berlin, Germany
| | - Oliver Hunsicker
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Campus Virchow-Klinikum, Berlin, Germany
| | - Claudia Spies
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Campus Virchow-Klinikum, Berlin, Germany
| | - Felix Balzer
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Campus Virchow-Klinikum, Berlin, Germany
- Institute of Medical Informatics, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Kerstin Rubarth
- Institute of Medical Informatics, Charité—Universitätsmedizin Berlin, Berlin, Germany
- Institute of Biometry and Clinical Epidemiology, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Christian von Heymann
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Campus Virchow-Klinikum, Berlin, Germany
- Department of Anesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin, Germany
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Sethapati VR, Pham TD, Quach T, Nguyen A, Le J, Cai W, Virk MS. Implementation and early outcomes with Pathogen Reduced Cryoprecipitated Fibrinogen Complex. Am J Clin Pathol 2024:aqae073. [PMID: 38967047 DOI: 10.1093/ajcp/aqae073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 05/20/2024] [Indexed: 07/06/2024] Open
Abstract
OBJECTIVES Cryoprecipitated antihemophilic factor (cryo) has been used for fibrinogen replacement in actively bleeding patients, dysfibrinogenemia, and hypofibrinogenemia. Cryo has a shelf life of 4 to 6 hours after thawing and a long turnaround time in issuing the product, posing a major limitation of its use. Recently, the US Food and Drug Administration approved Pathogen Reduced Cryoprecipitated Fibrinogen Complex (INTERCEPT Fibrinogen Complex [IFC]) for the treatment of bleeding associated with fibrinogen deficiency, which can be stored at room temperature and has a shelf life of 5 days after thawing. METHODS We identified locations and specific end users with high cryoprecipitate utilization and waste. We partnered with our blood supplier to use IFC in these locations. We analyzed waste and turnaround time before and after implementation. RESULTS Operative locations had a waste rate that exceeded nonoperative locations (16.7% vs 3%) and were targeted for IFC implementation. IFC was added to our inventory to replace all cryo orders from adult operating rooms, and waste decreased to 2.2% in these locations. Overall waste of cryoprecipitated products across all locations was reduced from 8.8% to 2.4%. The turnaround time for cryoprecipitated products was reduced by 58% from 30.4 minutes to 14.6 minutes. CONCLUSIONS There has been a substantial decrease in waste with improved turnaround time after IFC implementation. This has improved blood bank logistics, improved efficiency of patient care, and reduced costly waste.
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Affiliation(s)
- V Rakesh Sethapati
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR, US
| | - Tho D Pham
- Stanford Blood Center, Palo Alto, CA, US
| | - Thinh Quach
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, US
| | - Anhthu Nguyen
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, US
| | - Jimmy Le
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, US
| | - Wei Cai
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, US
| | - Mrigender Singh Virk
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, US
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Zanza C, Romenskaya T, Racca F, Rocca E, Piccolella F, Piccioni A, Saviano A, Formenti-Ujlaki G, Savioli G, Franceschi F, Longhitano Y. Severe Trauma-Induced Coagulopathy: Molecular Mechanisms Underlying Critical Illness. Int J Mol Sci 2023; 24:ijms24087118. [PMID: 37108280 PMCID: PMC10138568 DOI: 10.3390/ijms24087118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 03/29/2023] [Accepted: 03/30/2023] [Indexed: 04/29/2023] Open
Abstract
Trauma remains one of the leading causes of death in adults despite the implementation of preventive measures and innovations in trauma systems. The etiology of coagulopathy in trauma patients is multifactorial and related to the kind of injury and nature of resuscitation. Trauma-induced coagulopathy (TIC) is a biochemical response involving dysregulated coagulation, altered fibrinolysis, systemic endothelial dysfunction, platelet dysfunction, and inflammatory responses due to trauma. The aim of this review is to report the pathophysiology, early diagnosis and treatment of TIC. A literature search was performed using different databases to identify relevant studies in indexed scientific journals. We reviewed the main pathophysiological mechanisms involved in the early development of TIC. Diagnostic methods have also been reported which allow early targeted therapy with pharmaceutical hemostatic agents such as TEG-based goal-directed resuscitation and fibrinolysis management. TIC is a result of a complex interaction between different pathophysiological processes. New evidence in the field of trauma immunology can, in part, help explain the intricacy of the processes that occur after trauma. However, although our knowledge of TIC has grown, improving outcomes for trauma patients, many questions still need to be answered by ongoing studies.
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Affiliation(s)
- Christian Zanza
- Department of Anesthesia and Critical Care, AON SS. Antonio e Biagio e Cesare Arrigo, 15121 Alessandria, Italy
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA 15260, USA
| | - Tatsiana Romenskaya
- Department of Physiology and Pharmacology, Sapienza University of Rome, P. le A. Moro 5, 00185 Rome, Italy
| | - Fabrizio Racca
- Department of Anesthesia and Critical Care, AON SS. Antonio e Biagio e Cesare Arrigo, 15121 Alessandria, Italy
| | - Eduardo Rocca
- Department of Anesthesia and Critical Care, AON SS. Antonio e Biagio e Cesare Arrigo, 15121 Alessandria, Italy
| | - Fabio Piccolella
- Department of Anesthesia and Critical Care, AON SS. Antonio e Biagio e Cesare Arrigo, 15121 Alessandria, Italy
| | - Andrea Piccioni
- Department of Emergency Medicine, Polyclinic Agostino Gemelli/IRCCS, Catholic University of the Sacred Heart, 00168 Rome, Italy
| | - Angela Saviano
- Department of Emergency Medicine, Polyclinic Agostino Gemelli/IRCCS, Catholic University of the Sacred Heart, 00168 Rome, Italy
| | - George Formenti-Ujlaki
- Department of Surgery, San Carlo Hospital, ASST Santi Paolo and Carlo, 20142 Milan, Italy
| | - Gabriele Savioli
- Emergency Medicine and Surgery, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy
| | - Francesco Franceschi
- Department of Emergency Medicine, Polyclinic Agostino Gemelli/IRCCS, Catholic University of the Sacred Heart, 00168 Rome, Italy
| | - Yaroslava Longhitano
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA 15260, USA
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Sunnersjö L, Lindström H, Schött U, Törnquist N, Kander T. The precision of ROTEM EXTEM is decreased in hypocoagulable blood: a prospective observational study. Thromb J 2023; 21:23. [PMID: 36864467 PMCID: PMC9978281 DOI: 10.1186/s12959-023-00468-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 02/20/2023] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND The use of viscoelastic tests is becoming increasingly popular. There is a paucity of validation of the reproducibility of varying coagulation states. Therefore, we aimed to study the coefficient of variation (CV) for the ROTEM EXTEM parameters clotting time (CT), clot formation time (CFT), alpha-angle and maximum clot firmness (MCF) in blood with varying degrees of coagulation strength. The hypothesis was that CV increases in states of hypocoagulability. METHODS Critically ill patients and patients subjected to neurosurgery at a university hospital during three separate periods were included. Each blood sample was tested in eight parallel channels, yielding the CVs for the tested variables. In 25 patients, the blood samples were analysed both at baseline and after dilution with albumin 5%, as well as after being spiked with fibrinogen, simulating weak and strong coagulation. RESULTS In total, 225 unique blood samples were collected from 91 patients. All samples were analysed in eight parallel ROTEM channels, resulting in 1,800 measurements. In hypocoagulable samples, defined as those with values outside the normal reference range, the CV of CT was higher (median (interquartile range)) (6.3% (5.1-9.5)) than for normocoagulable samples (5.1% (3.6-7.5)), p < 0.001. CFT showed no difference (p = 0.14), while the CV of alpha-angle was higher in hypocoagulable samples (3.6% (2.5-4.6)) than in normocoagulable samples (1.1% (0.8-1.6), p < 0.001. The CV of MCF was higher in hypocoagulable samples (1.8% (1.3-2.6)) than in normocoagulable samples (1.2% (0.9-1.7)), p < 0.001. The CV ranges for the different variables were as follows: CT: 1.2%-37%, CFT: 1.7%-30%, alpha-angle: 0.0%-17% and MCF: 0.0%-8.1%. CONCLUSIONS CVs for the EXTEM ROTEM parameters CT, alpha-angle, and MCF increased in hypocoagulable blood compared to blood with normal coagulation, confirming the hypothesis for CT, alpha-angle, and MCF but not for CFT. Furthermore, the CVs for CT and CFT were much higher than those for alpha-angle and MCF. The results demonstrate that EXTEM ROTEM results from patients with weak coagulation should be interpreted with the notion of limited precision and that procoagulative treatment, based only on ROTEM EXTEM, should be given with some caution.
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Affiliation(s)
- Lotta Sunnersjö
- Department of Intensive and Perioperative Care, Skåne University Hospital, 214 28, Malmö, Sweden. .,The Medical Faculty, Lund University Sweden. Sölveg, 223 62, Lund, Sweden.
| | - Henrik Lindström
- grid.4514.40000 0001 0930 2361The Medical Faculty, Lund University Sweden. Sölveg, 223 62 Lund, Sweden
| | - Ulf Schött
- grid.4514.40000 0001 0930 2361The Medical Faculty, Lund University Sweden. Sölveg, 223 62 Lund, Sweden ,grid.411843.b0000 0004 0623 9987Department of Intensive and Perioperative Care, Skåne University Hospital, 221 85 Lund, Sweden
| | - Noa Törnquist
- grid.4514.40000 0001 0930 2361The Medical Faculty, Lund University Sweden. Sölveg, 223 62 Lund, Sweden
| | - Thomas Kander
- grid.4514.40000 0001 0930 2361The Medical Faculty, Lund University Sweden. Sölveg, 223 62 Lund, Sweden ,grid.411843.b0000 0004 0623 9987Department of Intensive and Perioperative Care, Skåne University Hospital, 221 85 Lund, Sweden
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Al-Hchaimi HA, Alhamaidah MF, Alkhfaji H, Qasim MT, Al-Nussairi AH, Abd-Alzahra HS. Intraoperative Fluid Management for Major Neurosurgery: Narrative study. 2022 INTERNATIONAL SYMPOSIUM ON MULTIDISCIPLINARY STUDIES AND INNOVATIVE TECHNOLOGIES (ISMSIT) 2022. [DOI: 10.1109/ismsit56059.2022.9932659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Affiliation(s)
- Hussein Ali Al-Hchaimi
- College of Health and Medical Technology, Al-Ayen University Nasiriya heart center,Department of Anesthesia,Thi-Qar,Iraq
| | - Majid Fakhir Alhamaidah
- College of Health and Medical Technology, Al-Ayen University AL-Rifaei General Hospital,Department of Anesthesia,Thi-Qar,Iraq
| | - Hussein Alkhfaji
- College of Health and Medical Technology, Al-Ayen University Bent AL Huda hospital,Department of Anesthesia,Thi-Qar,Iraq
| | - Maytham T. Qasim
- College of Health and Medical Technology, Al-Ayen University,Department of Anesthesia,Thi-Qar,Iraq
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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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8
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In Vivo Effects of Balanced Crystalloid or Gelatine Infusions on Functional Parameters of Coagulation and Fibrinolysis: A Prospective Randomized Crossover Study. J Pers Med 2022; 12:jpm12060909. [PMID: 35743694 PMCID: PMC9225437 DOI: 10.3390/jpm12060909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 05/21/2022] [Accepted: 05/28/2022] [Indexed: 02/05/2023] Open
Abstract
Prudent administration of fluids helps restore or maintain hemodynamic stability in the setting of perioperative blood loss. However, fluids may arguably exacerbate the existing coagulopathy. We sought to investigate the influence of balanced crystalloid and synthetic gelatine infusions on coagulation and fibrinolysis in healthy volunteers. This prospective randomized crossover study included 25 males aged 18–30 years. Infusions performed included 20 mL/kg of a balanced crystalloid solution (Optilyte®) or 20 mL/kg of gelatine 26.500 Da (Geloplasma®) in a random order over a period of 2 weeks. Laboratory analysis included conventional coagulation parameters and rotational thromboelastometry (ROTEM) assays. We confirmed a decrease in fibrinogen concentration and the number of platelets, and prolongation of PT after infusions. Compared to baseline values, differences in the ROTEM assays’ results after infusions signified the decrease in coagulation factors and fibrinogen concentration, causing impaired fibrin polymerization and clot structure. The ROTEM indicator of clot lysis remained unaffected. In the case of both Optilyte® and Geloplasma®, the results suggested relevant dilution. Gelatine disrupted the process of clot formation more than balanced crystalloid. Infusions of both crystalloid and saline-free colloid solutions causing up to 30% blood dilution cause significant dilution of the coagulation factors, platelets, and fibrinogen. However, balanced crystalloid infusion provides less infusion-induced coagulopathy compared to gelatine.
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Smart L, Boyd C, Litton E, Pavey W, Vlaskovsky P, Ali U, Mori T, Barden A, Ho KM. A randomised controlled trial of succinylated gelatin (4%) fluid on urinary acute kidney injury biomarkers in cardiac surgical patients. Intensive Care Med Exp 2021; 9:48. [PMID: 34549356 PMCID: PMC8455786 DOI: 10.1186/s40635-021-00412-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 08/13/2021] [Indexed: 11/10/2022] Open
Abstract
Background Fluid resuscitation is frequently required for cardiac surgical patients admitted to the intensive care unit. The ideal fluid of choice in regard to efficacy and safety remains uncertain. Compared with crystalloid fluid, colloid fluid may result in less positive fluid balance. However, some synthetic colloids are associated with increased risk of acute kidney injury (AKI). This study compared the effects of succinylated gelatin (4%) (GEL) with compound sodium lactate (CSL) on urinary AKI biomarkers in patients after cardiac surgery. Methods Cardiac surgical patients who required an intravenous fluid bolus of at least 500 mL postoperatively were randomly allocated to receive GEL or CSL as the resuscitation fluid of choice for the subsequent 24 h. Primary outcomes were serial urinary neutrophil gelatinase-associated lipocalin (NGAL) and cystatin C concentrations measured at baseline, 1 h, 5 h and 24 h after enrolment, with higher concentrations indicating greater kidney injury. Secondary biomarker outcomes included urinary clusterin, α1-microglobulin and F2-isoprostanes concentrations. Differences in change of biomarker concentration between the two groups over time were compared with mixed-effects regression models. Statistical significance was set at P < 0.05. Results Forty cardiac surgical patients (n = 20 per group) with similar baseline characteristics were included. There was no significant difference in the median volume of fluid boluses administered over 24 h between the GEL (1250 mL, Q1–Q3 500–1750) and CSL group (1000 mL, Q1–Q3 500–1375) (P = 0.42). There was a significantly greater increase in urinary cystatin C (P < 0.001), clusterin (P < 0.001), α1-microglobulin (P < 0.001) and F2-isoprostanes (P = 0.020) concentrations over time in the GEL group, compared to the CSL group. Change in urinary NGAL concentration (P = 0.68) over time was not significantly different between the groups. The results were not modified by adjustment for either urinary osmolality or EuroSCORE II predicted risk of mortality. Conclusions This preliminary randomised controlled trial showed that use of succinylated gelatin (4%) for fluid resuscitation after cardiac surgery was associated with increased biomarker concentrations of renal tubular injury and dysfunction, compared to crystalloid fluid. These results generate concern that use of intravenous gelatin fluid may contribute to clinically relevant postoperative AKI. Trial registration ANZCTR.org.au, ACTRN12617001461381. Registered on 16th October, 2017, http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373619&isReview=true. Supplementary Information The online version contains supplementary material available at 10.1186/s40635-021-00412-9.
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Affiliation(s)
- Lisa Smart
- College of Science, Health, Engineering and Education, Murdoch University, South St, Murdoch, WA, 6150, Australia. .,Centre for Clinical Research in Emergency Medicine, Perth, Australia.
| | - Corrin Boyd
- College of Science, Health, Engineering and Education, Murdoch University, South St, Murdoch, WA, 6150, Australia
| | - Edward Litton
- Intensive Care Unit, Fiona Stanley Hospital, Murdoch, Australia.,Intensive Care Unit, St John of God Hospital, Subiaco, Australia
| | - Warren Pavey
- College of Science, Health, Engineering and Education, Murdoch University, South St, Murdoch, WA, 6150, Australia.,Department of Anaesthesia, Fiona Stanley Hospital, Murdoch, Australia
| | | | - Umar Ali
- Department of Cardiothoracic Surgery and Transplantation, Fiona Stanley Hospital, Murdoch, Australia
| | - Trevor Mori
- Medical School, University of Western Australia, Perth, Australia
| | - Anne Barden
- Medical School, University of Western Australia, Perth, Australia
| | - Kwok Ming Ho
- College of Science, Health, Engineering and Education, Murdoch University, South St, Murdoch, WA, 6150, Australia.,Medical School, University of Western Australia, Perth, Australia.,Intensive Care Unit, Royal Perth Hospital, Perth, Australia
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10
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Chappell D, van der Linden P, Ripollés-Melchor J, James MFM. Safety and efficacy of tetrastarches in surgery and trauma: a systematic review and meta-analysis of randomised controlled trials. Br J Anaesth 2021; 127:556-568. [PMID: 34330414 DOI: 10.1016/j.bja.2021.06.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 05/17/2021] [Accepted: 06/02/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Hydroxyethyl starch (HES) 130 is a frequently used fluid to replace intravascular losses during surgery or trauma. In the past years, several trials performed in critically ill patients have raised questions regarding the safety of this product. Our aim in this meta-analysis was to evaluate the safety and efficacy of 6% HES during surgery and in trauma. METHODS This systematic review and meta-analysis was registered at PROSPERO (CRD42018100379). We included 85 fully published articles from 1980 to June 2018 according to the protocol and three additional recent articles up to June 2020 in English, French, German, and Spanish reporting on prospective, randomised, and controlled clinical trials applying volume therapy with HES 130/0.4 or HES 130/0.42, including combinations with crystalloids, to patients undergoing surgery. Comparators were albumin, gelatin, and crystalloids only. A meta-analysis could not be performed for the two trauma studies as there was only one study that reported data on endpoints of interest. RESULTS Surgical patients treated with HES had lower postoperative serum creatinine (P<0.001) and showed no differences in renal dysfunction, renal failure, or renal replacement therapy. Although there was practically no further difference in the colloids albumin or gelatin, the use of HES improved haemodynamic stability, reduced need for vasopressors (P<0.001), and decreased length of hospital stay (P<0.001) compared with the use of crystalloids alone. CONCLUSIONS HES was shown to be safe and efficacious in the perioperative setting. Results of the present meta-analysis suggest that when used with adequate indication, a combination of intravenous fluid therapy with crystalloids and volume replacement with HES as colloid has clinically beneficial effects over using crystalloids only.
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Affiliation(s)
- Daniel Chappell
- Department of Anaesthesiology and Intensive Care Medicine, Klinikum Frankfurt Höchst, Frankfurt, Germany.
| | - Philippe van der Linden
- Department of Anaesthesiology, Brugmann University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Javier Ripollés-Melchor
- Department of Anesthesiology and Critical Care, Infanta Leonor University Hospital, Madrid, Spain; Fluid Therapy and Hemodynamic Group of the Hemostasia, Transfusion Medicine, Fluid Therapy Section of the Spanish Society of Anesthesia and Critical Care (SEDAR), Madrid, Spain
| | - Michael F M James
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
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Schol PBB, de Lange NM, Woiski MD, Langenveld J, Smits LJM, Wassen MM, Henskens YM, Scheepers HCJ. Restrictive versus liberal fluid resuscitation strategy, influence on blood loss and hemostatic parameters in mild obstetric hemorrhage: An open-label randomized controlled trial. (REFILL study). PLoS One 2021; 16:e0253765. [PMID: 34170943 PMCID: PMC8232446 DOI: 10.1371/journal.pone.0253765] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 06/13/2021] [Indexed: 11/19/2022] Open
Abstract
Background Evidence for optimal hemostatic resuscitation in postpartum hemorrhage (PPH) is lacking. Liberal fluid administration may result in acidosis, hypothermia and coagulopathy. Objective We hypothesize that in early PPH a restrictive fluid administration results in less progression to moderate PPH. Study design In four Dutch hospitals we recruited women of 18 years and over, and more than 24 weeks pregnant. Exclusion criteria were: anticoagulant therapy, known coagulation disorders, pre-eclampsia, antenatal diagnosis of abnormally adhesive placenta, and a contraindication for liberal fluid therapy. We blindly randomized participants at 500 mL and ongoing blood loss in the third stage of labor between restrictive fluid administration (clear fluids 0.75–1.0 times the volume of blood lost) and liberal fluid administration (clear fluids 1.5–2.0 times the volume of blood lost). The primary outcome was progression to more than 1000 mL blood loss. Analyses were according to the intention-to-treat principle. Results From August 2014 till September 2019, 5190 women were informed of whom 1622 agreed to participate. A total of 252 women were randomized of which 130 were assigned to the restrictive group and 122 to the liberal group. In the restrictive management group 51 of the 130 patients (39.2%) progressed to more than 1000 mL blood loss versus 61 of the 119 patients (51.3%) in the liberal management group (difference, -12.0% [95%-CI -24.3% to 0.3%], p = 0.057). There was no difference in the need for blood transfusion, coagulation parameters, or in adverse events between the groups. Conclusions Although a restrictive fluid resuscitation in women with mild PPH could not been proven to be superior, it does not increase the need for blood transfusion, alter coagulation parameters, or cause a rise in adverse events. It can be considered as an alternative treatment option to liberal fluid resuscitation. Trial registration NTR3789.
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Affiliation(s)
- Pim B. B. Schol
- Department of Obstetrics and Gynecology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Obstetrics and Gynecology, Zuyderland, Sittard-Geleen, The Netherlands
- * E-mail:
| | - Natascha M. de Lange
- Department of Obstetrics and Gynecology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Obstetrics and Gynecology, Zuyderland, Sittard-Geleen, The Netherlands
| | - Mallory D. Woiski
- Department of Obstetrics and Gynecology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Josje Langenveld
- Department of Obstetrics and Gynecology, Zuyderland, Sittard-Geleen, The Netherlands
| | - Luc J. M. Smits
- Department of Epidemiology, Caphri School for Public Health and Primary Care, Maastricht, The Netherlands
| | - Martine M. Wassen
- Department of Obstetrics and Gynecology, Zuyderland, Sittard-Geleen, The Netherlands
| | - Yvonne M. Henskens
- Central Diagnostics Laboratory, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Hubertina C. J. Scheepers
- Department of Obstetrics and Gynecology, Maastricht University Medical Centre, Maastricht, The Netherlands
- GROW: School for Oncology and Developmental Biology and Department of Obstetrics and Gynecology, Maastricht University Medical Centre, Maastricht, The Netherlands
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Barimani B, Moisan P, Santaguida C, Weber M. Therapeutic Application of Fibrinogen in Spine Surgery: A Review Article. Int J Spine Surg 2021; 15:549-561. [PMID: 33963032 PMCID: PMC8176831 DOI: 10.14444/8075] [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: 11/20/2022] Open
Abstract
BACKGROUND The aim of this review is to investigate current uses of fibrinogen as a tool to reduce operative and postoperative blood loss in different surgical fields especially orthopedic spine surgery. This is a systematic review. METHODS MEDLINE (via Ovid 1946 to June 1, 2020) and Embase (via Ovid 1947 to June 1, 2020) were searched using the keywords "fibrinogen", "surgery", and "spine" for relevant studies. The search strategy used text words and relevant indexing to identify articles discussing the use of fibrinogen to control surgical blood loss. RESULTS The original literature search yielded 407 articles from which 68 duplications were removed. Three hundred thirty-nine abstracts and titles were screened. Results were separated by surgical specialties. CONCLUSIONS Multiple studies have looked at the role of fibrinogen for acute bleeding in the operative setting. The current evidence regarding the use of fibrinogen concentrate in spine surgery is promising but limited, even though this is a field with the potential for severe hemorrhage. Further trials are required to understand the utility of fibrinogen concentrate as a first-line therapy in spine surgery and to understand the importance of target fibrinogen levels and subsequent dosing and administration to allow recommendations to be made in this field.
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Affiliation(s)
- Bardia Barimani
- Division of Orthopedic Surgery, McGill University, Montreal, Quebec, Canada
| | - Philippe Moisan
- Division of Orthopedic Surgery, McGill University, Montreal, Quebec, Canada
| | - Carlos Santaguida
- Department of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada
| | - Michael Weber
- Department of Surgery, McGill University, Montreal, Quebec, Canada
- Montreal General Hospital, Montreal, Quebec, Canada
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Boyd CJ, Brainard BM, Smart L. Intravenous Fluid Administration and the Coagulation System. Front Vet Sci 2021; 8:662504. [PMID: 33937383 PMCID: PMC8081828 DOI: 10.3389/fvets.2021.662504] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 03/15/2021] [Indexed: 12/30/2022] Open
Abstract
Intravenous fluid administration in veterinary patients can alter coagulation function by several mechanisms. Both crystalloid and colloid fluids cause hemodilution, reducing platelet count and plasma coagulation protein concentrations. Hemodilution is associated with a hypercoagulable effect at low dilutions and a hypocoagulable effect at higher dilutions. Composition of crystalloid fluids likely has a minor effect, primarily dependent on fluid ion composition. Hypertonic crystalloids may also cause hypocoagulability. Colloids, both synthetic and natural, can cause hypocoagulability by several mechanisms beyond the effects of hemodilution. These include impaired platelet function, decreased plasma coagulation factor activity, impaired fibrin formation and crosslinking, and accelerated fibrinolysis. The vast majority of the veterinary literature investigates the hypocoagulable effects of hydroxyethyl starch-containing fluids using in vitro, experimental, and clinical studies. However, results are inconsistent, likely due to the varying doses and physicochemical properties of the specific fluid products across studies. In addition, some evidence exists for hypocoagulable effects of gelatin and albumin solutions. There is also evidence that these colloids increase the risk of clinical bleeding in people. Limitations of the veterinary evidence for the hypocoagulable effects of colloid fluids include a predominance of in vitro studies and in vivo studies using healthy subjects, which exclude the interaction of the effects of illness. Therefore, clinical relevance of these effects, especially for low-molecular-weight hydroxyethyl starch, is unknown. Firm recommendations about the most appropriate fluid to use in clinical scenarios cannot be made, although it is prudent to limit the dose of synthetic colloid in at-risk patients. Clinicians should closely monitor relevant coagulation assays and for evidence of hemorrhage in at-risk patients receiving any type of fluid therapy, especially in large volumes.
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Affiliation(s)
- Corrin J Boyd
- School of Veterinary Medicine, College of Science, Health, Engineering and Education, Murdoch University, Murdoch, WA, Australia
| | - Benjamin M Brainard
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, GA, United States
| | - Lisa Smart
- School of Veterinary Medicine, College of Science, Health, Engineering and Education, Murdoch University, Murdoch, WA, Australia
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14
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Gratz J, Zotti O, Pausch A, Wiegele M, Fleischmann E, Gruenberger T, Krenn CG, Kabon B. Effect of Goal-Directed Crystalloid versus Colloid Administration on Perioperative Hemostasis in Partial Hepatectomy: A Randomized, Controlled Trial. J Clin Med 2021; 10:jcm10081651. [PMID: 33924407 PMCID: PMC8068812 DOI: 10.3390/jcm10081651] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 03/27/2021] [Accepted: 04/09/2021] [Indexed: 02/06/2023] Open
Abstract
The use of colloids may impair hemostatic capacity. However, it remains unclear whether this also holds true when colloids are administered in a goal-directed manner. The aim of the present study was to assess the effect of goal-directed fluid management with 6% hydroxyethyl starch 130/0.4 on hemostasis compared to lactated Ringer’s solution in patients undergoing partial hepatectomy. We included 50 patients in this prospective, randomized, controlled trial. According to randomization, patients received boluses of either hydroxyethyl starch or lactated Ringer’s solution within the scope of goal-directed fluid management. Minimum perioperative FIBTEM maximum clot firmness (MCF) served as the primary outcome parameter. Secondary outcome parameters included fibrinogen levels and estimated blood loss. In the hydroxyethyl starch (HES) group the minimum FIBTEM MCF value was significantly lower (effect size −6 mm, 95% CI −10 to −3, p < 0.001) in comparison to the lactated Ringer’s solution (RL) group. These results returned to normal within 24 h. We observed no difference in plasma fibrinogen levels (RL 3.08 ± 0.37 g L−1 vs HES 2.65 ± 0.64 g L−1, p = 0.18) or the amount of blood loss between the two groups (RL 470 ± 299 mL vs HES 604 ± 351 mL, p = 0.18). We showed that goal-directed use of HES impairs fibrin polymerization in a dose-dependent manner when compared with RL. Results returned to normal on the first postoperative day without administration of procoagulant drugs and no differences in blood loss were observed.
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Affiliation(s)
- Johannes Gratz
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria; (J.G.); (O.Z.); (A.P.); (M.W.); (C.G.K.); (B.K.)
| | - Oliver Zotti
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria; (J.G.); (O.Z.); (A.P.); (M.W.); (C.G.K.); (B.K.)
| | - André Pausch
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria; (J.G.); (O.Z.); (A.P.); (M.W.); (C.G.K.); (B.K.)
| | - Marion Wiegele
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria; (J.G.); (O.Z.); (A.P.); (M.W.); (C.G.K.); (B.K.)
| | - Edith Fleischmann
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria; (J.G.); (O.Z.); (A.P.); (M.W.); (C.G.K.); (B.K.)
- Correspondence:
| | - Thomas Gruenberger
- Department of Surgery, HPB-Center, Kaiser Franz Josef Hospital Vienna, Kundratstrasse 3, 1100 Vienna, Austria;
| | - Claus G. Krenn
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria; (J.G.); (O.Z.); (A.P.); (M.W.); (C.G.K.); (B.K.)
| | - Barbara Kabon
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria; (J.G.); (O.Z.); (A.P.); (M.W.); (C.G.K.); (B.K.)
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AYDIN GÜZEY N, UYAR TÜRKYILMAZ HE. Comparison of hydroxyethylstarch 130/0.4 and ringer’s lactate on fibrinogen level in caesarean operations: a randomized clinical trial. JOURNAL OF HEALTH SCIENCES AND MEDICINE 2021. [DOI: 10.32322/jhsm.855395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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16
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Iannucci C, Dirkmann D, Howard J, Adamik KN. A prospective randomized open-label trial on the comparative effects of 6% hydroxyethyl starch 130/0.4 versus polyionic isotonic crystalloids on coagulation parameters in dogs with spontaneous hemoperitoneum. J Vet Emerg Crit Care (San Antonio) 2020; 31:32-42. [PMID: 33108052 DOI: 10.1111/vec.13018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 03/17/2019] [Accepted: 04/23/2019] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To evaluate the effects of 6% hydroxyethyl starch 130/0.4 (HES) and a polyionic isotonic crystalloid (CRYS) on standard coagulation tests and rotational thromboelastometry (ROTEM) in dogs with spontaneous hemoperitoneum (SHP). DESIGN Prospective randomized open-label clinical study. SETTING University teaching hospital. ANIMALS Forty-two client-owned dogs presented with SHP. INTERVENTIONS Dogs diagnosed with SHP and hypovolemic shock were randomly allocated to receive HES (10 mL/kg, n = 22) or CRYS (30 mL/kg, n = 20) intravenously over 20 minutes for hemodynamic stabilization. MEASUREMENTS AND MAIN RESULTS Parameters measured before (T0 ) and after (T1 ) treatment were HCT, platelet counts, prothrombin time, activated partial thromboplastin time, fibrinogen concentrations, and extrinsic activated (EXTEM), intrinsic activated (INTEM), and extrinsic activated with platelet inhibition ROTEM assays. Data were analyzed as absolute values and as the percentage change from T0 to T1 . No significant differences between groups were detected in any variable at T0 , and for HCT, platelet counts, prothrombin time, activated thromboplastin time, and fibrinogen concentrations at T1 . Clot formation time in EXTEM was significantly prolonged (P = 0.037), and maximum clot firmness was significantly decreased (P = 0.038) in the HES group compared to the CRYS group at T1 . The percentage change in EXTEM clotting time (P = 0.012) and INTEM clot formation time (P = 0.031) was greater after HES than CRYS. Lysis indices remained at 100% for all ROTEM assays in both groups. CONCLUSION Compared to a 3-fold volume of CRYS, administration of HES was associated with impairment in ROTEM parameters in dogs with SHP, but no evidence of hyperfibrinolysis was detected.
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Affiliation(s)
- Claudia Iannucci
- Division of Small Animal Emergency and Critical Care, Department of Clinical Veterinary Medicine, Vetsuisse Faculty, University of Bern, Bern, Switzerland
| | - Daniel Dirkmann
- Clinic for Anesthesiology and Intensive Care, Essen University Hospital, Essen, Germany
| | - Judith Howard
- Clinical Diagnostic Laboratory, Department of Clinical Veterinary Medicine, Vetsuisse Faculty, University of Bern, Bern, Switzerland
| | - Katja N Adamik
- Division of Small Animal Emergency and Critical Care, Department of Clinical Veterinary Medicine, Vetsuisse Faculty, University of Bern, Bern, Switzerland
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Palmer AJR, Gagné S, Fergusson DA, Murphy MF, Grammatopoulos G. Blood Management for Elective Orthopaedic Surgery. J Bone Joint Surg Am 2020; 102:1552-1564. [PMID: 32558663 DOI: 10.2106/jbjs.19.01417] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Antony J R Palmer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, United Kingdom
| | | | | | - Michael F Murphy
- NHS Blood and Transplant and Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
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Esfahani K, Dunn LK, Naik BI. Blood Conservation for Complex Spine and Intracranial Procedures. CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00383-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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19
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Ziebart A, Ruemmler R, Möllmann C, Kamuf J, Garcia-Bardon A, Thal SC, Hartmann EK. Fluid resuscitation-related coagulation impairment in a porcine hemorrhagic shock model. PeerJ 2020; 8:e8399. [PMID: 32095322 PMCID: PMC7017792 DOI: 10.7717/peerj.8399] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 12/16/2019] [Indexed: 12/21/2022] Open
Abstract
Background Fast and effective treatment of hemorrhagic shock is one of the most important preclinical trauma care tasks e.g., in combat casualties in avoiding severe end-organ damage or death. In scenarios without immediate availability of blood products, alternate regimens of fluid resuscitation represent the only possibility of maintaining sufficient circulation and regaining adequate end-organ oxygen supply. However, the fluid choice alone may affect the extent of the bleeding by interfering with coagulation pathways. This study investigates the impact of hydroxyethyl starch (HES), gelatine-polysuccinate (GP) and balanced electrolyte solution (BES) as commonly used agents for fluid resuscitation on coagulation using a porcine hemorrhagic shock model. Methods Following approval by the State and Institutional Animal Care Committee, life-threatening hemorrhagic shock was induced via arterial blood withdrawal in 24 anesthetized pigs. Isovolumetric fluid resuscitation with either HES, GP or BES (n = 3 × 8) was performed to compensate for the blood loss. Over four hours, hemodynamics, laboratory parameters and rotational thromboelastometry-derived coagulation were analyzed. As secondary endpoint the porcine values were compared to human blood. Results All the agents used for fluid resuscitation significantly affected coagulation. We measured a restriction of laboratory parameters, clot development and clot firmness, particularly in HES- and GP-treated animals. Hemoglobin content dropped in all groups but showed a more pronounced decline in colloid-treated pigs. This effect was not maintained over the four-hour monitoring period. Conclusion HES, GP, and BEL sufficiently stabilized the macrocirculation, but significantly affected coagulation. These effects were most pronounced after colloid and particularly HES administration. Despite suitability for rapid hemodynamic stabilization, colloids have to be chosen with caution, because their molecular properties may affect coagulation directly and as a consequence of pronounced hemodilution. Our comparison of porcine and human coagulation showed increased coagulation activity in pig blood.
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Affiliation(s)
- Alexander Ziebart
- Department of Anesthesiology, Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Robert Ruemmler
- Department of Anesthesiology, Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Christian Möllmann
- Department of Anesthesiology, Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Jens Kamuf
- Department of Anesthesiology, Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Andreas Garcia-Bardon
- Department of Anesthesiology, Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Serge C Thal
- Department of Anesthesiology, Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Erik K Hartmann
- Department of Anesthesiology, Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
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Shah A, Palmer AJR, Klein AA. Strategies to minimize intraoperative blood loss during major surgery. Br J Surg 2020; 107:e26-e38. [DOI: 10.1002/bjs.11393] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 09/12/2019] [Indexed: 12/19/2022]
Abstract
Abstract
Background
Reducing operative blood loss improves patient outcomes and reduces healthcare costs. The aim of this article was to review current surgical, anaesthetic and haemostatic intraoperative blood conservation strategies.
Methods
This narrative review was based on a literature search of relevant databases up to 31 July 2019 for publications relevant to reducing blood loss in the surgical patient.
Results
Interventions can begin early in the preoperative phase through identification of patients at high risk of bleeding. Directly acting anticoagulants can be stopped 48 h before most surgery in the presence of normal renal function. Aspirin can be continued for most procedures. Intraoperative cell salvage is recommended when anticipated blood loss is greater than 500 ml and this can be continued after surgery in certain situations. Tranexamic acid is safe, cheap and effective, and routine administration is recommended when anticipated blood loss is high. However, the optimal dose, timing and route of administration remain unclear. The use of topical agents, tourniquet and drains remains at the discretion of the surgeon. Anaesthetic techniques include correct patient positioning, avoidance of hypothermia and regional anaesthesia. Permissive hypotension may be beneficial in selected patients. Promising haemostatic strategies include use of pharmacological agents such as desmopressin, prothrombin complex concentrate and fibrinogen concentrate, and use of viscoelastic haemostatic assays.
Conclusion
Reducing perioperative blood loss requires a multimodal and multidisciplinary approach. Although high-quality evidence exists in certain areas, the overall evidence base for reducing intraoperative blood loss remains limited.
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Affiliation(s)
- A Shah
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - A J R Palmer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - A A Klein
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
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21
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Fenger-Eriksen C, Haas T, Fries D. Coagulation disturbances during major perioperative or traumatic bleeding. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2019. [DOI: 10.1016/j.tacc.2019.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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22
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Henderson RA, Mazzeffi MA, Strauss ER, Williams B, Wipfli C, Dawood M, Taylor BS, Tanaka KA. Impact of intraoperative high‐volume autologous blood collection on allogeneic transfusion during and after cardiac surgery: a propensity score matched analysis. Transfusion 2019; 59:2023-2029. [DOI: 10.1111/trf.15253] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 02/01/2019] [Accepted: 02/03/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Reney A. Henderson
- Division of Cardiovascular Anesthesia, Department of SurgeryUniversity of Maryland School of Medicine Baltimore Maryland
| | - Michael A. Mazzeffi
- Division of Cardiovascular Anesthesia, Department of SurgeryUniversity of Maryland School of Medicine Baltimore Maryland
| | - Erik R. Strauss
- Division of Cardiovascular Anesthesia, Department of SurgeryUniversity of Maryland School of Medicine Baltimore Maryland
| | - Brittney Williams
- Division of Cardiovascular Anesthesia, Department of SurgeryUniversity of Maryland School of Medicine Baltimore Maryland
| | - Camron Wipfli
- Division of Cardiovascular Anesthesia, Department of SurgeryUniversity of Maryland School of Medicine Baltimore Maryland
| | - Murtaza Dawood
- Division of Cardiovascular Anesthesia, Department of SurgeryUniversity of Maryland School of Medicine Baltimore Maryland
| | - Bradley S. Taylor
- Division of Cardiac Surgery, Department of SurgeryUniversity of Maryland School of Medicine Baltimore Maryland
| | - Kenichi A. Tanaka
- Division of Cardiovascular Anesthesia, Department of SurgeryUniversity of Maryland School of Medicine Baltimore Maryland
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Postoperative Blood Loss and Coagulation Changes After Balanced 6% Hydroxyethyl Starch 130/0.4 Administration During Spine Surgery: A Retrospective Study. Clin Spine Surg 2019; 32:E65-E70. [PMID: 30334822 DOI: 10.1097/bsd.0000000000000727] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Retrospective analysis. OBJECTIVE The objective of this study was to investigate the effects of intraoperative balanced 6% hydroxyethyl starch (HES) 130/0.4 on postoperative blood loss and the coagulation profile. SUMMARY OF BACKGROUND DATA The safety of colloid versus crystalloid transfusion for bleeding and coagulation during major spine surgery remains controversial and only a few studies exist. Thus, we compared the effects of balanced 6% HES 130/0.4 and crystalloid on postoperative bleeding and coagulation. METHODS Patients undergoing spine surgery between February 1, 2015 and February 28, 2017 were divided into 2 groups: patients receiving intraoperative balanced 6% HES 130/0.4 and patients receiving crystalloid. We compared the postoperative bleeding volume with changes in the coagulation profile and length of hospital stay between these 2 groups. Propensity score (PS)-matching and multivariate stepwise linear regression were performed. RESULTS A total of 169 patients who met the inclusion criteria were analyzed. The quantity of total colloid per patient was 10-15 mL/kg. A significant difference was observed in the total intraoperative transfused crystalloid volume between the 2 groups (colloid group, 1.394.6±1.414.0 mL; crystalloid group, 2.027.3±1.114.1 mL; P<0.001). Postoperative blood loss and coagulation profile changes were not significantly different in the 60 PS-matched paired patients. Furthermore, no differences in either postoperative transfusion requirement or length of hospital stay were observed between the groups. Multivariate stepwise linear regression revealed that operation time (β=0.549; P<0.001) and intraoperative transfusion of packed red blood cells (β=0.466; P=0.003) or fresh frozen plasma (β=-0.263; P=0.041) were independently associated with postoperative blood loss. However, intraoperative colloid administration was not a predictive factor. CONCLUSIONS Intraoperative infusion of balanced 6% HES 130/0.4 in patients undergoing spine surgery presented clinically insignificant changes in postoperative blood loss and coagulation compared to crystalloid. LEVEL OF EVIDENCE Level III.
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Miyata S, Itakura A, Ueda Y, Usui A, Okita Y, Ohnishi Y, Katori N, Kushimoto S, Sasaki H, Shimizu H, Nishimura K, Nishiwaki K, Matsushita T, Ogawa S, Kino S, Kubo T, Saito N, Tanaka H, Tamura T, Nakai M, Fujii S, Maeda T, Maeda H, Makino S, Matsunaga S. TRANSFUSION GUIDELINES FOR PATIENTS WITH MASSIVE BLEEDING. ACTA ACUST UNITED AC 2019. [DOI: 10.3925/jjtc.65.21] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Shigeki Miyata
- Department of Clinical Laboratory Medicine, National Cerebral and Cardiovascular Center
| | - Atsuo Itakura
- Department of Obstetrics and Gynecology, Faculty of Medicine, Juntendo University
| | - Yuichi Ueda
- Nara Prefectural Hospital Organization, Nara Prefecture General Medical Center
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Yutaka Okita
- Department of Cardiovascular Surgery, Kobe University
| | - Yoshihiko Ohnishi
- Operation Room, Anesthesiology, National Cerebral and Cardiovascular Center
| | - Nobuyuki Katori
- Department of Anesthesiology, Keio University School of Medicine
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine
| | - Hiroaki Sasaki
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | | | - Kunihiro Nishimura
- Department of Statistics and Data Analysis, Dept of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center
| | | | | | - Satoru Ogawa
- Department of Anesthesiology, Kyoto Prefectural University of Medicine
| | | | | | - Nobuyuki Saito
- Shock and Trauma Center, Nippon Medical School Chiba Hokusoh Hospital
| | - Hiroshi Tanaka
- Department of Surgery, Division of Minimum Invasive Surgery, Kobe University
| | | | - Michikazu Nakai
- Department of Statistics and Data Analysis, Dept of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center
| | - Satoshi Fujii
- Department of Laboratory Medicine, Asahikawa Medical University
| | - Takuma Maeda
- Division of Transfusion Medicine, National Cerebral and Cardiovascular Center
| | - Hiroo Maeda
- Transfusion Medicine and Cell Therapy, Saitama Medical Center/Saitama Medical University
| | - Shintaro Makino
- Department of Obstetrics and Gynecology, Faculty of Medicine, Juntendo University
| | - Shigetaka Matsunaga
- Department of Obstetrics and Gynecology, Saitama Medical Center/Saitama Medical University
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25
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MacDonald N, Pearse RM. Are we close to the ideal intravenous fluid? Br J Anaesth 2019; 119:i63-i71. [PMID: 29161385 DOI: 10.1093/bja/aex293] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2017] [Indexed: 01/01/2023] Open
Abstract
The approach to i.v. fluid therapy for hypovolaemia may significantly influence outcomes for patients who experience a systemic inflammatory response after sepsis, trauma, or major surgery. Currently, there is no single i.v. fluid agent that meets all the criteria for the ideal treatment for hypovolaemia. The physician must choose the best available agent(s) for each patient, and then decide when and how much to administer. Findings from large randomized trials suggest that some colloid-based fluids, particularly starch-based colloids, may be harmful in some situations, but it is unclear whether they should be withdrawn from use completely. Meanwhile, crystalloid fluids, such as saline 0.9% and Ringer's lactate, are more frequently used, but debate continues over which preparation is preferable. Perhaps most importantly, it remains unclear how to select the optimal dose of fluid in different patients and different clinical scenarios. There is good reason to believe that both inadequate and excessive i.v. fluid administration may lead to poor outcomes, including increased risk of infection and organ dysfunction, for hypovolaemic patients. In this review, we summarize the current knowledge on this topic and identify some key pitfalls and some areas of agreed best practice.
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Affiliation(s)
- N MacDonald
- Department of Perioperative and Pain Medicine, Barts Health NHS Trust, London E1 1BB, UK
| | - R M Pearse
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London EC1M 6BQ, UK
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Enk NM, Kutter APN, Kuemmerle-Fraune C, Sigrist NE. Correlation of plasma coagulation tests and fibrinogen Clauss with rotational thromboelastometry parameters and prediction of bleeding in dogs. J Vet Intern Med 2018; 33:132-140. [PMID: 30537199 PMCID: PMC6335517 DOI: 10.1111/jvim.15365] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 10/12/2018] [Indexed: 12/20/2022] Open
Abstract
Background Correlation of plasma fibrinogen concentration (fibrinogenClauss) with rotational thromboelastometry (ROTEM) parameters has not been investigated in dogs. Objectives To determine the correlation between plasma coagulation tests and fibrinogenClauss with ROTEM parameters and to evaluate their ability to predict bleeding in dogs. Animals Ninety‐seven dogs with concurrent determination of fibrinogenClauss and fibrin polymerization test (FIBTEM) analysis. Methods Signalment, pretreatment, clinical signs of bleeding, fibrinogenClauss, plasma coagulation test results, hematocrit, platelet count, FIBTEM, extrinsic (EXTEM) and intrinsic (INTEM) activated ROTEM assays were retrieved retrospectively. Correlations between fibrinogenClauss and FIBTEM maximum clot firmness (MCFFIBTEM) and between prothrombin time (PT) or activated partial thromboplastin time (aPTT) and ROTEM parameters were determined. Dogs were further assigned to groups with or without clinical signs of bleeding. The prognostic significance of significantly different parameters to predict bleeding was evaluated. Results FibrinogenClauss showed strong correlation with MCFFIBTEM (r = 0.860, n = 97, P < .001). PT showed strong correlation with EXTEM clotting time (CTEXTEM) (r = 0.839, n = 53, P < .001), and aPTT was strongly correlated with INTEM CT (CTINTEM) (r = 0.664, n = 31, P < .001). Platelet count, PT/aPTT, EXTEM clot formation time (CFTEXTEM), MCFEXTEM, EXTEM maximum clot elasticity (MCEEXTEM), and CTINTEM were significantly different between groups. A CTINTEM >149 seconds was 100% sensitive to detect bleeding. Conclusions and Clinical Importance The MCFFIBTEM can be used to evaluate the effect of fibrinogen on hemostasis as an alternative to determination of fibrinogenClauss. In addition, CTEXTEM and CTINTEM are strongly correlated with PT and aPTT, respectively.
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Affiliation(s)
- Nathalie M Enk
- Department for Small Animals, Critical Care Unit, University of Zurich, Zurich, Switzerland
| | - Annette P N Kutter
- Department of Clinical Diagnostics and Services, Section of Anesthesiology, University of Zurich, Zurich, Switzerland
| | - Claudia Kuemmerle-Fraune
- Clinic of Small Animal Internal Medicine, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
| | - Nadja E Sigrist
- Department for Small Animals, Critical Care Unit, University of Zurich, Zurich, Switzerland
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27
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Thromboelastography and Thromboelastometry in Assessment of Fibrinogen Deficiency and Prediction for Transfusion Requirement: A Descriptive Review. BIOMED RESEARCH INTERNATIONAL 2018; 2018:7020539. [PMID: 30596098 PMCID: PMC6286766 DOI: 10.1155/2018/7020539] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 09/28/2018] [Accepted: 11/06/2018] [Indexed: 12/22/2022]
Abstract
Fibrinogen is crucial for the formation of blood clot and clinical outcomes in major bleeding. Both Thromboelastography (TEG) and Rotational Thromboelastometry (ROTEM) have been increasingly used to diagnose fibrinogen deficiency and guide fibrinogen transfusion in trauma and surgical bleeding patients. We conducted a comprehensive and comparative review on the technologies and clinical applications of two typical functional fibrinogen assays using TEG (FF TEG) and ROTEM (FIBTEM) for assessment of fibrinogen level and deficiency, and prediction of transfusion requirement. Clot strength and firmness of FF TEG and ROTEM FIBTEM were the most used parameters, and their associations with fibrinogen levels as measured by Clauss method ranged from 0 to 0.9 for FF TEG and 0.27 to 0.94 for FIBTEM. A comparison of the interchangeability and clinical performance of the functional fibrinogen assays using the two systems showed that the results were correlated, but are not interchangeable between the two systems. It appears that ROTEM FIBTEM showed better associations with the Clauss method and more clinical use for monitoring fibrinogen deficiency and predicting transfusion requirements including fibrinogen replacement than FF TEG. TEG and ROTEM functional fibrinogen tests play important roles in the diagnosis of fibrinogen-related coagulopathy and guidance of transfusion requirements. Despite the fact that high-quality evidence is still needed, the two systems are likely to remain popular for the hemostatic management of bleeding patients.
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28
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Morrison GA, Koch J, Royds M, McGee D, Chalmers RTA, Anderson J, Nimmo AF. Fibrinogen concentrate vs. fresh frozen plasma for the management of coagulopathy during thoraco-abdominal aortic aneurysm surgery: a pilot randomised controlled trial. Anaesthesia 2018; 74:180-189. [DOI: 10.1111/anae.14495] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2018] [Indexed: 01/09/2023]
Affiliation(s)
- G. A. Morrison
- Department of Anaesthesia; Royal Infirmary of Edinburgh; Scotland UK
| | - J. Koch
- Department of Anaesthesia; Royal Infirmary of Edinburgh; Scotland UK
| | - M. Royds
- Department of Anaesthesia; Royal Infirmary of Edinburgh; Scotland UK
| | - D. McGee
- Better Blood Transfusion; Scottish National Blood Transfusion Service; The Jack Copland Centre; Heriot-Watt Research Park; Edinburgh UK
| | - R. T. A. Chalmers
- Department of Vascular Surgery; Royal Infirmary of Edinburgh; Scotland UK
| | - J. Anderson
- Department of Haematology; Royal Infirmary of Edinburgh; Scotland UK
| | - A. F. Nimmo
- Department of Anaesthesia; Royal Infirmary of Edinburgh; Scotland UK
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29
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Baker CE, Marvi T, Austin TM, Payne S, Mignemi ME, Gailani D, Wheeler AP, Nguyen TT, Lovejoy SA, Martus JE, Mencio GA, Schoenecker JG. Dilutional coagulopathy in pediatric scoliosis surgery: A single center report. Paediatr Anaesth 2018; 28:974-981. [PMID: 30295357 DOI: 10.1111/pan.13488] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 08/09/2018] [Accepted: 08/13/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Children undergoing posterior spinal fusion experience high blood loss often necessitating transfusion. An appropriately activated coagulation system provides hemostasis during surgery, but pathologic dysregulation can cause progressive bleeding and increased transfusions. Despite receiving antifibrinolytics for clot stabilization, many patients still require transfusions. AIMS We sought to examine the association of dilutional coagulopathy with blood loss and blood transfusion in posterior spinal fusion for pediatric scoliosis patients. METHODS A retrospective, single institution study of children undergoing posterior spinal fusion >6 levels with a standardized, prospective anesthetic protocol utilizing antifibrinolytics. Blood loss was evaluated using a hematocrit-based calculation. To evaluate transfusions, a normalized Blood Product Transfusion calculation was developed. Factors associated with blood loss and blood transfusions were determined by univariate analysis and multivariate regression modeling with multicollinearity and mediation analysis. RESULTS Patients received 73.7 mL/kg (standard deviation ±30.8) of fluid poor in coagulation factors. Estimated blood loss was 42.6 mL/kg (standard deviation ±18.0). There was a significant association between estimated blood loss and total fluids delivered (Spearman's rho = 0.51, 95% confidence interval 0.33-0.65, P < 0.001). Factors significantly associated with normalized Blood Product Transfusion in this cohort included age, weight, scoliosis type, levels fused, total osteotomies, pelvic fixation, total fluid, maximum prothrombin time, and minimum fibrinogen. Regression modeling showed the best combination of variables for modeling normalized Blood Product Transfusion included patient weight, number of levels fused, total fluid administered, and maximum prothrombin time. CONCLUSION Blood product transfusion remains a frustrating problem in pediatric scoliosis. Identifying and controlling dilutional coagulopathy in these patients may reduce blood loss and the need for blood transfusion.
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Affiliation(s)
- Courtney E Baker
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Tanya Marvi
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Thomas M Austin
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia
| | - Shelby Payne
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Megan E Mignemi
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Allison P Wheeler
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Thanh T Nguyen
- University of Colorado School of Medicine, Aurora, Colorado
| | - Steven A Lovejoy
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jeffrey E Martus
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Gregory A Mencio
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan G Schoenecker
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Pharmacology, Vanderbilt University, Nashville, Tennessee
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30
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The effects of Plasma-Lyte 148 solution on blood coagulation: an in-vitro, volunteer study using rotational thromboelastometry. Blood Coagul Fibrinolysis 2018; 29:446-450. [PMID: 29846277 PMCID: PMC6085130 DOI: 10.1097/mbc.0000000000000741] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The current study aimed to measure the effects of Plasma-Lyte 148 solution on the blood coagulation profile according to the hemodilution level using rotational thromboelastometry (ROTEM) tests. Venous blood was collected from 12 healthy volunteers and divided into four specimen bottles, which were diluted at different levels with Plasma-Lyte 148 (0, 20, 40, and 60%). Following this, ROTEM tests were performed on the study samples. We found that as the hemodilution level increased, the ROTEM values showed a hypocoagulable pattern. The change rate of the maximum clot firmness (MCF) of INTEM was greater in the 40 (P = 0.015) and 60% (P < 0.001) dilutions than it was in the 20% dilution. Greater lengthening of the clot formation time of EXTEM was observed in the 60% dilution than it was in the 20% dilution (P < 0.001). The alpha-angle of EXTEM showed a greater decrease in the 60% dilution than it did in the 20% dilution (P < 0.001). A larger change rate of the MCF of EXTEM was observed in the 40 (P = 0.003) and 60% (P < 0.001) dilutions than it was in the 20% dilution. A greater decrease in the MCF of FIBTEM was identified in the 40 (P = 0.009) and 60% (P < 0.001) dilutions than in the 20% dilution. All coagulation pathways exhibited hypocoagulable patterns as the hemodilution level increased. However, most of the mean values of ROTEM parameters were within the normal reference range, except for those of the 60% dilution.
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31
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Samama CM, Ickx B, Ozier Y, Steib A, Susen S, Godier A. The place of fibrinogen concentrates in the management of perioperative bleeding: A position paper from the Francophone Working Group on Perioperative Haemostasis (GIHP). Anaesth Crit Care Pain Med 2018; 37:355-365. [DOI: 10.1016/j.accpm.2018.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Accepted: 04/02/2018] [Indexed: 01/05/2023]
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32
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Kam P, Varanasi S, Yang KX. The effects of haemodilution with succinylated gelatin solution on coagulation in vitro as assessed by thromboelastometry and impedance (multiple electrode) aggregometry. Anaesth Intensive Care 2018; 46:272-277. [PMID: 29716485 DOI: 10.1177/0310057x1804600304] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We investigated the in vitro viscoelastic changes of progressive haemodilution with succinylated gelatin (SG) solution compared with normal saline (NS) using rotational thromboelastometry (ROTEM®). Whole blood (WB) samples obtained from 20 healthy volunteers were diluted in vitro with SG solution or NS by 10%, 20% and 40%. Fibrinogen concentration and ROTEM (EXTEM, FIBTEM) variables including coagulation time (CT), clot formation time (CFT), α-angle, and maximum clot firmness (MCF) were measured in the undiluted sample and at each degree of haemodilution. Haemodilution with SG decreased FIBTEM MCF by 34.8% at 20% dilution (SG 20% haemodilution mean 9.1 [standard deviation, SD 2.7] mm versus WB, mean 13.9 [SD 3.4] mm) whereas this was observed only at 40% haemodilution with NS (mean 8.5 [SD 2.7] mm, 38.7% decrease). We found that 40% haemodilution with SG slowed clot formation (EXTEM CFT; SG 40%, mean 179 [SD 39] seconds versus WB mean 87.9 [SD 13.7] seconds; increased CFT by 103%), reduced clot strength by 23.5% (EXTEM MCF; SG 40% mean 47.7 [SD 3.4] mm versus WB mean 62.4 [SD 2.5] mm), and decreased fibrin formation (FIBTEM MCF; SG 40% mean 5.8 [SD 1.6] mm versus WB mean 13.9 [SD 3.4] mm); 58.4% decrease). The platelet contribution to clot strength (EXTEM MCF-FIBTEM MCF) was not changed by SG. We found that haemodilution of more than 20% with SG impaired coagulation greater than that observed with NS haemodilution in this in vitro study. This suggests that at 40% haemodilution with SG, a clinical scenario that could occur during resuscitation of a patient in grade IV haemorrhagic shock, impaired coagulation could occur. Frequent monitoring of coagulation is advised when SG solutions are administered rapidly during volume resuscitation.
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Affiliation(s)
- Pca Kam
- Nuffield Professor of Anaesthetics, University of Sydney; Anaesthetics Department, Royal Prince Alfred Hospital; Sydney, New South Wales
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33
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Shin HJ, Min BH, Na HS. FIBTEM as a predictor of intra- and postoperative blood loss in revision total hip arthroplasty: A prospective observational study. Medicine (Baltimore) 2018; 97:e10929. [PMID: 29851830 PMCID: PMC6392916 DOI: 10.1097/md.0000000000010929] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Revision total hip arthroplasty (THA) may cause intra- and postoperative massive bleeding. This prospective observational study evaluated if the maximum clot firmness of FIBTEM (MCFFIB) could act as a predictor of perioperative massive bleeding in revision THA.Fifty-eight adult patients undergoing revision THA were included. Pre- and postoperative MCFFIB, hematological and hemostatic laboratory data, as well as the amount of intra- and postoperative blood loss (IBL and PBL) were obtained.The change rate (MCFFIB-C) between the pre- and postoperative MCFFIB had a significant correlation with IBL (ρ = 0.431, P = .001). Moreover, PBL had a significant correlation with MCFFIB-C (ρ = 0.292, P = .026). The MCFFIB-C cut-off value of ≥ 29% showed the highest sensitivity and specificity for predicting IBL ≥ 1000 mL or PBL ≥500 mL. The incidence of red blood cell transfusion in the postoperative period was higher in patients showing MCFFIB-C ≥ 29% (34% vs 8%, P = .015).The change rate between pre- and postoperative MCFFIB values was correlated well with the amount of IBL or PBL. Moreover, particular change rate of MCFFIB could predict massive bleeding in revision THA.
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34
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de Lange N, Schol P, Lancé M, Woiski M, Langenveld J, Rijnders R, Smits L, Wassen M, Henskens Y, Scheepers H. Restrictive Versus Massive Fluid Resuscitation Strategy (REFILL study), influence on blood loss and hemostatic parameters in obstetric hemorrhage: study protocol for a randomized controlled trial. Trials 2018; 19:166. [PMID: 29510717 PMCID: PMC5838856 DOI: 10.1186/s13063-018-2512-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 01/30/2018] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Postpartum hemorrhage (PPH) is associated with maternal morbidity and mortality and has an increasing incidence in high-resource countries, despite dissemination of guidelines, introduction of skills training, and correction for risk factors. Current guidelines advise the administration, as fluid resuscitation, of almost twice the amount of blood lost. This advice is not evidence-based and could potentially harm patients. METHODS All women attending the outpatient clinic who are eligible will be informed of the study; oral and written informed consent will be obtained. Where there is more than 500 ml blood loss and ongoing bleeding, patients will be randomized to care as usual, fluid resuscitation with 1.5-2 times the amount of blood loss or fluid resuscitation with 0.75-1.0 times the blood loss. Blood loss will be assessed by weighing all draping. A blood sample, for determining hemoglobin concentration, hematocrit, thrombocyte concentration, and conventional coagulation parameters will be taken at the start of the study, after 60 min, and 12-18 h after delivery. In a subgroup of women, additional thromboelastometric parameters will be obtained. DISCUSSION Our hypothesis is that massive fluid administration might lead to a progression of bleeding due to secondary coagulation disorders. In non-pregnant individuals with massive blood loss, restrictive fluid management has been shown to prevent a progression to dilution coagulopathy. These data, however, cannot be extrapolated to women in labor. Our objective is to compare both resuscitation protocols in women with early, mild PPH (blood loss 500-750 ml) and ongoing bleeding, taking as primary outcome measure the progression to severe PPH (blood loss > 1000 ml). TRIAL REGISTRATION Netherlands Trial Register, NTR 3789 . Registered on 11 January 2013.
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Affiliation(s)
- Natascha de Lange
- Department of Obstetrics and Gynecology, University Medical Centre Groningen, P.O. 11120, 9700 CC Groningen, the Netherlands
| | - Pim Schol
- Department of Obstetrics and Gynecology, Maastricht University Medical Centre, P.O. 616, 6200 MD Maastricht, the Netherlands
| | - Marcus Lancé
- Department of Anesthesiology and Pain Treatment, Department of Intensive Care, Hamad Medical Corporation, P.O. Box 3050, Doha, Qatar
| | - Mallory Woiski
- Department of Obstetrics and Gynecology, Radboud University Medical Centre, P.O. 9101, 6500 HB Nijmegen, the Netherlands
| | - Josje Langenveld
- Department of Obstetrics and Gynecology, Zuyderland, P.O. 5500, 6130 MB Sittard-Geleen, the Netherlands
| | - Robbert Rijnders
- Department of Obstetrics and Gynecology, Jeroen Bosch Hospital, P.O. 90153, 5200 ME ‘s-Hertogenbosch, the Netherlands
| | - Luc Smits
- Department of Epidemiology, Caphri School for Public Health and Primary Care, P.O. 616, 6200 MD Maastricht, the Netherlands
| | - Martine Wassen
- Department of Obstetrics and Gynecology, Zuyderland, P.O. 5500, 6130 MB Sittard-Geleen, the Netherlands
| | - Yvonne Henskens
- Central Diagnostics Laboratory, Maastricht University Medical Centre, P.O. 5500, 6202 AZ Maastricht, the Netherlands
| | - Hubertina Scheepers
- GROW: School for Oncology and Developmental Biology and Department of Obstetrics and Gynecology, Maastricht University Medical Centre, P.O. 616, 6200 MD Maastricht, the Netherlands
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Sanders JO, Friedrich K, Gerlach R, Platz J, Miesbach W, Hanke AA, Hofstetter C, Weber CF. Stellenwert der Thrombelastometrie für das Monitoring von Faktor XIII. Hamostaseologie 2017; 31:111-7. [DOI: 10.5482/ha-1132] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
SummaryRecently published studies give evidence, that an increased maximum lysis in the APTEM® – test (ML60 > 12%) of the ROTEM® (Tem International GmbH, Munich, Germany) might indicate a factor XIII deficiency (FXIII < 70%). It was the aim of this study to investigate the feasibility of thrombelastometric measurements with the ROTEM device to reflect the isolated influence of FXIII on clot stability and therefore to indicate potential factor XIII deficiencies. Patients, method: After approval by the local Scientific and Ethic Review Board, 26 consecutive patients, scheduled for elective craniotomy for tumour resection, were prospectively enrolled into this study. Blood samples were taken for conventional laboratory coagulation analyses, FXIII analyses and thrombelastometric measurements (EXTEM, FIBTEM and APTEM tests) after induction of general anaesthesia (T1), before skin incision (T2) as well as at (T3) and 24 hours after (T4) postoperative admission to ICU, respectively. Statistical analyses included Spearman rank order correlations and multiple linear regressions. Results: FXIII concentrations did not correlate with the ML60 in the APTEM test at any measuring point. Neither platelet count nor fibrinogen nor FXIII concentrations were of predictive value for ML60 of the APTEM test. Conclusion: The results lead to the assumption that thrombelastometric measurements may not be appropriate for the perioperative monitoring of FXIII concentration.
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Kvint S, Schuster J, Kumar MA. Neurosurgical applications of viscoelastic hemostatic assays. Neurosurg Focus 2017; 43:E9. [DOI: 10.3171/2017.8.focus17447] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Patients taking antithrombotic agents are very common in neurosurgical practice. The perioperative management of these patients can be extremely challenging especially as newer agents, with poorly defined laboratory monitoring and reversal strategies, become more prevalent. This is especially true with emergent cases in which rapid reversal of anticoagulation is required and the patient’s exact medical history is not available. With an aging patient population and the associated increase in diseases such as atrial fibrillation, it is expected that the use of these agents will continue to rise in coming years. Furthermore, thromboembolic complications such as deep venous thrombosis, pulmonary embolism, and myocardial infarction are common complications of major surgery. These trends, in conjunction with a growing understanding of the hemostatic process and its contribution to the pathophysiology of disease, stress the importance of the complete evaluation of a patient’s hemostatic profile in guiding management decisions. Viscoelastic hemostatic assays (VHAs), such as thromboelastography and rotational thromboelastometry, are global assessments of coagulation that account for the cellular and plasma components of coagulation. This FDA-approved technology has been available for decades and has been widely used in cardiac surgery and liver transplantation. Although VHAs were cumbersome in the past, advances in software and design have made them more accurate, reliable, and accessible to the neurosurgeon. VHAs have demonstrated utility in guiding intraoperative blood product transfusion, identifying coagulopathy in trauma, and managing postoperative thromboprophylaxis. The first half of this review aims to evaluate and assess VHAs, while the latter half seeks to appraise the evidence supporting their use in neurosurgical populations.
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Affiliation(s)
| | | | - Monisha A. Kumar
- Departments of 1Neurosurgery and
- 2Neurology, University of Pennsylvania, Philadelphia, Pennsylvania
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Perner A, Holst LB, Haase N, Hjortrup PB, Møller MH. Common Sense Approach to Managing Sepsis. Crit Care Clin 2017; 34:127-138. [PMID: 29149934 DOI: 10.1016/j.ccc.2017.08.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Sepsis results in many deaths, prolonged suffering among survivors and relatives, and high use of resources both in developed and developing countries. The updated Surviving Sepsis Campaign guidelines should aid clinicians in improving the identification and management of these patients, but many uncertainties remain because most of the guidance is based on low-quality evidence. This article discusses how to use some of the specific items of the guidelines together with a common-sense approach to aid clinical management of patients with sepsis while trying to balance the potential benefit and harm of the items.
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Affiliation(s)
- Anders Perner
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, Copenhagen DK-2100, Denmark.
| | - Lars B Holst
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, Copenhagen DK-2100, Denmark
| | - Nicolai Haase
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, Copenhagen DK-2100, Denmark
| | - Peter B Hjortrup
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, Copenhagen DK-2100, Denmark
| | - Morten H Møller
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, Copenhagen DK-2100, Denmark
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Lawrence MJ, Marsden N, Kaczynski J, Davies G, Davies N, Hawkins K, Perumal S, Brown MR, Morris K, Davidson SJ, Williams PR, Evans PA. An Investigation Into the Effects of In Vitro Dilution With Different Colloid Resuscitation Fluids on Clot Microstructure Formation. Anesth Analg 2017; 123:1081-1088. [PMID: 27636739 DOI: 10.1213/ane.0000000000001536] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Balancing the beneficial effects of resuscitation fluids against their detrimental effect on hemostasis is an important clinical issue. We aim to compare the in vitro effects of 3 different colloid resuscitation fluids (4.5% albumin, hydroxyethyl starch [Voluven 6%], and gelatin [Geloplasma]) on clot microstructure formation using a novel viscoelastic technique, the gel point. This novel hemorheologic technique measures the biophysical properties of the clot and provides an assessment of clot microstructure from its viscoelastic properties. Importantly, in contrast to many assays in routine clinical use, the measurement is performed using unadulterated whole blood in a near-patient setting and provides rapid assessment of coagulation. We hypothesized that different colloids will have a lesser or greater detrimental effect on clot microstructure formation when compared against each other. METHODS Healthy volunteers were recruited into the study (n = 104), and a 20-mL sample of whole blood was obtained. Each volunteer was assigned to 1 of the 3 fluids, and the sample was diluted to 1 of 5 different dilutions (baseline, 10%, 20%, 40%, and 60%). The blood was tested using the gel point technique, which measures clot mechanical strength and quantifies clot microstructure (df) at the incipient stages of fibrin formation. RESULTS df and clot mechanical strength decrease with progressive dilution for all 3 fluids. A significant reduction in df from baseline was recorded at dilutions of 20% for albumin (P < .0001), 40% for starch (P < .0001), and 60% for gelatin (P < .0001). We also observed significant differences, in terms of df, when comparing the different types of colloid (P < .0001). We found that albumin dilution produced the largest changes in clot microstructure, providing the lowest values of df (= 1.41 ± 0.061 at 60% dilution) compared with starch (1.52 ± 0.081) and gelatin (1.58 ± 0.063). CONCLUSIONS We show that dilution with all 3 fluids has a significant effect on coagulation at even relatively low dilution volumes (20% and 40%). Furthermore, we quantify, using a novel viscoelastic technique, how the physiochemical properties of the 3 colloids exert individual changes on clot microstructure.
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Affiliation(s)
- Matthew James Lawrence
- From the *NISCHR Haemostasis Biomedical Research Unit, Morriston Hospital, Abertawe Bro Morgannwg University Health Board, Swansea, United Kingdom; †NISCHR Biomedical Research Unit, Medical School, Swansea University, Swansea, United Kingdom; ‡The Welsh Centre for Burns and Plastic Surgery, Abertawe Bro Morgannwg University Health Board, Morriston Hospital, Swansea, United Kingdom; §Department of Surgery, Morriston Hospital, Abertawe Bro Morgannwg University Health Board, Swansea University, Swansea, United Kingdom; ∥Emergency Department, Morriston Hospital, Abertawe Bro Morgannwg University Health Board, Swansea, United Kingdom; ¶Centre of Complex Fluids, College of Engineering, Swansea University, Swansea, United Kingdom; #School of Applied Science, University of Wales Institute Cardiff, Cardiff, United Kingdom; and **Department of Haematology, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
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Jin S, Yu G, Hou R, Shen B, Jiang H. Effect of Hemodilution In Vitro with Hydroxyethyl Starch on Hemostasis. Med Sci Monit 2017; 23:2189-2197. [PMID: 28481865 PMCID: PMC5436429 DOI: 10.12659/msm.901588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background Hydroxyethyl starch (HES) solutions are used for volume expansion during surgery. We aimed to investigate how 6%HES 130/0.4 affects hemostasis. Material/Methods Blood samples were collected from 12 healthy adult volunteers, diluting with 6%HES 130/0.4 (HES group) or Ringer lactate solution (RL control group). The hemodilution ratio (HR) of citrated blood volume to plasma substitute volume was 10: 0 (undiluted), 10: 2, 10: 4, and 10: 6. Clotting factors activity was measured. Thrombin generation was monitored. Platelet function was analyzed. Results 1) Activity of coagulation factor was decreased with increasing HR compared to undiluted baseline, and the activity of FVIII was significantly decreased in HES vs. RL. 2) Calibrated automated thrombography (CAT) results showed HES extended lag time, time to peak (ttpeak), start tail, and decreased peak of thrombin generation. Although lag time and ttpeak were significantly prolonged in HES vs. RL, endogenous thrombin potential (ETP) did not change. 3) Flow cytometric (FCM) analysis showed that HES reduced platelet phospholipids serine (PS) vs. baseline and RL. 4) HES significantly decreased antithrombin activity (AT: A) of the anticoagulant system with increasing HR vs. baseline and RL. 5) For fibrinolytic system, HES did not affect fibrinogen degradation products (FDP) and D-dimers (D-D) vs. baseline, or α2-antiplasmin (α2-AP) vs. RL. Conclusions By reducing FVIII activity and platelet PS expression, HES interfered with PS combining to FXIa, FVIIIa, and FVa, which affected the acceleration and explosion stage of thrombin. The decreased velocity and peak of thrombin generation delays and reduces clot formation. Combined 6%HES 130/0.4 decreased anticoagulant activity and may have clinical utility.
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Affiliation(s)
- Shanliang Jin
- Department of Anesthesiology, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China (mainland)
| | - Guifang Yu
- Department of Anesthesiology, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China (mainland)
| | - Ruijiao Hou
- Department of Anesthesiology, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China (mainland)
| | - Boxiong Shen
- Department of Anesthesiology, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China (mainland)
| | - Hong Jiang
- Department of Anesthesiology, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China (mainland)
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Soleimani M, Masoumi N, Nooraei N, Lashay A, Safarinejad MR. The effect of fibrinogen concentrate on perioperative bleeding in transurethral resection of the prostate: a double-blind placebo-controlled and randomized study. J Thromb Haemost 2017; 15:255-262. [PMID: 27888575 DOI: 10.1111/jth.13575] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Indexed: 11/30/2022]
Abstract
Essentials Perioperative bleeding during prostate surgery is still a common morbidity. Anticoagulant and antiplatelet medications contribute to the risk of hemorrhage and prolonged hospital stay. Multiple pharmacological agents have been proposed, but none of them have been widely accepted. It is crucial to find a safe and effective modality to reduce hemorrhage. SUMMARY Background Hemorrhage during transurethral resection of the prostate (TUR-P) has always been a concern. Several studies have shown preoperative administration of fibrinogen concentrate to have promising results in reducing hemorrhage in cardiac surgery. Objectives To investigate the hemostatic effect of fibrinogen concentrate administration on reducing the amount of bleeding during TUR-P in patients with benign prostatic hyperplasia. Methods Sixty men with benign prostatic hyperplasia, who were chosen to undergo TUR-P, entered this prospective randomized double-blind placebo-controlled study. The participants were randomly assigned to two groups: treatment (n = 31) and placebo (n = 29). They received an infusion of 2 g of fibrinogen concentrate (treatment group) or normal saline (placebo group) before surgery. Data regarding the amount of bleeding, the operation and complications were recorded and analyzed. Results No difference was observed in bleeding between the fibrinogen and placebo groups during (521 mL versus 557 mL, respectively) and after (291 mL versus 341 mL, respectively) surgery. This lack of difference was also seen in operation time (43 min versus 42 min), irrigating fluid volume used during (17 L versus 19 L) and after (29 L versus 28 L) surgery, and resected adenoma volume (19 g versus 19 g). The mean blood pressure was also similar in both groups as a confounding factor for the amount of bleeding. Conclusion Preoperative administration of fibrinogen concentrate had no significant influence on intraoperative and postoperative bleeding in TUR-P surgery.
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Affiliation(s)
- M Soleimani
- Department of Urology, Shahid Modarress Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - N Masoumi
- Department of Urology, Shahid Modarress Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - N Nooraei
- Department of Anesthesiology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - A Lashay
- Department of Urology, Shahid Modarress Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - M R Safarinejad
- Clinical Center for Urological Disease Diagnosis, Private Clinic Specializing in Urological and Andrological Genetics, Tehran, Iran
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Evaluation of the efficiency under current use of human fibrinogen concentrate in trauma patients with life-threatening hemorrhagic disorders. Blood Coagul Fibrinolysis 2017; 28:66-71. [DOI: 10.1097/mbc.0000000000000543] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Shin HJ, Na HS, Jeon YT, Park HP, Nam SW, Hwang JW. The impact of irrigating fluid absorption on blood coagulation in patients undergoing transurethral resection of the prostate: A prospective observational study using rotational thromboelastometry. Medicine (Baltimore) 2017; 96:e5468. [PMID: 28079789 PMCID: PMC5266151 DOI: 10.1097/md.0000000000005468] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Although endoscopic transurethral resection of the prostate (TURP) is a well-established procedure as a treatment for benign prostatic hyperplasia, its complications remain a concern. Among these, coagulopathy may be caused by the absorption of irrigating fluid. This study aimed to evaluate such phenomenon using a rotational thromboelastometry (ROTEM).A total of 20 patients undergoing TURP participated in this study. A mixture of 2.7% sorbitol-0.54% mannitol solution and 1% ethanol was used as an irrigating fluid, and fluid absorption was measured via the ethanol concentration in expired breath. The effects on coagulation were assessed by pre- and postoperative laboratory blood tests, including hemoglobin, hematocrit, platelet count, international normalized ratio of prothrombin time (PT-INR), activated partial thromboplastin time, electrolyte, and ROTEM.INTEM-clotting time (INTEM-CT) was significantly lengthened by 14% (P = 0.001). INTEM-α-angle was significantly decreased by 3% (P = 0.011). EXTEM-clot formation time was significantly prolonged by 18% (P = 0.008), and EXTEM-maximum clot firmness (EXTEM-MCF) was significantly decreased by 4% (P = 0.010). FIBTEM-MCF was also significantly decreased by 13% (P = 0.015). Moreover, hemoglobin (P < 0.001), hematocrit (P < 0.001), platelet counts (P < 0.001), potassium (P = 0.024), and ionized calcium (P = 0.004) were significantly decreased, while PT-INR (P = 0.001) was significantly increased after surgery. The amount of irrigating fluid absorbed was significantly associated with the weight of resected prostatic tissue (P = 0.001) and change of INTEM-CT (P < 0.001).As shown by the ROTEM analysis, the irrigating fluid absorbed during TURP impaired the blood coagulation cascade by creating a disruption in the coagulation factor activity or by lowering the coagulation factor concentration via dilution.
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Affiliation(s)
- Hyun-Jung Shin
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam-si
| | - Hyo-Seok Na
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam-si
| | - Young-Tae Jeon
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam-si
| | - Hee-Pyoung Park
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Sun-Woo Nam
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam-si
| | - Jung-Won Hwang
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam-si
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Moore LJ, Todd SR. Hemorrhage and Transfusions in the Surgical Patient. COMMON PROBLEMS IN ACUTE CARE SURGERY 2017. [PMCID: PMC7120919 DOI: 10.1007/978-3-319-42792-8_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Hemorrhage remains the leading cause of intra-operative deaths and those in the first 24 h. Many cardiovascular and hepatobiliary procedures result in massive hemorrhage and postpartum hemorrhage events in labor and delivery place the patient at a high risk for mortality. Both upper and lower gastrointestinal bleeding (e.g., diverticulosis, esophageal and gastric varices, and peptic ulcer disease) can also result in significant blood loss requiring massive transfusion and resuscitation from hemorrhagic shock. Therefore, safe, timely, and effective transfusion of blood products is critical. The aim of this chapter is to provide clinicians with a discussion of the current literature on the various blood component products, their indications, and unique hemostatic conditions in the surgical patient. While the majority of data concerning optimal management of acquired coagulopathy and hemorrhagic shock resuscitation is based on trauma patients, many of the principles can and should be applied to the surgical patient (or likely any patient) with profound hemorrhage.
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Affiliation(s)
- Laura J. Moore
- Department of Surgery, The University of Texas McGovern Medical School - Houston, Houston, Texas USA
| | - S. Rob Todd
- General Surgery and Trauma Ben Taub Hospital, Houston, Texas USA
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FIBTEM provides prediction of massive bleeding in total hip replacement arthroplasty. Blood Coagul Fibrinolysis 2016; 27:340-6. [PMID: 26588448 DOI: 10.1097/mbc.0000000000000428] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This retrospective study evaluated the association between maximum clot firmness of FIBTEM (MCFFIB) and blood loss, and determined a cutoff value of MCFFIB that may predict massive bleeding in total hip replacement arthroplasty (THRA). Seventy-two adult patients undergoing THRA for avascular necrosis of the femoral head or degenerative arthritis of the hip were included. Patients' medical records were reviewed to collect pre and postoperative laboratory data, as well as the amount of intra and postoperative blood loss (IBL and PBL). Each pre and postoperative fibrinogen level had a significant correlation with the pre and postoperative MCFFIB, respectively (ρ = 0.289, P = 0.014 and ρ = 0.286, P = 0.015). IBL had significant correlations with pre and postoperative MCFFIB (ρ = -0.305, P = 0.010 and ρ = -0.297, P = 0.013, respectively), and PBL also showed significant correlations with the pre and postoperative MCFFIB (ρ = -0.471, P < 0.001 and ρ = -0.475, P < 0.001, respectively). A respective pre or postoperative MCFFI cutoff value of 16 mm or less or 10 mm or less showed the highest sensitivity and specificity for predicting IBL 1000 ml or above or PBL 400 ml or above. Postoperative transfusion was performed more frequently in patients showing postoperative MCFFIB 10 mm or less (31 vs. 3.3%, P = 0.005). MCFFIB correlated well with the amount of IBL or PBL. In addition, a particular value of pre or postoperative MCFFIB could offer the predictive standard for massive bleeding in THRA.
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Reuteler A, Axiak-Flammer S, Howard J, Adamik KN. Comparison of the effects of a balanced crystalloid-based and a saline-based tetrastarch solution on canine whole blood coagulation and platelet function. J Vet Emerg Crit Care (San Antonio) 2016; 27:23-34. [PMID: 27926787 DOI: 10.1111/vec.12556] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Revised: 05/03/2015] [Accepted: 06/14/2015] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To evaluate the effects of a 6% hydroxyethyl starch (130/0.42) solution in either a buffered, electrolyte-balanced (HES-BAL), or a saline (HES-SAL) carrier solution on canine platelet function and whole blood coagulation. DESIGN Prospective, randomized study. SETTING University teaching hospital. ANIMALS Thirty-seven client-owned dogs undergoing general anesthesia for arthroscopy or imaging studies. INTERVENTIONS Dogs received a 15 mL/kg intravenous bolus of HES-SAL (n = 13), HES-BAL (n = 14), or a modified Ringer's solution (n = 10) over 30-40 minutes. Coagulation was analyzed using a Platelet Function Analyzer-100 (closure time [CtPFA ]), and whole blood thromboelastometry (ROTEM) with extrinsically (ex-tem and fib-tem) and intrinsically (in-tem) activated assays, which assessed clotting time (CT), clot formation time (CFT), maximal clot firmness (MCF), and lysis index (LI). Coagulation samples were assayed prior to fluid administration (T0), and 5 minutes (T1), and 3 hours (T2) following fluid bolus administration, respectively. RESULTS Both HES solutions resulted in impaired platelet function as indicated by a significant prolongation of CtPFA at T1 as compared to T0, but which resolved by T2. An IV bolus of Ringer's solution did not alter platelet function. In both HES groups, whole blood coagulation was significantly impaired at T1 as indicated by a significant increase in in-tem CFT, and a significant decrease in ex-tem, in-tem, and fib-tem MCF compared to T0. Furthermore, a significant increase in ex-tem CFT at T1 compared to T0 was found in the HES-SAL group. With the exception of in-tem MCF after HES-BAL, these effects were not present at T2. No significant differences were found in CtPFA or any ROTEM variable at any time point between HES-SAL and HES-BAL. CONCLUSION Administration of a single bolus of 15 mL/kg 6% HES 130/0.42 results in significant but short-lived impairment of canine platelet function and whole blood coagulation, regardless of carrier solution.
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Affiliation(s)
- Annina Reuteler
- Sections of Small Animal Emergency and Critical Care, Department of Clinical Veterinary Medicine, University of Bern, Bern, Switzerland
| | - Shannon Axiak-Flammer
- Anesthesia, Department of Clinical Veterinary Medicine, University of Bern, Bern, Switzerland
| | - Judith Howard
- the Diagnostic Clinical Laboratory, Department of Clinical Veterinary Medicine, University of Bern, Bern, Switzerland
| | - Katja-Nicole Adamik
- Sections of Small Animal Emergency and Critical Care, Department of Clinical Veterinary Medicine, University of Bern, Bern, Switzerland
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Moeller C, Fleischmann C, Thomas-Rueddel D, Vlasakov V, Rochwerg B, Theurer P, Gattinoni L, Reinhart K, Hartog CS. How safe is gelatin? A systematic review and meta-analysis of gelatin-containing plasma expanders vs crystalloids and albumin. J Crit Care 2016; 35:75-83. [DOI: 10.1016/j.jcrc.2016.04.011] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 04/07/2016] [Accepted: 04/08/2016] [Indexed: 12/22/2022]
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Nair S, Nair BR, Vidyasagar A, Joseph M. Importance of fibrinogen in dilutional coagulopathy after neurosurgical procedures: A descriptive study. Indian J Anaesth 2016; 60:542-5. [PMID: 27601735 PMCID: PMC4989803 DOI: 10.4103/0019-5049.187778] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND AND AIMS The routine management of coagulopathy during surgery involves assessing haemoglobin, prothrombin time (PT), activated partial thromboplastin time (aPTT) and platelets. Correction of these parameters involves administration of blood, fresh frozen plasma and platelet concentrates. The study was aimed at identifying the most common coagulation abnormality during neurosurgical procedures and the treatment of dilutional coagulopathy with blood components. METHODS During 2 years period, all adult patients undergoing neurosurgical procedures who were transfused two or more units of red cells were prospectively evaluated for the presence of a coagulopathy. PT, aPTT, platelet count and fibrinogen levels were estimated before starting a component therapy. RESULTS After assessing PT, aPTT, platelet count and fibrinogen levels following two or more blood transfusions, thirty patients were found to have at least one abnormal parameter that required administration of a blood product. The most common abnormality was a low fibrinogen level, seen in 26 patients; this was the only abnormality in three patients. No patient was found to have an abnormal PT or aPTT without either the fibrinogen concentration or platelet count or both being low. CONCLUSION Low fibrinogen concentration was the most common coagulation abnormality found after blood transfusions for neurosurgical procedures.
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Affiliation(s)
- Shalini Nair
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Bijesh Ravindran Nair
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Ajay Vidyasagar
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Mathew Joseph
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
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Spiezia L, Vasques F, Behr A, Campello E, Maggiolo S, Berizzi A, Gavasso S, Woodhams B, Biancari F, Simioni P. Perioperative coagulation assessment of patients undergoing major elective orthopedic surgery. Intern Emerg Med 2016; 11:793-801. [PMID: 26951189 DOI: 10.1007/s11739-016-1414-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 02/13/2016] [Indexed: 10/22/2022]
Abstract
Traditional coagulative parameters are of limited use in identifying perioperative coagulopathy occurring in patients undergoing major elective orthopedic surgery (MEOS). The aim of our study was to evaluate the coagulation changes in patients undergoing MEOS and to facilitate an early detection of perioperative coagulopathy in patients experiencing major intraoperative bleeding. We enrolled 40 consecutive patients (M/F 10/30, age range 34-90 years) who underwent MEOS at the Orthopedic Unit of the Padua University Hospital, Italy, between January 2014 and January 2015. Blood samples were obtained at the following time points: T0-pre: 30 min before surgery; T0-post: 30 min after the end of the procedure; T1: morning of the first postoperative day; T2: 7 ± 2 days after surgery. Patients who experienced an intraoperative blood loss ≥250 mL/h were considered as cases. Routine coagulative parameters, thromboelastometry and thrombin generation (TG) profiles were evaluated. At baseline, a significantly lower platelet count and FIBTEM MCF/AUC were observed in patents with excessive bleeding (p < 0.05 and 0.02/0.01, respectively). At T0-post and T1 intervals, cases showed hypocoagulation characterized by a significantly low platelet count (p = 0.001), prolonged CFT INTEM/EXTEM, reduction of alpha-angle and MaxV INTEM/EXTEM, MCF and AUC INTEM/EXTEM/FIBTEM (p < 0.05 in all comparisons). The only TG parameter standing out between study groups was time to peak at T0-pre. A low platelet count and fibrinogen activity were associated with significant intraoperative bleeding in patients undergoing MEOS. Thromboelastometry performed by ROTEM(®) identifies patients with coagulopathy.
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Affiliation(s)
- Luca Spiezia
- Thrombotic and Hemorrhagic Unit, Department of Medicine, University of Padova, Via Ospedale Civile 105, 35100, Padua, Italy
| | - Francesco Vasques
- Anesthesiology and Intensive Care Unit, Department of Medicine, University of Padova, Padua, Italy
| | - Astrid Behr
- Anesthesiology and Intensive Care Unit, Department of Medicine, University of Padova, Padua, Italy
| | - Elena Campello
- Thrombotic and Hemorrhagic Unit, Department of Medicine, University of Padova, Via Ospedale Civile 105, 35100, Padua, Italy
| | - Sara Maggiolo
- Thrombotic and Hemorrhagic Unit, Department of Medicine, University of Padova, Via Ospedale Civile 105, 35100, Padua, Italy
| | - Antonio Berizzi
- Department of Orthopedics, University of Padova, Padua, Italy
| | - Sabrina Gavasso
- Thrombotic and Hemorrhagic Unit, Department of Medicine, University of Padova, Via Ospedale Civile 105, 35100, Padua, Italy
| | | | - Fausto Biancari
- Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Paolo Simioni
- Thrombotic and Hemorrhagic Unit, Department of Medicine, University of Padova, Via Ospedale Civile 105, 35100, Padua, Italy.
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Jensen NHL, Stensballe J, Afshari A. Comparing efficacy and safety of fibrinogen concentrate to cryoprecipitate in bleeding patients: a systematic review. Acta Anaesthesiol Scand 2016; 60:1033-42. [PMID: 27109179 DOI: 10.1111/aas.12734] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 02/24/2016] [Accepted: 03/06/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Bleeding is associated with the depletion of fibrinogen, thus increasing the risk of coagulopathy, further bleeding and transfusion requirements. Both fibrinogen concentrate and cryoprecipitate replenish low plasma fibrinogen levels. This systematic review aims to identify and evaluate evidence of efficacy and safety of fibrinogen concentrate and cryoprecipitate in bleeding patients. METHOD Cochrane Central Register of Controlled Trials (CENTRAL), Medline, EMBASE up to 2nd of March 2015 were among the electronic search strategies of randomized controlled trials and non-randomized studies with meta-analysis employed. Studies for inclusion required bleeding patients being treated with either fibrinogen concentrate or cryoprecipitate. Mortality was the primary endpoint. Secondary outcomes included bleeding, coagulopathy, transfusion requirements and clinical complications related to the intervention. PRISMA methodology, a data-extraction form and the Cochrane risk of bias tool were all employed. RESULTS Four studies were eligible for inclusion in this systematic review; one randomized controlled trial (RCT) consisting of 66 patients and three observational studies involving 218 patients in total. No mortality was reported in the published papers. There were no differences in fibrinogen-level increase, bleeding, RBC transfusions or thromboembolic complications. The RCT showed a possible increased functional improvement of haemostasis after cryoprecipitate therapy compared to fibrinogen concentrate. CONCLUSION The available evidence directly comparing fibrinogen concentrate to cryoprecipitate is sparse and with high risk of bias. Recommendation of one product over the other for fibrinogen substitution in the bleeding patient with acquired hypofibrinogenaemia is currently not possible. Future research should guide us towards evidence-based decisions of product superiority.
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Affiliation(s)
- N. H. L. Jensen
- Department of Anaesthesia; Bispebjerg Hospital; Copenhagen Denmark
| | - J. Stensballe
- Section for Transfusion Medicine; Capital Region Blood Bank, Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
- Department of Anaesthesia; Centre of Head and Orthopedics, Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - A. Afshari
- Juliane Marie Centre - Department of Anaesthesia; 4013 Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
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