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Rey Y Formoso V, Barreto Mota R, Soares H. Developmental hemostasis in the neonatal period. World J Pediatr 2022; 18:7-15. [PMID: 34981411 DOI: 10.1007/s12519-021-00492-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 11/17/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The hemostatic system is complex and evolves continuously since gestation and well into the adult years, in a process known as "developmental hemostasis." DATA SOURCES A comprehensive review was performed after an extensive literature search on PubMed/MEDLINE concerning developmental hemostasis during the neonatal period. Relevant cross references were also included. RESULTS Although part of a system, each component of the hemostatic system evolves differently, with many displaying both quantitative and qualitative age-related differences. This leads to drastic disparities between the coagulation system of neonates and both other children's and adults', while still maintaining a generally balanced and physiological hemostasis. The motives behind this process remain to be fully elucidated but may be, at least in part, related to non-hemostatic factors. CONCLUSIONS Knowledge regarding "developmental hemostasis" is essential for everyone caring for newborns or even children in general and in this review, we describe each hemostatic system component's neonatal characteristics and age-related progression as well as explore some of the possible physiological motives behind the process.
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Affiliation(s)
- Vicente Rey Y Formoso
- Neonatology Department (Reference Center for Congenital Heart Diseases), São João University Hospital Center, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal.
| | - Ricardo Barreto Mota
- Neonatology Department (Reference Center for Congenital Heart Diseases), São João University Hospital Center, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
| | - Henrique Soares
- Neonatology Department (Reference Center for Congenital Heart Diseases), São João University Hospital Center, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal.,Faculty of Medicine, Porto University, Porto, Portugal
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2
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Cannata G, Mariotti Zani E, Argentiero A, Caminiti C, Perrone S, Esposito S. TEG ® and ROTEM ® Traces: Clinical Applications of Viscoelastic Coagulation Monitoring in Neonatal Intensive Care Unit. Diagnostics (Basel) 2021; 11:1642. [PMID: 34573982 PMCID: PMC8465234 DOI: 10.3390/diagnostics11091642] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 08/28/2021] [Accepted: 09/04/2021] [Indexed: 12/14/2022] Open
Abstract
The concentration of the majority of hemostatic proteins differs considerably in early life, especially in neonates compared to adulthood. Knowledge of the concept of developmental hemostasis is an essential prerequisite for the proper interpretation of conventional coagulation tests (CCT) and is critical to ensure the optimal diagnosis and treatment of hemorrhagic and thrombotic diseases in neonatal age. Viscoelastic tests (VETs) provide a point-of-care, real-time, global, and dynamic assessment of the mechanical properties of the coagulation system with the examination of both cellular and plasma protein contributions to the initiation, formation, and lysis of clots. In this work, we provide a narrative review of the basic principles of VETs and summarize current evidence regarding the two most studied point-of-care VETs, thromboelastography (TEG®) and rotational thromboelastometry (ROTEM®), in the field of neonatal care. A literature analysis shows that viscoelastic hemostatic monitoring appears to be a useful additive technique to CCT, allowing targeted therapy to be delivered quickly. These tools may allow researchers to determine the neonatal coagulation profile and detect neonatal patients at risk for postoperative bleeding, coagulation abnormalities in neonatal sepsis, and other bleeding events in a timely manner, guiding transfusion therapies using the goal-oriented transfusion algorithm. However, diagnosis and treatment algorithms incorporating VETs for neonatal patients in a variety of clinical situations should be developed and applied to improve clinical outcomes. Further studies should be performed to make routinary diagnostic and therapeutic application possible for the neonatal population.
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Affiliation(s)
- Giulia Cannata
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, via Gramsci 14, 43126 Parma, Italy; (G.C.); (E.M.Z.); (A.A.)
| | - Elena Mariotti Zani
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, via Gramsci 14, 43126 Parma, Italy; (G.C.); (E.M.Z.); (A.A.)
| | - Alberto Argentiero
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, via Gramsci 14, 43126 Parma, Italy; (G.C.); (E.M.Z.); (A.A.)
| | - Caterina Caminiti
- Research and Innovation Unit, University Hospital of Parma, via Gramsci 14, 43126 Parma, Italy;
| | - Serafina Perrone
- Neonatology Unit, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, via Gramsci 14, 43126 Parma, Italy;
| | - Susanna Esposito
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, via Gramsci 14, 43126 Parma, Italy; (G.C.); (E.M.Z.); (A.A.)
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3
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Schmidt AE, Israel AK, Refaai MA. The Utility of Thromboelastography to Guide Blood Product Transfusion. Am J Clin Pathol 2019; 152:407-422. [PMID: 31263903 DOI: 10.1093/ajcp/aqz074] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES To provide an overview of the clot viscoelastic testing technology and to describe its utility in guiding blood product transfusions. METHODS A case scenario will be discussed as well as interpretation of thromboelastography (TEG) tracings. In addition, literature examining the utility of viscoelastic testing in guiding patient management and blood product transfusions will be reviewed. RESULTS TEG/rotational thromboelastometry (ROTEM) is useful in evaluating clot kinetics in trauma and acutely bleeding patients. TEG/ROTEM parameters are reflective of values measured using standard coagulation assays; however, TEG/ROTEM parameters are more rapidly available and more costly. TEG and ROTEM are used in three main settings: cardiac surgery, liver transplantation, and trauma to assess global hemostasis and administration of blood products. CONCLUSIONS TEG/ROTEM can be helpful in guiding resuscitation and blood product transfusion. Several studies have demonstrated a reduction in transfusion of blood components with TEG/ROTEM; however, other studies have suggested that TEG/ROTEM is not clinically effective in guiding transfusion.
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Affiliation(s)
- Amy E Schmidt
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY
| | - Anna Karolina Israel
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY
| | - Majed A Refaai
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY
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4
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Liu Q, Xu C, Chen X, Wang J, Ke Z, Hu H. Establishing a reference range for thromboelastograph parameters in the neonatal period. Int J Lab Hematol 2019; 41:530-535. [PMID: 31062936 PMCID: PMC6850129 DOI: 10.1111/ijlh.13043] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 04/04/2019] [Accepted: 04/13/2019] [Indexed: 11/29/2022]
Abstract
Introduction Acquired coagulation disorders are a common cause of neonatal bleeding. The thromboelastograph (TEG) comprehensively assesses haemostatic processes in the body. Unfortunately, the reference range of TEG parameters in the neonatal period has not yet been evaluated, which limits the use of the TEG in neonates. In this study, we aimed to establish the reference range of TEG parameters for the neonatal period. Methods This study included 371 full‐term infants (≥37 weeks of gestation), and we divided these infants into three groups according to age as follows: 1, 2‐7 and 8‐28 days. We measured their peripheral blood using TEG, coagulation routine and platelet count tests. We analysed differences among the groups. Results The reference ranges for TEG parameters are presented as medians and reference ranges (2.5th and 97.5th percentiles) as follows: R (clot reaction time, seconds) 4.80 (2.80‐7.17), Angle (fibrin production rate) 69.90 (44.91‐78.89), K (clot kinetics, min) 1.40 (0.80‐4.50), MA (maximum amplitude, mm) 63.50(44.34‐74.66) and LY30 (lysis at 30 minutes, %) 0.10 (0.10‐6.95). There were significant differences in Angle, K, MA and LY30 values between the different neonatal day age groups. Conclusion This study preliminarily establishes a reference range for TEG parameters during the neonatal period. The age of a newborn had a large influence on TEG parameters. Additionally, we demonstrated a correlation between laboratory tests and TEG parameters for this age period. The reference values provided herein are meaningful for future studies.
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Affiliation(s)
- Qin Liu
- Department of Blood Transfusion, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chunfen Xu
- Department of Blood Transfusion, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xin Chen
- Department of Blood Transfusion, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jia Wang
- Department of Blood Transfusion, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhunhui Ke
- Department of Blood Transfusion, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hongbing Hu
- Department of Blood Transfusion, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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5
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Ghirardello S, Raffaeli G, Scalambrino E, Chantarangkul V, Cavallaro G, Artoni A, Mosca F, Tripodi A. The intra-assay reproducibility of thromboelastography in very low birth weight infants. Early Hum Dev 2018; 127:48-52. [PMID: 30312859 DOI: 10.1016/j.earlhumdev.2018.10.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 07/26/2018] [Accepted: 10/04/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND AIMS Despite the potential benefits of thromboelastography (TEG) for bedside hemostatic assessment in critical care settings, its accuracy remains to be determined, especially in critically ill neonates. We determined the intra-assay reproducibility of TEG parameters: Reaction time (R), clot kinetics (K) and Maximum Amplitude (MA) in a cohort of very low birth weight (VLBW) infants. STUDY DESIGN Observational study. SUBJECTS One hundred VLBW newborns. OUTCOME MEASURES We performed TEG duplicate measurements for blood samples from VLBW newborns. To assess for correlation, we calculated the coefficients of correlation by plotting the values of the first vs the second measurement. Paired samples were compared with t-test and the coefficient of variation (CV) on paired results was also calculated as a measure of variability. To evaluate the agreement between duplicates, Bland-Altman (BA) analysis was performed. RESULTS We evaluated 228 TEG pairs. Both the coefficient of correlation and the BA analysis showed an acceptable level of agreement between duplicates. TEG variability (CV, mean ± SD) was highest for K (10.4%, ±12.9), lowest for MA (3.6%, ±8.0) and moderate for R (7.9%, ±9.0). The results from ANOVA one-way analysis describe different variability trends: K-CV increased at higher values, while MA-CV and R-CV increased at lower values. CONCLUSIONS In VLBW newborns, the agreement between TEG duplicate measurements for R and MA parameters is adequate for clinical purposes. TEG is a promising tool to quickly assess hemostasis ensuring a significant blood sparing in critically ill neonates.
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Affiliation(s)
- Stefano Ghirardello
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Italy.
| | - Genny Raffaeli
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Italy
| | - Erica Scalambrino
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Italy
| | - Veena Chantarangkul
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Italy
| | - Giacomo Cavallaro
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Italy.
| | - Andrea Artoni
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Italy.
| | - Fabio Mosca
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Italy.
| | - Armando Tripodi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Italy.
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6
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Arumainathan R, Stendall C, Visram A. Management of fluids in neonatal surgery. BJA Educ 2018; 18:199-203. [PMID: 33456833 DOI: 10.1016/j.bjae.2018.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2018] [Indexed: 10/16/2022] Open
Affiliation(s)
| | - C Stendall
- Great Ormond Street Hospital, London, UK
| | - A Visram
- Royal London Hospital, London, UK
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7
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In-vitro assessment of the effect of dabigatran on thrombosis of adult and neonatal plasma. Blood Coagul Fibrinolysis 2017; 28:551-557. [DOI: 10.1097/mbc.0000000000000639] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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8
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Nygaard G, Herfindal L, Asrud KS, Bjørnstad R, Kopperud RK, Oveland E, Berven FS, Myhren L, Hoivik EA, Lunde THF, Bakke M, Døskeland SO, Selheim F. Epac1-deficient mice have bleeding phenotype and thrombocytes with decreased GPIbβ expression. Sci Rep 2017; 7:8725. [PMID: 28821815 PMCID: PMC5562764 DOI: 10.1038/s41598-017-08975-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 07/17/2017] [Indexed: 11/16/2022] Open
Abstract
Epac1 (Exchange protein directly activated by cAMP 1) limits fluid loss from the circulation by tightening the endothelial barrier. We show here that Epac1-/- mice, but not Epac2-/- mice, have prolonged bleeding time, suggesting that Epac1 may limit fluid loss also by restraining bleeding. The Epac1-/- mice had deficient in vitro secondary hemostasis. Quantitative comprehensive proteomics analysis revealed that Epac1-/- mouse platelets (thrombocytes) had unbalanced expression of key components of the glycoprotein Ib-IX-V (GPIb-IX-V) complex, with decrease of GP1bβ and no change of GP1bα. This complex is critical for platelet adhesion under arterial shear conditions. Furthermore, Epac1-/- mice have reduced levels of plasma coagulation factors and fibrinogen, increased size of circulating platelets, increased megakaryocytes (the GP1bβ level was decreased also in Epac1-/- bone marrow) and higher abundance of reticulated platelets. Viscoelastic measurement of clotting function revealed Epac1-/- mice with a dysfunction in the clotting process, which corresponds to reduced plasma levels of coagulation factors like factor XIII and fibrinogen. We propose that the observed platelet phenotype is due to deficient Epac1 activity during megakaryopoiesis and thrombopoiesis, and that the defects in blood clotting for Epac1-/- is connected to secondary hemostasis.
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Affiliation(s)
- Gyrid Nygaard
- Department of Biomedicine, University of Bergen, Bergen, Norway
- The Proteomics Unit at the University of Bergen, Bergen, Norway
| | - Lars Herfindal
- Centre for Pharmacy, Department of Clinical Science, University of Bergen, Bergen, Norway
| | | | - Ronja Bjørnstad
- Centre for Pharmacy, Department of Clinical Science, University of Bergen, Bergen, Norway
- Hospital Pharmacies Enterprise, Western Norway, Bergen, Norway
| | | | - Eystein Oveland
- The Proteomics Unit at the University of Bergen, Bergen, Norway
| | - Frode S Berven
- Department of Biomedicine, University of Bergen, Bergen, Norway
- The Proteomics Unit at the University of Bergen, Bergen, Norway
| | - Lene Myhren
- Department of Biomedicine, University of Bergen, Bergen, Norway
| | - Erling A Hoivik
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Turid Helen Felli Lunde
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
| | - Marit Bakke
- Department of Biomedicine, University of Bergen, Bergen, Norway
| | | | - Frode Selheim
- Department of Biomedicine, University of Bergen, Bergen, Norway.
- The Proteomics Unit at the University of Bergen, Bergen, Norway.
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9
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Abstract
BACKGROUND Thromboelastography (TEG) is utilized as a point-of-care test of coagulation function to improve evidence-based blood product replacement in adults. In contrast to standard indices of coagulation, TEG reflects the dynamic interactions among the elements involved in hemostasis, including fibrinolysis. Although normal adult values and various abnormalities have been characterized, normative values for term neonates have not been described. Studies of neonatal TEG remain limited and have small sample sizes with inconsistent methodology. The aim of this study is to provide normative data on healthy term neonates, and to assess the impact of mode of delivery on TEG parameters at term. METHODS Venous umbilical blood was obtained from the placenta within 10 min of delivery. TEG analysis of citrated kaolin-activated samples was performed for 50 healthy term vaginal and 50 cesarean deliveries. Samples collected for cesarean sections were from scheduled cases or unscheduled ones due to failure of progression of labor. RESULTS Healthy neonates with uncomplicated vaginal term deliveries resulted in the following TEG parameters: R: 5.41 ± 1.34 (mean ± SD) min; K: 1.62 ± 0.75 min; α-angle: 65.39 ± 8.77°; MA: 65.86 ± 5.81 mm; and LY30: 1.40 ± 1.18%. Results for the cesarean delivery neonatal TEG assays showed: R: 5.51 ± 1.74 (mean ± SD) min; K: 1.52 ± 0.47 min; α-angle: 64.15 ± 4.61°; MA: 64.15 ± 4.61 mm; and LY30: 2.44 ± 3.51%. Of note, no statistical differences were observed (p < .01) between the groups. CONCLUSION TEG measurements from term neonates were no different when the neonates were delivered vaginally or by cesarean section. Labor had no effect on neonatal TEG levels. Neonatal TEG values may therefore serve as insight for fetal values at the appropriate postconceptional age.
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Affiliation(s)
- Nicholas J Schott
- a Department of Anesthesiology , University of Pittsburgh , Pittsburgh , PA , USA
| | - Stephen P Emery
- b Department of Obstetrics, Gynecology & Reproductive Sciences, Division of Ultrasound , University of Pittsburgh , Pittsburgh , PA , USA
| | - Courtney Garbee
- a Department of Anesthesiology , University of Pittsburgh , Pittsburgh , PA , USA
| | - Jonathan Waters
- c Department of Anesthesiology and Bioengineering , Magee Womens Hospital of UPMC , Pittsburgh , PA , USA
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10
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Sewell EK, Forman KR, Wong ECC, Gallagher M, Luban NLC, Massaro AN. Thromboelastography in term neonates: an alternative approach to evaluating coagulopathy. Arch Dis Child Fetal Neonatal Ed 2017; 102:F79-F84. [PMID: 27178714 DOI: 10.1136/archdischild-2016-310545] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 04/19/2016] [Accepted: 04/20/2016] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To develop normative ranges for citrate-modified and heparinase-modified thromboelastography (TEG) in term neonates. DESIGN Prospective observational study. SETTING An outborn neonatal and cardiac intensive care unit in a free-standing academic children's hospital. PATIENTS Thirty term neonates were enrolled as control subjects. Seventeen infants with clinically documented bleeding requiring blood transfusion were enrolled in the comparison group. MAIN OUTCOME MEASURES Citrate-modified and heparinase-modified TEG parameters were calculated from blood specimens drawn via peripheral arterial stick or arterial line. RESULTS TEG in neonates differs from older children and adults; clotting time (R) and clot kinetics (K) values are generally lower while fibrinolysis or rate of clot breakdown (LY30) and coagulation index (CI) are often higher in neonates. TEG values in term neonates calculated as median (Q1-Q3) are as follows: R 4.150 (3.200-6.200), K 1.550 (1.200-1.800), α angle (α) 70.100 (66.000-72.900), maximum amplitude (MA) 61.850 (59.400-66.000), LY30 1.050 (0.100-1.600) and CI 1.950 (0.100 to 2.900). Cut points selected for optimal predictive value for bleeding using receiver operating curve analyses were R>6.3 (sensitivity 82.4%, specificity 80%); K>2.5 (sensitivity 82.4%, specificity 96.7%); α<59 (sensitivity 82.4%, specificity 96.7%); MA<57 (sensitivity 82.4%, specificity 86.7%); CI<-0.15 (sensitivity 88.2%, specificity 83.3%). CONCLUSIONS The reference ranges and cut points for citrate-modified and heparinase-modified TEG can be used to diagnose and evaluate coagulopathy in term neonates.
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Affiliation(s)
- Elizabeth K Sewell
- Divisions of Neonatology, Children's National Health Systems, Washington DC, USA.,Departments of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington DC, USA
| | - Katie R Forman
- Divisions of Neonatology, Children's National Health Systems, Washington DC, USA.,Departments of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington DC, USA.,Department of Neonatal-Perinatal Medicine, Children's Hospital of Montefiore, Bronx, New York, USA
| | - Edward C C Wong
- Divisions of Laboratory Medicine, Children's National Health Systems, Washington DC, USA.,Departments of Pathology, The George Washington University School of Medicine and Health Sciences, Washington DC, USA
| | - Meanavy Gallagher
- Divisions of Laboratory Medicine, Children's National Health Systems, Washington DC, USA
| | - Naomi L C Luban
- Divisions of Laboratory Medicine, Children's National Health Systems, Washington DC, USA.,Departments of Pathology, The George Washington University School of Medicine and Health Sciences, Washington DC, USA
| | - An N Massaro
- Divisions of Neonatology, Children's National Health Systems, Washington DC, USA.,Departments of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington DC, USA
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11
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Sidlik R, Strauss T, Morag I, Shenkman B, Tamarin I, Lubetsky A, Livnat T, Kenet G. Assessment of Functional Fibrinolysis in Cord Blood Using Modified Thromboelastography. Pediatr Blood Cancer 2016; 63:839-43. [PMID: 26749087 DOI: 10.1002/pbc.25865] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 11/10/2015] [Accepted: 11/13/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND The fibrinolytic system in newborns is immature and probably impaired. The aim of this study was to prospectively evaluate functional fibrinolytic capacity of newborn's cord blood using a new thromboelastometry (rotational thromboelastogram, ROTEM®) test. METHODS Infants born at Sheba Medical Center were studied prospectively. Cord blood was obtained immediately after clumping, and ROTEM parameters were assessed applying non-activated TEM (NATEM) assay with increasing concentration of tissue plasminogen activator (tPA, 0-200 U/ml). Baseline clotting time (CT), clot formation time (CFT), alpha angle, and maximum clot firmness (MCF) were compared among infants versus adults. Each infant's demographic information was prospectively followed up until discharge. RESULTS One hundred one newborns were tested. CT and CFT values were lower and alpha angles were higher among neonate's cord blood compared to adults (n = 23; P = 0.001, 0.03, and 0.02, respectively). The addition of tPA significantly shortened CT and CFT, and reduced alpha angles and MCF in both groups. The lysis index at 30 min (LI30) and lysis onset time (LOT) decreased significantly, and fibrinolysis was more rapid in the newborns. Hematocrit and platelet counts in neonates correlated with LI30 (P = 0.035 and 0.037, respectively) and LOT (P = 0.02) when higher tPA concentrations were used. ROTEM values were unrelated to the occurrence of postnatal complications. CONCLUSIONS This first report of functional fibrinolysis in cord blood demonstrated that neonatal fibrinolysis may be augmented as compared to adult values. Further studies are required to validate this test and assess its predictive value and clinical relevance.
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Affiliation(s)
- Rakefet Sidlik
- Departments of Pediatrics, Thrombosis and the National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Tzipora Strauss
- Neonatology Department, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Iris Morag
- Neonatology Department, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Boris Shenkman
- Departments of Pediatrics, Thrombosis and the National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Ilia Tamarin
- Departments of Pediatrics, Thrombosis and the National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Aharon Lubetsky
- Departments of Pediatrics, Thrombosis and the National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Tami Livnat
- Departments of Pediatrics, Thrombosis and the National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Gili Kenet
- Departments of Pediatrics, Thrombosis and the National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Israel
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12
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Tanriverdi S, Koroglu OA, Uygur O, Balkan C, Yalaz M, Kultursay N. The effect of inhaled nitric oxide therapy on thromboelastogram in newborns with persistent pulmonary hypertension. Eur J Pediatr 2014; 173:1381-5. [PMID: 24791933 DOI: 10.1007/s00431-014-2325-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Revised: 04/16/2014] [Accepted: 04/17/2014] [Indexed: 12/01/2022]
Abstract
UNLABELLED Studies about the effects of inhaled nitric oxide (iNO) on bleeding time and platelet aggregation in newborns are limited in number and have inconclusive results. Thromboelastogram (TEG) shows the combined effects of coagulation factors and platelet functions. In this preliminary study, we aimed to evaluate the effects of iNO on coagulation using TEG in newborns with persistent pulmonary hypertension (PPH). TEG assays were performed in 10 term infants receiving iNO treatment for PPH and 32 healthy term infants. Samples of the iNO group were collected before and during iNO. Clot reaction time (R), clot kinetics (K), maximum amplitude (MA), and alpha angle were obtained from the TEG tracing. TEG-R values were statistically higher during iNO treatment (7.75 ± 3.34) when compared to the values before iNO (4.83 ± 1.38) and the healthy controls (3.75 ± 0.98). The alpha angle was lower in iNO treated infants at both periods (before iNO, 55.33 ± 8.58; during iNO, 42.90 ± 18.34) compared to the control group (64.95 ± 6.88). MA values before iNO treatment were the lowest (44.43 ± 14.09) and improved with the iNO treatment (48.40 ± 9.49) despite still being lower compared to the controls (53.67 ± 5.56). CONCLUSION Both PPH and iNO may negatively effect in vitro coagulation tests. Therefore, newborns with PPH requiring iNO treatment should be closely monitored for coagulation problems.
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Affiliation(s)
- Sema Tanriverdi
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine, Ege University, Bornova, 35100, Izmir, Turkey,
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Del Vecchio A, Stronati M, Franco C, Christensen RD. Bi-directional activation of inflammation and coagulation in septic neonates. Early Hum Dev 2014; 90 Suppl 1:S22-5. [PMID: 24709450 DOI: 10.1016/s0378-3782(14)70008-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Neonatal sepsis is frequently accompanied by significant and sometimes life-threatening coagulopathy. More complete understanding is needed of the molecular and cellular mechanisms underlying the interaction of the inflammatory and hemostatic systems. Such information may help focus future studies toward novel ways to improve the outcome of neonates who develop septic coagulopathy.
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Affiliation(s)
- Antonio Del Vecchio
- Division of Neonatology, Neonatal Intensive Care Unit, Di Venere Hospital, Bari, Italy.
| | - Mauro Stronati
- Neonatal Intensive Care Unit, Maternal-Infant Department, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Caterina Franco
- Division of Neonatology, Neonatal Intensive Care Unit, Di Venere Hospital, Bari, Italy
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