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Heuts S, Ceulemans A, Kuiper GJAJM, Schreiber JU, van Varik BJ, Olie RH, Ten Cate H, Maessen JG, Milojevic M, Maesen B. Optimal management of cardiac surgery patients using direct oral anticoagulants: recommendations for clinical practice. Eur J Cardiothorac Surg 2023; 64:ezad340. [PMID: 37812245 PMCID: PMC10585358 DOI: 10.1093/ejcts/ezad340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 09/26/2023] [Accepted: 10/06/2023] [Indexed: 10/10/2023] Open
Abstract
OBJECTIVES Literature is scarce on the management of patients using direct oral anticoagulants (DOACs) undergoing elective, urgent and emergency surgery. Therefore, we summarize the current evidence and provide literature-based recommendations for the management of patients on DOACs in the perioperative phase. METHODS A general literature review was conducted on the pharmacology of DOACs and for recommendations on the management of cardiac surgical patients on DOACs. Additionally, we performed a systematic review for studies on the use of direct DOAC reversal agents in the emergency cardiac surgical setting. RESULTS When surgery is elective, the DOAC cessation strategy is relatively straightforward and should be adapted to the renal function. The same approach applies to urgent cases, but additional DOAC activity drug level monitoring tests may be useful. In emergency cases, idarucizumab can be safely administered to patients on dabigatran in any of the perioperative phases. However, andexanet alfa, which is not registered for perioperative use, should not be administered in the preoperative phase to reverse the effect of factor Xa inhibitors, as it may induce temporary heparin resistance. Finally, the administration of (activated) prothrombin complex concentrate may be considered in all patients on DOACs, and such concentrates are generally readily available. CONCLUSIONS DOACs offer several advantages over vitamin K antagonists, but care must be taken in patients undergoing cardiac surgery. Although elective and urgent cases can be managed relatively straightforwardly, the management of emergency cases requires particular attention.
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Affiliation(s)
- Samuel Heuts
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre+, Maastricht, Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Angelique Ceulemans
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
- Department of Neurology, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Gerhardus J A J M Kuiper
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
- Department of Anaesthesiology and Pain Treatment, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Jan U Schreiber
- Department of Anaesthesiology and Pain Treatment, Maastricht University Medical Centre+, Maastricht, Netherlands
| | | | - Renske H Olie
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
- Thrombosis Expertise Centre, Maastricht University Medical Centre+, Maastricht, Netherlands
- Department of Internal Medicine, Section Vascular Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Hugo Ten Cate
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
- Thrombosis Expertise Centre, Maastricht University Medical Centre+, Maastricht, Netherlands
- Department of Internal Medicine, Section Vascular Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Jos G Maessen
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre+, Maastricht, Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Bart Maesen
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre+, Maastricht, Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
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Hulshof A, Braeken DCW, Ghossein‐Doha C, van Santen S, Sels JEM, Kuiper GJAJM, van der Horst ICC, ten Cate H, van Bussel BCT, Olie RH, Henskens YMC. Hemostasis and fibrinolysis in COVID-19 survivors 6 months after intensive care unit discharge. Res Pract Thromb Haemost 2021; 5:e12579. [PMID: 34595368 PMCID: PMC8463660 DOI: 10.1002/rth2.12579] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 07/08/2021] [Accepted: 07/15/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The prothrombotic phenotype has been extensively described in patients with acute coronavirus disease 2019 (COVID-19). However, potential long-term hemostatic abnormalities are unknown. OBJECTIVE To evaluate the changes in routine hemostasis laboratory parameters and tissue-type plasminogen activator (tPA) rotational thromboelastometry (ROTEM) 6 months after COVID-19 intensive care unit (ICU) discharge in patients with and without venous thromboembolism (VTE) during admission. METHODS Patients with COVID-19 of the Maastricht Intensive Care COVID cohort with tPA ROTEM measurement at ICU and 6-month follow-up were included. TPA ROTEM is a whole blood viscoelastic assay that illustrates both clot development and fibrinolysis due to simultaneous addition of tissue factor and tPA. Analyzed ROTEM parameters include clotting time, maximum clot firmness (MCF), lysis onset time (LOT), and lysis time (LT). RESULTS Twenty-two patients with COVID-19 were included and showed extensive hemostatic abnormalities before ICU discharge. TPA ROTEM MCF (75 mm [interquartile range, 68-78]-59 mm [49-63]; P ≤ .001), LOT (3690 seconds [2963-4418]-1786 seconds [1465-2650]; P ≤ .001), and LT (7200 seconds [6144-7200]-3138 seconds [2591-4389]; P ≤ .001) normalized 6 months after ICU discharge. Of note, eight and four patients still had elevated fibrinogen and D-dimer concentrations at follow-up, respectively. In general, no difference in median hemostasis parameters at 6-month follow-up was observed between patients with (n=14) and without (n=8) VTE, although fibrinogen appeared to be lower in the VTE group (VTE-, 4.3 g/L [3.7-4.7] vs VTE+, 3.4 g/L [3.2-4.2]; P = .05). CONCLUSIONS Six months after COVID-19 ICU discharge, no persisting hypercoagulable or hypofibrinolytic profile was detected by tPA ROTEM. Nevertheless, increased D-dimer and fibrinogen concentrations persist up to 6 months in some patients, warranting further exploration of the role of hemostasis in long-term morbidity after hospital discharge.
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Affiliation(s)
- Anne‐Marije Hulshof
- Central Diagnostic LaboratoryMaastricht University Medical Centre+Maastrichtthe Netherlands
- Cardiovascular Research Institute Maastricht (CARIM)Maastricht UniversityMaastrichtthe Netherlands
| | - Dionne C. W. Braeken
- Thrombosis Expertise Centre MaastrichtMaastricht University Medical Centre+Maastrichtthe Netherlands
| | - Chahinda Ghossein‐Doha
- Department of CardiologyMaastricht University Medical Centre+Maastrichtthe Netherlands
- Department of Intensive Care MedicineMaastricht University Medical Centre+Maastrichtthe Netherlands
| | - Susanne van Santen
- Department of Intensive Care MedicineMaastricht University Medical Centre+Maastrichtthe Netherlands
| | - Jan‐Willem E. M. Sels
- Department of Intensive Care MedicineMaastricht University Medical Centre+Maastrichtthe Netherlands
| | | | - Iwan C. C. van der Horst
- Cardiovascular Research Institute Maastricht (CARIM)Maastricht UniversityMaastrichtthe Netherlands
- Department of Intensive Care MedicineMaastricht University Medical Centre+Maastrichtthe Netherlands
| | - Hugo ten Cate
- Cardiovascular Research Institute Maastricht (CARIM)Maastricht UniversityMaastrichtthe Netherlands
- Thrombosis Expertise Centre MaastrichtMaastricht University Medical Centre+Maastrichtthe Netherlands
- Department of Internal MedicineSection Vascular MedicineMaastricht University Medical Centre+Maastrichtthe Netherlands
| | - Bas C. T. van Bussel
- Department of Intensive Care MedicineMaastricht University Medical Centre+Maastrichtthe Netherlands
- Care and Public Health Research Institute (CAPHRI)Maastricht UniversityMaastrichtthe Netherlands
| | - Renske H. Olie
- Cardiovascular Research Institute Maastricht (CARIM)Maastricht UniversityMaastrichtthe Netherlands
- Thrombosis Expertise Centre MaastrichtMaastricht University Medical Centre+Maastrichtthe Netherlands
- Department of Internal MedicineSection Vascular MedicineMaastricht University Medical Centre+Maastrichtthe Netherlands
| | - Yvonne M. C. Henskens
- Central Diagnostic LaboratoryMaastricht University Medical Centre+Maastrichtthe Netherlands
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Ho LTS, McVey MJ, Kuiper GJAJM, Gross PL, Karkouti K. Analysis of the effect of varying protamine-to-heparin ratio on coagulation in vitro. Br J Anaesth 2021; 127:e128-e130. [PMID: 34334192 DOI: 10.1016/j.bja.2021.06.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 06/15/2021] [Accepted: 06/20/2021] [Indexed: 10/20/2022] Open
Affiliation(s)
- Loretta T S Ho
- Department of Anaesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada; Department of Anaesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada.
| | - Mark J McVey
- Department of Anaesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada; Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, ON, Canada; Department of Physics, Ryerson University, Toronto, ON, Canada
| | - Gerhardus J A J M Kuiper
- Department of Anaesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada; Department of Anesthesiology and Pain Treatment, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Peter L Gross
- The Thrombosis and Atherosclerosis Research Institute, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Keyvan Karkouti
- Department of Anaesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada; Department of Anaesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada; Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada; Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
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Kuiper GJAJM, Wasowicz M. Transesophageal imaging of cor triatriatum sinistrum. Can J Anaesth 2020; 68:148-149. [PMID: 32886299 DOI: 10.1007/s12630-020-01800-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/18/2020] [Accepted: 08/19/2020] [Indexed: 11/29/2022] Open
Affiliation(s)
- Gerhardus J A J M Kuiper
- Department of Anesthesiology and Pain Medicine, Toronto General Hospital, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, ON, Canada.
| | - Marcin Wasowicz
- Department of Anesthesiology and Pain Medicine, Toronto General Hospital, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, ON, Canada
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Vries MJA, Macrae F, Nelemans PJ, Kuiper GJAJM, Wetzels RJH, Bowman P, Verhezen PWM, Ten Cate H, Ariëns RAS, Henskens YMC. Assessment and determinants of whole blood and plasma fibrinolysis in patients with mild bleeding symptoms. Thromb Res 2018; 174:88-94. [PMID: 30579151 DOI: 10.1016/j.thromres.2018.12.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Revised: 11/20/2018] [Accepted: 12/03/2018] [Indexed: 01/28/2023]
Abstract
Enhanced clot lysis is associated with bleeding, but assessment of lysis capacity remains difficult. The plasma turbidity lysis and whole blood tissue Plasminogen Activator-Rotational Thromboelastometry (tPA-ROTEM) assays estimate fibrinolysis under more physiological conditions than clinically used assays. We hypothesized that these assays could find signs of enhanced lysis capacity in patients who report bleeding symptoms, but are not diagnosed with bleeding disorders. We also aimed to gain insight in determinants of the results of these lysis assays. Data from 240 patients with and 95 patients without self-reported bleeding symptoms were obtained, who were included in a study that primarily aimed to assess prevalence of haemostatic abnormalities in preoperative patients. ROTEM and turbidity assays were performed with rtPA. Blood counts, fibrinolysis and coagulation factor activities were determined. Data were analysed using multivariable linear regression models. Remarkably, patients reporting bleeding symptoms showed signs of significantly impaired lysis capacity in the tPA-ROTEM, but not in the turbidity lysis assay. In these patients, the tPA-ROTEM results depended on FII, FXII, plasminogen, α2-antiplasmin, PAI-1 and TAFI levels. The turbidity lysis results were significantly influenced by fibrinogen, α2-antiplasmin, PAI-1 and TAFI. In conclusion, the tPA-ROTEM and the turbidity lysis assay could not detect enhanced fibrinolytic capacity in patients with bleeding symptoms. This suggests that these symptoms are not caused by enhanced fibrinolytic activity. As both assays were sensitive to important determinants of fibrinolysis they may be able to detect a fibrinolytic imbalance, but this needs to be validated in patients with known hypo- or hyperfibrinolytic disorders.
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Affiliation(s)
- Minka J A Vries
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands.
| | - Fraser Macrae
- Thrombosis and Tissue Repair Group, Division of Cardiovascular and Diabetes Research, Leeds Institute for Genetics, Health and Therapeutics, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, UK
| | - Patricia J Nelemans
- Department of Epidemiology and School for Public Health and Primary Care (CAPHRI), Maastricht University Medical Centre (MUMC+), Maastricht, the Netherlands
| | - Gerhardus J A J M Kuiper
- Department of Anaesthesiology, Maastricht University Medical Centre (MUMC+), Maastricht, the Netherlands
| | - Rick J H Wetzels
- Central Diagnostic Laboratory, Maastricht University Medical Centre (MUMC+), Maastricht, the Netherlands
| | - Polly Bowman
- Thrombosis and Tissue Repair Group, Division of Cardiovascular and Diabetes Research, Leeds Institute for Genetics, Health and Therapeutics, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, UK
| | - Paul W M Verhezen
- Central Diagnostic Laboratory, Maastricht University Medical Centre (MUMC+), Maastricht, the Netherlands
| | - Hugo Ten Cate
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands; Department of Internal Medicine, Maastricht University Medical Centre (MUMC+), Maastricht, the Netherlands
| | - Robert A S Ariëns
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands; Thrombosis and Tissue Repair Group, Division of Cardiovascular and Diabetes Research, Leeds Institute for Genetics, Health and Therapeutics, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, UK
| | - Yvonne M C Henskens
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands; Central Diagnostic Laboratory, Maastricht University Medical Centre (MUMC+), Maastricht, the Netherlands
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Kuiper GJAJM, Christiaans MHL, Mullens MHJM, Ten Cate H, Hamulýak K, Henskens YMC. Routine haemostasis testing before transplanted kidney biopsy: a cohort study. Transpl Int 2017; 31:302-312. [PMID: 29108097 DOI: 10.1111/tri.13090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 09/30/2017] [Accepted: 10/30/2017] [Indexed: 01/18/2023]
Abstract
Kidney biopsy can result in bleeding complications. Prebiopsy testing using bleeding time (BT) is controversial. New whole blood haemostasis tests, such as platelet function analyser-100 (PFA-100) and multiple electrode aggregometry (MEA), might perform better. We postulated that PFA-100 would be suitable to replace BT prebiopsy. In 154 patients, transplanted kidney biopsies were performed after measurement of bleeding time, PFA-100, MEA and mean platelet volume (MPV). Bleeding outcome (haemoglobin (Hb) drop, haematuria (±bladder catheterization), ultrasound finding of a bleeding, need for (non)surgical intervention and/or transfusion) after the biopsy was correlated to each test. Male-female ratio was 2:1. 50% had a surveillance biopsy at either three or 12 months. Around 17% (had) used acetylsalicylic acid (ASA) prebiopsy. Of 17 bleeding events, one subject needed a transfusion. Most bleeding events were Hb reductions over 1 mmol/l and all resolved uneventful. BT, PFA-100, MEA and MPV did not predict a bleeding outcome; prior ASA use however could (odds ratio 3.19; 95%-CI 1.06 to 9.61). Diagnostic performance data and Bland-Altman analysis showed that BT could not be substituted by PFA-100. ASA use was the best determinant of bleeding after kidney biopsy. Routine haemostasis testing prebiopsy has no added value.
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Affiliation(s)
- Gerhardus J A J M Kuiper
- Department of Anaesthesiology and Pain Treatment, Maastricht University Medical Center (Maastricht UMC+), Maastricht, the Netherlands.,Laboratory for Clinical Thrombosis and Haemostasis, Department of Internal Medicine, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center (Maastricht UMC+), Maastricht, The Netherlands
| | - Maarten H L Christiaans
- Department of Internal Medicine, Maastricht University Medical Center (Maastricht UMC+), Maastricht, The Netherlands.,Department of Internal Medicine, Subdivision of Nephrology, Maastricht University Medical Center (Maastricht UMC+), Maastricht, The Netherlands
| | - Monique H J M Mullens
- Department of Internal Medicine, Subdivision of Nephrology, Maastricht University Medical Center (Maastricht UMC+), Maastricht, The Netherlands
| | - Hugo Ten Cate
- Laboratory for Clinical Thrombosis and Haemostasis, Department of Internal Medicine, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center (Maastricht UMC+), Maastricht, The Netherlands.,Department of Internal Medicine, Maastricht University Medical Center (Maastricht UMC+), Maastricht, The Netherlands
| | - Karly Hamulýak
- Department of Internal Medicine, Maastricht University Medical Center (Maastricht UMC+), Maastricht, The Netherlands.,Department of Internal Medicine, Subdivision of Haematology, Maastricht University Medical Center (Maastricht UMC+), Maastricht, The Netherlands
| | - Yvonne M C Henskens
- Central Diagnostic Laboratory, Cluster for Haemostasis and Transfusion, Maastricht University Medical Center (Maastricht UMC+), Maastricht, The Netherlands
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Kuiper GJAJM, Houben R, Wetzels RJH, Verhezen PWM, Oerle RV, Ten Cate H, Henskens YMC, Lancé MD. The use of regression analysis in determining reference intervals for low hematocrit and thrombocyte count in multiple electrode aggregometry and platelet function analyzer 100 testing of platelet function. Platelets 2017; 28:668-675. [PMID: 28067094 DOI: 10.1080/09537104.2016.1257782] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Low platelet counts and hematocrit levels hinder whole blood point-of-care testing of platelet function. Thus far, no reference ranges for MEA (multiple electrode aggregometry) and PFA-100 (platelet function analyzer 100) devices exist for low ranges. Through dilution methods of volunteer whole blood, platelet function at low ranges of platelet count and hematocrit levels was assessed on MEA for four agonists and for PFA-100 in two cartridges. Using (multiple) regression analysis, 95% reference intervals were computed for these low ranges. Low platelet counts affected MEA in a positive correlation (all agonists showed r2 ≥ 0.75) and PFA-100 in an inverse correlation (closure times were prolonged with lower platelet counts). Lowered hematocrit did not affect MEA testing, except for arachidonic acid activation (ASPI), which showed a weak positive correlation (r2 = 0.14). Closure time on PFA-100 testing was inversely correlated with hematocrit for both cartridges. Regression analysis revealed different 95% reference intervals in comparison with originally established intervals for both MEA and PFA-100 in low platelet or hematocrit conditions. Multiple regression analysis of ASPI and both tests on the PFA-100 for combined low platelet and hematocrit conditions revealed that only PFA-100 testing should be adjusted for both thrombocytopenia and anemia. 95% reference intervals were calculated using multiple regression analysis. However, coefficients of determination of PFA-100 were poor, and some variance remained unexplained. Thus, in this pilot study using (multiple) regression analysis, we could establish reference intervals of platelet function in anemia and thrombocytopenia conditions on PFA-100 and in thrombocytopenia conditions on MEA.
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Affiliation(s)
- Gerhardus J A J M Kuiper
- a Department of Anaesthesiology and Pain Treatment , Maastricht University Medical Center (MUMC+) , Maastricht , The Netherlands.,b Laboratory for Clinical Thrombosis and Haemostasis, Department of Internal Medicine , Cardiovascular Research Institute Maastricht, Maastricht University Medical Center (MUMC+) , Maastricht , The Netherlands
| | - Rik Houben
- b Laboratory for Clinical Thrombosis and Haemostasis, Department of Internal Medicine , Cardiovascular Research Institute Maastricht, Maastricht University Medical Center (MUMC+) , Maastricht , The Netherlands.,c Department of Neurology , Maastricht University Medical Center (MUMC+) , Maastricht , The Netherlands
| | - Rick J H Wetzels
- d Central Diagnostic Laboratory, Cluster for Hemostasis and transfusion, Maastricht University Medical Center (MUMC+) , Maastricht , The Netherlands
| | - Paul W M Verhezen
- d Central Diagnostic Laboratory, Cluster for Hemostasis and transfusion, Maastricht University Medical Center (MUMC+) , Maastricht , The Netherlands
| | - Rene van Oerle
- b Laboratory for Clinical Thrombosis and Haemostasis, Department of Internal Medicine , Cardiovascular Research Institute Maastricht, Maastricht University Medical Center (MUMC+) , Maastricht , The Netherlands.,d Central Diagnostic Laboratory, Cluster for Hemostasis and transfusion, Maastricht University Medical Center (MUMC+) , Maastricht , The Netherlands
| | - Hugo Ten Cate
- b Laboratory for Clinical Thrombosis and Haemostasis, Department of Internal Medicine , Cardiovascular Research Institute Maastricht, Maastricht University Medical Center (MUMC+) , Maastricht , The Netherlands
| | - Yvonne M C Henskens
- d Central Diagnostic Laboratory, Cluster for Hemostasis and transfusion, Maastricht University Medical Center (MUMC+) , Maastricht , The Netherlands
| | - Marcus D Lancé
- a Department of Anaesthesiology and Pain Treatment , Maastricht University Medical Center (MUMC+) , Maastricht , The Netherlands
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Kuiper GJAJM, Henskens YMC. Rapid and Correct Prediction of Thrombocytopenia and Hypofibrinogenemia with Rotational Thromboelastometry in Cardiac Surgery Reconsidered. J Cardiothorac Vasc Anesth 2016; 30:e55-e56. [PMID: 27498262 DOI: 10.1053/j.jvca.2016.04.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Gerhardus J A J M Kuiper
- Department of Anaesthesiology and Pain Treatment, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Yvonne M C Henskens
- Central Diagnostic Laboratory, Cluster for Hemostasis and Transfusion, Maastricht University Medical Center, Maastricht, The Netherlands
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Kuiper GJAJM, Kleinegris MCF, van Oerle R, Spronk HMH, Lancé MD, Ten Cate H, Henskens YMC. Validation of a modified thromboelastometry approach to detect changes in fibrinolytic activity. Thromb J 2016; 14:1. [PMID: 26770073 PMCID: PMC4712545 DOI: 10.1186/s12959-016-0076-2] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 01/10/2016] [Indexed: 11/24/2022] Open
Abstract
Background Thus far, validated whole blood assays used in in vitro fibrinolysis experiments using thromboelastometry (ROTEM) are lacking or have yet to be tested in humans. The objective was first, to establish a standardized modified ROTEM approach to detect both hypo- and hyperfibrinolysis. And second, to perform a technical and clinical validation of the assay. Methods Blood was used of healthy volunteers, patients with sepsis, patients after cardiothoracic surgery, pregnant women, and cirrhotic liver disease patients. A whole blood tissue factor (TF) activated ROTEM assay with and without the addition of recombinant tissue plasminogen activator (rTPA) was developed. Plasma fibrinolysis determinants were measured in all volunteers and patients. Results Thirty five pM TF and additions of 125 and 175 ng/ml rTPA resulted in full lysis within 60 min in healthy volunteers. Coefficients of variation were below 10 % without and below 20 % with rTPA addition. In sepsis the hypofibrinolytic ROTEM profiles with 175 ng/ml rTPA were in line with the plasma determinants (high PAI-1, high fibrinogen, low tPA activity, and high d-dimers). After cardiothoracic surgery, reduced fibrinogen and platelet levels accounted for the reduced maximum clot firmness. The hypofibrinolytic profile is attributed to tranexamic acid use and elevated PAI-1 levels. The lowest rTPA concentration in cirrhosis resulted in hyperfibrinolysis in only few of the patients. In pregnancy normal profiles were found. Discussion Our high rTPA concentration demonstrates hypofibrinolytic profiles adequately in sepsis and after cardiothoracic surgery. Our low rTPA concentration of 125 ng/ml seems too high for demonstrating hyperfibrinolysis in cirrhotic liver disease. Conclusions We were able to present a validated whole blood ROTEM approach to fibrinolysis testing using added rTPA, which can be of added value next to classical plasma based fibrinolysis assays.
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Affiliation(s)
- Gerhardus J A J M Kuiper
- Department of Anaesthesiology and Pain Treatment, Maastricht University Medical Center (MUMC+), P. Debyelaan 25, PO Box 5800, 6202 AZ Maastricht, The Netherlands ; Department of Internal Medicine, Cardiovascular Research Institute Maastricht, Laboratory for Clinical Thrombosis and Haemostasis, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Marie-Claire F Kleinegris
- Department of Internal Medicine, Cardiovascular Research Institute Maastricht, Laboratory for Clinical Thrombosis and Haemostasis, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - René van Oerle
- Department of Internal Medicine, Cardiovascular Research Institute Maastricht, Laboratory for Clinical Thrombosis and Haemostasis, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands ; Central Diagnostic Laboratory, Cluster for Hemostasis and transfusion, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Henri M H Spronk
- Department of Internal Medicine, Cardiovascular Research Institute Maastricht, Laboratory for Clinical Thrombosis and Haemostasis, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Marcus D Lancé
- Department of Anaesthesiology and Pain Treatment, Maastricht University Medical Center (MUMC+), P. Debyelaan 25, PO Box 5800, 6202 AZ Maastricht, The Netherlands
| | - Hugo Ten Cate
- Department of Internal Medicine, Cardiovascular Research Institute Maastricht, Laboratory for Clinical Thrombosis and Haemostasis, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Yvonne M C Henskens
- Central Diagnostic Laboratory, Cluster for Hemostasis and transfusion, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
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Lancé MD, Ninivaggi M, Schols SEM, Feijge MAH, Oehrl SK, Kuiper GJAJM, Nikiforou M, Marcus MAE, Hamulyak K, van Pampus ECM, ten Cate H, Heemskerk JWM. Perioperative dilutional coagulopathy treated with fresh frozen plasma and fibrinogen concentrate: a prospective randomized intervention trial. Vox Sang 2011; 103:25-34. [PMID: 22211833 DOI: 10.1111/j.1423-0410.2011.01575.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVES Treatment of dilutional coagulopathy by transfusing fresh frozen plasma (FFP) remains sub-optimal. We hypothesized that partial replacement of transfused FFP by fibrinogen concentrate results in improved coagulant activity and haemostasis. This was tested in a controlled clinical intervention trial with patients experiencing massive bleeding during major surgery. METHODS Patients undergoing major elective surgery were treated according to current protocols. When transfusion with FFP was required, patients were randomized as follows: group A received 4 units FFP and group B received 2 units FFP plus 2 g fibrinogen concentrate. Blood samples were taken before and after the intervention. Analysts were blinded to the treatment type. RESULTS Group A (B) consisted of 21 (22) patients, in 16 (17) of whom bleeding stopped after intervention. Plasma fibrinogen increased significantly more in group B (0·57 g/l) than in group A (0·05 g/l). However, levels of prothrombin and factors VIII, IX and X increased more in group A than in group B. Rotational thromboelastometry (ROTEM) of whole blood and plasma revealed improved fibrin clot formation in group B but not in group A. Thrombin generation [calibrated automated thrombogram (CAT)] in plasma increased more in group A. Principal parameters determining whole-blood thromboelastometry were the fibrinogen level and platelet count. In vitro addition of fibrinogen and prothrombin complex concentrate to pre-intervention samples restored both ROTEM and CAT parameters. CONCLUSIONS Partial replacement of transfused FFP by fibrinogen increases fibrin clot formation at the expense of less improved thrombin generation. Coagulation factors other than fibrinogen alone are required for full restoration of haemostasis.
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Affiliation(s)
- M D Lancé
- Department of Anesthesiology, CARIM, Maastricht University Medical Center, Maastricht, The Netherlands
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Abstract
Monitoring the course of platelet function in HELLP (haemolysis, elevated liver-enzymes and low platelets) syndrome is important for clinical decision-making. We present a primigravid woman developing HELLP syndrome at 29 weeks and 6 days. Platelet function was monitored by multiple electrode aggregometry (MEA), platelet function analyzer (PFA-100®), platelet count and mean platelet volume (MPV) over an 11-day period. MPV and PFA-100® seem better predictors for platelet function than platelet levels.
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Affiliation(s)
- Gerhardus J A J M Kuiper
- Department of Anaesthesiology and Pain Treatment, Maastricht University Medical Centre (MUMC), Maastricht, the Netherlands
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