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Roh DJ, Chang TR, Kumar A, Burke D, Torres G, Xu K, Yang W, Cottarelli A, Moore E, Sauaia A, Hansen K, Velazquez A, Boehme A, Vrosgou A, Ghoshal S, Park S, Agarwal S, Claassen J, Connolly ES, Wagener G, Francis RO, Hod E. Hemoglobin Concentration Impacts Viscoelastic Hemostatic Assays in ICU Admitted Patients. Crit Care Med 2023; 51:267-278. [PMID: 36661453 PMCID: PMC11149397 DOI: 10.1097/ccm.0000000000005700] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES Low hemoglobin concentration impairs clinical hemostasis across several diseases. It is unclear whether hemoglobin impacts laboratory functional coagulation assessments. We evaluated the relationship of hemoglobin concentration on viscoelastic hemostatic assays in intracerebral hemorrhage (ICH) and perioperative patients admitted to an ICU. DESIGN Observational cohort study and separate in vitro laboratory study. SETTING Multicenter tertiary referral ICUs. PATIENTS Two acute ICH cohorts receiving distinct testing modalities: rotational thromboelastometry (ROTEM) and thromboelastography (TEG), and a third surgical ICU cohort receiving ROTEM were evaluated to assess the generalizability of findings across disease processes and testing platforms. A separate in vitro ROTEM laboratory study was performed utilizing ICH patient blood samples. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Relationships between baseline hemoglobin and ROTEM/TEG results were separately assessed across patient cohorts using Spearman correlations and linear regression models. A separate in vitro study assessed ROTEM tracing changes after serial hemoglobin modifications from ICH patient blood samples. In both our ROTEM (n = 34) and TEG (n = 239) ICH cohorts, hemoglobin concentrations directly correlated with coagulation kinetics (ROTEM r: 0.46; p = 0.01; TEG r: 0.49; p < 0.0001) and inversely correlated with clot strength (ROTEM r: -0.52, p = 0.002; TEG r: -0.40, p < 0.0001). Similar relationships were identified in perioperative ICU admitted patients (n = 121). We continued to identify these relationships in linear regression models. When manipulating ICH patient blood samples to achieve lower hemoglobin concentrations in vitro, we similarly identified that lower hemoglobin concentrations resulted in progressively faster coagulation kinetics and greater clot strength on ROTEM tracings. CONCLUSIONS Lower hemoglobin concentrations have a consistent, measurable impact on ROTEM/TEG testing in ICU admitted patients, which appear to be artifactual. It is possible that patients with low hemoglobin may appear to have normal viscoelastic parameters when, in fact, they have a mild hypocoagulable state. Further work is required to determine if these tests should be corrected for a patient's hemoglobin concentration.
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Affiliation(s)
- David J Roh
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Tiffany R Chang
- Department of Neurology and Neurosurgery, McGovern Medical School at UTHealth, Houston, TX
| | - Aditya Kumar
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Devin Burke
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Glenda Torres
- Department of Neurology and Neurosurgery, McGovern Medical School at UTHealth, Houston, TX
| | - Katherine Xu
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Winni Yang
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Azzurra Cottarelli
- Department of Pathology and Cell Biology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Ernest Moore
- Department of Surgery, University of Colorado Denver, Aurora, CO
| | - Angela Sauaia
- Department of Surgery, University of Colorado Denver, Aurora, CO
| | - Kirk Hansen
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver, Aurora, CO
| | - Angela Velazquez
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Amelia Boehme
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Athina Vrosgou
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Shivani Ghoshal
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Soojin Park
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Sachin Agarwal
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Jan Claassen
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - E Sander Connolly
- Department of Neurological Surgery, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Gebhard Wagener
- Department of Anesthesiology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Richard O Francis
- Department of Pathology and Cell Biology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Eldad Hod
- Department of Pathology and Cell Biology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
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Helms J, Frere C, Thiele T, Tanaka KA, Neal MD, Steiner ME, Connors JM, Levy JH. Anticoagulation in adult patients supported with extracorporeal membrane oxygenation: guidance from the Scientific and Standardization Committees on Perioperative and Critical Care Haemostasis and Thrombosis of the International Society on Thrombosis and Haemostasis. J Thromb Haemost 2023; 21:373-396. [PMID: 36700496 DOI: 10.1016/j.jtha.2022.11.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 11/08/2022] [Accepted: 11/09/2022] [Indexed: 01/26/2023]
Abstract
Anticoagulation of patients supported by extracorporeal membrane oxygenation is challenging because of a high risk of both bleeding and thrombotic complications, and often empirical. Practice in anticoagulation management is therefore highly variable. The scope of this guidance document is to provide clinicians with practical advice on the choice of an anticoagulant agent, dosing, and the optimal anticoagulant monitoring strategy during extracorporeal membrane oxygenation support in adult patients.
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Affiliation(s)
- Julie Helms
- Strasbourg University (UNISTRA), Strasbourg University Hospital, Medical Intensive Care Unit - NHC, INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Strasbourg, France.
| | - Corinne Frere
- Sorbonne Université, UMRS 1166, AP-HP. Sorbonne Université, Pitié-Salpêtrière Hospital, Paris, France
| | - Thomas Thiele
- Institut für Transfusionsmedizin, Universitätsmedizin Rostock, Schillingallee 36, Rostock, Germany
| | - Kenichi A Tanaka
- Department of Anesthesiology, Universit of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Matthew D Neal
- Department of Surgery, Trauma and Transfusion Medicine Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Marie E Steiner
- Division of Hematology/Oncology and Division of Critical Care, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - Jean M Connors
- Hematology Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC, USA
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Kristobak BM, McCarthy ML, Keneally RJ, Amberman KD, Ellis HJ, Call RC. Citrate does not change viscoelastic haemostatic assays after cardiopulmonary bypass. Ann Card Anaesth 2022; 25:453-459. [PMID: 36254910 PMCID: PMC9732968 DOI: 10.4103/aca.aca_34_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 06/10/2021] [Accepted: 07/25/2021] [Indexed: 06/16/2023] Open
Abstract
CONTEXT Viscoelastic hemostatic assays (VHA) are commonly used to identify specific cellular and humoral causes for bleeding in cardiac surgery patients. Cardiopulmonary bypass (CPB) alterations to coagulation are observable on VHA. Citrated VHA can approximate fresh whole blood VHA when kaolin is used as the activator in healthy volunteers. Some have suggested that noncitrated blood is more optimal than citrated blood for point-of-care analysis in some populations. AIMS To determine if storage of blood samples in citrate after CPB alters kaolin activated VHA results. SETTINGS AND DESIGN This was a prospective observational cohort study at a single tertiary care teaching hospital. METHODS AND MATERIAL Blood samples were subjected to VHA immediately after collection and compared to samples drawn at the same time and stored in citrate for 30, 90, and 150 min prior to kaolin activated VHA both before and after CPB. STATISTICAL ANALYSIS USED VHA results were compared using paired T-tests and Bland-Altman analysis. RESULTS Maximum clot strength and time to clot initiation were not considerably different before or after CPB using paired T-tests or Bland-Altman Analysis. CONCLUSIONS Citrated samples appear to be a clinically reliable substitute for fresh samples for maximum clot strength and time to VHA clot initiation after CPB. Concerns about the role of citrate in altering the validity of the VHA samples in the cardiac surgery population seem unfounded.
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Affiliation(s)
- Benjamin M. Kristobak
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Margaret L. McCarthy
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Ryan J. Keneally
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Keith D. Amberman
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Harvey J. Ellis
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Robert C. Call
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, MD, USA
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Volod O, Wegner J. Viscoelastic Testing in the Management of Adult Patients on Mechanical Circulatory Support Devices with Focus on Extracorporeal Membrane Oxygenation. Semin Thromb Hemost 2022; 48:814-827. [DOI: 10.1055/s-0042-1756303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
AbstractThromboembolic and hemorrhagic complications continue to remain frequent complications that significantly impact the morbidity and mortality of patients implanted with mechanical circulatory support devices (MCSDs). The severe acute respiratory syndrome caused by coronavirus 2 (SARS-CoV-2) has resulted in a number of COVID-19 patients being supported by MCSDs, specifically extracorporeal membrane oxygenation (ECMO), which in turn has created a crucial need for rapid assessment of hemostatic status in these patients to avoid bleeding and thrombotic complications. Currently, conventional plasma-based coagulation assays such as prothrombin time and activated partial thromboplastin time (aPTT) are used to assess hemostasis, and the activated clotting time (ACT) and aPTT are the most common tests used to monitor heparin anticoagulation in patients on ECMO. Unfractionated heparin remains the mainstay anticoagulation therapy for patients on ECMO. Extracorporeal Life Support Organization (ELSO) offers little guidance on the subject but does state that each institution should create its internal anticoagulation protocols. Viscoelastic assays (VEAs) are increasingly recognized by ELSO and ECMO community for their potential to assess hemostatic derangements in patients implanted with MCSDs as well as guidance for appropriate hemostatic therapy. This review focuses on the evidence for the use of viscoelastic assays to assess overall hemostasis and to guide the treatment of adult patients connected to an ECMO circuit. Limitations of the use of conventional assays, ACT, and VEA are also discussed.
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Affiliation(s)
- Oksana Volod
- Department of Pathology and Laboratory Medicine, Cedars Sinai Medical Center, Los Angeles, California
| | - Julie Wegner
- College of Health Professions, South University Online, Savannah, Georgia
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Regling K, Saini A, Cashen K. Viscoelastic Testing in Pediatric Mechanical Circulatory Support. Front Med (Lausanne) 2022; 9:854258. [PMID: 35602480 PMCID: PMC9120594 DOI: 10.3389/fmed.2022.854258] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 04/14/2022] [Indexed: 11/13/2022] Open
Abstract
Pediatric mechanical circulatory support can be lifesaving. However, managing anticoagulation is one of the most challenging aspects of care in patients requiring mechanical circulatory support. Effective anticoagulation is even more difficult in pediatric patients due to the smaller size of their blood vessels, increased turbulent flow, and developmental hemostasis. Recently, viscoelastic testing (VET) has been used as a qualitative measure of anticoagulation efficacy in patients receiving extracorporeal membrane oxygenation (ECMO) and ventricular assist devices (VAD). Thromboelastography (TEG®) and thromboelastometry (ROTEM®) provide a global qualitative assessment of hemostatic function from initiation of clot formation with the platelet-fibrin interaction, platelet aggregation, clot strength, and clot lysis. This review focuses on the TEG®/ROTEM® and important laboratory and patient considerations for interpretation in the ECMO and VAD population. We summarize the adult and pediatric ECMO/VAD literature regarding VET values, VET-platelet mapping, utility over standard laboratory monitoring, and association with outcome measures such as blood product utilization, bleeding, and thrombosis.
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Affiliation(s)
- Katherine Regling
- Division of Hematology Oncology, Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University School of Medicine, Detroit, MI, United States
- *Correspondence: Katherine Regling
| | - Arun Saini
- Division of Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor University School of Medicine, Houston, TX, United States
- Arun Saini
| | - Katherine Cashen
- Division of Critical Care Medicine, Department of Pediatrics, Duke Children's Hospital, Duke University School of Medicine, Durham, NC, United States
- Katherine Cashen
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Brokmeier HM, Wieruszewski ED, Nei SD, Loftsgard TO, Wieruszewski PM. Hemostatic Management in Extracorporeal Membrane Oxygenation. Crit Care Nurs Q 2022; 45:132-143. [PMID: 35212653 DOI: 10.1097/cnq.0000000000000396] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The use of extracorporeal membrane oxygenation (ECMO) for acute cardiac and/or respiratory failure has grown exponentially in the past several decades. Systemic anticoagulation is a fundamental element of caring for ECMO patients. Hemostatic management during ECMO walks a fine line to balance the risk of safe and effective anticoagulant delivery to mitigate thromboembolic complications and minimizing hemorrhagic sequelae. This review discusses the pharmacology, monitoring parameters, and special considerations for anticoagulation in patients requiring ECMO.
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Affiliation(s)
- Hannah M Brokmeier
- Departments of Pharmacy (Drs Brokmeier, E. D. Wieruszewski, Nei, and P. M. Wieruszewski), Cardiovascular Surgery (Mr Loftsgard), and Anesthesiology (Dr P. M. Wieruszewski), Mayo Clinic, Rochester, Minnesota
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7
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Burton CL, Furlong-Dillard JM, Jawad K, Feygin Y, Berkenbosch JW, Tzanetos DT. Analysis of Viscoelastic Testing in Pediatric Patients Using the Pediatric Extracorporeal Membrane Oxygenation Outcomes Registry. ASAIO J 2021; 67:1251-1256. [PMID: 33852495 DOI: 10.1097/mat.0000000000001388] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Use of viscoelastic tests (VETs), including thromboelastography (TEG) and rotational thromboelastometry (ROTEM), is increasing in the management of anticoagulation in extracorporeal membrane oxygenation (ECMO) patients. A retrospective review of data on 265 pediatric (<20 years old) ECMO patients who underwent VET and were submitted to the Pediatric ECMO Outcomes Registry (PEDECOR) was conducted to describe common coagulopathies in patients who underwent VET; associations between the VET parameters and traditional tests of coagulation; and comparisons in blood product usage in patients who underwent VET with those who did not. We calculated patient-level summary statistics and assessed differences between the groups using χ2 tests (categorical variables) and Kruskal-Wallis and Wilcoxon rank-sum tests (continuous variables). Viscoelastic test was utilized in 77% of patients in the analysis. Platelet dysfunction was the most common abnormality identified by TEG (30.8%) and ROTEM (9.7%). Bleeding patients who had VET performed received more cryoprecipitate transfusions than those who did not have VET (VET median = 9.7 ml/kg; interquartile range (IQR) = 4.3-22.0 ml/kg vs. no VET median = 5.1 ml/kg; IQR = 0-10.4 ml/kg; p = 0.0013). Given the growing use of VET in pediatric ECMO patients, further studies evaluating VET in managing complications as well as aiding in titration of anticoagulation therapy are needed.
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Affiliation(s)
- Cassondra L Burton
- From the Division of Pediatric Critical Care, Norton Children's Hospital, University of Louisville, Louisville, Kentucky
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8
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Jiritano F, Fina D, Lorusso R, Ten Cate H, Kowalewski M, Matteucci M, Serra R, Mastroroberto P, Serraino GF. Systematic review and meta-analysis of the clinical effectiveness of point-of-care testing for anticoagulation management during ECMO. J Clin Anesth 2021; 73:110330. [PMID: 33962338 DOI: 10.1016/j.jclinane.2021.110330] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 04/17/2021] [Accepted: 04/20/2021] [Indexed: 12/26/2022]
Abstract
STUDY OBJECTIVE Viscoelastic point-of-care (POC) tests are commonly used to provide prompt diagnosis of coagulopathy and allow targeted treatments in bleeding patients on ECMO. We evaluated the clinical effectiveness of point-of-care (POC) testing for anticoagulation management in patients on extracorporeal membrane oxygenation (ECMO). DESIGN Systematic review and meta-analysis. Eligible studies evaluating the use of thromboelastography- or thromboelastometry-guided algorithms, anti-factor Xa and platelet function testing were selected after screening the literature from July 1975 to January 2020. SETTING Patients on ECMO support. PATIENTS Anticoagulation management on ECMO patients. INTERVENTIONS Rotational thromboelastometry, thromboelastography, alone or combined with platelet function testing. Trials monitoring the anticoagulation effects during ECMO using an anti-factor Xa assay were included in the systematic review. MEASUREMENTS The primary outcomes were bleeding events, surgical revisions, thrombosis events and ECMO circuit change/failure. Secondary outcomes were blood-product transfusions, cerebrovascular accidents, mortality on ECMO, ECMO duration, intensive care unit and hospital discharge rates, and in-hospital mortality. MAIN RESULTS Thirty-one trials enrolling 1684 participants were included in the systematic review. Four trials enrolling 547 subjects were included in the meta-analysis. The use of a POC testing device resulted in improved detection of surgical bleeding (RR: 0.68, 95% CI 0.49 to 0.94, I2 = 0%; χ2 test for heterogeneity, P = 0.02). The use of POC-guided algorithms did not affect bleeding (RR:0.78, 95% CI 0.58 to 1.04, I2 = 47%; χ2 test for heterogeneity, P = 0.09), thrombosis events (RR:1.35, 95% CI 0.86 to 2.12, I2 = 37%; χ2 test for heterogeneity, P = 0.19), or ECMO circuit/change (RR:0.90, 95% CI 0.48 to 1.71, I2 = 28%; χ2 test for heterogeneity, P = 0.75). CONCLUSION Routine use of POC tests did not improve the main clinical outcomes beyond suggesting a diagnosis of surgical bleeding in ECMO patients.
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Affiliation(s)
- Federica Jiritano
- Cardiac Surgery Unit, Dept. Experimental and Clinical Medicine, University "Magna Graecia" of Catanzaro, Catanzaro, Italy; Cardio-Thoracic Surgery Dept., Heart & Vascular Centre, Maastricht University Medical Centre (MUMC), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands.
| | - Dario Fina
- Cardio-Thoracic Surgery Dept., Heart & Vascular Centre, Maastricht University Medical Centre (MUMC), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands; Città di Lecce Hospital, GVM Care and Research, Lecce, Italy
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Dept., Heart & Vascular Centre, Maastricht University Medical Centre (MUMC), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | - Hugo Ten Cate
- Laboratory for Clinical Thrombosis and Haemostasis, Department of Internal Medicine, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Mariusz Kowalewski
- Cardio-Thoracic Surgery Dept., Heart & Vascular Centre, Maastricht University Medical Centre (MUMC), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands; Clinical Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior and Administration, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Matteo Matteucci
- Cardio-Thoracic Surgery Dept., Heart & Vascular Centre, Maastricht University Medical Centre (MUMC), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands; Department of Cardiac Surgery, Circolo Hospital, University of Insubria, Varese, Italy
| | - Raffaele Serra
- Department of Medical and Surgical Sciences, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - Pasquale Mastroroberto
- Cardiac Surgery Unit, Dept. Experimental and Clinical Medicine, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - Giuseppe Filiberto Serraino
- Cardiac Surgery Unit, Dept. Experimental and Clinical Medicine, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
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Selewski DT, Wille KM. Continuous renal replacement therapy in patients treated with extracorporeal membrane oxygenation. Semin Dial 2021; 34:537-549. [PMID: 33765346 PMCID: PMC8250911 DOI: 10.1111/sdi.12965] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a life‐saving therapy utilized for patients with severe life‐threatening cardiorespiratory failure. Patients treated with ECMO are among the most severely ill encountered in critical care and are at high‐risk of developing multiple organ dysfunction, including acute kidney injury (AKI) and fluid overload. Continuous renal replacement therapy (CRRT) is increasingly utilized inpatients on ECMO to manage AKI and treat fluid overload. The indications for renal replacement therapy for patients on ECMO are similar to those of other critically ill populations; however, there is wide practice variation in how renal supportive therapies are utilized during ECMO. For patients requiring both CRRT and ECMO, CRRT may be connected directly to the ECMO circuit, or CRRT and ECMO may be performed independently. This review will summarize current knowledge of the epidemiology of AKI, indications and timing of CRRT, delivery of CRRT, and the outcomes of patients requiring CRRT with ECMO.
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Affiliation(s)
- David T Selewski
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Keith M Wille
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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10
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Giani M, Russotto V, Pozzi M, Forlini C, Fornasari C, Villa S, Avalli L, Rona R, Foti G. Thromboelastometry, Thromboelastography, and Conventional Tests to Assess Anticoagulation During Extracorporeal Support: A Prospective Observational Study. ASAIO J 2021; 67:196-200. [PMID: 33512915 DOI: 10.1097/mat.0000000000001196] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Optimal anticoagulation monitoring in patients with extracorporeal membrane oxygenation (ECMO) is fundamental to avoid hemorrhagic and thromboembolic complications. Besides conventional coagulation tests, there is growing interest in the use of viscoelastic hemostatic assays (VHA), in particular of tromboelastography (TEG). Evidence on the use of rotational thromboelastometry (ROTEM) is lacking in this setting. The aim of the study was to evaluate ROTEM as a tool for assessing hemostasis during ECMO, by comparing it to TEG and conventional coagulation assays. We conducted a prospective, observational, single-center study on adult patients on ECMO support anticoagulated with unfractioned heparin (UFH). Kaolin reaction time (R, min) for TEG and INTEM clotting time (CT, sec) for ROTEM were analyzed and compared with conventional coagulation tests. In the study period, we included 25 patients on ECMO support (14 V-A and 11 V-V); 84 data points were available for the analysis. Median UFH infusion rate was 15 [11-18] IU/min/kg. Median values for activated partial thromboplastin time (aPTT) ratio, Kaolin TEG R time, and INTEM CT were 1.44 [1.21-1.7], 22 [13-40] min, and 201 [183-225] sec, respectively. INTEM CT (ROTEM) showed a moderate correlation with standard coagulation tests (R2 = 0.34 and 0.3 for aPTT and activated clotting time (ACT), respectively, p < 0.001). No significant correlation was found between INTEM CT and Kaolin R time (R2 = 0.01). Further studies are needed to identify an appropriate anticoagulation target for ROTEM during ECMO.
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Affiliation(s)
- Marco Giani
- From the ASST Monza, Ospedale San Gerardo, Dipartimento di Emergenza-Urgenza, Monza, Italy
- Università degli Studi di Milano-Bicocca, Dipartimento di Medicina e Chirurgia, Monza, Italy
| | - Vincenzo Russotto
- From the ASST Monza, Ospedale San Gerardo, Dipartimento di Emergenza-Urgenza, Monza, Italy
- Università degli Studi di Milano-Bicocca, Dipartimento di Medicina e Chirurgia, Monza, Italy
| | - Matteo Pozzi
- From the ASST Monza, Ospedale San Gerardo, Dipartimento di Emergenza-Urgenza, Monza, Italy
| | - Clarissa Forlini
- Università degli Studi di Milano-Bicocca, Dipartimento di Medicina e Chirurgia, Monza, Italy
| | - Chiara Fornasari
- Università degli Studi di Milano-Bicocca, Dipartimento di Medicina e Chirurgia, Monza, Italy
| | - Silvia Villa
- From the ASST Monza, Ospedale San Gerardo, Dipartimento di Emergenza-Urgenza, Monza, Italy
| | - Leonello Avalli
- From the ASST Monza, Ospedale San Gerardo, Dipartimento di Emergenza-Urgenza, Monza, Italy
| | - Roberto Rona
- From the ASST Monza, Ospedale San Gerardo, Dipartimento di Emergenza-Urgenza, Monza, Italy
| | - Giuseppe Foti
- From the ASST Monza, Ospedale San Gerardo, Dipartimento di Emergenza-Urgenza, Monza, Italy
- Università degli Studi di Milano-Bicocca, Dipartimento di Medicina e Chirurgia, Monza, Italy
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Alvitigala BY, Gooneratne LV, Constantine GR, Wijesinghe RANK, Arawwawala LDAM. Pharmacokinetic, pharmacodynamic, and pharmacogenetic assays to monitor clopidogrel therapy. Pharmacol Res Perspect 2020; 8:e00686. [PMID: 33200888 PMCID: PMC7670852 DOI: 10.1002/prp2.686] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 10/20/2020] [Accepted: 10/21/2020] [Indexed: 12/11/2022] Open
Abstract
Clopidogrel is the most common and widely used antiplatelet agent for patients with coronary artery disease following confirmation by electrocardiographic studies. The nonresponsiveness of patients to clopidogrel and the possibility of testing for clopidogrel resistance by platelet function assays (PFA) are contentious issues. Light transmission aggregometry (LTA) is considered as the gold standard test among all PFA. In this review, the most commonly used PFA used for monitoring the effect of clopidogrel, LTA, vasodilator-stimulated phosphoprotein assay phosphorylation, rotational thromboelastometry (ROTEM) delta and ROTEM platelet, thromboelastography, PFA-100, VerifyNow P2Y12 assay, Multiplate analyzer, Plateletworks assay and pharmacogenetic studies, are comparatively discussed including their principles of action, advantages, and disadvantages. VerifyNow P2Y12 assay can be accepted as the ideal point of care test out of the discussed assays. However, modified assays are required which could overcome the limitations associated with currently available assays.
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Affiliation(s)
- Bhawani Yasassri Alvitigala
- Department of Medical Laboratory ScienceFaculty of Health SciencesThe Open University of Sri LankaNugegodaSri Lanka
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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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Abstract
Studies using whole blood platelet aggregometry as a laboratory research tool, provided important insights into the mechanism and modulators of platelet aggregation. Subsequently, a number of point-of-care (POC) platelet function tests (PFTs) were developed for clinical use, based on the concept that an individual’s thrombotic profile could be assessed in vitro by assessing the response to stimulation of platelet aggregation by specific, usually solo agonists such as adenosine diphosphate (ADP), collagen and thrombin. However, adjusting antiplatelet medication in order to improve the results of such POC PFTs has not translated into a meaningful reduction in cardiovascular events, which may be attributable to important differences between the POC PFT techniques and in vivo conditions, including patient-to-patient variability. Important limitations of most tests include the use of citrate-anticoagulated blood. Citrate directly and irreversibly diminishes platelet function and even after recalcification, it may result in altered platelet aggregation in response to ADP, epinephrine or collagen, and interfere with thrombin generation from activated platelets. Furthermore, most tests do not employ flowing blood and therefore do not assess the effect of high shear forces on platelets that initiate, propagate and stabilize arterial thrombi. Finally, the effect of endogenous thrombolysis, due to fibrinolysis and dislodgement, which ultimately determines the outcome of a thrombotic stimulus, is mostly not assessed. In order to accurately reflect an individual’s predisposition to arterial thrombosis, future tests of thrombotic status which overcome these limitations should be used, to improve cardiovascular risk prediction and to guide pharmacotherapy.
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Affiliation(s)
- Diana A Gorog
- National Heart and Lung Institute, Imperial College, Dovehouse Street, London, SW3 6LY, UK.
- University of Hertfordshire, Hertfordshire, UK.
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Comparison of citrated and fresh whole blood for viscoelastic coagulation testing during elective neurosurgery. Thromb Res 2017; 156:73-79. [PMID: 28601642 DOI: 10.1016/j.thromres.2017.05.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 05/11/2017] [Accepted: 05/29/2017] [Indexed: 12/24/2022]
Abstract
BACKGROUND Previous viscoelastic haemostatic tests studies have often indicated a hypercoagulative test signal with citrated blood, which could influence clinical decision makings. PURPOSE The aim of this study was to compare fresh and citrated whole blood using two non-automated viscoelastic ROTEM and Sonoclot tests. Our hypothesis was that citrated blood would demonstrate a hypercoagulative response in this setting, not tested before. METHODS Perioperative viscoelastic coagulation changes were evaluated with a ROTEM and Sonoclot in 38 patients undergoing elective brain tumor surgery. The citrated samples were recalcified with CaCl2. Wilcoxon nonparametric-paired tests and Bland-Altman plots were performed to compare the fresh and citrated blood analyses. RESULTS The citrated blood showed a hypercoagulative response in ROTEM NATEM-clot formation time and α-angle, Sonoclot-clot rate and platelet function, as compared to fresh blood (p<0.0001). CONCLUSIONS Fresh whole blood may theoretically reflect in vivo haemostasis more closely than citrated analyses, which indicated a hypercoagulative response as compared to the fresh whole blood analyses Bland-Altman plots also indicated that ROTEM reference ranges in patients undergoing brain surgery should be redefined. Future studies must establish the correlation between viscoelastic test results using fresh or citrate anticoagulated blood and clinical outcomes, such as bleeding, transfusion or reoperation for postoperative haematoma.
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Nogami K. The utility of thromboelastography in inherited and acquired bleeding disorders. Br J Haematol 2016; 174:503-14. [PMID: 27264484 DOI: 10.1111/bjh.14148] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 03/30/2016] [Indexed: 01/08/2023]
Abstract
Thromboelastography (TEG) was first described by Hartert in 1948, and was designed to monitor viscoelastic clot strength in whole blood in real time. The current TEG method and Rotational Thromboelastometry (ROTEM) were subsequently developed from the original principles. Both of the modern methods provide data by measuring changes in the viscoelastic strength of a small sample of clotting blood in response to a constant rotational force. The important advantage of these techniques is to visually observe and quantify blood coagulation including the propagation, stabilization and dissolution phases of clot formation under low shear conditions. Analysis of the results provides detailed kinetic data on fibrin generation, clot strength and fibrinolysis. These TEG/ROTEM analyses therefore enable evaluation of global clotting function and the monitoring of haemostatic treatment in various clinical situations, not only in patients with genetic bleeding disorders, such as haemophilia, but also in patients undergoing cardiac surgery, liver transplantation or suffering from traumatic injury. Some evidence suggests that haemostatic management using TEG/ROTEM leads to a reduction in total transfusions of whole blood or clotting factors. Wider clinical application of this technology seems likely.
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Affiliation(s)
- Keiji Nogami
- Department of Paediatrics, Nara Medical University, Kashihara, Nara, Japan
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All the bang without the bucks: Defining essential point-of-care testing for traumatic coagulopathy. J Trauma Acute Care Surg 2015; 79:117-24; discussion 124. [PMID: 26091324 DOI: 10.1097/ta.0000000000000691] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Rapid assessment and treatment of coagulopathy reduces postinjury morbidity and mortality. Although thrombelastography (TEG) may be more accurate and efficient than conventional coagulation tests, it requires significant financial and personnel investments. We hypothesized that point-of-care international normalized ratio (POC INR) may provide a rapid and accurate alternative to TEG. METHODS A retrospective review of sequential trauma patients who underwent both POC INR and rapid TEG (r-TEG) testing upon presentation to a Level I trauma center from July 2012 to December 2013 was performed. POC INR was compared with r-TEG values (R value, K time, α angle, maximum amplitude, percent clot lysis in 30 minutes) and transfusion requirements. Vital signs, admission laboratory values, and injury severity were analyzed. POC INR and venous blood gas testing was performed in the emergency department. All results and Pearson correlations noted were significant if p < 0.05. RESULTS We identified 628 trauma patients with concomitant r-TEG and POC INR testing. Median Injury Severity Score (ISS) was 13, 20% arrived in shock (base value < -5), 21% were transfused, and 11% died. POC INR correlated with all r-TEG values, with stronger correlations for patients in shock. POC INR and r-TEG had similar correlations with blood products transfused at 4 hours and 24 hours, but only POC INR predicted substantial bleeding and massive transfusion. POC INR also correlated strongly with standard INR testing. POC INR test duration was less than 1 minute, compared with at least 30 minutes for r-TEG. Total cohort charges for POC INR were estimated at $21,980 versus $396,896 for r-TEG. CONCLUSION POC INR testing is faster and cheaper than r-TEG. In addition, POC INR correlates not only with r-TEG values but also with acute blood product transfusions. POC INR provides a practical alternative for rapid coagulopathy assessment in the trauma patient at institutions that lack TEG capability. LEVEL OF EVIDENCE Diagnostic study, level III. Therapeutic/care management study, level IV.
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Time impact on non-activated and kaolin-activated blood samples in thromboelastography. BMC Anesthesiol 2015; 15:50. [PMID: 25927487 PMCID: PMC4404121 DOI: 10.1186/s12871-015-0033-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 04/09/2015] [Indexed: 11/15/2022] Open
Abstract
Background The correct methodology of thrombelastography might be influenced by elapsing time. In our study we investigated kaolin activated citrated samples together with non-activated citrated samples in relation to the elapsed times of 0, 15 and 30 minutes to compare both methods and to find out if there is an impact of time on results of thrombelastography. Methods Blood samples obtained from 10 healthy volunteers were analyzed after 0, 15 and 30 minutes from sampling with kaolin activation and without activation. Then the results were analysed and compared between the non-activated and the kaolin-activated method. Results All blood samples became more hypercoagulable with the time elapsing, both in non-activated and kaolin-activated samples and differences between both groups were found statistically and clinically significant after only 0 minutes. Conclusions The non-activated citrated method seems to be reliable and suitable for thrombelastography in non-emergency cases (planned surgical procedures) when we have time to wait 15–30 minutes to get results. In urgent situations a rapid thrombelastography test should be preferred. Although the kaolin-activated method can also be used, results must be interpreted with caution.
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Karon BS. Why is everyone so excited about thromboelastrography (TEG)? Clin Chim Acta 2014; 436:143-8. [DOI: 10.1016/j.cca.2014.05.013] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Revised: 05/14/2014] [Accepted: 05/15/2014] [Indexed: 11/27/2022]
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Whiting D, DiNardo JA. TEG and ROTEM: technology and clinical applications. Am J Hematol 2014; 89:228-32. [PMID: 24123050 DOI: 10.1002/ajh.23599] [Citation(s) in RCA: 404] [Impact Index Per Article: 40.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Revised: 09/23/2013] [Accepted: 09/23/2013] [Indexed: 12/13/2022]
Abstract
Initially described in 1948 by Hertert thromboelastography (TEG) provides a real-time assessment of viscoelastic clot strength in whole blood. Rotational thromboelastometry (ROTEM) evolved from TEG technology and both devices generate output by transducing changes in the viscoelastic strength of a small sample of clotting blood (300 µl) to which a constant rotational force is applied. These point of care devices allow visual assessment of blood coagulation from clot formation, through propagation, and stabilization, until clot dissolution. Computer analysis of the output allows sophisticated clot formation/dissolution kinetics and clot strength data to be generated. Activation of clot formation can be initiated with both intrinsic (kaolin, ellagic acid) and extrinsic (tissue factor) activators. In addition, the independent contributions of platelets and fibrinogen to final clot strength can be assessed using added platelet inhibitors (abciximab and cytochalasin D). Increasingly, ROTEM and TEG analysis is being incorporated in vertical algorithms to diagnose and treat bleeding in high-risk populations such as those undergoing cardiac surgery or suffering from blunt trauma. Some evidence suggests these algorithms might reduce transfusions, but further study is needed to assess patient outcomes.
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Affiliation(s)
- David Whiting
- Division of Cardiac Anesthesia, Department of Anaesthesia; Perioperative and Pain Medicine, Boston Children's Hospital; Boston Massachusetts
| | - James A. DiNardo
- Division of Cardiac Anesthesia, Department of Anaesthesia; Perioperative and Pain Medicine, Boston Children's Hospital; Boston Massachusetts
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