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Chen S, Lu L, Zheng X, Lin Y, Bao L, Zhang B, Yang Z. Case report: Anesthetic management for removal of tumor thrombus in the inferior vena cava and pulmonary artery in renal cell carcinoma. Front Oncol 2024; 14:1372625. [PMID: 38562176 PMCID: PMC10982337 DOI: 10.3389/fonc.2024.1372625] [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: 01/18/2024] [Accepted: 03/05/2024] [Indexed: 04/04/2024] Open
Abstract
Anesthetic management of patients with renal cell carcinoma with tumor thrombus in the inferior vena cava (IVC) is challenging. This paper reports the experience of anesthesia management in a patient with advanced renal cell carcinoma with thrombus accumulation in the IVC, right atrium, and pulmonary artery who underwent radical nephrectomy and tumor thrombus removal assisted by cardiopulmonary bypass. The emboli, measuring approximately 3 × 6 cm in the left inferior pulmonary artery and 4 × 13 cm in the right main pulmonary artery, were removed completely. During incision of the IVC under systemic heparinization, significant blood loss occurred in the surgical field. The surgery took 724 min, and cardiopulmonary bypass took 396 min. Intraoperative blood loss was 22,000 ml. The patient was extubated 39 hours after surgery and stayed in intensive care unit for 3 days. At 1 year follow-up, the patient was in good health and leading a normal life.
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Affiliation(s)
- Suli Chen
- Department of Anesthesiology, Aerospace Center Hospital, Peking University Aerospace School of Clinical Medicine, Beijing, China
| | - Liangyuan Lu
- Department of Anesthesiology, Aerospace Center Hospital, Peking University Aerospace School of Clinical Medicine, Beijing, China
| | - Xiangli Zheng
- Department of Anesthesiology, Aerospace Center Hospital, Peking University Aerospace School of Clinical Medicine, Beijing, China
| | - Yanjun Lin
- Department of Anesthesiology, Aerospace Center Hospital, Peking University Aerospace School of Clinical Medicine, Beijing, China
| | - Liming Bao
- Department of Cardiac Surgery, Aerospace Center Hospital, Peking University Aerospace School of Clinical Medicine, Beijing, China
| | - Bao Zhang
- Department of Urology, Aerospace Center Hospital, Peking University Aerospace School of Clinical Medicine, Beijing, China
| | - Zhanmin Yang
- Department of Anesthesiology, Aerospace Center Hospital, Peking University Aerospace School of Clinical Medicine, Beijing, China
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Kimura A, Shiraishi Y, Sawamura H, Inoue H, Takeshita K. Effectiveness of a two-stage posterior-anterior-posterior surgery using subcutaneously preserved autologous bone grafts for adult spinal deformity: a retrospective observational study. J Orthop Surg Res 2024; 19:91. [PMID: 38281002 PMCID: PMC10821239 DOI: 10.1186/s13018-024-04572-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 01/20/2024] [Indexed: 01/29/2024] Open
Abstract
BACKGROUND To achieve optimal correction of rigid kyphoscoliosis, we developed a novel two-stage posterior-anterior-posterior (PAP) surgery using subcutaneously preserved autologous bone grafts. This study aimed to investigate the effectiveness of two-stage PAP surgery versus single-stage anterior-posterior (AP) surgery. METHODS This was a retrospective analysis of patients undergoing combined anterior-posterior long-level fusion for adult spinal deformity (ASD) with a minimum 2-year follow-up. The indications for two-stage PAP surgery were rigid thoracolumbar deformity associated with hypertrophic facet arthritis and/or a large pelvic incidence-lumbar lordosis mismatch of > 25°. In the first stage of PAP surgery, pedicle screw insertion and multilevel Ponte osteotomies were performed. The resected local bone was embedded under sutured fascia. One week later, the embedded bone was retrieved in the right lateral position and used as an autograft for lateral lumbar interbody fusion. Final deformity correction was performed in the prone position. RESULTS From January 2018 to April 2021, 12 and 16 patients with ASD underwent two-stage PAP surgery (PAP group) and single-stage AP surgery (AP group), respectively. Although PAP surgery was associated with a significantly longer operation time, the total blood loss volume was significantly less in the PAP group than the AP group. Compared with the AP group, the PAP group showed significantly larger postoperative changes in radiological parameters in the sagittal and coronal planes. The overall complication rate did not differ significantly between the two groups. CONCLUSION Two-stage PAP surgery provided effective correction of rigid kyphoscoliosis without increasing blood loss and postoperative complication rates.
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Affiliation(s)
- Atsushi Kimura
- Department of Orthopaedic Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan.
| | - Yasuyuki Shiraishi
- Department of Orthopaedic Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Hideaki Sawamura
- Department of Orthopaedic Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Hirokazu Inoue
- Department of Orthopaedic Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Katsushi Takeshita
- Department of Orthopaedic Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
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Chalkias A. Shear Stress and Endothelial Mechanotransduction in Trauma Patients with Hemorrhagic Shock: Hidden Coagulopathy Pathways and Novel Therapeutic Strategies. Int J Mol Sci 2023; 24:17522. [PMID: 38139351 PMCID: PMC10743945 DOI: 10.3390/ijms242417522] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 12/13/2023] [Accepted: 12/14/2023] [Indexed: 12/24/2023] Open
Abstract
Massive trauma remains a leading cause of death and a global public health burden. Post-traumatic coagulopathy may be present even before the onset of resuscitation, and correlates with severity of trauma. Several mechanisms have been proposed to explain the development of abnormal coagulation processes, but the heterogeneity in injuries and patient profiles makes it difficult to define a dominant mechanism. Regardless of the pattern of death, a significant role in the pathophysiology and pathogenesis of coagulopathy may be attributed to the exposure of endothelial cells to abnormal physical forces and mechanical stimuli in their local environment. In these conditions, the cellular responses are translated into biochemical signals that induce/aggravate oxidative stress, inflammation, and coagulopathy. Microvascular shear stress-induced alterations could be treated or prevented by the development and use of innovative pharmacologic strategies that effectively target shear-mediated endothelial dysfunction, including shear-responsive drug delivery systems and novel antioxidants, and by targeting the venous side of the circulation to exploit the beneficial antithrombogenic profile of venous endothelial cells.
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Affiliation(s)
- Athanasios Chalkias
- Institute for Translational Medicine and Therapeutics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104-5158, USA;
- Outcomes Research Consortium, Cleveland, OH 44195, USA
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Quintana-Diaz M, Anania P, Juárez-Vela R, Echaniz-Serrano E, Tejada-Garrido CI, Sanchez-Conde P, Nanwani-Nanwani K, Serrano-Lázaro A, Marcos-Neira P, Gero-Escapa M, García-Criado J, Godoy DA. "COAGULATION": a mnemonic device for treating coagulation disorders following traumatic brain injury-a narrative-based method in the intensive care unit. Front Public Health 2023; 11:1309094. [PMID: 38125841 PMCID: PMC10730733 DOI: 10.3389/fpubh.2023.1309094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 11/21/2023] [Indexed: 12/23/2023] Open
Abstract
Introduction Coagulopathy associated with isolated traumatic brain injury (C-iTBI) is a frequent complication associated with poor outcomes, primarily due to its role in the development or progression of haemorrhagic brain lesions. The independent risk factors for its onset are age, severity of traumatic brain injury (TBI), volume of fluids administered during resuscitation, and pre-injury use of antithrombotic drugs. Although the pathophysiology of C-iTBI has not been fully elucidated, two distinct stages have been identified: an initial hypocoagulable phase that begins within the first 24 h, dominated by platelet dysfunction and hyperfibrinolysis, followed by a hypercoagulable state that generally starts 72 h after the trauma. The aim of this study was to design an acronym as a mnemonic device to provide clinicians with an auxiliary tool in the treatment of this complication. Methods A narrative analysis was performed in which intensive care physicians were asked to list the key factors related to C-iTBI. The initial sample was comprised of 33 respondents. Respondents who were not physicians, not currently working in or with experience in coagulopathy were excluded. Interviews were conducted for a month until the sample was saturated. Each participant was asked a single question: Can you identify a factor associated with coagulopathy in patients with TBI? Factors identified by respondents were then submitted to a quality check based on published studies and proven evidence. Because all the factors identified had strong support in the literature, none was eliminated. An acronym was then developed to create the mnemonic device. Results and conclusion Eleven factors were identified: cerebral computed tomography, oral anticoagulant & antiplatelet use, arterial blood pressure (Hypotension), goal-directed haemostatic therapy, use fluids cautiously, low calcium levels, anaemia-transfusion, temperature, international normalised ratio (INR), oral antithrombotic reversal, normal acid-base status, forming the acronym "Coagulation." This acronym is a simple mnemonic device, easy to apply for anyone facing the challenge of treating patients of moderate or severe TBI on a daily basis.
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Affiliation(s)
- Manuel Quintana-Diaz
- Department of Medicine, Faculty of Medicine, Autonomous University of Madrid, Madrid, Spain
- Intensive Care Unit, La Paz University Hospital, Madrid, Spain
- Institute for Health Research (idiPAZ), La Paz University Hospital, Madrid, Spain
| | - Pasquale Anania
- Department of Neurosurgery, Ospedale Policlinico San Martino, Istituto di Ricovero eCura a Carattere Scientifico (IRCCS) for Oncology and Neuroscience, Genoa, Italy
| | - Raúl Juárez-Vela
- Institute for Health Research (idiPAZ), La Paz University Hospital, Madrid, Spain
- Department of Nursing, University of La Rioja, Logroño, Spain
- Health and Healthcare Research Group (GRUPAC), Faculty of Health Sciences, University of La Rioja, Logroño, Spain
| | - Emmanuel Echaniz-Serrano
- Department of Nursing and Physiatry, Faculty of Health Sciences, University of Zaragoza, Zaragoza, Spain
- Aragon Healthcare Service, Aragon, Zaragoza, Spain
| | - Clara Isabel Tejada-Garrido
- Department of Nursing, University of La Rioja, Logroño, Spain
- Health and Healthcare Research Group (GRUPAC), Faculty of Health Sciences, University of La Rioja, Logroño, Spain
| | | | - Kapil Nanwani-Nanwani
- Intensive Care Unit, La Paz University Hospital, Madrid, Spain
- Institute for Health Research (idiPAZ), La Paz University Hospital, Madrid, Spain
| | - Ainhoa Serrano-Lázaro
- Institute for Health Research (idiPAZ), La Paz University Hospital, Madrid, Spain
- Intensive Care Unit, Valencia University Clinical Hospital, Valencia, Spain
| | - Pilar Marcos-Neira
- Intensive Care Unit, Germans Trias i Pujol University Hospital, Badalona, Spain
| | | | | | - Daniel Agustín Godoy
- Critical Care Department, Neurointensive Care Unit, Sanatorio Pasteur, Catamarca, Argentina
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Bian W, Bian W, Li Y, Feng X, Song M, Zhou P. Hypothermia may reduce mortality and improve neurologic outcomes in adult patients treated with VA-ECMO: A systematic review and meta-analysis. Am J Emerg Med 2023; 70:163-170. [PMID: 37327682 DOI: 10.1016/j.ajem.2023.05.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 04/08/2023] [Accepted: 05/21/2023] [Indexed: 06/18/2023] Open
Abstract
BACKGROUND VA-ECMO can greatly reduce mortality in critically ill patients, and hypothermia attenuates the deleterious effects of ischemia-reperfusion injury. We aimed to study the effects of hypothermia on mortality and neurological outcomes in VA-ECMO patients. METHODS A systematic search of the PubMed, Embase, Web of Science, and Cochrane Library databases was performed from the earliest available date to 31 December 2022. The primary outcome was discharge or 28-day mortality and favorable neurological outcomes in VA-ECMO patients, and the secondary outcome was bleeding risk in VA-ECMO patients. The results are presented as odds ratios (ORs) and 95% confidence intervals (CIs). Based on the heterogeneity assessed by the I2 statistic, meta-analyses were performed using random or fixed-effects models. GRADE methodology was used to rate the certainty in the findings. RESULTS A total of 27 articles (3782 patients) were included. Hypothermia (33-35 °C) lasting at least 24 h can significantly reduce discharge or 28-day mortality (OR, 0.45; 95% CI, 0.33-0.63; I2 = 41%) and significantly improve favorable neurological outcomes (OR, 2.08; 95% CI, 1.66-2.61; I2 = 3%) in VA-ECMO patients. Additionally, there was no risk associated with bleeding (OR, 1.15; 95% CI, 0.86-1.53; I2 = 12%). In our subgroup analysis according to in-hospital or out-of-hospital cardiac arrest, hypothermia reduced short-term mortality in both VA-ECMO-assisted in-hospital (OR, 0.30; 95% CI, 0.11-0.86; I2 = 0.0%) and out-of-hospital cardiac arrest (OR, 0.41; 95% CI, 0.25-0.69; I2 = 52.3%). Out-of-hospital cardiac arrest patients assisted by VA-ECMO for favorable neurological outcomes were consistent with the conclusions of this paper (OR, 2.10; 95% CI, 1.63-2.72; I2 = 0.5%). CONCLUSIONS Our results show that mild hypothermia (33-35 °C) lasting at least 24 h can greatly reduce short-term mortality and significantly improve favorable short-term neurologic outcomes in VA-ECMO-assisted patients without bleeding-related risks. As the grade assessment indicated that the certainty of the evidence was relatively low, hypothermia as a strategy for VA-ECMO-assisted patient care may need to be treated with caution.
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Affiliation(s)
- Wentao Bian
- School of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, China
| | - Wenkai Bian
- Xi'an Radio Research Institute, Xian, Shaanxi Province, China
| | - Yi Li
- Emergency Intensive Care Unit, Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, China
| | - Xuanlin Feng
- Emergency Intensive Care Unit, Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, China
| | - Menglong Song
- Emergency Intensive Care Unit, Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, China
| | - Ping Zhou
- Emergency Intensive Care Unit, Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, China.
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Peng YY, Lu XM, Li S, Tang C, Ding Y, Wang HY, Yang C, Wang YT. Effects and mechanisms of extremely cold environment on body response after trauma. J Therm Biol 2023; 114:103570. [PMID: 37344028 DOI: 10.1016/j.jtherbio.2023.103570] [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: 11/21/2022] [Revised: 04/07/2023] [Accepted: 04/07/2023] [Indexed: 06/23/2023]
Abstract
With the outbreak of the Ukrainian crisis, extremely cold environment warfare has once again become the focus of international attention. People exposed to extremely cold environments may suffer from cold damage, further aggravate trauma, trigger high disability and mortality rates, and even cause serious sequelae. To declare the effects and mechanisms of the extremely cold environment on the body after trauma, this paper reviews, firstly, physiological reaction of human body in an extremely cold environment. Then, the post-traumatic body response in an extremely cold environment was introduced, and finally, the sequelae of trauma in extremely cold environment was further summarized in the paper. The results indicated that extremely cold environment can cause a series of damage to the body, especially the body after trauma. The extremely cold factor is a double-edged sword, showing a favorable and unfavorable side in different aspects. Moreover, in addition to the trauma suffered by the body, the subsequent sequelae such as cognitive dysfunction, anxiety, depression and even post-traumatic stress disorder may also be induced. The paper summarizes the human body's physiological response in an extremely cold environment, and declares the effects and mechanisms of the extremely cold environment on the body after trauma, which may provide a theoretical basis for effectively improving the level of combat trauma treatment in extremely cold regions.
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Affiliation(s)
- Yu-Yuan Peng
- State Key Laboratory of Trauma, Burns and Combined Injury, Daping Hospital, Army Medical University, Chongqing, 400042, China; College of Pharmacy and Bioengineering, Chongqing University of Technology, Chongqing, 400054, China
| | - Xiu-Min Lu
- College of Pharmacy and Bioengineering, Chongqing University of Technology, Chongqing, 400054, China
| | - Sen Li
- State Key Laboratory of Trauma, Burns and Combined Injury, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Can Tang
- College of Pharmacy and Bioengineering, Chongqing University of Technology, Chongqing, 400054, China
| | - Yang Ding
- College of Pharmacy and Bioengineering, Chongqing University of Technology, Chongqing, 400054, China
| | - Hai-Yan Wang
- State Key Laboratory of Trauma, Burns and Combined Injury, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Ce Yang
- State Key Laboratory of Trauma, Burns and Combined Injury, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Yong-Tang Wang
- State Key Laboratory of Trauma, Burns and Combined Injury, Daping Hospital, Army Medical University, Chongqing, 400042, China.
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How to manage coagulopathies in critically ill patients. Intensive Care Med 2023; 49:273-290. [PMID: 36808215 DOI: 10.1007/s00134-023-06980-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 01/06/2023] [Indexed: 02/19/2023]
Abstract
Coagulopathy is a severe and frequent complication in critically ill patients, for which the pathogenesis and presentation may be variable depending on the underlying disease. Based on the dominant clinical phenotype, the current review differentiates between hemorrhagic coagulopathies, characterized by a hypocoagulable and hyperfibrinolysis state, and thrombotic coagulopathies with a systemic prothrombotic and antifibrinolytic phenotype. We discuss the differences in pathogenesis and treatment of the common coagulopathies.
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Carlo A, Yan Q, Ten Cate H, De Laat-Kremers R, De Laat B, Ninivaggi M. Semi-automated thrombin dynamics applying the ST Genesia thrombin generation assay. Front Cardiovasc Med 2022; 9:912433. [PMID: 35958413 PMCID: PMC9360406 DOI: 10.3389/fcvm.2022.912433] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 06/30/2022] [Indexed: 01/15/2023] Open
Abstract
Background The haemostatic balance is an equilibrium of pro- and anticoagulant factors that work synergistically to prevent bleeding and thrombosis. As thrombin is the central enzyme in the coagulation pathway, it is desirable to measure thrombin generation (TG) in order to detect possible bleeding or thrombotic phenotypes, as well as to investigate the capacity of drugs affecting the formation of thrombin. By investigating the underlying processes of TG (i.e., prothrombin conversion and inactivation), additional information is collected about the dynamics of thrombin formation. Objectives To obtain reference values for thrombin dynamics (TD) analysis in 112 healthy donors using an automated system for TG. Methods TG was measured on the ST Genesia, fibrinogen on the Start, anti-thrombin (AT) on the STA R Max and α2Macroglobulin (α2M) with an in-house chromogenic assay. Results TG was measured using STG-BleedScreen, STG-ThromboScreen and STG-DrugScreen. The TG data was used as an input for TD analysis, in combination with plasma levels of AT, α2M and fibrinogen that were 113% (108-118%), 2.6 μM (2.2 μM-3.1 μM) and 2.9 g/L (2.6-3.2 g/L), respectively. The maximum rate of the prothrombinase complex (PCmax) and the total amount of prothrombin converted (PCtot) increased with increasing tissue factor (TF) concentration. PCtot increased from 902 to 988 nM, whereas PCmax increased from 172 to 508 nM/min. Thrombin (T)-AT and T-α2M complexes also increased with increasing TF concentration (i.e., from 860 to 955 nM and from 28 to 33 nm, respectively). PCtot, T-AT and T-α2M complex formation were strongly inhibited by addition of thrombomodulin (-44%, -43%, and -48%, respectively), whereas PCmax was affected less (-24%). PCtot, PCmax, T-AT, and T-α2M were higher in women using oral contraceptives (OC) compared to men/women without OC, and inhibition by thrombomodulin was also significantly less in women on OC (p < 0.05). Conclusions TG measured on the ST Genesia can be used as an input for TD analysis. The data obtained can be used as reference values for future clinical studies as the balance between prothrombin conversion and thrombin inactivation has shown to be useful in several clinical settings.
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Affiliation(s)
- Audrey Carlo
- Diagnostica Stago S.A.S., Asnières-sur-Seine, France
| | - Qiuting Yan
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, Netherlands.,Department of Biochemistry, Maastricht University, Maastricht, Netherlands
| | - Hugo Ten Cate
- Department of Biochemistry, Maastricht University, Maastricht, Netherlands
| | - Romy De Laat-Kremers
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, Netherlands.,Department of Data Analysis and Artificial Intelligence, Synapse Research Institute, Maastricht, Netherlands
| | - Bas De Laat
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, Netherlands.,Department of Data Analysis and Artificial Intelligence, Synapse Research Institute, Maastricht, Netherlands
| | - Marisa Ninivaggi
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, Netherlands
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HIPEC as a risk factor for postoperative coagulopathy after cytoreductive surgery for peritoneal metastases. Updates Surg 2022; 74:1715-1723. [PMID: 35932406 DOI: 10.1007/s13304-022-01340-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 07/19/2022] [Indexed: 10/15/2022]
Abstract
AIM OF THE STUDY Postoperative coagulopathy is a poorly investigated condition after Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC). This study aims to evaluate the occurrence and risk factors of coagulative disorders after surgery for peritoneal metastases. PATIENTS AND METHODS The records were extracted from a prospectively maintained database of consecutive patients who underwent CRS between January 2018 and September 2020. The study was approved by the local Ethics Committee. For each patient, the coagulation profile (CP), which included international normalized ratio (INR), partial thromboplastin time (aPTT), and platelets (PLTS) before surgery, intensive care unit admission,1st, 3rd, 5th postoperative day (POD) and the day before discharge was collected. Risk factors for postoperative coagulopathy were identified at multivariate analysis. RESULTS During the study period, 125 patients were included in the study. Among these, 48 (38.4%) underwent CRS only, and 77 (61.6%) CRS followed by HIPEC. Twenty-one patients (16.8%) developed severe coagulopathy, 5 (10.4%) after CRS and 16 (20.8%) after CRS-HIPEC. At multivariate analysis, HIPEC and blood loss ≥ 500 ml represented independent risk factors for severe alteration of INR > 1.5 (p = 0.05, OR 1.2) and PLTS < 75 109/L (p = 0.03, OR 1.3), respectively. CONCLUSION HIPEC is an independent risk factor for postoperative coagulopathy after CRS. Further studies are necessary to assess the usefulness of the point-of-care test in patients treated with CRS-HIPEC.
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Tao E, Chen C, Chen Y, Xie D, Yuan T, Fu Q, Jiang M. Profound Hypothermia Concomitant With Severe Coagulation Dysfunction and Leukopenia in a Preterm Infant. Adv Neonatal Care 2022; 22:E120-E125. [DOI: 10.1097/anc.0000000000000988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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11
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Thrombin Generation in Trauma Patients: How Do we Navigate Through Scylla and Charybdis? CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-021-00502-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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12
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Moore EE, Moore HB, Kornblith LZ, Neal MD, Hoffman M, Mutch NJ, Schöchl H, Hunt BJ, Sauaia A. Trauma-induced coagulopathy. Nat Rev Dis Primers 2021; 7:30. [PMID: 33927200 PMCID: PMC9107773 DOI: 10.1038/s41572-021-00264-3] [Citation(s) in RCA: 291] [Impact Index Per Article: 97.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/19/2021] [Indexed: 12/12/2022]
Abstract
Uncontrolled haemorrhage is a major preventable cause of death in patients with traumatic injury. Trauma-induced coagulopathy (TIC) describes abnormal coagulation processes that are attributable to trauma. In the early hours of TIC development, hypocoagulability is typically present, resulting in bleeding, whereas later TIC is characterized by a hypercoagulable state associated with venous thromboembolism and multiple organ failure. Several pathophysiological mechanisms underlie TIC; tissue injury and shock synergistically provoke endothelial, immune system, platelet and clotting activation, which are accentuated by the 'lethal triad' (coagulopathy, hypothermia and acidosis). Traumatic brain injury also has a distinct role in TIC. Haemostatic abnormalities include fibrinogen depletion, inadequate thrombin generation, impaired platelet function and dysregulated fibrinolysis. Laboratory diagnosis is based on coagulation abnormalities detected by conventional or viscoelastic haemostatic assays; however, it does not always match the clinical condition. Management priorities are stopping blood loss and reversing shock by restoring circulating blood volume, to prevent or reduce the risk of worsening TIC. Various blood products can be used in resuscitation; however, there is no international agreement on the optimal composition of transfusion components. Tranexamic acid is used in pre-hospital settings selectively in the USA and more widely in Europe and other locations. Survivors of TIC experience high rates of morbidity, which affects short-term and long-term quality of life and functional outcome.
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Affiliation(s)
- Ernest E Moore
- Ernest E Moore Shock Trauma Center at Denver Health, Denver, CO, USA.
- Department of Surgery, University of Colorado Denver, Aurora, CO, USA.
| | - Hunter B Moore
- Department of Surgery, University of Colorado Denver, Aurora, CO, USA
| | - Lucy Z Kornblith
- Trauma and Surgical Critical Care, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, CA, USA
| | - Matthew D Neal
- Pittsburgh Trauma Research Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Maureane Hoffman
- Duke University School of Medicine, Transfusion Service, Durham VA Medical Center, Durham, NC, USA
| | - Nicola J Mutch
- Aberdeen Cardiovascular & Diabetes Centre, School of Medicine, Medical Sciences and Nutrition, Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK
| | - Herbert Schöchl
- Department of Anesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Salzburg and Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria
| | | | - Angela Sauaia
- Department of Surgery, University of Colorado Denver, Aurora, CO, USA
- Colorado School of Public Health, University of Colorado Denver, Aurora, CO, USA
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Colomina MJ, Méndez E, Sabate A. Altered Fibrinolysis during and after Surgery. Semin Thromb Hemost 2021; 47:512-519. [PMID: 33878781 DOI: 10.1055/s-0041-1722971] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Major surgery induces hemostatic changes related to surgical stress, tissue destruction, and inflammatory reactions. These changes involve a shift of volume from extravascular space to intravascular and interstitial spaces, a "physiologic" hemodilution of coagulation proteins, and an increase of plasmatic fibrinogen concentration and platelets. Increases in fibrinogen and platelets together with a simultaneous dilution of pro- and anticoagulant factors and development of a hypofibrinolytic status result in a postoperative hypercoagulable state. This profile is accentuated in more extensive surgery, but the balance can shift toward hemorrhagic tendency in specific types of surgeries, for example, in prolonged cardiopulmonary bypass or in patients with comorbidities, especially liver diseases, sepsis, and hematological disorders. Also, acquired coagulopathy can develop in patients with trauma, during obstetric complications, and during major surgery as a result of excessive blood loss and subsequent consumption of coagulation factors as well as hemodilution. In addition, an increasing number of patients receive anticoagulants and antiplatelet drugs preoperatively that might influence the response to surgical hemostasis. This review focuses on those situations that may change normal hemostasis and coagulation during surgery, producing both hyperfibrinolysis and hypofibrinolysis, such as overcorrection with coagulation factors, bleeding and hyperfibrinolysis that may occur with extracorporeal circulation and high aortic-portal-vena cava clamps, and hyperfibrinolysis related to severe maintained hemodynamic disturbances. We also evaluate the role of tranexamic acid for prophylaxis and treatment in different surgical settings, and finally the value of point-of-care testing in the operating room is commented with regard to investigation of fibrinolysis.
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Affiliation(s)
- Maria J Colomina
- Department of Anaesthesia and Critical Care, Bellvitge University Hospital, L'Hospitalet de LLobregat, Barcelona, Spain.,Universidad de Barcelona, Barcelona, Spain
| | - Esther Méndez
- Department of Anaesthesia and Critical Care, Bellvitge University Hospital, L'Hospitalet de LLobregat, Barcelona, Spain
| | - Antoni Sabate
- Department of Anaesthesia and Critical Care, Bellvitge University Hospital, L'Hospitalet de LLobregat, Barcelona, Spain.,Universidad de Barcelona, Barcelona, Spain
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14
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Savioli G, Ceresa IF, Caneva L, Gerosa S, Ricevuti G. Trauma-Induced Coagulopathy: Overview of an Emerging Medical Problem from Pathophysiology to Outcomes. MEDICINES (BASEL, SWITZERLAND) 2021; 8:16. [PMID: 33805197 PMCID: PMC8064317 DOI: 10.3390/medicines8040016] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/15/2021] [Accepted: 03/07/2021] [Indexed: 12/17/2022]
Abstract
Coagulopathy induced by major trauma is common, affecting approximately one-third of patients after trauma. It develops independently of iatrogenic, hypothermic, and dilutive causes (such as iatrogenic cause in case of fluid administration), which instead have a pejorative aspect on coagulopathy. Notwithstanding the continuous research conducted over the past decade on Trauma-Induced Coagulopathy (TIC), it remains a life-threatening condition with a significant impact on trauma mortality. We reviewed the current evidence regarding TIC diagnosis and pathophysiological mechanisms and summarized the different iterations of optimal TIC management strategies among which product resuscitation, potential drug administrations, and hemostatis-focused approaches. We have identified areas of ongoing investigation and controversy in TIC management.
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Affiliation(s)
- Gabriele Savioli
- Emergency Department, IRCCS Policlinico San Matteo, PhD University of Pavia, 27100 Pavia, Italy; (I.F.C.); (S.G.)
| | - Iride Francesca Ceresa
- Emergency Department, IRCCS Policlinico San Matteo, PhD University of Pavia, 27100 Pavia, Italy; (I.F.C.); (S.G.)
| | - Luca Caneva
- Anesthesia and Intensive Care, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
| | - Sebastiano Gerosa
- Emergency Department, IRCCS Policlinico San Matteo, PhD University of Pavia, 27100 Pavia, Italy; (I.F.C.); (S.G.)
| | - Giovanni Ricevuti
- Department of Drug Science, University of Pavia, 27100 Pavia, Italy;
- Saint Camillus International University of Health Sciences, 00152 Rome, Italy
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15
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Nechipurenko DY, Shibeko AM, Sveshnikova AN, Panteleev MA. In Silico Hemostasis Modeling and Prediction. Hamostaseologie 2020; 40:524-535. [PMID: 32916753 DOI: 10.1055/a-1213-2117] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Computational physiology, i.e., reproduction of physiological (and, by extension, pathophysiological) processes in silico, could be considered one of the major goals in computational biology. One might use computers to simulate molecular interactions, enzyme kinetics, gene expression, or whole networks of biochemical reactions, but it is (patho)physiological meaning that is usually the meaningful goal of the research even when a single enzyme is its subject. Although exponential rise in the use of computational and mathematical models in the field of hemostasis and thrombosis began in the 1980s (first for blood coagulation, then for platelet adhesion, and finally for platelet signal transduction), the majority of their successful applications are still focused on simulating the elements of the hemostatic system rather than the total (patho)physiological response in situ. Here we discuss the state of the art, the state of the progress toward the efficient "virtual thrombus formation," and what one can already get from the existing models.
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Affiliation(s)
- Dmitry Y Nechipurenko
- Faculty of Physics, Lomonosov Moscow State University, Moscow, Russia.,Center for Theoretical Problems of Physicochemical Pharmacology of the Russian Academy of Sciences, Moscow, Russia.,Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Aleksey M Shibeko
- Center for Theoretical Problems of Physicochemical Pharmacology of the Russian Academy of Sciences, Moscow, Russia.,Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Anastasia N Sveshnikova
- Faculty of Physics, Lomonosov Moscow State University, Moscow, Russia.,Center for Theoretical Problems of Physicochemical Pharmacology of the Russian Academy of Sciences, Moscow, Russia.,Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Mikhail A Panteleev
- Faculty of Physics, Lomonosov Moscow State University, Moscow, Russia.,Center for Theoretical Problems of Physicochemical Pharmacology of the Russian Academy of Sciences, Moscow, Russia.,Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
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16
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Kristensen SR, Nybo J, Pedersen S. Reply to a letter from Jackson J et al: Effect of pH on thrombin activity measured by calibrated automated thrombinography. Res Pract Thromb Haemost 2020; 4:1065. [PMID: 32864558 PMCID: PMC7443424 DOI: 10.1002/rth2.12371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 04/30/2020] [Indexed: 01/07/2023] Open
Affiliation(s)
- Søren Risom Kristensen
- Department of Clinical Biochemistry Aalborg University Hospital Aalborg Denmark.,Department of Clinical Medicine Aalborg University Aalborg Denmark
| | - Jette Nybo
- Department of Clinical Biochemistry Aalborg University Hospital Aalborg Denmark
| | - Shona Pedersen
- Department of Clinical Biochemistry Aalborg University Hospital Aalborg Denmark.,Department of Clinical Medicine Aalborg University Aalborg Denmark
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17
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Mitrophanov AY, Merrill-Skoloff G, Grover SP, Govindarajan V, Kolanjiyil A, Hariprasad DS, Unnikrishnan G, Flaumenhaft R, Reifman J. Injury Length and Arteriole Constriction Shape Clot Growth and Blood-Flow Acceleration in a Mouse Model of Thrombosis. Arterioscler Thromb Vasc Biol 2020; 40:2114-2126. [PMID: 32640902 DOI: 10.1161/atvbaha.120.314786] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Quantitative relationships between the extent of injury and thrombus formation in vivo are not well understood. Moreover, it has not been investigated how increased injury severity translates to blood-flow modulation. Here, we investigated interconnections between injury length, clot growth, and blood flow in a mouse model of laser-induced thrombosis. Approach and Results: Using intravital microscopy, we analyzed 59 clotting events collected from the cremaster arteriole of 14 adult mice. We regarded injury length as a measure of injury severity. The injury caused transient constriction upstream and downstream of the injury site resulting in a 50% reduction in arteriole diameter. The amount of platelet accumulation and fibrin formation did not depend on arteriole diameter or deformation but displayed an exponentially increasing dependence on injury length. The height of the platelet clot depended linearly on injury length and the arteriole diameter. Upstream arteriolar constriction correlated with delayed upstream velocity increase, which, in turn, determined downstream velocity. Before clot formation, flow velocity positively correlated with the arteriole diameter. After the onset of thrombus growth, flow velocity at the injury site negatively correlated with the arteriole diameter and with the size of the above-clot lumen. CONCLUSIONS Injury severity increased platelet accumulation and fibrin formation in a persistently steep fashion and, together with arteriole diameter, defined clot height. Arterial constriction and clot formation were characterized by a dynamic change in the blood flow, associated with increased flow velocity.
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Affiliation(s)
- Alexander Y Mitrophanov
- From the DoD Biotechnology High Performance Computing Software Applications Institute, Telemedicine and Advanced Technology Research Center, US Army Medical Research and Development Command, Ft. Detrick, MD (A.Y.M., V.G., A.K., D.S.H., G.U., J.R.).,The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, MD (A.Y.M., V.G., A.K., D.S.H., G.U.)
| | - Glenn Merrill-Skoloff
- Division of Hemostasis and Thrombosis, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (G.M.-S., S.P.G., R.F.)
| | - Steven P Grover
- Division of Hemostasis and Thrombosis, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (G.M.-S., S.P.G., R.F.)
| | - Vijay Govindarajan
- From the DoD Biotechnology High Performance Computing Software Applications Institute, Telemedicine and Advanced Technology Research Center, US Army Medical Research and Development Command, Ft. Detrick, MD (A.Y.M., V.G., A.K., D.S.H., G.U., J.R.).,The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, MD (A.Y.M., V.G., A.K., D.S.H., G.U.)
| | - Arun Kolanjiyil
- From the DoD Biotechnology High Performance Computing Software Applications Institute, Telemedicine and Advanced Technology Research Center, US Army Medical Research and Development Command, Ft. Detrick, MD (A.Y.M., V.G., A.K., D.S.H., G.U., J.R.).,The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, MD (A.Y.M., V.G., A.K., D.S.H., G.U.)
| | - Daniel S Hariprasad
- From the DoD Biotechnology High Performance Computing Software Applications Institute, Telemedicine and Advanced Technology Research Center, US Army Medical Research and Development Command, Ft. Detrick, MD (A.Y.M., V.G., A.K., D.S.H., G.U., J.R.).,The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, MD (A.Y.M., V.G., A.K., D.S.H., G.U.)
| | - Ginu Unnikrishnan
- From the DoD Biotechnology High Performance Computing Software Applications Institute, Telemedicine and Advanced Technology Research Center, US Army Medical Research and Development Command, Ft. Detrick, MD (A.Y.M., V.G., A.K., D.S.H., G.U., J.R.).,The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, MD (A.Y.M., V.G., A.K., D.S.H., G.U.)
| | - Robert Flaumenhaft
- Division of Hemostasis and Thrombosis, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (G.M.-S., S.P.G., R.F.)
| | - Jaques Reifman
- From the DoD Biotechnology High Performance Computing Software Applications Institute, Telemedicine and Advanced Technology Research Center, US Army Medical Research and Development Command, Ft. Detrick, MD (A.Y.M., V.G., A.K., D.S.H., G.U., J.R.)
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