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Lee J, Lee DK, Kwon WK, Lee S, Oh CS, Görlinger K, Kim TY. Effect of ultrafiltration on whole blood coagulation profile during cardiopulmonary bypass in cardiac surgery: a retrospective analysis. Korean J Anesthesiol 2024; 77:236-245. [PMID: 38287212 PMCID: PMC10982537 DOI: 10.4097/kja.23698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 01/02/2024] [Accepted: 01/07/2024] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND Ultrafiltration (UF) would enhance coagulation profiles by concentrating coagulation elements during cardiopulmonary bypass (CPB) for cardiac surgery. METHODS We retrospectively reviewed electronic medical records of 75 patients who had undergone cardiac surgery with rotational thromboelastometry-based coagulation management in a university hospital and analyzed the UF-induced changes in the maximum clot firmness (MCF) of extrinsically activated test with tissue factor (EXTEM) during CPB in 30 patients. RESULTS The median volume of filtered-free water was 1,350 ml, and median hematocrit was significantly increased from 22.5% to 25.5%. As the primary measure, UF significantly increased the median MCF-EXTEM from 48.0 mm to 50.5 mm (P = 0.015, effect size r = 0.44). The area under the receiver operating characteristic curve pre-UF MCF-EXTEM for discrimination of any increase of MCF-EXTEM after applying UF was 0.89 (95% CI [0.77, 1.00], P < 0.001), and its cut-off value was 50.5 mm (specificity of 81.8% and sensitivity of 84.2% in Youden's J statistic). In the secondary analyses using the cut-off value, UF significantly increased the median MCF-EXTEM from 40.5 mm to 42.5 mm in 18 patients with pre-UF MCF-EXTEM ≤ 50.5 mm. However, it did not increase MCF-EXTEM in 12 patients with pre-UF MCF-EXTEM > 50.5 mm. There was a significant interaction between pre-UF MCF-EXTEM values and applying UF (P < 0.001 for the subgroup, P = 0.046 for UF, P = 0.003 for interaction). CONCLUSIONS Applying UF improved clot firmness, and the improvement was more pronounced when pre-UF MCF-EXTEM had been reduced during CPB.
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Affiliation(s)
- Jaemoon Lee
- Department of Anesthesiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Dong-Kyu Lee
- Department of Anesthesiology and Pain Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Won-Kyoung Kwon
- Department of Anesthesiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Sookyung Lee
- Department of Anesthesiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Chung-Sik Oh
- Department of Anesthesiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Klaus Görlinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, Essen, Germany
- Medical Department, TEM Innovations GmbH/Werfen PBM, Munich, Germany
| | - Tae-Yop Kim
- Department of Anesthesiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
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Pascreau T, Gougeon M, Fessler J, Zia Chahabi S, Le Guen M, Vasse M. Interest in the new thromboelastometry device, Clot Pro®, for predicting thrombocytopenia and hypofibrinogenemia during lung transplantation. Thromb Res 2024; 233:203-211. [PMID: 38128338 DOI: 10.1016/j.thromres.2023.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 10/30/2023] [Accepted: 11/27/2023] [Indexed: 12/23/2023]
Abstract
INTRODUCTION Lung transplantation is associated with high proportion of transfusion. Monitoring of coagulopathy using viscoelastic tests could aid in the perioperative management of bleeding. The aim of the study was to assess the predictive cut-off values for thrombocytopenia and hypofibrinogenemia using the new thromboelastography analyzer, ClotPro. METHODS We retrospectively enrolled 65 patients who underwent lung transplantation and were sampled for both viscoelastic assays and conventional coagulation assays simultaneously during the procedure. We characterized the correlation between the EX-test (extrinsic pathway) and platelet count as well as between the FIB-test (extrinsic pathway after platelet inhibition) and fibrinogen concentration. Then, we used ROC curve analysis to determine the optimal EX-test and FIB-test values for predicting thrombocytopenia and hypofibrinogenemia. RESULTS All the amplitude values of the EX-test (A5, A10, A20, MCF) showed correlation with platelets count (Spearman's rank correlation coefficient ranging from 0.75 to 0.77, all p < 0.0001). We also observed a strong correlation between the amplitude values of the FIB-test (A5, A10, A20 and MCF) and the fibrinogen concentration (Spearman's rank correlation coefficient ranging from 0.68 to 0.71, all p < 0.0001). The AUCs of the EX-test values for thrombocytopenia <100 G/L and <80 G/L ranged from 0.80 to 0.93. Similarly, the AUCs of the FIB-test values for hypofibrinogenemia <1.5 g/L and <2 g/L ranged from 0.74 to 0.83. These results indicate that only the five-minute parameter of thromboelastometry is sufficient for detecting thrombocytopenia and hypofibrinogenemia in patients undergoing lung transplantation. The proposed cut off values for the EX-test to predict thrombocytopenia <80 G/L showed high sensitivity (>86 %), high specificity (>89 %) and high negative predictive value (>95 %). FIB-test cut off values predictive of fibrinogen below 1.5 g/L showed sensitivity (>78 %), specificity (>55 %) and negative predictive value (>88 %). CONCLUSIONS Our study provided preliminary results that are useful for developing a ClotPro-based algorithm to guide transfusion in lung transplantation. Future interventional studies will be necessary to validate these cut-off values of ClotPro for guiding transfusion.
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Affiliation(s)
- Tiffany Pascreau
- Department of clinical biology, Foch hospital, Suresnes, France; Université Paris-Saclay, INSERM, Hémostase inflammation thrombose HITH U1176, Le Kremlin-Bicêtre, France.
| | - Marine Gougeon
- Department of clinical biology, Foch hospital, Suresnes, France
| | - Julien Fessler
- Department of Anesthesiology and Pain Medicine, Hôpital Foch, Suresnes, France; Université Versailles-Saint-Quentin-en-Yvelines, Versailles, France
| | | | - Morgan Le Guen
- Department of Anesthesiology and Pain Medicine, Hôpital Foch, Suresnes, France; Université Versailles-Saint-Quentin-en-Yvelines, Versailles, France
| | - Marc Vasse
- Department of clinical biology, Foch hospital, Suresnes, France; Université Paris-Saclay, INSERM, Hémostase inflammation thrombose HITH U1176, Le Kremlin-Bicêtre, France
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3
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Zeng Y, Yamamoto Y, Hayashi Y, Uchida T. Evaluation of fibrinogen concentration by clot firmness using a dielectric blood coagulation test system. J Anesth 2023; 37:56-63. [PMID: 36316533 DOI: 10.1007/s00540-022-03131-x] [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: 05/19/2022] [Accepted: 10/20/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE To determine if fibrinogen concentration can be evaluated by dielectric permittivity changes in dielectric blood coagulation testing (DBCM) during cardiovascular surgery with cardiopulmonary bypass (CPB). METHODS We performed a single-center prospective observational study at a university hospital. One hundred patients undergoing cardiovascular surgery with CPB were enrolled. Whole-blood samples were obtained after weaning from CPB, and dielectric clot strength (DCS) was measured by intrinsic pathway testing with or without heparinase in DBCM. The FIBTEM test was performed during rotational thromboelastometry using the same samples, and maximum clot firmness (MCF) was evaluated. Spearman's correlation analysis was performed, and receiver operating characteristics (ROC) curve analyses were used to evaluate the performance of hypofibrinogenemia detection. RESULTS DCS showed a strong positive correlation with plasma fibrinogen concentration (Rs = 0.76, P < 0.0001). The area under the ROC curve for evaluating plasma fibrinogen concentration < 200 mg/dL was 0.91 (95% confidence interval (CI) 0.85-0.97) for DCS, compared with 0.88 (95% CI 0.81-0.94) for FIBTEM MCF. The optimal cutoff value of DCS was 17.0 (sensitivity 94%, specificity 80%). CONCLUSIONS DCS variables showed a significantly strong correlation with plasma fibrinogen concentration, and the diagnostic performance for hypofibrinogenemia was comparable to that for FIBTEM MCF. This novel methodology has the potential to provide a point-of-care test with sufficient accuracy for the detection of perioperative hypofibrinogenemia during cardiovascular surgery with CPB.
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Affiliation(s)
- Yulin Zeng
- Department of Anesthesiology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8519, Japan
| | - Yudai Yamamoto
- Department of Anesthesiology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8519, Japan
| | - Yoshihito Hayashi
- Biomedical R&D Department, R&D Division, Medical Business Group, Sony Imaging Products & Solutions Inc., Bunkyo-Ku, Tokyo, 113-8519, Japan
- Tokyo Laboratory 11, R&D Center, Sony Group Corporation, Bunkyo-Ku, Tokyo, 113-8519, Japan
| | - Tokujiro Uchida
- Department of Anesthesiology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8519, Japan.
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Yoshii R, Sawa T, Kawajiri H, Amaya F, Tanaka KA, Ogawa S. A comparison of the ClotPro system with rotational thromboelastometry in cardiac surgery: a prospective observational study. Sci Rep 2022; 12:17269. [PMID: 36241854 PMCID: PMC9568545 DOI: 10.1038/s41598-022-22119-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 10/10/2022] [Indexed: 01/06/2023] Open
Abstract
Viscoelastic coagulation tests have been increasingly used for hemostasis management in cardiac surgery. The ClotPro system is a novel viscoelastic device based on principles of rotational thromboelastometry. We aimed to compare ClotPro with ROTEM and plasma coagulation assays in cardiopulmonary bypass (CPB) patients. Blood samples were collected from 25 CPB patients at (1) baseline, (2) start of CPB, (3) end of CPB, and (4) end of surgery. The EX-test, IN-test, HI-test, FIB-test parameters on ClotPro were compared with corresponding ROTEM assay (EXTEM, INTEM, HEPTEM, and FIBTEM). Standard plasma coagulation assays and endogenous thrombin generation (TG) were simultaneously evaluated. Pearson correlation analyses showed moderate correlations between clotting times (CTs) (r = 0.63-0.67; p < 0.001, respectively), and strong correlations with maximal clot firmness (MCF) (r = 0.93-0.98; p < 0.001, respectively) between ClotPro and ROTEM. EX-test and IN-test MCF parameters were interchangeable with acceptable percentage errors (EX-test MCF: 7.3%, IN-test MCF: 8.3%), but FIB-test MCF (27.0%) and CT results were not (EX-test CT: 44.7%, IN-test CT: 31.4%). The correlations of PT/INR or peak TG with EX-test CTs were higher than with EXTEM CTs (PT/INR: r = 0.80 and 0.41, peak TG: 0.43 and 0.18, respectively). FIB-test MCF has strong correlation with plasma fibrinogen and factor XIII level (r = 0.84 and 0.66, respectively). ROC analyses showed that ClotPro was capable of emulating well-established ROTEM thresholds (area under curves: 0.83-1.00). ClotPro demonstrated strong correlations in MCF parameters of ROTEM in CPB patients. It may be reasonable to modify ROTEM-based transfusion algorithm pertaining to MCF parameters to establish cut-off values for ClotPro device.
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Affiliation(s)
- Ryogo Yoshii
- grid.272458.e0000 0001 0667 4960Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Teiji Sawa
- grid.272458.e0000 0001 0667 4960Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hidetake Kawajiri
- grid.272458.e0000 0001 0667 4960Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, Kyoto, Kyoto, Japan
| | - Fumimasa Amaya
- grid.272458.e0000 0001 0667 4960Department of Pain Management and Palliative Care Medicine, Kyoto Prefectural University of Medicine, Kawaramachi Hirokoji, Kamigyo, Kyoto, 602-8566 Japan
| | - Kenichi A. Tanaka
- grid.266902.90000 0001 2179 3618Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma, USA
| | - Satoru Ogawa
- grid.272458.e0000 0001 0667 4960Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan ,grid.272458.e0000 0001 0667 4960Department of Pain Management and Palliative Care Medicine, Kyoto Prefectural University of Medicine, Kawaramachi Hirokoji, Kamigyo, Kyoto, 602-8566 Japan
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Choi S, Mazzeffi MA, Henderson R, Mondal S, Morita Y, Deshpande S, Tanaka KA. The
FIBTEM
paradox: Do coronary artery bypass grafting patients with high baseline
FIBTEM
clot firmness need more allogeneic blood transfusion? Transfusion 2022; 62:2020-2028. [DOI: 10.1111/trf.17065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 06/10/2022] [Accepted: 07/30/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Seung Choi
- Department of Anesthesiology University of Maryland School of Medicine Baltimore Maryland USA
| | - Michael A. Mazzeffi
- Department of Anesthesiology and Critical Care Medicine George Washington University School of Medicine and Health Sciences Washington District of Columbia USA
| | - Reney Henderson
- Department of Anesthesiology University of Maryland School of Medicine Baltimore Maryland USA
| | - Samhati Mondal
- Department of Anesthesiology University of Maryland School of Medicine Baltimore Maryland USA
| | - Yoshihisa Morita
- Department of Anesthesiology Thomas Jefferson University Philadelphia Pennsylvania USA
| | - Seema Deshpande
- Department of Anesthesiology University of Maryland School of Medicine Baltimore Maryland USA
| | - Kenichi A. Tanaka
- Department of Anesthesiology University of Oklahoma Health Sciences Center Oklahoma City Oklahoma USA
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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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7
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Gauger MS, Kaufmann P, Kamber F, Quitt J, Berdajs D, Bolliger D, Mauermann E. Rotational Thromboelastometry Values After On-Pump Cardiac Surgery - A Retrospective Cohort Study. Semin Cardiothorac Vasc Anesth 2022; 26:209-220. [PMID: 35616448 DOI: 10.1177/10892532221088216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Viscoelastic coagulation monitoring is recommended for coagulation management after cardiac surgery, but optimum target values are poorly defined. AIMS To determine "to-be-expected" values in rotational thromboelastometry (ROTEM) after heparin reversal, to correlate ROTEM parameters with fibrinogen levels and platelet count, and to estimate the effect of hemoglobin levels on these measurements. METHODS We retrospectively analyzed 571 consecutive adult patients undergoing cardiac surgery with cardiopulmonary bypass from 12/2018 to 08/2020. ROTEM and conventional laboratory measurements were performed 5 to 10 minutes after protamine administration. RESULTS Clotting times in EXTEM, INTEM, and FIBTEM were significantly prolonged (72.6%, 96.1%, and 31.8% above reference ranges, respectively). Clot firmness parameters in EXTEM and INTEM were relevantly reduced (7.9% to 14.4% and 9.1% to 32.3% below the reference ranges, respectively). There was an excellent linear correlation of FIBTEM amplitude after 10 min (A10) and of maximal clot firmness (MCF) with fibrinogen concentrations (r = .81 and .80). Areas under receiver operating characteristic (AUROC) for identifying hypofibrinogenemia <1.5 g/L were between .80 and .87. No effect of hematocrit was observed. We also found a linear correlation of EXTEM, INTEM, and EXTEM-FIBTEM at both A10 and MCF with platelet counts (.32 to .68). The AUROCs for identifying thrombocytopenia (<100,000/μL) were .79 to .84, and were greater for A10 than for MCF measurements (P=.074, .001, and <.001, respectively). CONCLUSIONS "To-be-expected" ROTEM values after CPB are different from the published reference ranges. ROTEM parameters might allow for reliable estimation of fibrinogen level and platelet count without being influenced by hematocrit.
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Affiliation(s)
- Maria S Gauger
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Philip Kaufmann
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Firmin Kamber
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Jonas Quitt
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Denis Berdajs
- Clinic for Cardiac Surgery, University Hospital Basel, Basel, Switzerland
| | - Daniel Bolliger
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Eckhard Mauermann
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
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8
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Abstract
Massive diffuse bleeding is still a problem in cardiovascular surgery. The first line treatment is platelet concentrate transfusion, although there is still insufficient information regarding efficacy, quantity, and timing. The objective of this prospective cohort study was to find out whether the amount of 4 apheresis platelet concentrates could reduce intraoperative bleeding and improve viscoelasticity and aggregometry.10 patients were enrolled intraoperatively because of life-threatening diffuse bleeding after cardiopulmonary bypass and received 4 apheresis platelet concentrates back-to-back. The units were given every 5 minutes. After every unit, thromboelastometry, performed by ROTEM®, and aggregometry, performed by Multiplate®, were done together with Hematocrit, Hemoglobin, and Platelet Count.Hematocrit and Hemoglobin showed a statistically significant decrease of 14%, whereas Platelet Count showed a statistically significant increase of 205%. MCE-EXTEM increased statistically significant: 46%. There was no statistically significant increase in both ADP and COL results.Even a series of 4 platelet concentrates did not comprehensively improve both essential components of an adequate hemostasis: viscoelasticity and aggregation. Just the transfusion of platelet concentrates alone did not build a sufficient strategy improving hemostasis and reducing bleeding. A positive effect of surgical packing on stopping the bleeding could be seen.
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Affiliation(s)
- Lisa Blath
- Department for Anesthesiology and Intensive Care Medicine, Franziskus Hospital Bielefeld, Bielefeld, Germany
| | - Jörg Martens
- Institute for Transfusion Medicine and Transplant Engineering, Hannover Medical School, Hannover, Germany
| | - Niels Rahe-Meyer
- Department for Anesthesiology and Intensive Care Medicine, Franziskus Hospital Bielefeld, Bielefeld, Germany.,Department for Anesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
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Sekar PK, Liang XM, Kahng SJ, Shu Z, Dichiara AB, Chung JH, Wu Y, Gao D. Simultaneous multiparameter whole blood hemostasis assessment using a carbon nanotube-paper composite capacitance sensor. Biosens Bioelectron 2022; 197:113786. [PMID: 34801797 DOI: 10.1016/j.bios.2021.113786] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 11/07/2021] [Accepted: 11/10/2021] [Indexed: 12/14/2022]
Abstract
Rapid and accurate clinical assessment of hemostasis is essential for managing patients who undergo invasive procedures, experience hemorrhages, or receive antithrombotic therapies. Hemostasis encompasses an ensemble of interactions between the cellular and non-cellular blood components, but current devices assess only partial aspects of this complex process. In this work, we describe the development of a new approach to simultaneously evaluate coagulation function, platelet count or function, and hematocrit using a carbon nanotube-paper composite (CPC) capacitance sensor. CPC capacitance response to blood clotting at 1.3 MHz provided three sensing parameters with distinctive sensitivities towards multiple clotting elements. Whole blood-based hemostasis assessments were conducted to demonstrate the potential utility of the developed sensor for various hemostatic conditions, including pathological conditions, such as hemophilia and thrombocytopenia. Results showed good agreements when compared to a conventional thromboelastography. Overall, the presented CPC capacitance sensor is a promising new biomedical device for convenient non-contact whole-blood based comprehensive hemostasis evaluation.
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Affiliation(s)
- Praveen K Sekar
- Department of Mechanical Engineering, University of Washington, Seattle, WA, 98195, USA
| | - Xin M Liang
- Wellman Center for Photomedicine, Division of Hematology and Oncology, Division of Endocrinology, Massachusetts General Hospital, VA Boston Healthcare System, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02115, USA.
| | - Seong-Joong Kahng
- Department of Mechanical Engineering, University of Washington, Seattle, WA, 98195, USA
| | - Zhiquan Shu
- Department of Mechanical Engineering, University of Washington, Seattle, WA, 98195, USA; School of Engineering and Technology, University of Washington Tacoma, Tacoma, WA, 98402, USA
| | - Anthony B Dichiara
- School of Environmental and Forest Sciences, University of Washington, Seattle, WA, 98195, USA
| | - Jae-Hyun Chung
- Department of Mechanical Engineering, University of Washington, Seattle, WA, 98195, USA
| | - Yanyun Wu
- Department of Mechanical Engineering, University of Washington, Seattle, WA, 98195, USA.
| | - Dayong Gao
- Department of Mechanical Engineering, University of Washington, Seattle, WA, 98195, USA; Department of Bioengineering, University of Washington, Seattle, WA, 98195, USA.
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10
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Abstract
Background: Fibrinogen is a substrate for blood clots formation. In cardiac surgery, a number of different mechanisms lead to a decrease in fibrinogen levels and consequent impaired haemostasis. Patients undergoing cardiac surgery are therefore frequently exposed to blood loss and allogeneic blood transfusion, which are risk factors associated with morbidity and mortality. Thus, particular efforts in fibrinogen management should be made to decrease bleeding and the need for blood transfusion. Therefore, fibrinogen remains an active focus of investigations from basic science to clinical practice. This review aims to summarise the latest evidence regarding the role of fibrinogen and current practices in fibrinogen management in adult cardiac surgery. Methods: The PubMed database was systematically searched for literature investigating the role and disorders of fibrinogen in cardiac surgery and diagnostic and therapeutic procedures related to fibrinogen deficiency aimed at reducing blood loss and transfusion requirements. Clinical trials and reviews from the last 10 years were included. Results: In total, 146 articles were analysed. Conclusion: The early diagnosis and treatment of fibrinogen deficiency is crucial in maintaining haemostasis in bleeding patients. Further studies are needed to better understand the association between fibrinogen levels, bleeding, and fibrinogen supplementation and their impacts on patient outcomes in different clinical settings.
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Abstract
Abstract
Purpose of Review
This narrative review focuses on aging-related modifications in coagulation resulting in increased thromboembolic and hemorrhagic risk of the elderly. We further discuss the current evidence and emerging data relating the perioperative treatment of elderly patients with antithrombotic therapy.
Recent Findings
Relevant changes in all elements of the Virchow’s triad can be found with aging. Increased blood stasis due to immobility, progressive endothelial dysfunction with altered microcirculation, elevated concentrations of several coagulation factors, and increased platelet reactivity all lead to a procoagulant state. Elderly people are, therefore, commonly treated with oral anticoagulation and antiplatelet drugs. This antithrombotic therapy might be essentially causative for their increased bleeding risk.
Summary
Elderly patients are at increased risk for thromboembolism due to changes in the hemostatic system in combination with frailty and multimorbidity. Both the thromboembolic due to aging and bleeding risk due to antithrombotic therapy need special attention in the elderly surgical patients.
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Rotational thromboelastometry and conventional coagulation tests in patients undergoing major cardiac or aortic surgery: a retrospective single-center cohort study. J Thromb Thrombolysis 2021; 53:149-157. [PMID: 34232454 PMCID: PMC8791921 DOI: 10.1007/s11239-021-02519-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/24/2021] [Indexed: 11/05/2022]
Abstract
Algorithms for treatment of diffuse bleeding in cardiac surgery are based on intervention thresholds of coagulation tests, such as rotational thromboelastometry (ROTEM) or conventional laboratory tests. The relationship between these two approaches is unclear in patients with increased risk of coagulation abnormalities. We retrospectively analyzed the data of 248 patients undergoing major cardiac and/or aortic surgery. ROTEM and conventional laboratory tests were performed simultaneously after termination of cardiopulmonary bypass and protamine administration to investigate the extrinsic and intrinsic system, and to determine deficiencies in platelets and fibrinogen. We evaluated the association between ROTEM and conventional tests by linear regression analysis and compared the frequency of exceeding established thresholds for clinical intervention. Significant linear associations between ROTEM 10 min after the start of coagulation, and plasma fibrinogen concentration or platelet count (FIBTEM A10, R2 = 0.67, p < 0.001; EXTEM A10, R2 = 0.47, p < 0.001) were obtained. However, the 95% prediction intervals exceeded clinically useful ranges (92–233 mg/dL fibrinogen at the intervention threshold of FIBTEM A10 = 10 mm; 14 × 103–122 × 103/µL platelets at the intervention threshold of EXTEM A10 = 40 mm). The association between EXTEM and INR (R2 = 0.23), and INTEM and aPTT (R2 = 0.095) was poor. The frequency of exceeding intervention thresholds and, consequently, of triggering treatment, varied markedly between ROTEM and conventional tests (p < 0.001 for all comparisons). The predictability of conventional coagulation test results by ROTEM is limited, thus hampering the interchangeability of methods in clinical practice.
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Bareille M, Hardy M, Douxfils J, Roullet S, Lasne D, Levy JH, Stépanian A, Susen S, Frère C, Lecompte T, Mullier F. Viscoelastometric Testing to Assess Hemostasis of COVID-19: A Systematic Review. J Clin Med 2021; 10:jcm10081740. [PMID: 33923851 PMCID: PMC8072929 DOI: 10.3390/jcm10081740] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 04/09/2021] [Accepted: 04/12/2021] [Indexed: 02/06/2023] Open
Abstract
Infection by SARS-CoV-2 is associated with a high risk of thrombosis. The laboratory documentation of hypercoagulability and impaired fibrinolysis remains a challenge. Our aim was to assess the potential usefulness of viscoelastometric testing (VET) to predict thrombotic events in COVID-19 patients according to the literature. We also (i) analyzed the impact of anticoagulation and the methods used to neutralize heparin, (ii) analyzed whether maximal clot mechanical strength brings more information than Clauss fibrinogen, and (iii) critically scrutinized the diagnosis of hypofibrinolysis. We performed a systematic search in PubMed and Scopus databases until 31st December 2020. VET methods and parameters, and patients' features and outcomes were extracted. VET was performed for 1063 patients (893 intensive care unit (ICU) and 170 non-ICU, 44 studies). There was extensive heterogeneity concerning study design, VET device used (ROTEM, TEG, Quantra and ClotPro) and reagents (with non-systematic use of heparin neutralization), timing of assay, and definition of hypercoagulable state. Notably, only 4 out of 25 studies using ROTEM reported data with heparinase (HEPTEM). The common findings were increased clot mechanical strength mainly due to excessive fibrinogen component and impaired to absent fibrinolysis, more conspicuous in the presence of an added plasminogen activator. Only 4 studies out of the 16 that addressed the point found an association of VETs with thrombotic events. So-called functional fibrinogen assessed by VETs showed a variable correlation with Clauss fibrinogen. Abnormal VET pattern, often evidenced despite standard prophylactic anticoagulation, tended to normalize after increased dosing. VET studies reported heterogeneity, and small sample sizes do not support an association between the poorly defined prothrombotic phenotype of COVID-19 and thrombotic events.
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Affiliation(s)
- Marion Bareille
- Namur Thrombosis and Hemostasis Center (NTHC), CHU UCL Namur, Université Catholique de Louvain, 5530 Yvoir, Belgium;
- Correspondence:
| | - Michaël Hardy
- Service D’anesthésiologie, CHU UCL Namur, Université Catholique de Louvain, 5530 Yvoir, Belgium;
| | - Jonathan Douxfils
- Namur Thrombosis and Hemostasis Center (NTHC), Département de Pharmacie, Université de Namur, 5000 Namur, Belgium;
- Qualiblood S.A., 5000 Namur, Belgium
| | - Stéphanie Roullet
- CHU Bordeaux, Service D’Anesthésie-Réanimation Tripode, 33000 Bordeaux, France;
- Biologie des Maladies Cardiovasculaire, University Bordeaux, INSERM U1034, 33600 Pessac, France
| | - Dominique Lasne
- Laboratoire D’hématologie Générale, Hôpital Universitaire Necker-Enfants Malades, AP-HP, 75015 Paris, France;
| | - Jerrold H. Levy
- Departments of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, NC 27710, USA;
| | - Alain Stépanian
- Hôpital Lariboisière, Service D’Hématologie Biologique, Institut de Recherche Saint-Louis, Université de Paris, AP-HP Nord-Université de Paris, EA 3518, 75010 Paris, France;
| | - Sophie Susen
- Laboratoire D’Hématologie-Hémostase, Université de Lille, CHU Lille, 59037 Lille, France;
| | - Corinne Frère
- Department of Hematology, Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, INSERM UMRS_1166, Sorbonne Université, 75013 Paris, France;
| | - Thomas Lecompte
- Départements de Médecine, Service D’angiologie et D’hémostase et Faculté de Médecine Geneva Platelet Group (GpG), Université de Genève et Hôpitaux Universitaires de Genève, 1205 Genève, Switzerland;
| | - François Mullier
- Namur Thrombosis and Hemostasis Center (NTHC), CHU UCL Namur, Université Catholique de Louvain, 5530 Yvoir, Belgium;
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Patel PA, Henderson RA, Bolliger D, Erdoes G, Mazzeffi MA. The Year in Coagulation: Selected Highlights from 2020. J Cardiothorac Vasc Anesth 2021; 35:2260-2272. [PMID: 33781668 DOI: 10.1053/j.jvca.2021.02.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 02/26/2021] [Indexed: 01/28/2023]
Abstract
This is the second annual review in the Journal of Cardiothoracic and Vascular Anesthesia to cover highlights in coagulation for cardiac surgery. The goal of this article is to provide readers with a focused summary from the literature of the prior year's most important coagulation topics. In 2020, this included a discussion covering allogeneic transfusion, antiplatelet and anticoagulant therapy, factor concentrates, coagulation testing, mechanical circulatory support, and the effects of coronavirus disease 2019.
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Affiliation(s)
- Prakash A Patel
- Department of Anesthesiology, Cardiothoracic Division, Yale University School of Medicine, New Haven, CT.
| | - Reney A Henderson
- Department of Anesthesiology, Division of Cardiothoracic Anesthesia, University of Maryland School of Medicine, Baltimore, MD
| | - Daniel Bolliger
- Department of Anesthesiology, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Gabor Erdoes
- Department of Anesthesiology and Pain Medicine, Inselspital, University Hospital of Bern, Bern, Switzerland
| | - Michael A Mazzeffi
- Department of Anesthesiology, Division of Cardiothoracic Anesthesia, University of Maryland School of Medicine, Baltimore, MD; Department of Anesthesiology, Division of Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD
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Bolliger D, Kamber F, Mauermann E. Same Same but Different: Viscoelastic Hemostatic Assays in Cardiac Surgery. J Cardiothorac Vasc Anesth 2021; 35:1037-1039. [PMID: 33483267 DOI: 10.1053/j.jvca.2021.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 01/01/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Daniel Bolliger
- Department for Anesthesia, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Firmin Kamber
- Department for Anesthesia, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Eckhard Mauermann
- Department for Anesthesia, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, University of Basel, Basel, Switzerland
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Naik BI, Tanaka K, Sudhagoni RG, Viola F. Prediction of hypofibrinogenemia and thrombocytopenia at the point of care with the Quantra® QPlus® System. Thromb Res 2021; 197:88-93. [DOI: 10.1016/j.thromres.2020.11.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 10/03/2020] [Accepted: 11/01/2020] [Indexed: 01/21/2023]
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Hardy M, Lecompte T, Douxfils J, Lessire S, Dogné JM, Chatelain B, Testa S, Gouin-Thibault I, Gruel Y, Medcalf RL, ten Cate H, Lippi G, Mullier F. Management of the thrombotic risk associated with COVID-19: guidance for the hemostasis laboratory. Thromb J 2020; 18:17. [PMID: 32922211 PMCID: PMC7474970 DOI: 10.1186/s12959-020-00230-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 07/21/2020] [Indexed: 02/07/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) is associated with extreme inflammatory response, disordered hemostasis and high thrombotic risk. A high incidence of thromboembolic events has been reported despite thromboprophylaxis, raising the question of a more effective anticoagulation. First-line hemostasis tests such as activated partial thromboplastin time, prothrombin time, fibrinogen and D-dimers are proposed for assessing thrombotic risk and monitoring hemostasis, but are vulnerable to many drawbacks affecting their reliability and clinical relevance. Specialized hemostasis-related tests (soluble fibrin complexes, tests assessing fibrinolytic capacity, viscoelastic tests, thrombin generation) may have an interest to assess the thrombotic risk associated with COVID-19. Another challenge for the hemostasis laboratory is the monitoring of heparin treatment, especially unfractionated heparin in the setting of an extreme inflammatory response. This review aimed at evaluating the role of hemostasis tests in the management of COVID-19 and discussing their main limitations.
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Affiliation(s)
- M. Hardy
- Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Hematology Laboratory, Yvoir, Belgium
- Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Anesthesiology Department, Yvoir, Belgium
| | - T. Lecompte
- Département de Médecine, Hôpitaux Universitaires de Genève, service d’angiologie et d’hémostase et Faculté de Médecine Geneva Platelet Group (GpG), Université de Genève, Geneva, Suisse Switzerland
| | - J. Douxfils
- Pharmacy Department, University of Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur, Belgium
- Qualiblood s.a, Namur, Belgium
| | - S. Lessire
- Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Anesthesiology Department, Yvoir, Belgium
| | - J. M. Dogné
- Pharmacy Department, University of Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur, Belgium
| | - B. Chatelain
- Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Hematology Laboratory, Yvoir, Belgium
| | - S. Testa
- Haemostasis and Thrombosis Center, Cremona Hospital, Cremona, Italy
| | - I. Gouin-Thibault
- Département d’Hématologie Biologique, INSERM, CIC 1414 (Centre d’Investigation Clinique de Rennes), Université de Rennes, CHU de Rennes, Rennes, France
| | - Y. Gruel
- Laboratoire d’Hématologie-Hémostase, CHRU de Tours, Hôpital Trousseau, Tours, France
| | - R. L. Medcalf
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria Australia
| | - H. ten Cate
- Department of Internal Medicine, Cardiovascular Research Institute (CARIM), Maastricht University Medical Center, Maastricht, the Netherlands
| | - G. Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
| | - F. Mullier
- Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Hematology Laboratory, Yvoir, Belgium
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Bolliger D, Tanaka KA. More Is Not Always Better: Effects of Cell Salvage in Cardiac Surgery on Postoperative Fibrinogen Concentrations. J Cardiothorac Vasc Anesth 2020; 34:2383-2385. [DOI: 10.1053/j.jvca.2020.03.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 03/19/2020] [Indexed: 12/25/2022]
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Son K, Yamada T, Tarao K, Kitamura Y, Okazaki J, Sato Y, Isono S. Effects of Cardiac Surgery and Salvaged Blood Transfusion on Coagulation Function Assessed by Thromboelastometry. J Cardiothorac Vasc Anesth 2020; 34:2375-2382. [DOI: 10.1053/j.jvca.2020.02.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 02/01/2020] [Accepted: 02/05/2020] [Indexed: 12/13/2022]
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Bolliger D, Lancé MD. Factor Concentrate-Based Approaches to Blood Conservation in Cardiac Surgery: European Perspectives in 2020. CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00382-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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21
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Scala E, Coutaz C, Gomez F, Alberio L, Marcucci C. Comparison of ROTEM Sigma to Standard Laboratory Tests and Development of an Algorithm for the Management of Coagulopathic Bleeding in a Tertiary Center. J Cardiothorac Vasc Anesth 2020; 34:640-649. [DOI: 10.1053/j.jvca.2019.10.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 10/03/2019] [Accepted: 10/07/2019] [Indexed: 01/17/2023]
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Erdoes G, Koster A, Meesters MI, Ortmann E, Bolliger D, Baryshnikova E, Ahmed A, Lance MD, Ravn HB, Ranucci M, Heymann C, Agarwal S. The role of fibrinogen and fibrinogen concentrate in cardiac surgery: an international consensus statement from the Haemostasis and Transfusion Scientific Subcommittee of the European Association of Cardiothoracic Anaesthesiology. Anaesthesia 2019; 74:1589-1600. [DOI: 10.1111/anae.14842] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2019] [Indexed: 12/23/2022]
Affiliation(s)
- G. Erdoes
- Department of Anaesthesiology and Pain Medicine Inselspital, Bern University Hospital University of Bern Switzerland
| | - A. Koster
- Institute for Anaesthesiology, Heart and Diabetes Centre NRW Ruhr‐University Bochum Bad Oeynhausen Germany
| | - M. I. Meesters
- Department of Anaesthesiology University Medical Centre Utrecht The Netherlands
| | - E. Ortmann
- Department of Anaesthesia Kerckhoff Heart and Lung Centre Bad Nauheim Germany
| | - D. Bolliger
- Department of Anaesthesia Surgical Intensive Care Prehospital Emergency Medicine, and Pain Therapy University Hospital Basel Switzerland
| | - E. Baryshnikova
- Department of Cardiovascular Anaesthesia and Intensive Care Unit IRCCS Policlinico San Donato Milan Italy
| | - A. Ahmed
- Department of Anaesthesia University Hospitals of Leicester NHS Trust LeicesterUK
| | - M. D. Lance
- Hamad Medical Corporation, HMC Anaesthesiology ICU and Peri‐operative Medicine Doha Qatar
| | - H. B. Ravn
- Department of Cardiothoracic Anaesthesiology Copenhagen University Hospital Copenhagen Denmark
| | - M. Ranucci
- Department of Cardiovascular Anaesthesia and Intensive Care Unit IRCCS Policlinico San Donato Milan Italy
| | - C. Heymann
- Department of Anaesthesia Intensive Care Medicine, Emergency Medicine and Pain Therapy Vivantes Klinikum im Friedrichshain Berlin Germany
| | - S. Agarwal
- Department of Anaesthesia Manchester University Hospitals Manchester UK
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23
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Bouzat P, Guerin R, Boussat B, Nicolas J, Lambert A, Greze J, Maegele M, David JS. Diagnostic performance of thromboelastometry in trauma-induced coagulopathy: a comparison between two level I trauma centres using two different devices. Eur J Trauma Emerg Surg 2019; 47:343-351. [PMID: 31183527 DOI: 10.1007/s00068-019-01165-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 06/04/2019] [Indexed: 11/26/2022]
Abstract
PURPOSE The implementation of a ROTEM®-based algorithm requires reliable thresholds to mirror a prothrombin time (PT) ratio > 1.2 and/or a fibrinogen concentration < 1.5 g l-1. Our goal was to compare the diagnostic performances of two devices (ROTEM® Sigma and Delta, IL Werfen, Munich, Germany) in two level-I trauma centres for the diagnostic of post-traumatic coagulopathy. METHODS We conducted a retrospective analysis of two registries across two periods of time: from September 2014 to December 2015 in Lyon-Sud university trauma centre and from April 2016 to January 2018 in the Grenoble Alps Trauma Centre. Accuracies of EXTEM and FIBTEM assays to detect patients with coagulation disorders were tested for each device using receiver operating characteristic (ROC) analyses. RESULTS Within the study period, 74 trauma patients in the Grenoble cohort and 75 trauma patients in the Lyon cohort had concomitant ROTEM® and standard coagulation testing on admission. No statistically significant difference was found between the two ROC curves for FIBTEM amplitude at 5 min (A5), FIBTEM maximum clot firmness, EXTEM clotting time (CT) and EXTEM A5 for ROTEM® Sigma and Delta to diagnose post-traumatic coagulation disorders. The best threshold for FIBTEM A5 to predict low fibrinogen concentration was 7 mm for each device. EXTEM CT thresholds to diagnose PT ratio > 1.2 were 78 s and 74 s for ROTEM® Sigma and Delta, respectively. CONCLUSIONS These results suggest that ROTEM®-based algorithms may be transposed from one trauma centre to another independently of the setting and the ROTEM® device in use.
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Affiliation(s)
- Pierre Bouzat
- Department of Anaesthesiology and Intensive Care Medicine, Grenoble Alps Trauma Centre, Grenoble University Hospital, 38000, Grenoble, France.
- Grenoble Alps University, 38000, Grenoble, France.
- Pôle d'Anesthésie-Réanimation, Hôpital Albert Michallon, BP 217, 38043, Grenoble, France.
| | - Romain Guerin
- Department of Anaesthesiology and Intensive Care Medicine, Grenoble Alps Trauma Centre, Grenoble University Hospital, 38000, Grenoble, France
| | - Bastien Boussat
- Grenoble Alps University, 38000, Grenoble, France
- Quality of Care Unit, Grenoble University Hospital, 38000, Grenoble, France
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, T2N 4N1, Canada
| | - Jérôme Nicolas
- Charles Mérieux-Lyon Sud School of Medicine, University Lyon 1, 69495, Oullins, France
| | - Aline Lambert
- Charles Mérieux-Lyon Sud School of Medicine, University Lyon 1, 69495, Oullins, France
| | - Jules Greze
- Department of Anaesthesiology and Intensive Care Medicine, Grenoble Alps Trauma Centre, Grenoble University Hospital, 38000, Grenoble, France
| | - Marc Maegele
- Department of Traumatology and Orthopaedic Surgery, Cologne-Merheim Medical Center, Institue for Research in Operative Medicine, University Witten-Herdecke, Cologne, Germany
| | - Jean-Stéphane David
- Charles Mérieux-Lyon Sud School of Medicine, University Lyon 1, 69495, Oullins, France
- Department of Anaesthesiology and Critical Care Medicine, Lyon-Sud Hospital, Hospices Civils de Lyon, 69495, Pierre Bénite, France
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Activation of Blood Coagulation After Aneurysmal Subarachnoid Hemorrhage: A Prospective Observational Trial of Rotational Thromboelastometry. World Neurosurg 2019; 122:e334-e341. [DOI: 10.1016/j.wneu.2018.10.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 10/03/2018] [Accepted: 10/04/2018] [Indexed: 11/17/2022]
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25
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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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26
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Matzelle SA, Weightman WM, Gibbs NM. An Audit of the Diagnostic Accuracy of Rotational Thromboelastometry for the Identification of Hypofibrinogenaemia and Thrombocytopenia during Cardiopulmonary Bypass. Anaesth Intensive Care 2018; 46:620-626. [DOI: 10.1177/0310057x1804600614] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We audited the diagnostic accuracy of ROTEM® (TEM Innovations, GmbH, Munich, Germany) measurements of hypofibrinogenaemia (fibrinogen <1.5 g/l) and thrombocytopenia (platelet count <100 × 109/l) in 200 adult non-transplant patients during cardiopulmonary bypass (CPB). Blood samples were obtained for FIBTEM (assay for the fibrin part of the clot), PLTEM (calculated platelet-specific component), and laboratory measurements simultaneously. Our thresholds for FIBTEM and PLTEM were A10 (clot firmness 10 minutes after clotting time) ≤8 mm, and <35 mm respectively. We also calculated the accuracy of smaller thresholds and earlier indices. We found that FIBTEM A10 ≤8 mm had low sensitivity (0.62) for hypofibrinogenaemia. With the 13% hypofibrinogenaemia prevalence in our sample, the positive predictive value (PPV) was 0.47. In contrast, FIBTEM A10 ≤8 mm had higher specificity (0.90) (negative predictive value [NPV] 0.94). Of the other FIBTEM values analysed, only A5 ≤6 mm had similar or superior accuracy. The PLTEM results were less encouraging (sensitivity 0.81, specificity 0.62). With our prevalence of thrombocytopenia (also 13%), the PPV was only 0.24. However, the NPV was high (0.96). Of the other PLTEM values analysed, only A5 <25 mm had similar or superior accuracy. These findings indicate that during CPB FIBTEM A10 ≤8 mm and PLTEM A10 <35 mm have greater accuracy in identifying the absence of hypofibrinogenaemia and thrombocytopenia respectively than their presence. On the basis of these results we would be reassured by FIBTEM A10 values >8 mm and PLTEM A10 values ≥35 mm, but would continue to use laboratory measurements for confirmation. We would not use FIBTEM A10 ≤8 mm or PLTEM A10 <35 mm values alone to guide replacement therapy unless clinical conditions warranted an immediate decision before laboratory measurements were available.
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Affiliation(s)
- S. A. Matzelle
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Perth, Western Australia
| | - W. M. Weightman
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Perth, Western Australia
| | - N. M. Gibbs
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Perth, Western Australia
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27
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Curry NS, Davenport R, Pavord S, Mallett SV, Kitchen D, Klein AA, Maybury H, Collins PW, Laffan M. The use of viscoelastic haemostatic assays in the management of major bleeding: A British Society for Haematology Guideline. Br J Haematol 2018; 182:789-806. [PMID: 30073664 DOI: 10.1111/bjh.15524] [Citation(s) in RCA: 113] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Nicola S Curry
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,NIHR BRC, Blood Theme, Oxford University, Oxford, UK
| | - Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Sue Pavord
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,NIHR BRC, Blood Theme, Oxford University, Oxford, UK
| | - Susan V Mallett
- Department of Anaesthesia, Royal Free London NHS Foundation Trust, London, UK
| | | | - Andrew A Klein
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
| | - Helena Maybury
- Department of Obstetrics, Leicester Royal Infirmary, Leicester, UK
| | - Peter W Collins
- Department of Haematology, School of Medicine, Cardiff University, Cardiff, UK
| | - Mike Laffan
- Department of Haematology, Imperial College and Hammersmith Hospital, London, UK
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28
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Design and Utility of a Point-of-Care Microfluidic Platform to Assess Hematocrit and Blood Coagulation. Cell Mol Bioeng 2018; 11:519-529. [PMID: 31105798 DOI: 10.1007/s12195-018-0541-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Purpose— To develop a small volume whole blood analyzer capable of measuring the hematocrit and coagulation kinetics of whole blood. Methods and Results— A co-planar microfluidic chamber designed to facilitate self-driven capillary action across an internal electrical chip was developed and used to measure the electric parameters of whole human blood that had been anticoagulated or allowed to clot. To promote blood clotting, select chip surfaces were coated with a prothrombin time (PT) reagent containing lipidated tissue factor (TF), which activates the extrinsic pathway of coagulation to promote thrombin generation and fibrin formation. Whole human blood was added to the microfluidic device, and voltage changes within the platform were measured and interpreted using basic resistor-capacitor (RC) circuit and fluid dynamics theory. Upon wetting of the sensing zone, a circuit between two co-planar electrodes within the sensing zone was closed to generate a rapid voltage drop from baseline. The voltage then rose due to sedimentation of red blood cells (RBC) in the sensing zone. For anticoagulated blood samples, the time for the voltage to return to baseline was dependent on hematocrit. In the presence of coagulation, the initiation of fibrin formation in the presence of the PT reagent prevented the return of voltage to baseline due to the reduced packing of RBCs in the sensing zone. Conclusions— The technology presented in this study has potential for monitoring the hematocrit and coagulation parameters of patient samples using a small volume of whole blood, suggesting it may hold clinical utility as a point-of-care test.
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Hayashi Y, Brun MA, Machida K, Lee S, Murata A, Omori S, Uchiyama H, Inoue Y, Kudo T, Toyofuku T, Nagasawa M, Uchimura I, Nakamura T, Muneta T. Simultaneous assessment of blood coagulation and hematocrit levels in dielectric blood coagulometry. Biorheology 2018; 54:25-35. [PMID: 28800301 PMCID: PMC5676769 DOI: 10.3233/bir-16118] [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] [Indexed: 01/15/2023]
Abstract
BACKGROUND In a whole blood coagulation test, the concentration of any in vitro diagnostic agent in plasma is dependent on the hematocrit level but its impact on the test result is unknown. OBJECTIVE The aim of this work was to clarify the effects of reagent concentration, particularly Ca2+, and to find a method for hematocrit estimation compatible with the coagulation test. METHODS Whole blood coagulation tests by dielectric blood coagulometry (DBCM) and rotational thromboelastometry were performed with various concentrations of Ca2+ or on samples with different hematocrit levels. DBCM data from a previous clinical study of patients who underwent total knee arthroplasty were re-analyzed. RESULTS Clear Ca2+ concentration and hematocrit level dependences of the characteristic times of blood coagulation were observed. Rouleau formation made hematocrit estimation difficult in DBCM, but use of permittivity at around 3 MHz made it possible. The re-analyzed clinical data showed a good correlation between permittivity at 3 MHz and hematocrit level (R2=0.83). CONCLUSIONS Changes in the hematocrit level may affect whole blood coagulation tests. DBCM has the potential to overcome this effect with some automated correction using results from simultaneous evaluations of the hematocrit level and blood coagulability.
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Affiliation(s)
- Yoshihito Hayashi
- LE Development Department, R&D Division, Medical Business Unit, Imaging Products & Solutions Sector, Sony Corporation, Tokyo, Japan
| | - Marc-Aurèle Brun
- Life Science Department, Biomedical R&D Division, RDS Platform, Sony Corporation, Tokyo, Japan
| | - Kenzo Machida
- LE Development Department, R&D Division, Medical Business Unit, Imaging Products & Solutions Sector, Sony Corporation, Tokyo, Japan
| | - Seungmin Lee
- LE Development Department, R&D Division, Medical Business Unit, Imaging Products & Solutions Sector, Sony Corporation, Tokyo, Japan
| | - Aya Murata
- LE Development Department, R&D Division, Medical Business Unit, Imaging Products & Solutions Sector, Sony Corporation, Tokyo, Japan
| | - Shinji Omori
- LE Development Department, R&D Division, Medical Business Unit, Imaging Products & Solutions Sector, Sony Corporation, Tokyo, Japan
| | - Hidetoshi Uchiyama
- Department of Surgical Specialities, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Yoshinori Inoue
- Department of Surgical Specialities, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Toshifumi Kudo
- Department of Surgical Specialities, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Takahiro Toyofuku
- Department of Surgical Specialities, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Masayuki Nagasawa
- Department of Pediatrics, Tokyo Medical and Dental University, Tokyo, Japan.,Department of Pediatrics, Musashino Red Cross Hospital, Musashino-city, Tokyo, Japan
| | - Isao Uchimura
- Department of Endocrinology and Metabolism, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tomomasa Nakamura
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Takeshi Muneta
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital, Tokyo, Japan
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Roullet S, de Maistre E, Ickx B, Blais N, Susen S, Faraoni D, Garrigue D, Bonhomme F, Godier A, Lasne D. Position of the French Working Group on Perioperative Haemostasis (GIHP) on viscoelastic tests: What role for which indication in bleeding situations? Anaesth Crit Care Pain Med 2018; 38:539-548. [PMID: 29355793 DOI: 10.1016/j.accpm.2017.12.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 12/18/2017] [Accepted: 12/18/2017] [Indexed: 12/12/2022]
Abstract
PURPOSE Viscoelastic tests (VETs), thromboelastography (TEG®) and thromboelastometry (ROTEM®) are global tests of coagulation performed on whole blood. They evaluate the mechanical strength of a clot as it builds and develops after coagulation itself. The time required to obtain haemostasis results remains a major problem for clinicians dealing with bleeding, although some teams have developed a rapid laboratory response strategy. Indeed, the value of rapid point-of-care diagnostic devices such as VETs has increased over the years. However, VETs are not standardised and there are few recommendations from the learned societies regarding their use. In 2014, the recommendations of the International Society of Thrombosis and Haemostasis (ISTH) only concerned haemophilia. The French Working Group on Perioperative haemostasis (GIHP) therefore proposes to summarise knowledge on the clinical use of these techniques in the setting of emergency and perioperative medicine. METHODS A review of the literature. PRINCIPAL FINDINGS The role of the VETs seems established in the management of severe trauma and in cardiac surgery, both adult and paediatric. In other situations, their role remains to be defined: hepatic transplantation, postpartum haemorrhage, and non-cardiac surgery. They must be part of the global management of haemostasis based on algorithms defined in each centre and for each population of patients. Their position at the bedside or in the laboratory is a matter of discussion between clinicians and biologists. CONCLUSION VETs must be included in algorithms. In consultation with the biology laboratory, these devices should be situated according to the way each centre functions.
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Affiliation(s)
- Stéphanie Roullet
- Inserm U 12-11, service anesthésie-réanimation 1, université de Bordeaux, CHU de Bordeaux, 33000 Bordeaux, France.
| | | | - Brigitte Ickx
- Université Libre de Bruxelles, Erasme University Hospital, Department of Anesthesiology, Brussels, Belgium
| | - Normand Blais
- Hématologie et oncologie médicale, CHUM, Montréal, Canada
| | - Sophie Susen
- Institut d'hématologie et transfusion, CHRU de Lille, 59037 Lille, France
| | - David Faraoni
- Department of Anaesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | | | - Fanny Bonhomme
- Service d'anesthésiologie, hôpital universitaire de Genève, Geneva, Switzerland
| | - Anne Godier
- Service d'anesthésie-réanimation, Fondation Rothschild, 75019 Paris, France
| | - Dominique Lasne
- Laboratoire d'hématologie, hôpital Necker, 75015 Paris, France
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Boer C, Meesters MI, Milojevic M, Benedetto U, Bolliger D, von Heymann C, Jeppsson A, Koster A, Osnabrugge RL, Ranucci M, Ravn HB, Vonk AB, Wahba A, Pagano D. 2017 EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery. J Cardiothorac Vasc Anesth 2018; 32:88-120. [DOI: 10.1053/j.jvca.2017.06.026] [Citation(s) in RCA: 203] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Indexed: 01/28/2023]
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Pagano D, Milojevic M, Meesters MI, Benedetto U, Bolliger D, von Heymann C, Jeppsson A, Koster A, Osnabrugge RL, Ranucci M, Ravn HB, Vonk ABA, Wahba A, Boer C. 2017 EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery. Eur J Cardiothorac Surg 2017; 53:79-111. [DOI: 10.1093/ejcts/ezx325] [Citation(s) in RCA: 192] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Muirhead B, Weiss ADH. Massive hemorrhage and transfusion in the operating room. Can J Anaesth 2017; 64:962-978. [DOI: 10.1007/s12630-017-0925-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 05/11/2017] [Accepted: 06/20/2017] [Indexed: 12/01/2022] Open
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Abstract
Haemorrhage in the setting of severe trauma is associated with significant morbidity and mortality. There is increasing awareness of the important role fibrinogen plays in traumatic haemorrhage. Fibrinogen levels fall precipitously in severe trauma and the resultant hypofibrinogenaemia is associated with poor outcomes. Hence, it has been postulated that early fibrinogen replacement in severe traumatic haemorrhage may improve outcomes, although, to date there is a paucity of high quality evidence to support this hypothesis. In addition there is controversy regarding the optimal method for fibrinogen supplementation. We review the current evidence regarding the role of fibrinogen in trauma, the rationale behind fibrinogen supplementation and discuss current research.
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Williams B, McNeil J, Crabbe A, Tanaka KA. Practical Use of Thromboelastometry in the Management of Perioperative Coagulopathy and Bleeding. Transfus Med Rev 2017; 31:11-25. [DOI: 10.1016/j.tmrv.2016.08.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Revised: 08/23/2016] [Accepted: 08/23/2016] [Indexed: 12/23/2022]
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Bolliger D, Tanaka K. Fibrinogen—is it a universal haemostatic agent? Br J Anaesth 2016; 117:548-550. [DOI: 10.1093/bja/aew332] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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Crabbe A, McNeil JS, Deshpande SP, Kon Z, Pham SM, Tanaka KA. Therapeutic plasma exchange in heart transplantation: role of coagulation assessment with thromboelastometry. JA Clin Rep 2016; 2:31. [PMID: 29492426 PMCID: PMC5814793 DOI: 10.1186/s40981-016-0058-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 10/11/2016] [Indexed: 11/12/2022] Open
Abstract
Therapeutic plasma exchange (TPE) is a potentially life-saving procedure which effectively removes donor-specific human leukocyte antigen (HLA) antibodies from the bloodstream, allowing critically ill heart transplant recipients to receive a donor organ with less wait time, and reducing the risk of acute organ rejection. The bulk of coagulation factors is initially removed from the blood during TPE using albumin and is later replaced with allogeneic plasma. Coagulopathy may develop during TPE and then can persist due to intraoperative blood loss and hemodilution during surgery and cardiopulmonary bypass. We hereby describe the utility of rotational thromboelastometry to assess rapid coagulation changes during TPE and subsequent heart transplant (HT) surgery.
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Affiliation(s)
- Andrew Crabbe
- Department of Anesthesiology, University of Maryland, 22 South Greene Street, Suite S8D12, Baltimore, MD 21201 USA
| | - John S McNeil
- Department of Anesthesiology, University of Virginia, Charlottesville, VA USA
| | - Seema P Deshpande
- Department of Anesthesiology, University of Maryland, 22 South Greene Street, Suite S8D12, Baltimore, MD 21201 USA
| | - Zachary Kon
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland, Baltimore, MD USA
| | - Si M Pham
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland, Baltimore, MD USA
| | - Kenichi A Tanaka
- Department of Anesthesiology, University of Maryland, 22 South Greene Street, Suite S8D12, Baltimore, MD 21201 USA
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Sirachainan N, Chuansumrit A, Kadegasem P, Sasanakul W, Wongwerawattanakoon P, Mahaklan L. Normal hemostatic parameters in children and young adults with α-thalassemia diseases. Thromb Res 2016; 146:35-42. [DOI: 10.1016/j.thromres.2016.08.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 08/11/2016] [Accepted: 08/21/2016] [Indexed: 11/16/2022]
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Karkouti K, Callum J, Wijeysundera DN, Rao V, Crowther M, Grocott HP, Pinto R, Scales DC. Point-of-Care Hemostatic Testing in Cardiac Surgery: A Stepped-Wedge Clustered Randomized Controlled Trial. Circulation 2016; 134:1152-1162. [PMID: 27654344 DOI: 10.1161/circulationaha.116.023956] [Citation(s) in RCA: 190] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 09/02/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Cardiac surgery is frequently complicated by coagulopathic bleeding that is difficult to optimally manage using standard hemostatic testing. We hypothesized that point-of-care hemostatic testing within the context of an integrated transfusion algorithm would improve the management of coagulopathy in cardiac surgery and thereby reduce blood transfusions. METHODS We conducted a pragmatic multicenter stepped-wedge cluster randomized controlled trial of a point-of-care-based transfusion algorithm in consecutive patients undergoing cardiac surgery with cardiopulmonary bypass at 12 hospitals from October 6, 2014, to May 1, 2015. Following a 1-month data collection at all participating hospitals, a transfusion algorithm incorporating point-of-care hemostatic testing was sequentially implemented at 2 hospitals at a time in 1-month intervals, with the implementation order randomly assigned. No other aspects of care were modified. The primary outcome was red blood cell transfusion from surgery to postoperative day 7. Other outcomes included transfusion of other blood products, major bleeding, and major complications. The analysis adjusted for secular time trends, within-hospital clustering, and patient-level risk factors. All outcomes and analyses were prespecified before study initiation. RESULTS Among the 7402 patients studied, 3555 underwent surgery during the control phase and 3847 during the intervention phase. Overall, 3329 (45.0%) received red blood cells, 1863 (25.2%) received platelets, 1645 (22.2%) received plasma, and 394 (5.3%) received cryoprecipitate. Major bleeding occurred in 1773 (24.1%) patients, and major complications occurred in 740 (10.2%) patients. The trial intervention reduced rates of red blood cell transfusion (adjusted relative risk, 0.91; 95% confidence interval, 0.85-0.98; P=0.02; number needed to treat, 24.7), platelet transfusion (relative risk, 0.77; 95% confidence interval, 0.68-0.87; P<0.001; number needed to treat, 16.7), and major bleeding (relative risk, 0.83; 95% confidence interval, 0.72-0.94; P=0.004; number needed to treat, 22.6), but had no effect on other blood product transfusions or major complications. CONCLUSIONS Implementation of point-of-care hemostatic testing within the context of an integrated transfusion algorithm reduces red blood cell transfusions, platelet transfusions, and major bleeding following cardiac surgery. Our findings support the broader adoption of point-of-care hemostatic testing into clinical practice. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT02200419.
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Affiliation(s)
- Keyvan Karkouti
- From Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Canada (K.K.); Department of Laboratory Medicine and Pathobiology, Sunnybrook Health Sciences Centre, University of Toronto, Canada (J.C.); Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Canada (D.N.W.); Division of Cardiac Surgery, Department of Surgery, Toronto General Hospital, University Health Network, University of Toronto, Canada (V.R.); Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada (M.C.); Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, Canada (H.P.G.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada (R.P.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre and Interdepartmental Division of Critical Care, University of Toronto, Canada (D.C.S.); and the Peter Munk Cardiac Centre, University Health Network, Toronto, Canada (K.K., D.N.W., V.R.).
| | - Jeannie Callum
- From Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Canada (K.K.); Department of Laboratory Medicine and Pathobiology, Sunnybrook Health Sciences Centre, University of Toronto, Canada (J.C.); Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Canada (D.N.W.); Division of Cardiac Surgery, Department of Surgery, Toronto General Hospital, University Health Network, University of Toronto, Canada (V.R.); Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada (M.C.); Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, Canada (H.P.G.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada (R.P.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre and Interdepartmental Division of Critical Care, University of Toronto, Canada (D.C.S.); and the Peter Munk Cardiac Centre, University Health Network, Toronto, Canada (K.K., D.N.W., V.R.)
| | - Duminda N Wijeysundera
- From Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Canada (K.K.); Department of Laboratory Medicine and Pathobiology, Sunnybrook Health Sciences Centre, University of Toronto, Canada (J.C.); Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Canada (D.N.W.); Division of Cardiac Surgery, Department of Surgery, Toronto General Hospital, University Health Network, University of Toronto, Canada (V.R.); Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada (M.C.); Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, Canada (H.P.G.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada (R.P.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre and Interdepartmental Division of Critical Care, University of Toronto, Canada (D.C.S.); and the Peter Munk Cardiac Centre, University Health Network, Toronto, Canada (K.K., D.N.W., V.R.)
| | - Vivek Rao
- From Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Canada (K.K.); Department of Laboratory Medicine and Pathobiology, Sunnybrook Health Sciences Centre, University of Toronto, Canada (J.C.); Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Canada (D.N.W.); Division of Cardiac Surgery, Department of Surgery, Toronto General Hospital, University Health Network, University of Toronto, Canada (V.R.); Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada (M.C.); Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, Canada (H.P.G.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada (R.P.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre and Interdepartmental Division of Critical Care, University of Toronto, Canada (D.C.S.); and the Peter Munk Cardiac Centre, University Health Network, Toronto, Canada (K.K., D.N.W., V.R.)
| | - Mark Crowther
- From Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Canada (K.K.); Department of Laboratory Medicine and Pathobiology, Sunnybrook Health Sciences Centre, University of Toronto, Canada (J.C.); Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Canada (D.N.W.); Division of Cardiac Surgery, Department of Surgery, Toronto General Hospital, University Health Network, University of Toronto, Canada (V.R.); Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada (M.C.); Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, Canada (H.P.G.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada (R.P.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre and Interdepartmental Division of Critical Care, University of Toronto, Canada (D.C.S.); and the Peter Munk Cardiac Centre, University Health Network, Toronto, Canada (K.K., D.N.W., V.R.)
| | - Hilary P Grocott
- From Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Canada (K.K.); Department of Laboratory Medicine and Pathobiology, Sunnybrook Health Sciences Centre, University of Toronto, Canada (J.C.); Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Canada (D.N.W.); Division of Cardiac Surgery, Department of Surgery, Toronto General Hospital, University Health Network, University of Toronto, Canada (V.R.); Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada (M.C.); Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, Canada (H.P.G.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada (R.P.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre and Interdepartmental Division of Critical Care, University of Toronto, Canada (D.C.S.); and the Peter Munk Cardiac Centre, University Health Network, Toronto, Canada (K.K., D.N.W., V.R.)
| | - Ruxandra Pinto
- From Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Canada (K.K.); Department of Laboratory Medicine and Pathobiology, Sunnybrook Health Sciences Centre, University of Toronto, Canada (J.C.); Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Canada (D.N.W.); Division of Cardiac Surgery, Department of Surgery, Toronto General Hospital, University Health Network, University of Toronto, Canada (V.R.); Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada (M.C.); Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, Canada (H.P.G.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada (R.P.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre and Interdepartmental Division of Critical Care, University of Toronto, Canada (D.C.S.); and the Peter Munk Cardiac Centre, University Health Network, Toronto, Canada (K.K., D.N.W., V.R.)
| | - Damon C Scales
- From Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Canada (K.K.); Department of Laboratory Medicine and Pathobiology, Sunnybrook Health Sciences Centre, University of Toronto, Canada (J.C.); Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Canada (D.N.W.); Division of Cardiac Surgery, Department of Surgery, Toronto General Hospital, University Health Network, University of Toronto, Canada (V.R.); Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada (M.C.); Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, Canada (H.P.G.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada (R.P.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre and Interdepartmental Division of Critical Care, University of Toronto, Canada (D.C.S.); and the Peter Munk Cardiac Centre, University Health Network, Toronto, Canada (K.K., D.N.W., V.R.)
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Schöchl H, Grottke O, Maegele M. Comparing the viscoelastomeric fibrin polymerization assays FIBTEM® (ROTEM) vs. Functional Fibrinogen® (TEG): or why is a higher threshold for fibrinogen substitution better than a lower one? Clin Chem Lab Med 2016; 54:e275-6. [PMID: 27159919 DOI: 10.1515/cclm-2015-1208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 03/28/2016] [Indexed: 11/15/2022]
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Maegele M, Inaba K, Rizoli S, Veigas P, Callum J, Davenport R, Fröhlich M, Hess J. [Early viscoelasticity-based coagulation therapy for severely injured bleeding patients: Report of the consensus group on the consensus conference 2014 for formulation of S2k guidelines]. Anaesthesist 2016; 64:778-94. [PMID: 26136120 DOI: 10.1007/s00101-015-0040-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Although there is increasing interest in the use of a viscoelastic test procedure (ROTEM/TEG) for diagnostics and therapy guidance of severely injured and bleeding patients, currently no uniformly accepted guidelines exist for how this technology should be integrated into clinical treatment. In September 2014 an international multidisciplinary group of opinion leaders in the field of trauma-induced coagulopathy and other disciplines involved in the treatment of severely injured patients were assembled for a 2-day consensus conference in Philadelphia (USA). This panel included trauma/accident surgeons, general/abdominal surgeons, vascular surgeons, emergency/intensive care surgeons, hematologists, transfusion specialists, anesthesiologists, laboratory physicians, pathobiologists/pathophysiologists and the lay public. A total of nine questions regarding the impact of viscoelastic testing in the early treatment of trauma patients were developed prior to the conference by a panel consensus. Early use was defined as baseline viscoelastic test result thresholds obtained within the first minutes of hospital arrival, when conventional laboratory results are not yet available. The available data for each question were then reviewed in person using standardized presentations by the expert panel. A consensus summary document was then developed and reviewed by the panel in an open forum. Finally, a 2-round Delphi poll was administered to the panel of experts regarding viscoelastic thresholds for triggering the initiation of specific treatments including fibrinogen (concentrates), platelet concentrates, blood plasma products and prothrombin complex concentrates (PCC). This report summarizes the findings and recommendations of this consensus conference, which correspond to a S2k guideline according to the system of the Association of the Scientific Medical Societies in Germany (AWMF) and taking formal consensus findings including Delphi methods into consideration.
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Affiliation(s)
- M Maegele
- Klinik für Orthopädie, Unfallchirurgie und Sporttraumatologie, Kliniken der Stadt Köln-Merheim, Institut für Forschung in der Operativen Medizin (IFOM), Private Universität Witten/Herdecke (UW/H), Ostmerheimerstr. 200, 51109, Köln, Deutschland.
| | - K Inaba
- Division of Trauma and Surgical Critical Care, University of Southern California, Los Angeles, California, USA
| | - S Rizoli
- Departments of Surgery & Critical Care Medicine, St. Michael's Hospital and University of Toronto, Toronto, Ontario, Kanada
| | - P Veigas
- Department of Surgery, Sunnybrook Health Sciences Center and Institute of Medical Science, University of Toronto, Toronto, Ontario, Kanada
| | - J Callum
- Department of Clinical Pathology, Sunnybrook Health Sciences Center Toronto, Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Kanada
| | - R Davenport
- Centre for Trauma Sciences, Blizard Institute, Bart's and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - M Fröhlich
- Klinik für Orthopädie, Unfallchirurgie und Sporttraumatologie, Kliniken der Stadt Köln-Merheim, Institut für Forschung in der Operativen Medizin (IFOM), Private Universität Witten/Herdecke (UW/H), Ostmerheimerstr. 200, 51109, Köln, Deutschland
| | - J Hess
- Department of Laboratory Medicine, School of Medicine, University of Washington, Seattle, WA, USA
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Mace H, Lightfoot N, McCluskey S, Selby R, Roy D, Timoumi T, Karkouti K. Validity of Thromboelastometry for Rapid Assessment of Fibrinogen Levels in Heparinized Samples During Cardiac Surgery: A Retrospective, Single-center, Observational Study. J Cardiothorac Vasc Anesth 2016; 30:90-5. [DOI: 10.1053/j.jvca.2015.04.030] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Indexed: 11/11/2022]
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Maegele M, Inaba K, Rizoli S, Veigas P, Callum J, Davenport R, Fröhlich M, Hess J. Frühe viskoelastizitätsbasierte Gerinnungstherapie bei blutenden Schwerverletzten. Notf Rett Med 2015. [DOI: 10.1007/s10049-015-0071-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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2014 Consensus conference on viscoelastic test-based transfusion guidelines for early trauma resuscitation: Report of the panel. J Trauma Acute Care Surg 2015; 78:1220-9. [PMID: 26151526 DOI: 10.1097/ta.0000000000000657] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
There has been an increased interest in the use of viscoelastic testing to guide blood product replacement during the acute resuscitation of the injured patient. Currently, no uniformly accepted guidelines exist for how this technology should be integrated into clinical care. In September 2014, an international multidisciplinary group of leaders in the field of trauma coagulopathy and resuscitation was assembled for a 2-day consensus conference in Philadelphia, Pennsylvania. This panel included trauma surgeons, hematologists, blood bank specialists, anesthesiologists, and the lay public.Nine questions regarding the impact of viscoelastic testing in the early resuscitation of trauma patients were developed before the conference by panel consensus. Early use was defined as baseline viscoelastic test result thresholds obtained within the first minutes of hospital arrival-when conventional laboratory results are not available. The available data for each question were then reviewed in person using standardized presentations by the expert panel. A consensus summary document was then developed and reviewed by the panel in an open forum. Finally, a two-round Delphi poll was administered to the panel of experts regarding viscoelastic thresholds for triggering the initiation of specific treatments including fibrinogen, platelets, plasma, and prothrombin complex concentrates. This report summarizes the findings and recommendations of this consensus conference.
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Bolliger D, Tanaka K. Haemostatic efficacy of fibrinogen concentrate: is it the threshold or the timing of therapy? Br J Anaesth 2015; 115:158-61. [DOI: 10.1093/bja/aev167] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Bolliger D, Mauermann E, Tanaka KA. Thresholds for Perioperative Administration of Hemostatic Blood Components and Coagulation Factor Concentrates: An Unmet Medical Need. J Cardiothorac Vasc Anesth 2015; 29:768-76. [DOI: 10.1053/j.jvca.2015.02.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Indexed: 12/19/2022]
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Ji SM, Kim SH, Nam JS, Yun HJ, Choi JH, Lee EH, Choi IC. Predictive value of rotational thromboelastometry during cardiopulmonary bypass for thrombocytopenia and hypofibrinogenemia after weaning of cardiopulmonary bypass. Korean J Anesthesiol 2015; 68:241-8. [PMID: 26045926 PMCID: PMC4452667 DOI: 10.4097/kjae.2015.68.3.241] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 01/02/2015] [Accepted: 01/03/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The early detection of coagulopathy helps guide decisions regarding optimal transfusion management during cardiac surgery. This study aimed to determine whether rotational thromboelastometry (ROTEM) analysis during cardiopulmonary bypass (CPB) could predict thrombocytopenia and hypofibrinogenemia after CPB. METHODS We analyzed 138 cardiac surgical patients for whom ROTEM tests and conventional laboratory tests were performed simultaneously both during and after CPB. An extrinsically activated ROTEM test (EXTEM), a fibrin-specific ROTEM test (FIBTEM) and PLTEM calculated by subtracting FIBTEM from EXTEM were evaluated. Correlations between clot amplitude at 10 min (A10), maximal clot firmness, platelet count, and fibrinogen concentrations at each time point were calculated. A receiver operating characteristic analysis with area under the curve (AUC) was used to assess the thresholds of EXTEM, PLTEM and FIBTEM parameters during CPB and for predicting thrombocytopenia and hypofibrinogenemia after weaning of CPB. RESULTS The A10 on EXTEM, PLTEM, and FIBTEM during CPB showed a good correlation with platelet counts (r = 0.622 on EXTEM and r = 0.637 on PLTEM; P < 0.0001 for each value) and fibrinogen levels (r = 0.780; P < 0.0001) after CPB. A10 on a FIBTEM threshold of 8 mm during the CPB predicted a fibrinogen concentration < 150 mg/dl (AUC = 0.853) after CPB. Additionally, the threshold level of A10 on EXTEM during CPB for predicting platelet counts < 100,000 /µl after CPB was 42 mm (AUC = 0.768). CONCLUSIONS EXTEM, PLTEM, and FIBTEM parameters during CPB may be useful for predicting thrombocytopenia and hypofibrinogenemia after weaning of CPB.
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Affiliation(s)
- Sung-Mi Ji
- Department of Anesthesiology and Pain Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Sung-Hoon Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae-Sik Nam
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hye-Joo Yun
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong-Hyun Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun-Ho Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - In-Cheol Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Erdoes G, Gerster G, Colucci G, Kaiser H, Alberio L, Eberle B. Prediction of Post-Weaning Fibrinogen Status during Cardiopulmonary Bypass: An Observational Study in 110 Patients. PLoS One 2015; 10:e0126692. [PMID: 26011420 PMCID: PMC4444179 DOI: 10.1371/journal.pone.0126692] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 03/13/2015] [Indexed: 12/13/2022] Open
Abstract
Background After cardiac surgery with cardiopulmonary bypass (CPB), acquired coagulopathy often leads to post-CPB bleeding. Though multifactorial in origin, this coagulopathy is often aggravated by deficient fibrinogen levels. Objective To assess whether laboratory and thrombelastometric testing on CPB can predict plasma fibrinogen immediately after CPB weaning. Patients / Methods This prospective study in 110 patients undergoing major cardiovascular surgery at risk of post-CPB bleeding compares fibrinogen level (Clauss method) and function (fibrin-specific thrombelastometry) in order to study the predictability of their course early after termination of CPB. Linear regression analysis and receiver operating characteristics were used to determine correlations and predictive accuracy. Results Quantitative estimation of post-CPB Clauss fibrinogen from on-CPB fibrinogen was feasible with small bias (+0.19 g/l), but with poor precision and a percentage of error >30%. A clinically useful alternative approach was developed by using on-CPB A10 to predict a Clauss fibrinogen range of interest instead of a discrete level. An on-CPB A10 ≤10 mm identified patients with a post-CPB Clauss fibrinogen of ≤1.5 g/l with a sensitivity of 0.99 and a positive predictive value of 0.60; it also identified those without a post-CPB Clauss fibrinogen <2.0 g/l with a specificity of 0.83. Conclusions When measured on CPB prior to weaning, a FIBTEM A10 ≤10 mm is an early alert for post-CPB fibrinogen levels below or within the substitution range (1.5–2.0 g/l) recommended in case of post-CPB coagulopathic bleeding. This helps to minimize the delay to data-based hemostatic management after weaning from CPB.
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Affiliation(s)
- Gabor Erdoes
- Department of Anesthesiology and Pain Therapy, University Hospital Bern, Bern, Switzerland
- * E-mail:
| | - Germaine Gerster
- Department of Anesthesiology and Pain Therapy, University Hospital Bern, Bern, Switzerland
| | | | - Heiko Kaiser
- Department of Anesthesiology and Pain Therapy, University Hospital Bern, Bern, Switzerland
| | - Lorenzo Alberio
- Hématologie non-maligne et Hémostase, Service et Laboratoire central d`Hématologie, University Hospital Lausanne, Lausanne, Switzerland
| | - Balthasar Eberle
- Department of Anesthesiology and Pain Therapy, University Hospital Bern, Bern, Switzerland
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Xu X, Teng X. Effect of fibrinogen on blood coagulation detected by optical coherence tomography. Phys Med Biol 2015; 60:4185-95. [PMID: 25955503 DOI: 10.1088/0031-9155/60/10/4185] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Our previous work demonstrated that an optical coherence tomography (OCT) technique and the parameter 1/e light penetration depth (d1/e) were able to characterize the whole blood coagulation process in contrast to existing optical tests that are performed on plasma samples. To evaluate the feasibility of the technique for quantifying the effect of fibrinogen (Fbg) on blood coagulation, a dynamic study of d1/e of blood in various Fbg concentrations was performed in static state. Two groups of blood samples of hematocrit (HCT) in 35, 45, and 55% were reconstituted of red blood cells with: 1) treated plasma with its intrinsic Fbg removed and commercial Fbg added (0-8 g L(-1)); and 2) native plasma with commercial Fbg added (0-8 g L(-1)). The results revealed a typical behavior due to coagulation induced by calcium ions and the clotting time is Fbg concentration-dependent. The clotting time was decreased by the increasing amount of Fbg in both groups. Besides, the blood of lower HCT with various levels of Fbg took shorter time to coagulate than that of higher HCT. Consequently, the OCT method is a useful and promising tool for the detection of blood-coagulation processes induced with different Fbg levels.
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Affiliation(s)
- Xiangqun Xu
- Department of Chemistry, Zhejiang Sci-Tech University, Hangzhou 310018, People's Republic of China
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Detection of elevated INR by thromboelastometry and thromboelastography in warfarin treated patients and healthy controls. Thromb Res 2015; 135:1007-11. [DOI: 10.1016/j.thromres.2015.02.022] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 01/29/2015] [Accepted: 02/18/2015] [Indexed: 11/24/2022]
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