Intravenous enoxaparin as alternative ECMO anticoagulation over a period of 94 days: a case report

BACKGROUND

Unfractionated heparin is used worldwide as a standard anticoagulation therapy for extracorporeal membrane oxygenation (ECMO) machines. However, its use brings about significant bleeding and thrombotic complications for critically ill patients. This case report shows that low molecular weight heparin together with ECMO-produced primary haemostasis pathology can be used as an alternative way of ECMO anticoagulation.

CASE PRESENTATION

This paper presents the case of a patient with respiratory failure who subsequently suffered from cardiac failure and spent 94 days on combined V-V and V-A ECMO devices (two ECMO devices running simultaneously on one patient) with intravenous enoxaparin used instead of unfractionated heparin anticoagulation. No life-threatening bleeding/thrombotic events happened during this period, nor did any technical problems with ECMO occur.

CONCLUSIONS

In this case report, continuous intravenous low molecular weight heparin anticoagulation was used as a safe alternative to ECMO anticoagulation.

Effect of targeted coagulopathy management and 5% albumin as volume replacement therapy during lung transplantation on allograft function: a secondary analysis of a randomized clinical trial

BACKGROUND

Primary graft dysfunction (PGD) after lung transplantation (LuTx) contributes substantially to early postoperative morbidity. Both intraoperative transfusion of a large amount of blood products during the surgery and ischemia-reperfusion injury after allograft implantation play an important role in subsequent PGD development.

METHODS

We have previously reported a randomized clinical trial of 67 patients where point of care (POC) targeted coagulopathy management and intraoperative administration of 5% albumin led to significant reduction of blood loss and blood product consumption during the lung transplantation surgery. A secondary analysis of the randomized clinical trial evaluating the effect of targeted coagulopathy management and intraoperative administration of 5% albumin on early lung allograft function after LuTx and 1-year survival was performed.

RESULTS

Compared to the patients in the control (non-POC) group, those in study (POC) group showed significantly superior graft function, represented by the Horowitz index (at 72 h after transplantation 402.87 vs 308.03 with p < 0.001, difference between means: 94.84, 95% CI: 60.18-129.51). Furthermore, the maximum doses of norepinephrine administered during first 24 h were significantly lower in the POC group (0.193 vs 0.379 with p < 0.001, difference between the means: 0.186, 95% CI: 0.105-0.267). After dichotomization of PGD (0-1 vs 2-3), significant difference between the non-POC and POC group occurred only at time point 72, when PGD grade 2-3 developed in 25% (n = 9) and 3.2% (n = 1), respectively (p = 0.003). The difference in 1-year survival was not statistically significant (10 patients died in non-POC group vs. 4 patients died in POC group; p = 0.17).

CONCLUSIONS

Utilization of a POC targeted coagulopathy management combined with Albumin 5% as primary resuscitative fluid may improve early lung allograft function, provide better circulatory stability during the early post-operative period, and have potential to decrease the incidence of PGD without negative effect on 1-year survival.

TRIAL REGISTRATION

This clinical trial was registered at ClinicalTrials.gov (NCT03598907).

Extracorporeal membrane oxygenation seems to induce impairment of primary hemostasis pathology as measured by a Multiplate analyzer: An observational retrospective study

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) support is often associated with bleeding complications caused by secondary or primary hemostasis pathology. However, there are limited data investigating primary hemostasis using Multiplate aggregometry with specific diagnostics tests for vWF (von Willebrand factor) deficiency.

AIMS

The aim of this study was to find out whether short-term ECMO produces the pathology of primary hemostasis that is detected by Multiplate aggregometry and to investigate the pathology of vWF.

METHODS

In this study, blood samples of 20 patients undergoing lung transplantations with short-term perioperative ECMO support were analyzed. The multimeric structure, the levels of von Willebrand factor antigen (vWF), ristocetin cofactor (RCo), collagen-binding protein (CB), and the results of multiple electrode aggregometry RISTO (ristocetin), ADP (adenosine diphosphate), ASPI (Aspirin®; arachidonic acid), and TRAP (thrombin receptor activating peptide) tests were compared to the samples obtained before and after ECMO support.

RESULTS

The Multiplate ADP and RISTO tests showed the presence of significant pathology in primary hemostasis after surgery (p < 0.05), suggesting the presence of acquired platelet dysfunction. Although the RISTO tests suggest the presence of acquired vWF deficiency, laboratory tests for vWF antigen and RCo and CB tests showed an increase in this case. The multimeric structure of vWF did not show clinically significant deterioration.

CONCLUSIONS

Multiple aggregometry ADP, ASPI, and TRAP tests seem to be able to detect primary hemostasis pathology (platelets aggregation and adhesion pathology) that is present during short-term perioperative ECMO support in lung transplantation procedures. Interestingly, RISTO tests seem to be more suitable for the diagnosis of platelet dysfunction than the diagnosis of acquired vWF deficiency in this situation.

Rotational thromboelastometry reduces blood loss and blood product usage after lung transplantation

BACKGROUND

The shortage of blood products has become a worldwide problem, especially during the COVID-19 Pandemic. Here, we investigated whether a point of care (POC) approach to perioperative bleeding and coagulopathy based on rotational thromboelastometry (ROTEM) results could decrease perioperative blood loss and the perioperative consumption of blood products during lung transplantation.

METHODS

Patients undergoing bilateral lung transplantation were randomized into two groups: In the first group, designated the "non POC" group, the management of perioperative bleeding and coagulopathy was based on the clinical experience of the anesthesiologist; in the second group, designated the "POC" group, the management of perioperative bleeding, and coagulopathy was based on the ROTEM results.

RESULTS

After performing an interim statistical analysis, the project was prematurely terminated as the results were significantly in favor of the POC approach. Data were analyzed for the period January 2018 until June 2020 when 67 patients were recruited into the study. There was significantly decreased perioperative blood loss in the POC group (n = 31 patients) with p = 0.013, decreased perioperative consumption of RBC with p = 0.009, and decreased perioperative consumption of fresh frozen plasma with p < 0.0001 (practically no fresh frozen plasma was used in the POC group) without deteriorating clot formation in secondary and primary hemostasis as compared to the non POC group (n = 36).

CONCLUSION

POC management of perioperative bleeding and coagulopathy based on ROTEM results is a promising strategy to decrease perioperative blood loss and the consumption of blood products in lung transplantation.

Utility of rotational thromboelastometry in total hip replacement revision surgery (case-control study)

Total hip replacement revision surgery is accompanied by significant blood loss. Using rotational thrombelastometry (ROTEM) perioperatively to diagnose coagulopathy may help to provide rapid aimed therapy and thus decrease blood loss and the consumption of transfusion products. The aim of this case-control study was to find out whether point of care using of ROTEM may reduce blood loss and the consumption of blood transfusion products in hip replacement revision surgery.Data were prospectively collected from patients who underwent hip replacement revision surgery in the period 2017 to 2018 when the management of bleeding and coagulopathy was based on the results of ROTEM. Data were compared with a group of historical controls for the period 2015 to 2016 when bleeding and coagulopathy management was not based on ROTEM results. The consumption of blood transfusion products and perioperative blood loss were compared between the groups.The total number of analyzed patients was 90. Forty five patients were analyzed in the ROTEM group and the same number of patients were analyzed in the non-ROTEM group. Significantly decreased perioperative consumption of fresh frozen plasma and packed red blood cells was found in the ROTEM, as well as decreased perioperative blood loss comparing to non-ROTEM group. All data were statistically different with P < .05.Perioperative management of bleeding and coagulopathy based on the results of ROTEM during hip replacement revision surgery seems to help to decrease perioperative blood loss and the consumption of blood transfusion products, especially fresh frozen plasma.

Usefulness of perioperative rotational thrombelastometry during scoliosis surgery in children

OBJECTIVE

Surgical correction of scoliosis in pediatric patients is associated with significant blood loss. Rotational thrombelastometry (ROTEM) might help to decrease the use of blood transfusion products by enabling an early point of care (POC) diagnosis of coagulopathy, thus helping to provide targeted therapy. The aim of this case-control study was to find out whether POC use of ROTEM during scoliosis surgery in children helps to reduce the need for blood transfusion products.

METHODS

Data were prospectively analyzed from all patients treated during 2016-2018 who received ROTEM-based therapy during scoliosis surgery. These patients were compared with a group of historical controls treated during 2014-2016 whose scoliosis treatment did not include ROTEM. Perioperative blood loss, consumption of blood transfusion products, and hospital LOS were compared between the groups.

RESULTS

A total of 37 patients were analyzed, 22 patients in the non-ROTEM group and 15 patients in the ROTEM group. In the ROTEM group compared with the non-ROTEM group, there was significantly lower perioperative blood loss and administration of packed red blood cell units, no administration of fresh-frozen plasma, and shorter overall hospital LOS (p < 0.05).

CONCLUSIONS

ROTEM use during scoliosis surgery in children seems to help to decrease blood loss and the use of blood transfusion products and may also shorten the hospital LOS.Clinical trial registration no.: NCT03699813 (clinicaltrials.gov).

Effect of Balanced Crystalloid, Gelatin and Hydroxyethyl Starch on Coagulation Detected by Rotational Thromboelastometry In Vitro

BACKGROUND

Fluid resuscitation with crystalloid and colloid solutions is a common treatment in perioperative medicine. However, a variety of unbalanced or balanced solutions are used in clinical practice and there is still vivid debate going on regarding selection of optimal fluid with minimal negative effect on coagulation to minimize bleeding and blood transfusion requirements. The aim of the study was to investigate adverse effects of balanced crystalloids and colloids on coagulation measured by thromboelastometry in vitro.

METHODS

Blood samples were obtained from healthy volunteers undergoing knee arthroscopy. Adverse effects of balanced crystalloid, hydroxyethyl starch, and gelatin were evaluated by thromboelastometry after 20% dilution of blood with the solution in vitro. Parameters of EXTEM and FIBTEM test were evaluated.

RESULTS

Clotting time of EXTEM was not significantly influenced by any of the investigated solutions (p > 0.05). However, significant impairment of clot formation time of EXTEM was detected in hydroxyethyl starch and gelatin groups in comparison with controls (p < 0.05), while crystalloid did not affect this parameter significantly (p > 0.05). Similar results were found in α angle although significant coagulopathy effect was found only in hydroxyethyl starch samples (p < 0.05). Maximum clot firmness of EXTEM and FIBTEM tests was significantly affected by both hydroxyethyl starch and gelatin (p < 0.05) but not by crystalloid.

CONCLUSIONS

Balanced crystalloid solution does not seem to have a negative influence on the coagulation process as measured by thromboelastometry. On the other hand, balanced colloids may impair propagation phase of coagulation, strength of coagulum, and level of functional fibrinogen. Hydroxyethyl starch seems to have a stronger anticoagulant effect compared to gelatin.

Thromboelastometry as an Alternative Method for Coagulation Assessment in Pediatric Patients Undergoing Invasive Procedures: A Pilot Study

INTRODUCTION

 Standard coagulation tests (activated partial thromboplastin time [aPTT] and prothrombin time [PT]) are used for the assessment of coagulation profile in critically ill pediatric patients undergoing invasive interventions such as insertion of central venous catheter, tonsillectomy, laparotomy, etc. However, these tests do not reflect the profile of whole blood coagulation. Rotational thromboelastometry (ROTEM) as a point of care (POC) viscoelastic test may serve as an alternative method. Due to its ability to assess coagulation profile of the whole blood, it might yield normal results despite prolonged aPTT/PT results. The aim of this study was to find out if there was any severe bleeding during or after invasive procedures if ROTEM test was normal despite prolonged values of aPTT/PT in pediatric patients.

MATERIALS AND METHODS

 We retrospectively analyzed data for the years 2015 to 2017 for pediatric patients with prolonged values of aPTT or PT and normal ROTEM tests-internal thromboelastometry (INTEM) (assessing internal pathway of coagulation) and external thromboelastometry (EXTEM) (assessing external pathway of coagulation)-and we looked for severe bleeding during or after invasive procedures.

RESULTS

 In 26 pediatric patients (children from 2 months to 17 years old), we found that INTEM and EXTEM tests showed normal coagulation despite prolonged values of aPTT ratio with a median of 1.47 (minimum 1.04 and maximum 2.05), international normalized ratio with a median of 1.4 (minimum 0.99 and maximum 2.10), and PT ratio with a median of 1.30 (minimum 0.89 and maximum 2.11). In these patients, no severe bleeding was observed during interventions or postoperatively.

CONCLUSION

 Our data support using thromboelastometry method as an alternative coagulation test for the assessment of coagulation profile in pediatric patients undergoing surgical or other invasive procedures, especially using it as a POC test. All invasive procedures in our study were performed without severe bleeding despite prolonged values of PT/aPTT with normal ROTEM results. It seems that ROTEM assessment of coagulation may lead to decreased administration of fresh frozen plasma and shorten time of patient preparation for intervention.

Extracorporeal membrane oxygenation-induced fibrinolysis detected by rotational thromboelastometry and treated by oxygenator exchange

Coagulopathy and bleeding is a frequent phenomenon in patients on extracorporeal membrane oxygenation. The cause may be multifactorial and it may change over time. We present a case when bleeding was caused by hyperfibrinolysis induced by oxygenator. The diagnosis was established by comparing thromboelastometry result from blood obtained before and after oxygenator. Hyperfibrinolysis and bleeding could be successfully treated merely by oxygenator exchange.

Rotational Thromboelastometry Helps to Reduce Blood Product Consumption in Critically Ill Patients during Small Surgical Procedures at the Intensive Care Unit - a Retrospective Clinical Analysis and Literature Search

Background

Patients at intensive care units (ICUs) are often transfused to correct increased coagulation parameters (prothrombin time and activated partial thromboplastine time) and/or low platelet count. Thromboelastometry using whole blood is considered to be superior to these tests. In clinical praxis, prolonged standard tests are seen but thromboelastometry values are normal. The objective was to compare the blood product consumptions before and after the introduction of thromboelastometry assays into the treatment protocol during small surgical procedures at our mixed ICU.

Methods

We analyzed 1,879 patients treated at our ICU who underwent small interventions. We compared the fresh frozen plasma and platelet consumption before and after the introduction of rotational thromboelastometry into the routine use. The obtained data were compared to relevant research results from the PubMed database, the MeSH index in the Medline database, and Google Scholar using key words 'tromboelastometry', 'fresh frozen plasma' and 'platelets'.

Results

Annual fresh frozen plasma and platelet consumptions were significantly decreased following thromboelastometry introduction. The number of patients and procedures did not differ significantly during the periods analyzed.

Conclusion

Routine thromboelastometry assays can enable significant reduction of blood product consumption in critically ill patients undergoing small surgery without any bleeding complications.

[Rotational thromboelastometry in therapy of life threatening bleeding]

Bleeding and coagulopathy is a common problem in the fields of internal medicine. In case of life-threatening bleeding, rotational thromboelastometry (ROTEM) has critical role in diagnosis and therapy of coagulopathy. In contrast to commonly used tests such as prothrombin time and activated partial thromboplastin time, ROTEM evaluates coagulation of the whole blood as a bedside method. The use of ROTEM for rapid diagnosis and targeted therapy of coagulopathy leads to reduction in bleeding and thus to reduction in administration of blood transfusion products. ROTEM is a viscoelastic method incorporated in current European and Czech-Slovak guidelines for managing life-threatening bleeding. In this article, we provide the reader with information on the method and also a simple scheme for the treatment of coagulopathy guided by ROTEM.Key words: bleeding - coagulopathy - thromboelastometry.

Evaluation of Thromboelastometry in Sepsis in Correlation With Bleeding During Invasive Procedures

Prolongation of prothrombin time (PT) is often encountered in patients with sepsis. On the other hand, thromboelastometry as a global coagulation test might yield normal results. The aim of our study was to evaluate whether prolonged PT in the presence of normal thromboelastometry parameters is associated with severe bleeding in patients with sepsis undergoing invasive procedures. In patients with sepsis undergoing low-risk bleeding invasive procedures (central venous catheter placement, dialysis catheter insertion, drain insertion, and so on) or high-risk bleeding invasive procedures (surgical tracheostomy, surgical laparotomy, thoracotomy, and so on), coagulation was assessed by thromboelastometry using EXTEM test (test for evaluation of the extrinsic pathway of coagulation, contains activator of extrinsic pathway) and with PT. For period of years 2013 to 2016, we assessed occurrence of severe bleeding during those procedures and 24 hours later in patients with prolonged PT and normal thromboelastometry results. This retrospective study was performed at Department of Anaesthesiology and Intensive Care Medicine of Motol University Hospital in Prague. Data from 76 patients with sepsis were analyzed. Median value of international normalized ratio (INR) was 1.59 (min—1.3 and max—2.56), and median value of prothrombin ratio (PR) was 1.5 (min—1.23 and max—2.55) with normal thromboelastometry finding. Despite prolonged INR/PR, no severe bleeding was observed during invasive procedures. Our data show that sepsis may be accompanied by normal thromboelastometry results, despite prolonged values of PT, and invasive procedures were performed without severe bleeding. This approach to coagulation assessment in sepsis may reduce administration of fresh frozen plasma to the patients. The study was registered at Clinical Trials.gov with assigned number NCT02971111.

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

Endogenous Heparinoids May Cause Bleeding in Mucor Infection and can be Detected by Nonactivated Thromboelastometry and Treated by Recombinant Activated Factor VII: A Case Report

Mucormycosis is an aggressive fungal infection, which invades endothelial cells of blood vessels. This condition might lead to destruction of endothelium and release of heparin-like substances to the bloodstream and cause life-threatening bleeding, which is not well described in the literature.We present a patient with mucormycosis who experienced life-threatening bleeding, although no standard laboratory test could detect any coagulopathy.The cause of bleeding-coagulopathy was detected only by nonactivated thromboelastometry (NATEM), which revealed the presence of heparin-like substances. After treatment with recombinant activated FVII rotational thromboelastometry, results improved and the patient stopped bleeding. Regular application of the drug was necessary during acute phase of infection to prevent further bleeding.In this case report, we show that NATEM can detect the presence of heparin-like substances in bleeding patient with mucormycosis infection and that recombinant activated FVII can be used to stop and prevent bleeding until infection resolves.

[The role of rotational thromboelastometry (ROTEM) in the perioperative period in a warfarinized patient (case report)]

Warfarin overdose with unmeasurable values of the prothrombin time (PT-INR) is a significant problem in the preoperative preparation of the patient for acute invasive surgery. In contrast to conventional blood clotting assays, rotational thromboelastometry (ROTEM) evaluates the coagulation profile of the whole blood and provides a more complex view of the coagulation status of the patient. Thromboelastometry results are available within about 10 minutes and help us to provide targeted "bedside" therapy of coagulopathy in a bleeding patient. In our case report we describe a case of a patient with warfarin overdose and unmeasurable PT-INR values. The patient was indicated for urgent gastroscopy because of haematemesis and abdominal surgery because of ileus. Haematemesis was stopped by ROTEM targeted treatment of coagulopathy and the operation was performed without bleeding complications with normal ROTEM despite the prolongation of PT-INR to 1.8. Finally, we would like to say that ROTEM method can be used for rapid management of warfarin-induced coagulopathy and that surgery may be performed safely without any correction of PT-INR in case of normal ROTEM.

KEY WORDS

prothrombin time - bleeding - surgery thromboelastometry (ROTEM) warfarin.

Evaluation of fibrinogen concentrates and prothrombin complex concentrates on coagulation changes in a hypothermic in vitro model using thromboelastometry and thromboelastography

BACKGROUND

Hypothermic coagulopathy is very challenging in bleeding trauma patients. Therefore, we decided to evaluate the efficacy of fibrinogen and prothrombin complex in 30°C hypothermia in vitro to investigate if higher levels of fibrinogen and prothrombin complex concentrate can compensate for the hypothermic effect on coagulation as measured by thromboelastometry/thromboelastography.

METHODS

Blood samples were obtained from 12 healthy volunteers (six men and six women) in our study. Measurements were performed at 37°C and 30°C simultaneously, then at 30°C with adding fibrinogen and prothrombin complex and in the last step samples with added coagulation factors were warmed back to 37°C.

RESULTS

We found that 30°C hypothermic coagulopathy can be detected both by thromboelastometry and thromboelastography. Hypothermic coagulopathy can be restored by fibrinogen to the point where the results do not significantly differ from 37°C values (p > 0.05). After warming the sample with fibrinogen to 37°C, the thrombodynamic potential index was not significantly different from baseline (p > 0.05), although there was a trend to prothrombotic status. The addition of prothrombin complex concentrate to 30°C hypothermic sample was not able to correct hypothermic coagulopathy in vitro.

CONCLUSIONS

Coagulopathy caused by the 30°C hypothermia in vitro model can be corrected by fibrinogen concentrate compared to prothrombin complex concentrate. In spite of a tendency to prothrombotic status, this was not significant with the use of the recommended dose of fibrinogen even after warming the blood to 37°C. However, measurement performed at 37°C seems to be safer than at 30°C.

Role of prothrombin complex concentrate in perioperative coagulation therapy

Prothrombin complex concentrate (PCC) is a term to describe pharmacological products that contain lyophilized, human plasma-derived vitamin K-dependent factors (F), FII, FVII, FIX, FX, and various amounts of proteins C and S. PCCs can be rapidly reconstituted in a small volume (20 ml for about 500 international units (IU)) at bedside and administered regardless of the patient’s blood type. PCCs are categorized as 4-factor PCC if they contain therapeutic amounts of FVII, and 3-factor PCC when FVII content is low. In addition, activated PCC which contains activated FVII and FX with prothrombin is available for factor VIII bypassing therapy in hemophilia patients with inhibitors. Currently, 4-factor PCC is approved for the management of bleeding in patients taking warfarin, but there has been increasing use of various PCCs in the treatment of acquired perioperative coagulopathy unrelated to warfarin therapy and in the management of bleeding due to novel oral anticoagulants. There is also an ongoing controversy about plasma transfusion and its potential hazards including transfusion-related lung injury (TRALI). Early fixed ratio plasma transfusion has been implemented in many trauma centers in the USA, whereas fibrinogen concentrate and PCC are preferred over plasma transfusion in some European centers.

In this review, the rationales for including PCCs in the perioperative hemostatic management will be discussed in conjunction with plasma transfusion.

Early diagnostic markers of sepsis after oesophagectomy (including thromboelastography)

Background

Early diagnosis of sepsis and its differentiation from the noninfective SIRS is very important in order that treatment can be initiated in a timely and appropriate way. In this study we investigated standard haematological and biochemical parameters and thromboelastography (TEG) in patients who had undergone surgical resection of the oesophagus to find out if changes in any of these parameters could help in early differentiation between SIRS and sepsis development.

Methods

We enrolled 43 patients (aged 41–74 years) of whom 38 were evaluable. Blood samples were obtained on the morning of surgery and then at 24-hour intervals for the next 6 days. Samples were analysed for procalcitonin (PCT), C-reactive protein (CRP), interleukin-6 (IL- 6), aspartate transaminase (AST), alanine transaminase (ALT) , lactate, white blood count (WBC), D-dimers, antithrombin (AT), international normalised ratio (INR), activated partial thromboplastin time (APTT) and parameters of TEG.

Results

Significant differences between patients who developed sepsis during this period (9 patients) and SIRS were found in ALT on Day 1, in AST on Days 1–4, in PCT on Days 2–6; in CRP on Days 3–6; in IL-6 on Days 2–5; in leucocytes on Days 2, 3 and 6; and in D-dimers on Days 2 and 4. Significance values ranged from p < 0.0001 to p < 0.05.

Conclusions

Sequential measurements of ALT, AST, PCT and IL-6 during the early postoperative period can be used for early differentiation of sepsis and postoperative SIRS after oesophagectomy. Among the coagulation parameters measured, only D-dimer concentrations appeared to be helpful in this process. TEG does not seem to be a useful early predictor of sepsis development; however it can be used to differentiate sepsis and SIRS from Day 5 after surgery.