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Gopal N, Panwar S, Saluja V, Garg N, Gupta S, Kumar G, Maiwall R. Impact of coagulopathy assessment with thromboelastography and thromboelastometry on transfusion requirements in critically ill cirrhosis with nonvariceal bleeding: A prospective observational study. Int J Crit Illn Inj Sci 2024; 14:67-73. [PMID: 39005979 PMCID: PMC11245136 DOI: 10.4103/ijciis.ijciis_65_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 12/18/2023] [Accepted: 12/23/2023] [Indexed: 07/16/2024] Open
Abstract
Background Viscoelastic tests are now routinely used for coagulopathy correction in patients with cirrhosis. Thromboelastography (TEG®) and rotational thromboelastometry (RoTEM®) are the most widely studied tests in this population. However, they have not been compared with each other in critically ill patients with liver disease presenting with nonvariceal bleed. Hence, we aimed to compare these tests for coagulopathy correction in patients with liver disease presenting with nonvariceal bleeding. Methods Sixty adult patients with liver cirrhosis presented to the liver intensive care unit, presenting with a nonvariceal upper gastrointestinal (GI) bleed (diagnosed by doing upper GI endoscopy which revealed bleeding from a nonvariceal source) oral or nasal bleed were enrolled. The patients were allocated to the TEG® group (Group T) or RoTEM® group (Group R) depending on the immediate availability of the viscoelastic test. Coagulopathy correction was done in each group as per established protocols and the results were compared. Results There was a significant difference in the fresh frozen plasma (FFP) transfusion between the groups. The TEG® group received more FFP when compared to the RoTEM® group (P = 0.001). Conclusion RoTEM®-based coagulopathy correction leads to lesser use of blood products with similar control of bleeding when compared to TEG, in critically ill patients with cirrhosis.
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Affiliation(s)
- Nimi Gopal
- Department of Anaesthesia and Critical Care, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shivali Panwar
- Department of Anaesthesia and Critical Care, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Vandana Saluja
- Department of Anaesthesia and Critical Care, Amrita Hospital, Faridabad, Haryana, India
| | - Neha Garg
- Department of Anaesthesia and Critical Care, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Surbhi Gupta
- Department of Anaesthesia and Critical Care, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Guresh Kumar
- Department of Biostatistics, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Rakhi Maiwall
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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2
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Rodrigues AB, Rodrigues A, Correia CJ, Jesus GN, Ribeiro JM. Anticoagulation Management in V-V ECMO Patients: A Multidisciplinary Pragmatic Protocol. J Clin Med 2024; 13:719. [PMID: 38337414 PMCID: PMC10856724 DOI: 10.3390/jcm13030719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 01/11/2024] [Accepted: 01/24/2024] [Indexed: 02/12/2024] Open
Abstract
(1) Background: Extracorporeal membrane oxygenation (ECMO) is a complex procedure affecting both the risk of thrombosis and bleeding. High-quality data to personalize anticoagulation management in ECMO are lacking, resulting in a high variability in practice among centers. For this reason, we review coagulation methods and monitoring and share a pragmatic proposal of coagulation management, as performed in our high-volume ECMO Referral Centre; (2) Methods: We revised the anticoagulation options and monitoring methods available for coagulation management in ECMO through PubMed search based on words including "anticoagulation," "coagulation assays," "ECMO," "ELSO," and "ISTH"; (3) Results: Actual revision of the literature was described as our routine practice regarding ECMO anticoagulation and monitoring; (4) Conclusions: No coagulation test is exclusively predictive of bleeding or thrombotic risk in patients undergoing ECMO support. An approach that allows for a tailored regimen of anticoagulation (regardless of agent used) and monitoring is mandatory. To accomplish this, we propose that the titration of anticoagulation therapies should include multiple laboratory tests, including anti-Xa, aPTT, ACT, viscoelastic tests, AT levels, platelet count, fibrinogen, and FXIII levels. Anticoagulation regimens should be tailored to a specific patient and personalized based on this complex array of essays.
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Affiliation(s)
- Ana Bento Rodrigues
- Serviço de Medicina Intensiva, Centro Hospitalar Universitário Lisboa Norte, 1649-028 Lisboa, Portugal; (G.N.J.); (J.M.R.)
- Clínica Universitária de Medicina Intensiva, Faculdade de Medicina de Lisboa, 1649-028 Lisboa, Portugal
- ECMO Referral Centre, Intensive Care Department, Centro Hospitalar Universitário Lisboa Norte, 1649-028 Lisboa, Portugal
| | - Anabela Rodrigues
- Serviço de Imuno-Hemoterapia, Blood Transfusion Department, Centro Hospitalar Universitário Lisboa Norte, 1649-028 Lisboa, Portugal; (A.R.); (C.J.C.)
| | - Catarina Jacinto Correia
- Serviço de Imuno-Hemoterapia, Blood Transfusion Department, Centro Hospitalar Universitário Lisboa Norte, 1649-028 Lisboa, Portugal; (A.R.); (C.J.C.)
| | - Gustavo Nobre Jesus
- Serviço de Medicina Intensiva, Centro Hospitalar Universitário Lisboa Norte, 1649-028 Lisboa, Portugal; (G.N.J.); (J.M.R.)
- Clínica Universitária de Medicina Intensiva, Faculdade de Medicina de Lisboa, 1649-028 Lisboa, Portugal
- ECMO Referral Centre, Intensive Care Department, Centro Hospitalar Universitário Lisboa Norte, 1649-028 Lisboa, Portugal
| | - João Miguel Ribeiro
- Serviço de Medicina Intensiva, Centro Hospitalar Universitário Lisboa Norte, 1649-028 Lisboa, Portugal; (G.N.J.); (J.M.R.)
- ECMO Referral Centre, Intensive Care Department, Centro Hospitalar Universitário Lisboa Norte, 1649-028 Lisboa, Portugal
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3
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Goyal VD, Pahade A, Misra G, Kaira V. Mitral valve replacement in patients of rheumatic heart disease associated with immune thrombocytopenia. Indian J Thorac Cardiovasc Surg 2023; 39:516-521. [PMID: 37609607 PMCID: PMC10441999 DOI: 10.1007/s12055-023-01517-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 04/02/2023] [Accepted: 04/05/2023] [Indexed: 08/24/2023] Open
Abstract
Immune thrombocytopenia in association with rheumatic heart disease is not commonly seen. Surgical management of rheumatic heart disease becomes more challenging in the presence of immune thrombocytopenia. The risk of complications increases manifold and judicious medical management before, during, and after surgery is imperative. We discuss two such cases, the complications we faced and the problems we anticipated before, and their prevention. Both patients were managed without using immunoglobulins or doing splenectomy. The literature on valve replacement in patients of immune thrombocytopenia and the implications of immune thrombocytopenia in the management of patients with rheumatic heart disease is also reviewed.
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Affiliation(s)
| | - Akhilesh Pahade
- Department of Anaesthesia, SRMS, IMS, Bareilly, UP 243202 India
| | - Gaurav Misra
- Department of Anaesthesia, SRMS, IMS, Bareilly, UP 243202 India
| | - Vaanika Kaira
- Department of Pathology, SRMS, IMS, Bareilly, UP 243202 India
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4
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Larsen JB, Hvas CL, Hvas AM. Modified Rotational Thromboelastometry Protocol Using Tissue Plasminogen Activator for Detection of Hypofibrinolysis and Hyperfibrinolysis. Methods Mol Biol 2023; 2663:763-773. [PMID: 37204751 DOI: 10.1007/978-1-0716-3175-1_51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Viscoelastic testing includes thromboelastography (TEG®) and thromboelastometry (ROTEM®) and is widely used in bleeding patients to detect hypocoagulability and guide transfusion therapy. However, the ability of standard viscoelastic tests to assess fibrinolytic capacity is limited. We here describe a modified ROTEM® protocol with addition of tissue plasminogen activator that can be used to identify hypofibrinolysis or hyperfibrinolysis.
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Affiliation(s)
- Julie Brogaard Larsen
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark.
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - Christine Lodberg Hvas
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Anne-Mette Hvas
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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5
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Reddy S, Perepu US, Lentz SR. Guiding fibrinogen replacement by rotational thromboelastometry in liver transplantation: bridging the evidence gaps. JOURNAL OF THROMBOSIS AND HAEMOSTASIS : JTH 2023; 21:24-25. [PMID: 36695392 DOI: 10.1016/j.jtha.2022.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 10/20/2022] [Indexed: 01/11/2023]
Affiliation(s)
- Sundara Reddy
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Usha S Perepu
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Steven R Lentz
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA.
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Gong J, Zhang Y, Zhang H, Li Q, Ren G, Lu W, Wang J. Evaluation of Blood Coagulation by Optical Vortex Tracking. SENSORS (BASEL, SWITZERLAND) 2022; 22:4793. [PMID: 35808290 PMCID: PMC9269077 DOI: 10.3390/s22134793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 06/20/2022] [Accepted: 06/21/2022] [Indexed: 06/15/2023]
Abstract
Blood coagulation is a complicated dynamic process that maintains the blood's fluid state and prevents uncontrollable bleeding. The real-time monitoring of coagulation dynamics is critical for blood transfusion guidance, emergency management of trauma-induced coagulopathy, perioperative bleeding, and targeted hemostatic therapy. Here, we utilize optical vortex dynamics to detect the blood coagulation dynamic process in a rapid and non-contact manner. To characterize the temporal changes in viscoelastic properties of blood during coagulation, we track the stochastic motion of optical vortices in the time-varying speckles reflected from 100 blood samples with varied coagulation profiles. The mean square displacement (MSD) of the vortices increases nonlinearly with time lag during blood coagulation reminiscent of the particles in viscoelastic fluids. The MSD curves with coagulation time are similar to the tracings of thromboelastography (TEG) during the blood coagulation. The retrieved coagulation parameters, such as reaction time and activated clotting time measured using the optical vortex method, exhibit a close correlation to those parameters acquired from TEG. These results demonstrate the feasibility of the optical vortex method for monitoring blood coagulation at the point of care. Our method is also applicable to measuring the viscoelasticity of complex fluids and turbid soft matters.
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Affiliation(s)
- Jiaxing Gong
- College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan 430074, China; (J.G.); (Y.Z.); (H.Z.); (Q.L.); (G.R.); (W.L.)
- Shenzhen Huazhong University of Science and Technology Research Institute, Shenzhen 518000, China
| | - Yaowen Zhang
- College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan 430074, China; (J.G.); (Y.Z.); (H.Z.); (Q.L.); (G.R.); (W.L.)
| | - Hui Zhang
- College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan 430074, China; (J.G.); (Y.Z.); (H.Z.); (Q.L.); (G.R.); (W.L.)
| | - Qi Li
- College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan 430074, China; (J.G.); (Y.Z.); (H.Z.); (Q.L.); (G.R.); (W.L.)
- Shenzhen Huazhong University of Science and Technology Research Institute, Shenzhen 518000, China
| | - Guangbin Ren
- College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan 430074, China; (J.G.); (Y.Z.); (H.Z.); (Q.L.); (G.R.); (W.L.)
| | - Wenjian Lu
- College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan 430074, China; (J.G.); (Y.Z.); (H.Z.); (Q.L.); (G.R.); (W.L.)
| | - Jing Wang
- College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan 430074, China; (J.G.); (Y.Z.); (H.Z.); (Q.L.); (G.R.); (W.L.)
- Shenzhen Huazhong University of Science and Technology Research Institute, Shenzhen 518000, China
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Sarin K, Chandra A, Garg A. Technological Advances in Cardiac Anesthesia: We Live in Exciting Times Ensuring Better Patient Safety and Care. BALI JOURNAL OF ANESTHESIOLOGY 2022. [DOI: 10.4103/bjoa.bjoa_58_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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