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Ramanujam V, DiMaria S, Varma V. Thromboelastography in the Perioperative Period: A Literature Review. Cureus 2023; 15:e39407. [PMID: 37362492 PMCID: PMC10287184 DOI: 10.7759/cureus.39407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2023] [Indexed: 06/28/2023] Open
Abstract
Assessing coagulation status is essential for prompt intervention to reduce morbidity and mortality related to bleeding and thrombotic complications during the perioperative period. Traditional coagulation tests such as platelet count, activated partial thromboplastin time (aPTT), prothrombin time (PT), international normalized ratio (INR), and activated clotting time (ACT) provide only static evaluation. These tests are not designed for assessment of dynamically changing coagulation conditions during the perioperative time. However, viscoelastic coagulation testing such as thromboelastography (TEG) produces a rapid numerical and graphical representation that helps to detect and direct targeted hemostatic therapy. Searching the literature through PubMed, Medline, Ovid, CINAHL, and ClinicalTrials.gov we retrieved 210 studies, which represent the use of TEG in the perioperative period. The included studies were categorized under various settings such as trauma, obstetrics, orthopedics, intensive care unit (ICU), cardiovascular, transplant, and miscellaneous scenarios. TEG showed promising results in trauma surgeries in predicting mortality, hypercoagulability, and bleeding even when it was compared to conventional methods. TEG was also useful in monitoring anticoagulant therapy in orthopedic and obstetric surgeries; however, its role in predicting thrombotic events, hypercoagulability, or complications was questionable. In ICU patients, it showed promising results, especially in the prediction or improvement of sepsis, coagulopathy, thrombotic events, ICU duration, hospital stay, and ventilator duration. TEG parameters effectively predicted hypercoagulation in transplant surgeries. Regarding cardiovascular surgeries, they were effective in the prediction of the need for blood products, coagulopathy, thrombotic events, and monitoring anticoagulation therapy. More randomized clinical trials comparing TEG parameters with standardized tools are needed to produce robust results to standardize its use in different perioperative settings.
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Affiliation(s)
- Vendhan Ramanujam
- Department of Anesthesiology, Rhode Island Hospital/The Warren Alpert Medical School of Brown University, Providence, USA
| | - Stephen DiMaria
- Department of Anesthesiology, Rhode Island Hospital/The Warren Alpert Medical School of Brown University, Providence, USA
| | - Vivek Varma
- Department of Anesthesiology, Rhode Island Hospital/The Warren Alpert Medical School of Brown University, Providence, USA
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Stewart E, Nydam TL, Hendrickse A, Pomposelli JJ, Pomfret EA, Moore HB. Viscoelastic Management of Coagulopathy during the Perioperative Period of Liver Transplantation. Semin Thromb Hemost 2023; 49:119-133. [PMID: 36318962 PMCID: PMC10366939 DOI: 10.1055/s-0042-1758058] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Viscoelastic testing (VET) in liver transplantation (LT) has been used since its origin, in combination with standard laboratory testing (SLT). There are only a few, small, randomized controlled trials that demonstrated a reduction in transfusion rates using VET to guide coagulation management. Retrospective analyses contrasting VET to SLT have demonstrated mixed results, with a recent concern for overtreatment and the increase in postoperative thrombotic events. An oversight of many studies evaluating VET in LT is a single protocol that does not address the different phases of surgery, in addition to pre- and postoperative management. Furthermore, the coagulation spectrum of patients entering and exiting the operating room is diverse, as these patients can have varying anatomic and physiologic risk factors for thrombosis. A single transfusion strategy for all is short sighted. VET in combination with SLT creates the opportunity for personalized resuscitation in surgery which can address the many challenges in LT where patients are at a paradoxical risk for both life-threatening bleeding and clotting. With emerging data on the role of rebalanced coagulation in cirrhosis and hypercoagulability following LT, there are numerous potential roles in VET management of LT that have been unaddressed.
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Affiliation(s)
- Erin Stewart
- Department of Anesthesia, University of Colorado School of Medicine, Aurora, Colorado
| | - Trevor L. Nydam
- Division of Transplant Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Adrian Hendrickse
- Department of Anesthesia, University of Colorado School of Medicine, Aurora, Colorado
| | - James J. Pomposelli
- Division of Transplant Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Elizabeth A. Pomfret
- Division of Transplant Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Hunter B. Moore
- Division of Transplant Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
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Shenoy A, Louissaint J, Shannon C, Tapper EB, Lok AS. Viscoelastic Testing Prior to Non-surgical Procedures Reduces Blood Product Use Without Increasing Bleeding Risk in Cirrhosis. Dig Dis Sci 2022; 67:5290-5299. [PMID: 35122595 PMCID: PMC9352812 DOI: 10.1007/s10620-021-07376-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 12/28/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND/AIMS Thromboelastography (TEG) and Rotational Thromboelastometry (ROTEM) analyze hemostatic function in patients with coagulopathy. We sought to quantify the impact of TEG and ROTEM-guided transfusion algorithms on blood product utilization in patients with cirrhosis undergoing non-surgical procedures. METHODS We performed a systematic review and meta-analysis on the utility of viscoelastic testing prior to non-surgical procedures to determine their impact on pre-procedural blood product use and post-procedural bleeding events. Studies comparing TEG or ROTEM-guided transfusions with standard-of-care (SOC) prior to non-surgical procedures in adult patients with cirrhosis were included. Primary outcomes were fresh frozen plasma (FFP) and platelet transfusion and secondary outcomes of post-procedure bleeding, transfusion-related complications, and mortality; and were reported as standardized mean differences (SMD) and risk ratios (RR). RESULTS Six studies (five randomized controlled trials and one cohort study) involving 367 patients met inclusion criteria. Compared with SOC, TEG/ROTEM-guided transfusions led to an overall decreased number of patients who received FFP transfusions (SMD = -0.93, 95% CI [-1.54, -0.33], p < 0.001) and platelets transfusions (SMD = -1.50, CI [-1.85, -1.15], p < 0.001). Total amount of FFP (SMD-0.86, p < 0.001) and platelet (SMD = -0.99, p < 0.001) transfused in the TEG/ROTEM group were also lower. Decreased pre-procedure transfusion in the TEG/ROTEM group did not result in increased post-procedure bleeding (RR = 0.61, p = 0.09) or in mortality (RR = 0.91, p = 0.93). CONCLUSION In patients with cirrhosis, TEG or ROTEM significantly reduces blood product utilization prior to non-surgical procedures, with no increase in post-procedure bleeding or mortality. TEG and ROTEM utilization can promote high-value care and improve transfusion stewardship in this population.
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Affiliation(s)
- Abhishek Shenoy
- Division of Gastroenterology and Hepatology, University of Michigan, 1500 E Medical Center Dr, 3912 Taubman Center, Box 5362, Ann Arbor, MI, 48109, USA.
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, USA.
| | - Jeremy Louissaint
- Division of Gastroenterology and Hepatology, University of Michigan, 1500 E Medical Center Dr, 3912 Taubman Center, Box 5362, Ann Arbor, MI, 48109, USA
| | - Carol Shannon
- Taubman Health Sciences Library, University of Michigan, Ann Arbor, USA
| | - Elliot B Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, 1500 E Medical Center Dr, 3912 Taubman Center, Box 5362, Ann Arbor, MI, 48109, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, USA
| | - Anna S Lok
- Division of Gastroenterology and Hepatology, University of Michigan, 1500 E Medical Center Dr, 3912 Taubman Center, Box 5362, Ann Arbor, MI, 48109, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, USA
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The Addition of ROTEM Parameter Did Not Significantly Improve the Massive Transfusion Prediction in Severe Trauma Patients. Emerg Med Int 2022; 2022:7219812. [PMID: 36285178 PMCID: PMC9588372 DOI: 10.1155/2022/7219812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 10/03/2022] [Indexed: 11/18/2022] Open
Abstract
Background. Rotational thrombelastometry (ROTEM) has been used to evaluate the coagulation state, predict transfusion, and optimize hemostatic management in trauma patients. However, there were limited studies on whether the prediction value could be improved by adding the ROTEM parameter to the prediction model for in-hospital mortality and massive transfusion (MT) in trauma patients. Objective. This study assessed whether ROTEM data could improve the MT prediction model. Method. This was a single-center, retrospective study. Patients who presented to the trauma center and underwent ROTEM between 2016 and 2020 were included. The primary and secondary outcomes were massive transfusions and in-hospital mortality, respectively. We constructed two models using multivariate logistic regression with backward conditional stepwise elimination (Model 1: without the ROTEM parameter and Model 2: with the ROTEM parameter). The area under the receiver operating characteristic curve (AUROC) was calculated to assess the predictive ability of the models. Result. In total, 969 patients were included; 196 (20.2%) received MT. The in-hospital mortality rate was 14.1%. For MT, the AUROC was 0.854 (95% confidence interval [CI], 0.825–0.883) and 0.860 (95% CI, 0.832–0.888) for Model 1 and 2, respectively. For in-hospital mortality, the AUROC was 0.886 (95% CI, 0.857–0.915) and 0.889 (95% CI, 0.861–0.918) for models 1 and 2, respectively. The AUROC values for models 1 and 2 were not statistically different for either MT or in-hospital mortality. Conclusion. We found that the addition of the ROTEM parameter did not significantly improve the predictive power of MT and in-hospital mortality in trauma patients.
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Brill JB, Brenner M, Duchesne J, Roberts D, Ferrada P, Horer T, Kauvar D, Khan M, Kirkpatrick A, Ordonez C, Perreira B, Priouzram A, Cotton BA. The Role of TEG and ROTEM in Damage Control Resuscitation. Shock 2021; 56:52-61. [PMID: 33769424 PMCID: PMC8601668 DOI: 10.1097/shk.0000000000001686] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 12/05/2019] [Accepted: 10/20/2020] [Indexed: 11/26/2022]
Abstract
ABSTRACT Trauma-induced coagulopathy is associated with very high mortality, and hemorrhage remains the leading preventable cause of death after injury. Directed methods to combat coagulopathy and attain hemostasis are needed. The available literature regarding viscoelastic testing, including thrombelastography (TEG) and rotational thromboelastometry (ROTEM), was reviewed to provide clinically relevant guidance for emergency resuscitation. These tests predict massive transfusion and developing coagulopathy earlier than conventional coagulation testing, within 15 min using rapid testing. They can guide resuscitation after trauma, as well. TEG and ROTEM direct early transfusion of fresh frozen plasma when clinical gestalt has not activated a massive transfusion protocol. Reaction time and clotting time via these tests can also detect clinically significant levels of direct oral anticoagulants. Slowed clot kinetics suggest the need for transfusion of fibrinogen via concentrates or cryoprecipitate. Lowered clot strength can be corrected with platelets and fibrinogen. Finally, viscoelastic tests identify fibrinolysis, a finding associated with significantly increased mortality yet one that no conventional coagulation test can reliably detect. Using these parameters, guided resuscitation begins within minutes of a patient's arrival. A growing body of evidence suggests this approach may improve survival while reducing volumes of blood products transfused.
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Affiliation(s)
- Jason B. Brill
- Department of Surgery, University of Texas Health Science Center, Houston, Texas
| | - Megan Brenner
- Department of Surgery, University of California Riverside, Riverside, California
| | - Juan Duchesne
- Division Chief Acute Care Surgery, Department of Surgery Tulane, New Orleans, Louisiana
| | - Derek Roberts
- Division Chief Acute Care Surgery, Department of Surgery Tulane, New Orleans, Louisiana
| | - Paula Ferrada
- VCU Surgery Trauma, Critical Care and Emergency Surgery, Richmond, Virginia
| | - Tal Horer
- Department of Cardiothoracic and Vascular Surgery, Faculty of Life Science Örebro University Hospital and University, Örebro, Sweden
| | - David Kauvar
- Vascular Surgery Service, San Antonio Military Medical Center, San Antonio, Texas
| | - Mansoor Khan
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, UK
| | - Andrew Kirkpatrick
- Regional Trauma Services Foothills Medical Centre, Calgary, Alberta, Canada
- Departments of Surgery, Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
- Canadian Forces Health Services, Calgary, Alberta, Canada
| | - Carlos Ordonez
- Fundación Valle del Lili, Division of Trauma and Acute Care Surgery, Department of Surgery. Universidad del Valle, Valle, Colombia
| | - Bruno Perreira
- Department of Surgery and Surgical Critical Care, University of Campinas, Campinas, Brazil
| | - Artai Priouzram
- Department of Cardiothoracic and Vascular Surgery, Linköping University Hospital, Linköping, Sweden
| | - Bryan A. Cotton
- Department of Surgery, University of Texas Health Science Center, Houston, Texas
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Stravitz RT, Fontana RJ, Meinzer C, Durkalski V, Hanje AJ, Olson J, Koch D, Hamid B, Schilsky ML, McGuire B, Ganger D, Liou I, Karvellas CJ, Rule JA, Lisman T, Clasen K, Reuben A, Cripps MW, Lee WM. Coagulopathy, Bleeding Events, and Outcome According to Rotational Thromboelastometry in Patients With Acute Liver Injury/Failure. Hepatology 2021; 74:937-949. [PMID: 33636020 PMCID: PMC10668528 DOI: 10.1002/hep.31767] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 02/01/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Patients with acute liver injury or failure (ALI/ALF) experience bleeding complications uncommonly despite an abnormal hemostatic profile. Rotational thromboelastometry (ROTEM), which assesses clot formation in whole blood, was used to determine the nature of abnormal hemostasis and whether it contributes to bleeding events, illness severity, or survival. APPROACH AND RESULTS A total of 200 patients were recruited from sites of the ALF Study Group. Blood collected daily for up to 5 days was analyzed using ROTEM delta devices. Consistent with standard laboratory evidence of hypocoagulability (median international normalized ratio = 2.9 and platelet count = 144 × 109 /L), patients frequently exhibited ROTEM parameters outside the normal range (73% and 62% had abnormalities in clot formation from extrinsic and intrinsic clotting cascades, respectively); however, measures of clot stability were generally normal. Eighteen patients (9%) experienced bleeding events, in whom clot initiation, assembly, and firmness were more severely deranged than patients without bleeding. Abnormal ROTEM parameters were more frequently observed in patients with non-acetaminophen ALI/ALF than those with acetaminophen ALI/ALF (clot initiation [P < 0.001], assembly [P = 0.02], firmness at 10 minutes [P = 0.05], and maximal firmness [P = 0.06]). Patients with more severe systemic complications (high-grade hepatic encephalopathy and need for renal replacement therapy) also had a higher incidence of abnormal ROTEM parameters. Finally, more hypocoagulable ROTEM parameters (clot initiation (P = 0.005), stiffness at 10 minutes (P = 0.05), and maximal stiffness by fibrin assembly (P = 0.004)) were observed in patients who died or underwent liver transplantation than those who survived with their native liver. CONCLUSIONS In patients with ALI/ALF, abnormal ROTEM parameters are frequent and proportional to disease severity. Whether the increased bleeding risk associated with abnormal ROTEM indicates hemostatic failure or is a proxy for disease severity requires additional study.
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Affiliation(s)
- RT Stravitz
- Hume-Lee Transplant Center of Virginia Commonwealth University, Richmond, VA
| | - RJ Fontana
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - C Meinzer
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - V Durkalski
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - AJ Hanje
- Department of Medicine, The Ohio State University, Columbus, OH
| | - J Olson
- Division of Gastroenterology, University of Kansas Medical Center, Kansas City, KS
| | - D Koch
- Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - B Hamid
- Department of Medicine, University of California at San Francisco, San Francisco, CA
| | - ML Schilsky
- Divisions of Digestive Disease and Transplant and Immunology, Yale University, New Haven, CT
| | - B McGuire
- Division of Gastroenterology, University of Alabama, Birmingham, AL
| | - D Ganger
- Division of Gastroenterology, Northwestern University, Chicago, IL
| | - I Liou
- Department of Medicine, University of Washington, Seattle, WA
| | - CJ Karvellas
- Division of Gastroenterology (Liver Unit) and Department of Critical Care Medicine, University of Alberta, Edmonton, AB, Canada
| | - JA Rule
- Department of Internal Medicine, University of Texas, Southwestern Medical Center, Dallas, TX
| | - T Lisman
- Department of Surgery, University of Groningen, Groningen, The Netherlands
| | - K Clasen
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - A Reuben
- Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - MW Cripps
- Department of Surgery, University of Texas, Southwestern Medical Center, Dallas, TX
| | - WM Lee
- Department of Internal Medicine, University of Texas, Southwestern Medical Center, Dallas, TX
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7
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Giani M, Russotto V, Pozzi M, Forlini C, Fornasari C, Villa S, Avalli L, Rona R, Foti G. Thromboelastometry, Thromboelastography, and Conventional Tests to Assess Anticoagulation During Extracorporeal Support: A Prospective Observational Study. ASAIO J 2021; 67:196-200. [PMID: 33512915 DOI: 10.1097/mat.0000000000001196] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Optimal anticoagulation monitoring in patients with extracorporeal membrane oxygenation (ECMO) is fundamental to avoid hemorrhagic and thromboembolic complications. Besides conventional coagulation tests, there is growing interest in the use of viscoelastic hemostatic assays (VHA), in particular of tromboelastography (TEG). Evidence on the use of rotational thromboelastometry (ROTEM) is lacking in this setting. The aim of the study was to evaluate ROTEM as a tool for assessing hemostasis during ECMO, by comparing it to TEG and conventional coagulation assays. We conducted a prospective, observational, single-center study on adult patients on ECMO support anticoagulated with unfractioned heparin (UFH). Kaolin reaction time (R, min) for TEG and INTEM clotting time (CT, sec) for ROTEM were analyzed and compared with conventional coagulation tests. In the study period, we included 25 patients on ECMO support (14 V-A and 11 V-V); 84 data points were available for the analysis. Median UFH infusion rate was 15 [11-18] IU/min/kg. Median values for activated partial thromboplastin time (aPTT) ratio, Kaolin TEG R time, and INTEM CT were 1.44 [1.21-1.7], 22 [13-40] min, and 201 [183-225] sec, respectively. INTEM CT (ROTEM) showed a moderate correlation with standard coagulation tests (R2 = 0.34 and 0.3 for aPTT and activated clotting time (ACT), respectively, p < 0.001). No significant correlation was found between INTEM CT and Kaolin R time (R2 = 0.01). Further studies are needed to identify an appropriate anticoagulation target for ROTEM during ECMO.
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Affiliation(s)
- Marco Giani
- From the ASST Monza, Ospedale San Gerardo, Dipartimento di Emergenza-Urgenza, Monza, Italy
- Università degli Studi di Milano-Bicocca, Dipartimento di Medicina e Chirurgia, Monza, Italy
| | - Vincenzo Russotto
- From the ASST Monza, Ospedale San Gerardo, Dipartimento di Emergenza-Urgenza, Monza, Italy
- Università degli Studi di Milano-Bicocca, Dipartimento di Medicina e Chirurgia, Monza, Italy
| | - Matteo Pozzi
- From the ASST Monza, Ospedale San Gerardo, Dipartimento di Emergenza-Urgenza, Monza, Italy
| | - Clarissa Forlini
- Università degli Studi di Milano-Bicocca, Dipartimento di Medicina e Chirurgia, Monza, Italy
| | - Chiara Fornasari
- Università degli Studi di Milano-Bicocca, Dipartimento di Medicina e Chirurgia, Monza, Italy
| | - Silvia Villa
- From the ASST Monza, Ospedale San Gerardo, Dipartimento di Emergenza-Urgenza, Monza, Italy
| | - Leonello Avalli
- From the ASST Monza, Ospedale San Gerardo, Dipartimento di Emergenza-Urgenza, Monza, Italy
| | - Roberto Rona
- From the ASST Monza, Ospedale San Gerardo, Dipartimento di Emergenza-Urgenza, Monza, Italy
| | - Giuseppe Foti
- From the ASST Monza, Ospedale San Gerardo, Dipartimento di Emergenza-Urgenza, Monza, Italy
- Università degli Studi di Milano-Bicocca, Dipartimento di Medicina e Chirurgia, Monza, Italy
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Bansal S, Garg A, Khatuja A, Ray R, Bora G. An observational study of hemostatic profile during different stages of liver transplant surgery using laboratory-based tests and thromboelastography. Anesth Essays Res 2021; 15:194-201. [PMID: 35281353 PMCID: PMC8916130 DOI: 10.4103/aer.aer_89_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 09/01/2021] [Accepted: 09/01/2021] [Indexed: 12/02/2022] Open
Abstract
Background: Liver produces most of the blood coagulation factors, so it is not surprising to see a deranged coagulation profile in patients receiving liver transplants. Besides standard laboratory methods to evaluate coagulation profile, point-of-care assays are being used regularly since their results are rapidly available. However, sparse information is available on the comparability of point-of-care coagulation assays with laboratory coagulation assays in this special setting. In this study, our aim is to observe the changing hemostatic profile during different stages of liver transplant surgery using laboratory-based tests and thromboelastography (TEG). Methods: Fifty patients undergoing living donor liver transplantation surgery were selected. Coagulation tests (prothrombin time [PT], activated partial thromboplastin time [APTT], platelet count, and fibrinogen) and TEG were performed at various intervals during liver transplant surgeries – before induction of anesthesia, 2 h into dissection phase, 30 min into anhepatic phase, 30 min after reperfusion of homograft, postoperative – at closure of surgery, 12 h postoperative, and 24 h postoperative. Statistical analysis and Pearson correlation were performed between laboratory-based coagulation tests and TEG, and their pattern through various stages of the surgery analyzed. Results: Platelet count and fibrinogen have a significant positive correlation with TEG in almost all phases of liver transplant. PT and APTT have a positive correlation with TEG until uptake of new liver and predominantly negative correlation after that. However, this correlation is significant only before induction of anesthesia and anhepatic phase. Conclusions: TEG can be used to estimate platelet count and fibrinogen concentrations in all phases but PT and APTT only before induction and anhepatic phase of liver transplant surgery. The decision regarding transfusion of blood products should be based on a combination of the clinical assessment of surgeon and anesthesia personnel combined with results from laboratory and TEG.
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9
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Gaspari R, Teofili L, Aceto P, Valentini CG, Punzo G, Sollazzi L, Agnes S, Avolio AW. Thromboelastography does not reduce transfusion requirements in liver transplantation: A propensity score-matched study. J Clin Anesth 2020; 69:110154. [PMID: 33333373 DOI: 10.1016/j.jclinane.2020.110154] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 11/05/2020] [Accepted: 11/21/2020] [Indexed: 01/02/2023]
Abstract
STUDY OBJECTIVE To compare total blood product requirements in liver transplantation (LT) assisted by thromboelastography (TEG) or conventional coagulation tests (CCTs). DESIGN Retrospective observational study. SETTING A tertiary care referral center for LT. PATIENTS Adult patients undergoing LT from deceased donor. INTERVENTION Hemostasis was monitored by TEG or CCTs and corresponding transfusion algorithms were adopted. MEASUREMENTS Number and types of blood products (red blood cells, RBC; fresh-frozen plasma, FFP; platelets, PLT) transfused from the beginning of surgery until the admission to the intensive care unit. METHODS We compared data retrospectively collected in 226 LTs, grouped according to the type of hemostasis monitoring (90 with TEG and 136 with CCTs, respectively). Confounding variables affecting transfusion needs (recipient age, sex, previous hepatocellular carcinoma surgery, Model for End Stage Liver Disease - MELD, baseline hemoglobin, fibrinogen, creatinine, veno-venous by pass, and trans-jugular intrahepatic portosystemic shunt) were managed by propensity score match (PSM). MAIN RESULTS The preliminary analysis showed that patients in the TEG group received fewer total blood products (RBC + FFP + PLT; p = 0.001, FFP (p = 0.001), and RBC (p = 0.001). After PSM, 89 CCT patients were selected and matched to the 90 TEG patients. CCT and TEG matched patients received similar amount of total blood products. In a subgroup of 39 patients in the top MELD quartile (MELD ≥25), the TEG use resulted in lower consumption of FFP units and total blood products. Nevertheless, due to the low number of patients, any meaningful conclusion could be achieved in this subgroup. CONCLUSIONS In our experience, TEG-guided transfusion in LT does not reduce the intraoperative blood product consumption. Further studies are warranted to assess an advantage for TEG in either the entire LT population or the high-MELD subgroup of patients.
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Affiliation(s)
- Rita Gaspari
- Dipartimento di Scienze dell'emergenza, Anestesiologiche e della rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; Università Cattolica del Sacro Cuore, Roma, Italy
| | - Luciana Teofili
- Dipartimento di Diagnostica per immagini, Radioterapia oncologia ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; Università Cattolica del Sacro Cuore, Roma, Italy
| | - Paola Aceto
- Dipartimento di Scienze dell'emergenza, Anestesiologiche e della rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; Università Cattolica del Sacro Cuore, Roma, Italy.
| | - Caterina G Valentini
- Dipartimento di Diagnostica per immagini, Radioterapia oncologia ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Giovanni Punzo
- Dipartimento di Scienze dell'emergenza, Anestesiologiche e della rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Liliana Sollazzi
- Dipartimento di Scienze dell'emergenza, Anestesiologiche e della rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; Università Cattolica del Sacro Cuore, Roma, Italy
| | - Salvatore Agnes
- Università Cattolica del Sacro Cuore, Roma, Italy; Dipartimento di scienze mediche e chirurgiche, Chirurgia Generale e del Trapianto di Fegato, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Alfonso W Avolio
- Università Cattolica del Sacro Cuore, Roma, Italy; Dipartimento di scienze mediche e chirurgiche, Chirurgia Generale e del Trapianto di Fegato, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
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10
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Uludag Yanaral T, Ertugrul G, Ulukan MO, Karaaslan P, Karaca IO, Dayangac M. Combined liver transplantation and off-pump coronary artery bypass grafting: a report of two cases. Acta Chir Belg 2020; 122:269-274. [PMID: 33251981 DOI: 10.1080/00015458.2020.1857570] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Liver transplantation (LT) is the most effective treatment modality in patients with end-stage liver disease (ESLD). With the increased prevalence of diabetes and non-alcoholic fatty liver disease (NAFLD), coupled with a steady increase in the age of transplant population, liver transplant candidates are at increased risk for coronary artery disease (CAD). Improvements in anesthesia, surgical experiences, and increased effectiveness of drugs have facilitated concurrent surgical interventions in transplantation, allowing for orthotopic LT to be performed in elderly patients with a high incidence of coexisting diseases, especially those of the cardiovascular system. In this study, we present two cases of combined off-pump coronary artery bypass surgery and living donor liver transplantation. CASE PRESENTATION A 68-year-old male patient with ESLD due to chronic hepatitis C infection and multi-vessel CAD, and a 65-year-old female patient with NAFLD cirrhosis and multi-vessel CAD were referred to our institution for an LT evaluation. We performed combined living donor LT and off-pump coronary artery bypass surgery in both patients. Both the first and second patients were alive with good liver and cardiac function at the 25 and 15 months after surgery, respectively. CONCLUSION Combined off-pump coronary artery bypass surgery and living donor LT are an alternative treatment for patients with severe CAD and ESLD. We consider that combined coronary artery bypass graft surgery and LT can be safely performed by experienced anesthesia and surgical teams in selected patients.
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Affiliation(s)
- Tumay Uludag Yanaral
- Department of Anesthesiology and Reanimation, Istanbul Medipol University Faculty of Medicine, Istanbul, Turkey
| | - Gokhan Ertugrul
- Department of General Surgery, Istanbul Medipol University Faculty of Medicine, Istanbul, Turkey
| | - Mustafa Ozer Ulukan
- Department of Cardiovascular Surgery, Istanbul Medipol University Faculty of Medicine, Istanbul, Turkey
| | - Pelin Karaaslan
- Department of Anesthesiology and Reanimation, Istanbul Medipol University Faculty of Medicine, Istanbul, Turkey
| | - Ibrahim Oguz Karaca
- Department of Cardiology, Istanbul Medipol University Faculty of Medicine, Istanbul, Turkey
| | - Murat Dayangac
- Department of General Surgery, Istanbul Medipol University Faculty of Medicine, Istanbul, Turkey
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11
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Shenoy A, Intagliata NM. Thromboelastography and Utility in Hepatology Practice. Clin Liver Dis (Hoboken) 2020; 16:149-152. [PMID: 33163167 PMCID: PMC7609700 DOI: 10.1002/cld.947] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 02/11/2020] [Indexed: 02/06/2023] Open
Affiliation(s)
- Abhishek Shenoy
- Department of MedicineUniversity of VirginiaCharlottesvilleVA
| | - Nicolas M. Intagliata
- Department of MedicineUniversity of VirginiaCharlottesvilleVA,Division of Gastroenterology and HepatologyUniversity of VirginiaCharlottesvilleVA
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12
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Sakai T. Viscoelastic testing in liver transplantation. Transfusion 2020; 60 Suppl 6:S61-S69. [PMID: 33089935 DOI: 10.1111/trf.16077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/19/2020] [Accepted: 06/19/2020] [Indexed: 01/24/2023]
Abstract
Despite the lack of large randomized clinical studies, viscoelastic tests (VETs) have been a critical armamentarium for hemostatic control in liver transplantation (LT) since the 1960s. Many transplant institutions have adopted VETs in their clinical practice. Several small-size randomized clinical trials on LT patients have suggested that VET-guided hemostatic treatment algorithms have led to decreased indications for and amounts of transfused blood products, especially fresh-frozen plasma, compared to standard laboratory-based hemostatic management. VETs have also been reported to offer insight into the diagnosis and prediction of LT patients' development of hypercoagulability-related morbidity and mortality. There is still a need for VET device-specific hemostatic algorithms in LT, and clinicians must take into account the tendency to underestimate the coagulation capacity of VETs in patients with end-stage liver disease where hemostasis is rebalanced.
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Affiliation(s)
- Tetsuro Sakai
- Department of Anesthesiology and Perioperative Medicine, UPMC (University of Pittsburgh Medical Center), Pittsburgh, Pennsylvania, USA
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13
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Rengeiné TK, Máthé Z, Piros L, Dinya E, Smudla A, Mándli T, Kóbori L, Doros A, Kanizsai P, Fazakas J. How Much Is the Inevitable Loss of Different Coagulation Factors During Blood Product-Free Liver Transplantations? Transplant Proc 2020; 52:2988-2995. [PMID: 32653159 DOI: 10.1016/j.transproceed.2020.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 03/27/2020] [Accepted: 05/12/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Bloodless liver transplantations (LT) have already been reported, but special characteristics of hemostatic changes remain less defined. The aim of this study was to evaluate the "inevitable" loss of coagulation factors (CF) in blood product-free LT. METHODS Blood product and CF concentrate-free LT patient data were analyzed in terms of the first 2 days of perioperative hemostasis kinetics (N = 59). CF levels (FI, II, V, VII, X, and XIII), platelet (PLT) levels, and hemoglobin levels were measured before LT (T1), on arrival at the intensive care unit (T2), and 12, 24, and 48 hours after LT (T3, T4, and T5, respectively). Thromboelastographic (TEG) parameters were determined before and at the end of LT (T1-T2). RESULTS Fibrinogen levels decreased by 1.2 ± 0.6 g/L, prothrombin levels by 26% ± 14%, factor V levels by 40% ± 23%, VII levels by 29% ± 19%, and X levels by 39% ± 22% (P < .001). From T2 to T4 fibrinogen increased by 0.9 ± 0.6g/L for 24 hours (P < .001). Factor II, V, and VII levels increased by 20% ± 16%, 31% ± 32%, and 12% ± 27%, respectively, between T3 and T5 (P < .001). However, factor X reached only half of the T1 level (T3-T5, P < .001). Platelet count increased in 34 (58%) patients at T2 (P < .001). The TEG parameters remained in the normal range during LT (T1-T2). CONCLUSION The major findings of this study advocate that "inevitable" levels of CF decrease during LT by an average of 1.2 g/L in terms of fibrinogen and 23% to 40% regarding factors II, V, VII, and X. The authors suggest that knowing the "magic numbers" and comparing them against baseline laboratory results might predict the possibility of blood product-free transplant, providing confidence and safety to the surgeon and the anesthetist.
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Affiliation(s)
- T K Rengeiné
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary.
| | - Z Máthé
- Department of Surgery, Division of Transplant Surgery, Medical University Graz, Graz, Austria
| | - L Piros
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - E Dinya
- Semmmelweis University, Institute of Digital Health Sciences, Budapest, Hungary
| | - A Smudla
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - T Mándli
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - L Kóbori
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - A Doros
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - P Kanizsai
- Department of Emergency Medicine, University of Pécs, Clinical Centre, Pécs, Hungary
| | - J Fazakas
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
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14
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Katz R, Efremov V, Mooney C, El-Khuffash A, Heaphy L, Cosgrave D, Loughrey J, Thornton P. Assessment of the reliability and validity of a novel point-of-care fibrinogen (F-Point) device against an industry standard at fibrinogen levels >2 g/L in non-haemorrhage scenarios. Int J Obstet Anesth 2020; 43:91-96. [PMID: 32386992 DOI: 10.1016/j.ijoa.2020.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 03/27/2020] [Accepted: 04/07/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION A diagnostic accuracy study assessing the reliability and validity of a novel plasma fibrinogen point-of-care (F-Point) device compared with the von Clauss method of assay. METHODS Forty-one women presenting for elective caesarean delivery and 43 non-pregnant female patients presenting for elective gynaecological surgery were recruited to assess agreement at normal fibrinogen levels (elective gynaecological cohort) and high fibrinogen levels (elective caesarean section cohort). Validity was assessed by comparing the F-Point results with the gold standard of von Clauss fibrinogen assay performed on the ACL Top 500. Reliability (test-retest) and validity were assessed using the intraclass correlation to control for operator variance (two-way random absolute agreement method), presented as intra class correlation coefficients (ICCs) and 95% confidence interval, and Bland-Altman analysis, presented as mean bias and 95% limits of agreement and coefficient of variation (COV). RESULTS The results demonstrated a high test-retest reliability demonstrated in the paired F-Point measurements with an intraclass correlation coefficient (ICC) of 0.95, a bias of 0 (-00.69 to 0.69) and a COV of 9%. Similarly, there was acceptable agreement demonstrated between F-Point and von Clauss assay with an ICC of 0.91, a bias of -0.1 (-0.96 to 0.75) and a COV of 11%. CONCLUSIONS Our novel plasma fibrinogen point-of-care device has been shown to be reliable and valid when testing fibrinogen levels as low as 2 g/L. Future studies investigating the correlation at lower fibrinogen levels, for example during haemorrhage and in patients with coagulopathies, are required.
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Affiliation(s)
- R Katz
- Rotunda Hospital, Parnell Square E, Dublin, Ireland
| | - V Efremov
- Dublin City University, Glasnevin, Dublin, Ireland
| | - C Mooney
- Rotunda Hospital, Parnell Square E, Dublin, Ireland
| | | | - L Heaphy
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - D Cosgrave
- Rotunda Hospital, Parnell Square E, Dublin, Ireland
| | - J Loughrey
- Rotunda Hospital, Parnell Square E, Dublin, Ireland
| | - P Thornton
- Rotunda Hospital, Parnell Square E, Dublin, Ireland.
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15
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Park SY. Viscoelastic coagulation test for liver transplantation. Anesth Pain Med (Seoul) 2020; 15:143-151. [PMID: 33329806 PMCID: PMC7713821 DOI: 10.17085/apm.2020.15.2.143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 03/05/2020] [Indexed: 01/09/2023] Open
Abstract
Coagulation and transfusion management in patients undergoing liver transplantation is challenging. Proper perioperative monitoring of hemostasis is essential to predict the risk of bleeding during surgery, to detect potential causes of hemorrhage in time, and to guide hemostatic therapy. The value of conventional coagulation test is questionable in the acute perioperative setting due to their long turnaround time and the inability to adequately reflect the complex changes in hemostasis in patients with liver disease. Viscoelastic coagulation tests provide simultaneous measurement of multiple aspects of whole-blood coagulation including plasmatic coagulation and fibrinolytic factors and inhibitors that reflect most aspects of hemostasis. Coagulation initiation, mechanical clot stability, and fibrinolysis can be estimated immediately using point-of-care techniques. Therefore, viscoelastic coagulation tests including ROTEM & TEG would be useful to guide patient blood management strategy during liver transplantation.
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Affiliation(s)
- Sun Young Park
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Seoul Hospital, Seoul, Korea
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16
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Singh SA, Krishnan G, Ashraf H, Subramanian R, Pandey V, Nasa VK, Goyal S, Gupta S. Correlation between thromboelastography and rotational thromboelastometry values in adult liver transplant recipients. Indian J Anaesth 2020; 64:286-291. [PMID: 32489202 PMCID: PMC7259407 DOI: 10.4103/ija.ija_762_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 01/19/2020] [Accepted: 02/17/2020] [Indexed: 11/18/2022] Open
Abstract
Background and Aims: Viscoelastic haemostatic assays (VHA) namely Thromboelastogram (TEG) and Rotational thromboelastometry (ROTEM) are used for global assessment of coagulopathy and guiding transfusion during living donor liver transplant (LDLT).We conducted a study to compare the interchangeability of the values obtained from these devices in patients with End stage liver disease (ESLD) undergoing LDLT. Methods: In 76 patients undergoing LDLT, ROTEM and TEG were performed and assessed for interchangeability using Spearman Correlation. The direction and strength of correlation between equivalent parameters was calculated using Inter Class Correlation (ICC) and Bland Altman analysis. Results: The correlation ρ between CT (clotting time) of ROTEM and R of TEG was 0.16 (P = 0.19).The ICC was 0.15, with 95% confidence interval (CI) of -0.38-0.48 (P = 0.25).The ρ of CFT (ROTEM) with K (TEG) was 0.425 (P=<0.001). The ICC was0.49 with 95% CI of 0.17-0.69, P = 0.003.Alpha of ROTEM correlated with Angle of TEG with ρ of 0.475 (P=<0.001). The ICC was 0.61, with 95% CI of 0.36-0.76, P=<0.001.Maximum Clot firmness (MCF) correlated with maximum amplitude (MA) with ρ=0.76 (P=<0.001).The ICC was 0.86, with 95% CI of 0.77-0.92, P=<0.001. Lysis index (L30) of ROTEM correlated clot lysis (CL30) of TEG with ρ of 0.16 (P = 0.18).However, the ICC was 0.45, with 95% CI of 0.11-0.66, P = 0.08. The correlation between CT of ROTEM and R of TEG as well as L30 of ROTEM and CL30 of TEG was not significant.The strongest correlation was found between MCF and MA (P < 0.001). However the MCF/MA showed an agreement of only 86% (ICC = 0.86). Conclusion: Values from ROTEM and TEG were not found to be interchangeable.
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Affiliation(s)
- Shweta A Singh
- Center for Liver and Biliary Sciences Anaesthesia and Critical Care, Max Super Speciality Hospital, New Delhi, India
| | - Gopi Krishnan
- Center for Liver and Biliary Sciences Anaesthesia and Critical Care, Max Super Speciality Hospital, New Delhi, India
| | - Hashir Ashraf
- Center for Liver and Biliary Sciences Anaesthesia and Critical Care, Max Super Speciality Hospital, New Delhi, India
| | - Rajkumar Subramanian
- Center for Liver and Biliary Sciences Anaesthesia and Critical Care, Max Super Speciality Hospital, New Delhi, India
| | - Vijaykant Pandey
- Center for Liver and Biliary Sciences Anaesthesia and Critical Care, Max Super Speciality Hospital, New Delhi, India
| | - Vaibhav K Nasa
- Center for Liver and Biliary Sciences Anaesthesia and Critical Care, Max Super Speciality Hospital, New Delhi, India
| | - Sumit Goyal
- Center for Liver and Biliary Sciences Anaesthesia and Critical Care, Max Super Speciality Hospital, New Delhi, India
| | - Subhash Gupta
- Center for Liver and Biliary Sciences Anaesthesia and Critical Care, Max Super Speciality Hospital, New Delhi, India
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17
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Systemic inflammation and portal vein thrombosis in cirrhotic patients with gastroesophageal varices. Eur J Gastroenterol Hepatol 2020; 32:401-405. [PMID: 31356372 DOI: 10.1097/meg.0000000000001526] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Cirrhotic patients with gastroesophageal varices and non-tumoral portal vein thrombosis have a higher risk of re-bleeding and poor prognosis. This study aimed to analyze inflammatory biomarkers and thromboelastography in cirrhotic patients with portal vein thrombosis. METHODS A total of 385 consecutive cirrhotic patients with gastroesophageal varices were prospectively enrolled between 1 December 2016, and 31 August 2017. Of these, 231 were eligible for analysis and were divided into portal vein thrombosis (n = 103) and non-portal vein thrombosis (n = 128) groups based on computerized tomography angiography findings. RESULTS Patients with portal vein thrombosis generally had higher Child-Pugh scores than those without portal vein thrombosis (6.38 ± 0.12 vs. 5.81 ± 0.09, P < 0.001). The serum albumin levels were significantly lower in patients with portal vein thrombosis (35.90 ± 0.52 vs. 38.52 ± 0.43, P < 0.001). The portal vein thrombosis group had significant higher serum levels of interleukin 6 [4.85 (3.15-6.99) vs. 3.09 (2.06-5.20) pg/ml, P < 0.001] and tumor necrosis factor alpha [10.70 (7.60-15.20) vs. 9.07 (7.03-11.60) pg/ml, P = 0.020]. The interleukin 6 level was 2.5-fold higher in patients with portal vein thrombosis (adjusted odds ratio: 2.574; 95% confidential interval: 1.248-5.310). Thromboelastography showed that TEG-R, the reaction time, was significantly lower in the portal vein thrombosis group [5.20 (4.80-6.30) vs. 6.00 (5.20-6.95), P = 0.009], indicating enhanced coagulation activity. CONCLUSION This study confirmed the important role of systemic inflammation in portal vein thrombosis. Interleukin 6, an important inflammatory cytokine, is independently associated with portal vein thrombosis. The correlation between the interleukin 6 level and portal vein thrombosis requires further investigation.
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18
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Rocha LL, Neto AS, Pessoa CMS, Almeida MD, Juffermans NP, Crochemore T, Rodrigues RR, Filho RR, de Freitas Chaves RC, Cavalheiro AM, Prado RR, Assunção MSC, Guardia BD, Silva E, Corrêa TD. Comparison of three transfusion protocols prior to central venous catheterization in patients with cirrhosis: A randomized controlled trial. J Thromb Haemost 2020; 18:560-570. [PMID: 31667992 DOI: 10.1111/jth.14672] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 10/28/2019] [Accepted: 10/29/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Transfusion of blood components prior to invasive procedures in cirrhosis patients is high and associated with adverse events. OBJECTIVES We compared three transfusion strategies prior to central venous catheterization in cirrhosis patients. PATIENTS/METHODS Single center randomized trial that included critically ill cirrhosis patients with indication for central venous line in a tertiary private hospital in Brazil. INTERVENTIONS Restrictive protocol, thromboelastometry-guided protocol, or usual care (based on coagulogram). The primary endpoint was the proportion of patients transfused with any blood component (ie, fresh frozen plasma, platelets, or cryoprecipitate). The secondary endpoints included incidence of bleeding and transfusion-related adverse events. RESULTS A total of 57 patients (19 per group; 64.9% male; mean age, 53.4 ± 11.3 years) were enrolled. Prior to catheterization, 3/19 (15.8%) in the restrictive arm, 13/19 (68.4%) in the thromboelastometry-guided arm, and 14/19 (73.7%) in the coagulogram-guided arm received blood transfusion (odds ratio [OR], 0.07; 95% confidence interval [CI], 0.01-0.45; P = .002 for restrictive versus coagulogram-guided arm; OR, 0.09; 95% CI, 0.01-0.56; P = .006 for restrictive versus thromboelastometry-guided arm; and OR, 0.77; 95% CI, 0.14-4.15; P = .931 for thromboelastometry-guided versus coagulogram-guided arm). The restrictive protocol was cost saving. No difference in bleeding, length of stay, mortality, and transfusion-related adverse events was found. CONCLUSIONS The use of a restrictive strategy is associated with a reduction in transfusion prior to central venous catheterization and costs in critically ill cirrhosis patients. No effect on bleeding was found among the groups.
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Affiliation(s)
- Leonardo L Rocha
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Department of Critical Care Medicine, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Ary S Neto
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Laboratory for Critical Care Research, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Department of Intensive Care, Academic Medical Center, Amsterdam, the Netherlands
| | - Camila M S Pessoa
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Márcio D Almeida
- Liver Transplant Program, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Nicole P Juffermans
- Department of Intensive Care, Academic Medical Center, Amsterdam, the Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, Amsterdam, the Netherlands
| | - Tomaz Crochemore
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Roseny R Rodrigues
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Roberto R Filho
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | - Ana M Cavalheiro
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Rogério R Prado
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Laboratory for Critical Care Research, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Murillo S C Assunção
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Bianca D Guardia
- Liver Transplant Program, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Eliézer Silva
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Thiago D Corrêa
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
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19
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Magnesium Therapy Improves Rotational Thromboelastometry Findings Prior to Liver Transplantation: A Randomized Clinical Trial. Indian J Hematol Blood Transfus 2020; 36:505-511. [PMID: 32647425 DOI: 10.1007/s12288-020-01260-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Accepted: 02/03/2020] [Indexed: 10/24/2022] Open
Abstract
An important challenge during orthotopic liver transplantation (OLT) is optimal coagulation management. There are diverse studies regarding effect of Mg sulfate on coagulation system. This study evaluates the impact of Mg sulfate on the coagulation parameters of the rotational thromboelastometry (ROTEM) in patients about to undergo OLT. In this randomized clinical trial, 60 patients who were going to undergo OLT were randomly allocated into two groups. In the Mg group, the patients received a 1.5 g infusion of Mg 5 min before the surgical incision. In the control group, patients received a physiological saline instead of Mg. Plasma Mg levels before and after the infusions were measured in both groups. Also, three ROTEM tests: EXTEM, INTEM and FIBTEM were performed before and after the infusions. Baseline mean plasma magnesium levels were within normal range in the control and Mg groups: 2.06 and 2.18 mg/dl, respectively. After magnesium therapy, the mean plasma Mg level in the Mg group increased to 2.78 mg/dl in compared to the control group that was 2.01 mg/dl (P < 0.000). Mean value of the clotting time (CT) in the magnesium group were significantly decreased from 129.50 ± 7.76, 381.86 ± 8.51 and 114.26 ± 6.80 to 86.13 ± 3.4, 209.33 ± 6.68 and 81.56 ± 5.01 in the EXTEM, INTEM, and FIBTEM respectively after intervention in the Mg group (P = 0.001). Among patients with end-stage liver diseases who have ROTEM evidence of hypocoagulability, magnesium could correct CT parameter of the ROTEM tests.
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20
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Lange NW, Salerno DM, Berger K, Cushing MM, Brown RS. Management of Hepatic Coagulopathy in Bleeding and Nonbleeding Patients: An Evidence-Based Review. J Intensive Care Med 2020; 36:524-541. [PMID: 32079443 DOI: 10.1177/0885066620903027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Patients with varying degrees of hepatic dysfunction often present with presumed bleeding diathesis based on interpretation of routine measures of coagulation (prothrombin time [PT], international normalized ratio [INR], and activated partial thromboplastin time). However, standard markers of coagulation do not reflect the actual bleeding risk in this population and may lead to inappropriate administration of hemostatic agents and blood products. The concept of "rebalanced hemostasis" explains both the risk of bleeding and clotting seen in patients with liver dysfunction. The role of pharmacologic agents and blood products for prevention of bleeding during high-risk procedures and treatment of clinically significant bleeding remains unclear. Viscoelastic measurements of the clotting cascade provide information about platelets, fibrinogen/fibrin polymerization, coagulation factors, and fibrinolysis that might better represent hemostasis in vivo and may better inform management strategies. Due to the paucity of available data, firm recommendations for the use of blood products and pharmacologic agents in patients with hepatic coagulopathies are lacking, and thus, these products should not be routinely administered. Traditional laboratory tests such as PT/INR should not be the sole determinant of potential interventions. Rather, clinicians should assess factors such as the severity of bleed or bleeding risk of the procedure, the patient's risk of thromboembolism, and the strength of available evidence for specific agents and blood products to guide decision-making.
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Affiliation(s)
- Nicholas W Lange
- Department of Pharmacy, 25065NewYork-Presbyterian Hospital, New York, NY, USA
| | - David M Salerno
- Department of Pharmacy, 25065NewYork-Presbyterian Hospital, New York, NY, USA
| | - Karen Berger
- Department of Pharmacy, 25065NewYork-Presbyterian Hospital, New York, NY, USA
| | - Melissa M Cushing
- Department of Pathology and Laboratory Medicine, 159947Weill Cornell Medicine, New York, NY, USA
- Department of Anesthesiology, 159947Weill Cornell Medicine, New York, NY, USA
| | - Robert S Brown
- Division of Gastroenterology, Department of Medicine, 159947Weill Cornell Medicine, New York, NY, USA
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21
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Tritapepe L, Carriero G. Are there real or semantic differences between thromboelastography and thromboelastometry? Minerva Anestesiol 2019; 85:1262-1264. [DOI: 10.23736/s0375-9393.19.14248-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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22
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Liu P, Hum J, Jou J, Scanlan RM, Shatzel J. Transfusion strategies in patients with cirrhosis. Eur J Haematol 2019; 104:15-25. [PMID: 31661175 DOI: 10.1111/ejh.13342] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 10/13/2019] [Accepted: 10/21/2019] [Indexed: 12/12/2022]
Abstract
Bleeding related to portal hypertension and coagulopathy is a common complication in patients with cirrhosis. Complications and management of bleeding is a significant source of healthcare cost and utilization, as well as morbidity and mortality. Due to the scarcity of evidence surrounding transfusion strategies and hemostatic interventions in patients with cirrhosis, there has been significant debate regarding the best practice. Emerging data suggest that evidence supporting transfusion of packed red blood cells to a hemoglobin threshold of 7-8 g/dL is strong. thrombopoietin (TPO) receptor agonists have shown promise in increasing platelet levels and reducing transfusions preprocedurally, although have not specifically been found to reduce bleeding risk. Data for viscoelastic testing (VET)-guided transfusions appear favorable for reducing blood transfusion requirements prior to minor procedures and during orthotopic liver transplantation. Hemostatic agents such as recombinant factor VIIa, prothrombin complex concentrates, and tranexamic acid have been examined but their role in cirrhotic patients is unclear. Other areas of growing interest include balanced ratio and whole blood transfusion. In the following manuscript, we summarize the most up to date evidence for threshold-guided, VET-guided, balanced-ratio, and whole blood transfusions as well as the use of hemostatic agents in cirrhotic patients to provide practice guidance to clinicians.
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Affiliation(s)
- Patricia Liu
- The Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Justine Hum
- The Division of Gastroenterology and Hepatology, Oregon Health & Science University, Portland, Oregon
| | - Janice Jou
- The Division of Gastroenterology and Hepatology, Oregon Health & Science University, Portland, Oregon
| | - Richard M Scanlan
- The Division of Laboratory Medicine, Department of Pathology, Oregon Health & Science University, Portland, Oregon
| | - Joseph Shatzel
- The Division of Hematology & Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon
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Coppel J, Gilbert-Kawai E, Bottomley T, Sugarman J, Martin D. The effect of normobaric hypoxic exposure on coagulation as measured by thromboelastography. Thromb Res 2019; 184:105-109. [PMID: 31715543 DOI: 10.1016/j.thromres.2019.10.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 10/28/2019] [Accepted: 10/31/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION The physiological impact of hypoxia on coagulation has significant importance in the clinical setting, but it is not yet fully understood. Various static methods exist to investigate the process of coagulation, however, thromboelastography (TEG) provides a dynamic assessment of clot formation that can be quantitatively assessed. METHOD Twenty-five participants were exposed to normobaric hypoxia (12.5% oxygen) for 8 h. Venous blood was taken from the participants directly pre- and post-hypoxic exposure, and coagulation was tested using TEG. Coagulation variables assessed included reaction time, split point, alpha angle, kinetics and maximum amplitude. RESULTS Time taken for clot initiation, (assessed using the split point and reaction time) was significantly reduced after 8 h of hypoxic exposure. The split point reduced from a mean of 5.20 to 4.23 min (p = 0.022), whilst the reaction time reduced from 6.09 to 4.94 min (p = 0.004). Maximum amplitude, alpha angle and kinetics did not change significantly after hypoxic exposure. CONCLUSION The results demonstrate that subacute normobaric hypoxic exposure increases the tendency for whole blood to coagulate, as demonstrated by a reduced split and reaction time using TEG.
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Affiliation(s)
- Jonny Coppel
- University College London Centre for Altitude, Space, and Extreme Environment Medicine, University College London Hospitals National Institute for Health Research Biomedical Research Centre, Institute of Sport and Exercise Health, London, United Kingdom.
| | - Edward Gilbert-Kawai
- University College London Centre for Altitude, Space, and Extreme Environment Medicine, University College London Hospitals National Institute for Health Research Biomedical Research Centre, Institute of Sport and Exercise Health, London, United Kingdom
| | - Tom Bottomley
- University College London Centre for Altitude, Space, and Extreme Environment Medicine, University College London Hospitals National Institute for Health Research Biomedical Research Centre, Institute of Sport and Exercise Health, London, United Kingdom
| | - Joel Sugarman
- University College London Centre for Altitude, Space, and Extreme Environment Medicine, University College London Hospitals National Institute for Health Research Biomedical Research Centre, Institute of Sport and Exercise Health, London, United Kingdom
| | - Daniel Martin
- University College London Centre for Altitude, Space, and Extreme Environment Medicine, University College London Hospitals National Institute for Health Research Biomedical Research Centre, Institute of Sport and Exercise Health, London, United Kingdom
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24
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Terada R, Ikeda T, Mori Y, Yamazaki S, Kashiwabara K, Yamauchi H, Ono M, Yamada Y, Okazaki H. Comparison of two point of care whole blood coagulation analysis devices and conventional coagulation tests as a predicting tool of perioperative bleeding in adult cardiac surgery-a pilot prospective observational study in Japan. Transfusion 2019; 59:3525-3535. [PMID: 31614002 DOI: 10.1111/trf.15523] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 06/10/2019] [Accepted: 08/13/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND It is widely accepted that Point-of Care Test (PoCT) devices are useful in the detection of coagulopathies in situations of massive bleeding such as major cardiac surgery. These devices contribute to the reduction of blood transfusion. However, their implementation remains limited in Japan because of their cost and lack of health insurance support. STUDY DESIGN AND METHODS Conventional coagulation tests and thromboelastography (TEG)/Sonoclot values were measured in 50 consecutive cardiac surgery cases. Clinical background information such as operative procedures was obtained from electronic medical records, and the theoretical perioperative total blood loss was calculated by measuring the hemoglobin content and total red blood cell transfusion volume. The correlation between perioperative total blood loss and the measured laboratory values or clinical parameters was evaluated by a multivariate linear regression analysis. The risk factors of the total amount of platelet transfusion and postoperative drain bleeding volume were similarly evaluated. RESULTS No significant association between the estimated perioperative total blood loss (eTBL) and the laboratory measurements including conventional coagulation tests, TEG and Sonoclot was observed. On the other hand, postoperative drain bleeding volume was significantly associated with postoperative Sonoclot CR (p = 0.039) as well as preoperative use of oral anticoagulants and cell saver treated blood volume. Platelet transfusion amount was significantly associated with post-CBP PF and time to peak value of Sonoclot (p = 0.014 and 0.001, respectively). CONCLUSION Sonoclot measurements may be useful to estimate the risks of postoperative bleeding and platelet transfusion in cardiac surgeries in Japan.
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Affiliation(s)
- Rui Terada
- Department of Blood Transfusion, The University of Tokyo Hospital, Tokyo, Japan
| | - Toshiyuki Ikeda
- Department of Blood Transfusion, The University of Tokyo Hospital, Tokyo, Japan
| | - Yoshiteru Mori
- Department of Anesthesiology and Pain Relief Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Sho Yamazaki
- Department of Blood Transfusion, The University of Tokyo Hospital, Tokyo, Japan
| | - Kosuke Kashiwabara
- Department of Biostatistics Division, Clinical Research Support Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Haruo Yamauchi
- Department of Cardiac Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Minoru Ono
- Department of Cardiac Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Yoshitsugu Yamada
- Department of Anesthesiology and Pain Relief Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Hitoshi Okazaki
- Department of Blood Transfusion, The University of Tokyo Hospital, Tokyo, Japan
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25
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Abstract
Two of the most commonly used viscoelastic hemostatic assays, thromboelastometry (ROTEM) and thrombelastography (TEG), have proven to decrease allogenic blood transfusions with cost reduction and possibly decrease mortality and morbidity in cardiac, trauma, and other bleeding patients. This article compares the two devices to provide guidance on the selection and use of these monitoring systems. Their second-generation assays, TEG 6S and ROTEM Sigma, are also discussed.
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Affiliation(s)
- Tetsuro Sakai
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA -
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26
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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: 29] [Impact Index Per Article: 5.8] [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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27
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Citrated kaolin thrombelastography (TEG) thresholds for goal-directed therapy in injured patients receiving massive transfusion. J Trauma Acute Care Surg 2019; 85:734-740. [PMID: 30059456 DOI: 10.1097/ta.0000000000002037] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Goal-directed hemostatic resuscitation based on thrombelastography (TEG) has a survival benefit compared with conventional coagulation assays such as international normalized ratio, activated partial thromboplastin time, fibrinogen level, and platelet count. While TEG-based transfusion thresholds for patients at risk for massive transfusion (MT) have been defined using rapid TEG, cutoffs have not been defined for TEG using other activators such as kaolin. The purpose of this study was to develop thresholds for blood product transfusion using citrated kaolin TEG (CK-TEG) in patients at risk for MT. METHODS CK-TEG was assessed in trauma activation patients at two Level 1 trauma centers admitted between 2010 and 2017. Receiver operating characteristic (ROC) curve analyses were performed to test the predictive performance of CK-TEG measurements in patients requiring MT, defined as >10 units of red blood cells or death within the first 6 hours. The Youden Index defined optimal thresholds for CK-TEG-based resuscitation. RESULTS Of the 825 trauma activations, 671 (81.3%) were men, 419 (50.8%) suffered a blunt injury, and 62 (7.5%) received a MT. Patients who had a MT were more severely injured, had signs of more pronounced shock, and more abnormal coagulation assays. CK-TEG R-time was longer (4.9 vs. 4.4 min, p = 0.0084), angle was lower (66.2 vs. 70.3 degrees, p < 0.0001), maximum amplitude was lower in MT (57 vs. 65.5 mm, p < 0.0001), and LY30 was greater (1.8% vs. 1.2%, p = 0.0012) in patients with MT compared with non-MT. To predict MT, R-time yielded an area under the ROC curve (AUROC) = 0.6002 and a cut point of >4.45 min. Angle had an AUROC = 0.6931 and a cut point of <67 degrees. CMA had an AUROC = 0.7425, and a cut point of <60 mm. LY30 had an AUROC = 0.623 with a cut point of >4.55%. CONCLUSION We have identified CK-TEG thresholds that can guide MT in trauma. We propose plasma transfusion for R-time >4.45 min, fibrinogen products for an angle <67 degrees, platelet transfusion for MA <60 mm, and antifibrinolytics for LY30 >4.55%. LEVEL OF EVIDENCE Therapeutic study, level V.
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28
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Peng HT, Nascimento B, Tien H, Callum J, Rizoli S, Rhind SG, Beckett A. A comparative study of viscoelastic hemostatic assays and conventional coagulation tests in trauma patients receiving fibrinogen concentrate. Clin Chim Acta 2019; 495:253-262. [DOI: 10.1016/j.cca.2019.04.066] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 03/27/2019] [Accepted: 04/15/2019] [Indexed: 12/13/2022]
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29
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Leon-Justel A, Alvarez-Rios AI, Noval-Padillo JA, Gomez-Bravo MA, Porras M, Gomez-Sosa L, Lopez-Romero JL, Guerrero JM. Point-of-care haemostasis monitoring during liver transplantation is cost effective. Clin Chem Lab Med 2019; 57:883-890. [PMID: 30530897 DOI: 10.1515/cclm-2018-0889] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 10/26/2018] [Indexed: 12/12/2022]
Abstract
Background Optimal haemostasis management in orthotropic liver transplant (OLT) could reduce blood loss and transfusion volume, improve patient outcomes and reduce cost. Methods We performed a study including 336 OLTs to evaluate the clinical and cost effectiveness of a new point-of-care (POC)-based haemostatic management approach in OLT patients. Results In terms of health benefit we found that the new approach showed a significant reduction in transfusion requirements (red blood cell transfusion units were reduced from 5.3±4.6 to 2.8±2.9 [p<0.001], free frozen plasma from 3.1±3.3 to 0.4±1.0 [p<0.001] and platelets from 2.9±3.9 to 0.4±0.9 [p<0.001], transfusion avoidance, 9.7% vs. 29.1% [p<0.001] and massive transfusion, 14.5% vs. 3.8% [p=0.001]); we also found a significant improvement in patient outcomes, such, reoperation for bleeding or acute-kidney-failure (8.3% vs. 2.4%, p=0.015; 33.6% vs. 5.4%, p<0.001), with a significant reduction in the length of the hospital total stay (40.6±13.8 days vs. 38.2±14.4 days, p=0.001). The lowest cost incurred was observed with the new approach (€73,038.80 vs. €158,912.90) with significant patient saving associated to transfusion avoidance (€1278.36), ICU-stay (€3037.26), total-stay (€3800.76) and reoperation for bleeding (€80,899.64). Conclusions POC haemostatic monitoring during OLT is cost effective.
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Affiliation(s)
| | - Ana I Alvarez-Rios
- Department of Clinical Biochemistry, Virgen del Rocío University Hospital, Seville, Spain.,Instituto de Biomedicina de Sevilla, IBIS (Universidad de Sevilla, HUVR, Junta de Andalucía, CSIC), Seville, Spain
| | - Jose A Noval-Padillo
- Department of Clinical Biochemistry, Virgen del Rocío University Hospital, Seville, Spain.,Instituto de Biomedicina de Sevilla, IBIS (Universidad de Sevilla, HUVR, Junta de Andalucía, CSIC), Seville, Spain
| | - Miguel A Gomez-Bravo
- Department of Hepatobiliary Surgery, Virgen del Rocío University Hospital, Seville, Spain
| | - Manuel Porras
- Department of Intensive Care Medicine, Virgen del Rocío University Hospital, Seville, Spain
| | - Laura Gomez-Sosa
- Department of Anaesthesiology, Virgen del Rocío University Hospital, Seville, Spain
| | - Juan L Lopez-Romero
- Department of Anaesthesiology, Virgen del Rocío University Hospital, Seville, Spain
| | - Juan M Guerrero
- Department of Clinical Biochemistry, Virgen del Rocío University Hospital, Seville, Spain.,Instituto de Biomedicina de Sevilla, IBIS (Universidad de Sevilla, HUVR, Junta de Andalucía, CSIC), Seville, Spain
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30
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Lim HY, O'Malley C, Donnan G, Nandurkar H, Ho P. A review of global coagulation assays - Is there a role in thrombosis risk prediction? Thromb Res 2019; 179:45-55. [PMID: 31078120 DOI: 10.1016/j.thromres.2019.04.033] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 04/19/2019] [Accepted: 04/30/2019] [Indexed: 01/27/2023]
Abstract
Normal haemostasis requires maintenance of a careful equilibrium between the necessity to clot when bleeding and the retention of fluid phase at all other times. Disruption of this equilibrium can result in catastrophic outcomes, e.g. acute myocardial infarction and pulmonary embolism. However, despite the significant therapeutic advances in cardiovascular medicine over recent years, our ability to provide an accurate cardiovascular risk assessment remains an unmet need. Routine coagulation testing is not a useful reflection of haemostasis and cannot be reliably used to predict bleeding and thrombosis risks. Global coagulation assays such as viscoelastic testing, thrombin and fibrin generation have been proposed as better measures of the haemostatic function. These assays, particularly viscoelastic testing, have been increasingly used to assess bleeding risks and guide blood product replacement in trauma and massive transfusion settings. However, the role of these assays in thrombosis is less well-defined but given the complexities of the coagulation system, these global coagulation assays when used in combination may provide a better assessment of cardiovascular and thrombosis risk at an individual level. Hence, we explore the role of some of the currently available global coagulation assays - the viscoelastic, thrombin generation and fibrin generation tests - and provide a review of the literature of the current evidence for these assays specifically in the field of venous thromboembolism and cardiovascular diseases.
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Affiliation(s)
- Hui Yin Lim
- Department of Haematology, Northern Hospital, 185 Cooper St, Epping, VIC 3076, Australia; Australian Centre for Blood Diseases, Monash University, Monash AMREP Building, Level 1 Walkway via the Alfred Centre, 99 Commercial Road, Melbourne, VIC 3004, Australia; The Florey Institute of Neuroscience and Mental Health, University of Melbourne, 30 Royal Parade (corner Genetics Lane), Parkville, VIC 3052, Australia.
| | - Cindy O'Malley
- RMIT University, Plenty Road, Bundoora, VIC 3083, Australia
| | - Geoffrey Donnan
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, 30 Royal Parade (corner Genetics Lane), Parkville, VIC 3052, Australia
| | - Harshal Nandurkar
- Australian Centre for Blood Diseases, Monash University, Monash AMREP Building, Level 1 Walkway via the Alfred Centre, 99 Commercial Road, Melbourne, VIC 3004, Australia
| | - Prahlad Ho
- Department of Haematology, Northern Hospital, 185 Cooper St, Epping, VIC 3076, Australia; Australian Centre for Blood Diseases, Monash University, Monash AMREP Building, Level 1 Walkway via the Alfred Centre, 99 Commercial Road, Melbourne, VIC 3004, Australia; The Florey Institute of Neuroscience and Mental Health, University of Melbourne, 30 Royal Parade (corner Genetics Lane), Parkville, VIC 3052, Australia
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31
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Yoon J, Cheon J, Choi YJ, Byeon G, Ahn J, Choi E, Park JY. The correlation between conventional coagulation tests and thromboelastography in each phase of liver transplantation. Clin Transplant 2019; 33:e13478. [DOI: 10.1111/ctr.13478] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 12/18/2018] [Accepted: 12/23/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Ji‐Uk Yoon
- Department of Anesthesia and Pain Medicine Pusan National University Yangsan Hospital Yangsan Korea
- Department of Anesthesia and Pain Medicine, School of Medicine Pusan National University Yangsan Korea
| | - Ji‐Hyun Cheon
- Department of Anesthesia and Pain Medicine, School of Medicine Pusan National University Yangsan Korea
| | - Yoon Ji Choi
- Department of Anesthesiology and Pain Medicine Korea University Ansan Hospital Ansan Korea
| | - Gyeong‐Jo Byeon
- Department of Anesthesia and Pain Medicine Pusan National University Yangsan Hospital Yangsan Korea
- Department of Anesthesia and Pain Medicine, School of Medicine Pusan National University Yangsan Korea
| | - Ji‐Hye Ahn
- Department of Dental Anesthesia and Pain Medicine, School of Dentistry Pusan National University, Dental Research Institute Yangsan Korea
| | - Eun‐Ji Choi
- Department of Anesthesia and Pain Medicine Pusan National University Yangsan Hospital Yangsan Korea
- Department of Anesthesia and Pain Medicine, School of Medicine Pusan National University Yangsan Korea
| | - Ju Yeon Park
- Department of Anesthesia and Pain Medicine Pusan National University Yangsan Hospital Yangsan Korea
- Department of Anesthesia and Pain Medicine, School of Medicine Pusan National University Yangsan Korea
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32
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Campbell RAS, Thomson EM, Beattie C. Effect of Liver Disease Etiology on ROTEM Profiles in Patients Undergoing Liver Transplantation. Transplant Proc 2019; 51:783-789. [PMID: 30979465 DOI: 10.1016/j.transproceed.2018.12.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 12/27/2018] [Accepted: 12/28/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Coagulation abnormalities in liver transplant patients are complex and may be related to the underlying liver disease. We evaluated the effects of disease etiology on whole-blood rotational thromboelastometry (ROTEM; Pentapharm GmbH, Munich, Germany) profile and association with thrombotic complications following liver transplantation. METHODS Analysis of perioperative data from patients undergoing liver transplantation between January 1, 2012 and December 31, 2016. Patients were grouped based on the biology of their underlying liver disease: hepatocellular carcinoma (HCC), biliary etiology, and non-biliary etiology. The primary outcome was the EXTEM A10 value of the pre-incision ROTEM. Secondary outcomes included associations between EXTEM A10 value and incidence of postoperative thrombotic complications. RESULTS Three hundred fifty patients met the eligibility criteria: 60 had biliary etiologies, 203 had non-biliary etiologies, and 87 had HCC. EXTEM A10 values were significantly higher in patients with biliary etiologies than those with non-biliary etiologies (mean difference, 13.8; 95% CI: 10.1 to 17.5; P = .001) and those with HCC (mean difference, 10.4; 95% CI: 6.2 to 14.7; P = .001). Patients with non-biliary etiologies had slightly higher values than those with HCC (mean difference, -3.3; 95% CI: -6.6 to -0.1; P = .04). Higher values for biliary etiologies remained after adjusting for liver disease severity, platelet count, and fibrinogen level. There was no significant difference in EXTEM A10 values between patients who suffered thrombotic complications and those who did not (mean difference: 4.3, 95% CI: -1.3 to 9.9, P = .13). CONCLUSION Patients with biliary diseases demonstrated higher EXTEM A10 values compared to those with non-biliary diseases or HCC. This was not fully explained by differences in disease severity, platelet count, or fibrinogen level. Pre-incision EXTEM A10 values do not predict incidence of postoperative thrombotic complications.
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Affiliation(s)
| | - E M Thomson
- Department of Anaesthetics, Critical Care and Pain Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - C Beattie
- Department of Anaesthetics, Critical Care and Pain Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
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33
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The Bleeding Post-op CT Patient: Coagulation Tests Versus Thromboelastography. DIFFICULT DECISIONS IN SURGERY: AN EVIDENCE-BASED APPROACH 2019. [DOI: 10.1007/978-3-030-04146-5_30] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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34
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Zamper RPC, Amorim TC, Queiroz VNF, Lira JDO, Costa LGV, Takaoka F, Juffermans NP, Neto AS. Association between viscoelastic tests-guided therapy with synthetic factor concentrates and allogenic blood transfusion in liver transplantation: a before-after study. BMC Anesthesiol 2018; 18:198. [PMID: 30579327 PMCID: PMC6303918 DOI: 10.1186/s12871-018-0664-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 12/03/2018] [Indexed: 02/06/2023] Open
Abstract
Background Perioperative bleeding and transfusion are important causes of morbidity and mortality in patients undergoing liver transplantation. The aim of this study is to assess whether viscoelastic tests-guided therapy with the use of synthetic factor concentrates impact transfusion rates of hemocomponents in adult patients undergoing liver transplantation. Methods This is an interventional before-after comparative study. Patients undergoing liver transplantation before the implementation of a protocol using thromboelastometry and synthetic factor concentrates were compared to patients after the implementation. Primary outcome was transfusion of any hemocomponents. Secondary outcomes included: transfusion of red blood cells (RBC), fresh frozen plasma (FFP), cryoprecipitate or platelets, clinical complications, length of stay and in-hospital mortality. Results A total of 183 patients were included in the control and 54 in the intervention phase. After propensity score matching, the proportion of patients receiving any transfusion of hemocomponents was lower in the intervention phase (37.0 vs 58.4%; OR, 0.42; 95% CI, 0.20–0.87; p = 0.019). Patients in the intervention phase received less RBC (30.2 vs 52.5%; OR, 0.21; 95% CI, 0.08–0.56; p = 0.002) and FFP (5.7 vs 27.3%; OR, 0.11; 95% CI, 0.03–0.43; p = 0.002). There was no difference regarding transfusion of cryoprecipitate and platelets, complications related to the procedure, hospital length of stay and mortality. Conclusions Use of a viscoelastic test-guided transfusion algorithm with the use of synthetic factor concentrates reduces the transfusion rates of allogenic blood in patients submitted to liver transplantation. Trial registration This trial was registered retrospectively on November 15th, 2018 – clinicaltrials.gov – Identifier: NCT03756948. Electronic supplementary material The online version of this article (10.1186/s12871-018-0664-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Raffael P C Zamper
- Department of Transplant Anesthesia, Hospital Israelita Albert Einstein, Rua Galeno de Almeida 107 ap 172-A, Pinheiros, SP, 05410-030, Brazil.
| | - Thiago C Amorim
- Resident of the Anesthesiology Program, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Veronica N F Queiroz
- Resident of the Anesthesiology Program, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Jordana D O Lira
- Resident of the Anesthesiology Program, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Luiz Guilherme V Costa
- Department of Transplant Anesthesia, Hospital Israelita Albert Einstein, Rua Galeno de Almeida 107 ap 172-A, Pinheiros, SP, 05410-030, Brazil
| | - Flavio Takaoka
- Department of Transplant Anesthesia, Hospital Israelita Albert Einstein, Rua Galeno de Almeida 107 ap 172-A, Pinheiros, SP, 05410-030, Brazil
| | - Nicole P Juffermans
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Ary S Neto
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil.,Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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35
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Thromboelastography and Thromboelastometry in Assessment of Fibrinogen Deficiency and Prediction for Transfusion Requirement: A Descriptive Review. BIOMED RESEARCH INTERNATIONAL 2018; 2018:7020539. [PMID: 30596098 PMCID: PMC6286766 DOI: 10.1155/2018/7020539] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 09/28/2018] [Accepted: 11/06/2018] [Indexed: 12/22/2022]
Abstract
Fibrinogen is crucial for the formation of blood clot and clinical outcomes in major bleeding. Both Thromboelastography (TEG) and Rotational Thromboelastometry (ROTEM) have been increasingly used to diagnose fibrinogen deficiency and guide fibrinogen transfusion in trauma and surgical bleeding patients. We conducted a comprehensive and comparative review on the technologies and clinical applications of two typical functional fibrinogen assays using TEG (FF TEG) and ROTEM (FIBTEM) for assessment of fibrinogen level and deficiency, and prediction of transfusion requirement. Clot strength and firmness of FF TEG and ROTEM FIBTEM were the most used parameters, and their associations with fibrinogen levels as measured by Clauss method ranged from 0 to 0.9 for FF TEG and 0.27 to 0.94 for FIBTEM. A comparison of the interchangeability and clinical performance of the functional fibrinogen assays using the two systems showed that the results were correlated, but are not interchangeable between the two systems. It appears that ROTEM FIBTEM showed better associations with the Clauss method and more clinical use for monitoring fibrinogen deficiency and predicting transfusion requirements including fibrinogen replacement than FF TEG. TEG and ROTEM functional fibrinogen tests play important roles in the diagnosis of fibrinogen-related coagulopathy and guidance of transfusion requirements. Despite the fact that high-quality evidence is still needed, the two systems are likely to remain popular for the hemostatic management of bleeding patients.
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36
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Thomas W, Samama CM, Greinacher A, Hunt BJ. The utility of viscoelastic methods in the prevention and treatment of bleeding and hospital-associated venous thromboembolism in perioperative care: guidance from the SSC of the ISTH. J Thromb Haemost 2018; 16:2336-2340. [PMID: 30171663 DOI: 10.1111/jth.14265] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Indexed: 12/19/2022]
Affiliation(s)
- W Thomas
- Department of Haematology, Haemophilia and Thrombophilia Centre, Box 217, Addenbrooke's Hospital, Cambridge, UK
| | - C-M Samama
- Department of Anaesthesia and Intensive Care, Assistance publique-Hôpitaux de Paris, Cochin University Hospital, Université Paris Descartes, Paris, France
| | - A Greinacher
- Institut für Immunologie und Transfusionsmedizin, Greifswald, Germany
| | - B J Hunt
- Thrombosis and Haemophilia Centre, Guy's & St Thomas' Hospital NHS Foundation Trust, London, UK
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Incidence and clinical significance of hyperfibrinolysis during living donor liver transplantation. Blood Coagul Fibrinolysis 2018; 29:322-326. [PMID: 29621008 DOI: 10.1097/mbc.0000000000000733] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
: We evaluated the incidence and clinical significance of hyperfibrinolysis during living donor liver transplantation (LDLT) using viscoelastic coagulation tests. We retrospectively reviewed adult LDLT recipients from February 2010 to February 2015. Hyperfibrinolysis was defined when clot lysis index [LY60 = (MA - A60)/MA × 100, %] was less than 85, where A60 is the clot amplitude at 60 min after maximum amplitude (MA) occurred. Viscoelastic coagulation tests were performed six times (T1: immediately after anesthetic induction, T2: end of preanhepatic phase, T3: 1 h after anhepatic phase, T4: 5 min after reperfusion, T5: 1 h after reperfusion, and T6: 3 h after reperfusion). One hundred-ten recipients were included in final analysis. Hyperfibrinolysis was uncommon in preanhepatic phase (0% at T1 and 4.5% at T2) and aggravated during anhepatic phase and peaked immediately after reperfusion, 18% at T3 and 71% at T4. However, hyperfibrinolysis nearly disappeared 1 h after reperfusion and did not recur; 0.9% at T5 and 0% at T6. Hyperfibrinolysis was not predicted from preoperative demographics and coagulation profiles. However, the degree of coagulation profile derangements and intraoperative blood loss was greater in the hyperfibrinolysis group. During LDLT, hyperfibrionlysis frequently occurred at anhepatic phase and immediately after reperfusion, but it was resolved during postreperfusion phase.
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Veronese LR, Miller M, Spearman WC. Thromboelastography in mild, chronic liver disease: challenging conventional coagulation tests preceding liver biopsy. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2018. [DOI: 10.1080/22201181.2018.1510234] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- LR Veronese
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
| | - M Miller
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
| | - WC Spearman
- Division of Hepatology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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Abuelkasem E, Tanaka KA, Planinsic RM. Recent update on coagulation management and hemostatic therapies in liver transplantation. Minerva Anestesiol 2018; 84:1070-1080. [DOI: 10.23736/s0375-9393.18.12487-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Curry NS, Davenport R, Pavord S, Mallett SV, Kitchen D, Klein AA, Maybury H, Collins PW, Laffan M. The use of viscoelastic haemostatic assays in the management of major bleeding: A British Society for Haematology Guideline. Br J Haematol 2018; 182:789-806. [PMID: 30073664 DOI: 10.1111/bjh.15524] [Citation(s) in RCA: 113] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Nicola S Curry
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,NIHR BRC, Blood Theme, Oxford University, Oxford, UK
| | - Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Sue Pavord
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,NIHR BRC, Blood Theme, Oxford University, Oxford, UK
| | - Susan V Mallett
- Department of Anaesthesia, Royal Free London NHS Foundation Trust, London, UK
| | | | - Andrew A Klein
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
| | - Helena Maybury
- Department of Obstetrics, Leicester Royal Infirmary, Leicester, UK
| | - Peter W Collins
- Department of Haematology, School of Medicine, Cardiff University, Cardiff, UK
| | - Mike Laffan
- Department of Haematology, Imperial College and Hammersmith Hospital, London, UK
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Bleszynski MS, Bressan AK, Joos E, Morad Hameed S, Ball CG. Acute care and emergency general surgery in patients with chronic liver disease: how can we optimize perioperative care? A review of the literature. World J Emerg Surg 2018; 13:32. [PMID: 30034510 PMCID: PMC6052581 DOI: 10.1186/s13017-018-0194-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 07/10/2018] [Indexed: 12/15/2022] Open
Abstract
The increasing prevalence of advanced cirrhosis among operative candidates poses a major challenge for the acute care surgeon. The severity of hepatic dysfunction, degree of portal hypertension, emergency of surgery, and severity of patients’ comorbidities constitute predictors of postoperative mortality. Comprehensive history taking, physical examination, and thorough review of laboratory and imaging examinations typically elucidate clinical evidence of hepatic dysfunction, portal hypertension, and/or their complications. Utilization of specific scoring systems (Child-Pugh and MELD) adds objectivity to stratifying the severity of hepatic dysfunction. Hypovolemia and coagulopathy often represent major preoperative concerns. Resuscitation mandates judicious use of intravenous fluids and blood products. As a general rule, the most expeditious and least invasive operative procedure should be planned. Laparoscopic approaches, advanced energy devices, mechanical staplers, and topical hemostatics should be considered whenever applicable to improve safety. Precise operative technique must acknowledge common distortions in hepatic anatomy, as well as the risk of massive hemorrhage from porto-systemic collaterals. Preventive measures, as well as both clinical and laboratory vigilance, for postoperative hepatic and renal decompensation are essential.
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Affiliation(s)
| | - Alexsander K Bressan
- 2Department of Surgery, University of Calgary, Foothills Medical Centre, 1403 - 29 Street NW, Calgary, Alberta Canada
| | - Emilie Joos
- 1Department of Surgery, University of British Columbia, Vancouver, Canada
| | - S Morad Hameed
- 1Department of Surgery, University of British Columbia, Vancouver, Canada
| | - Chad G Ball
- 2Department of Surgery, University of Calgary, Foothills Medical Centre, 1403 - 29 Street NW, Calgary, Alberta Canada
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43
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Roullet S, de Maistre E, Ickx B, Blais N, Susen S, Faraoni D, Garrigue D, Bonhomme F, Godier A, Lasne D. Position of the French Working Group on Perioperative Haemostasis (GIHP) on viscoelastic tests: What role for which indication in bleeding situations? Anaesth Crit Care Pain Med 2018; 38:539-548. [PMID: 29355793 DOI: 10.1016/j.accpm.2017.12.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 12/18/2017] [Accepted: 12/18/2017] [Indexed: 12/12/2022]
Abstract
PURPOSE Viscoelastic tests (VETs), thromboelastography (TEG®) and thromboelastometry (ROTEM®) are global tests of coagulation performed on whole blood. They evaluate the mechanical strength of a clot as it builds and develops after coagulation itself. The time required to obtain haemostasis results remains a major problem for clinicians dealing with bleeding, although some teams have developed a rapid laboratory response strategy. Indeed, the value of rapid point-of-care diagnostic devices such as VETs has increased over the years. However, VETs are not standardised and there are few recommendations from the learned societies regarding their use. In 2014, the recommendations of the International Society of Thrombosis and Haemostasis (ISTH) only concerned haemophilia. The French Working Group on Perioperative haemostasis (GIHP) therefore proposes to summarise knowledge on the clinical use of these techniques in the setting of emergency and perioperative medicine. METHODS A review of the literature. PRINCIPAL FINDINGS The role of the VETs seems established in the management of severe trauma and in cardiac surgery, both adult and paediatric. In other situations, their role remains to be defined: hepatic transplantation, postpartum haemorrhage, and non-cardiac surgery. They must be part of the global management of haemostasis based on algorithms defined in each centre and for each population of patients. Their position at the bedside or in the laboratory is a matter of discussion between clinicians and biologists. CONCLUSION VETs must be included in algorithms. In consultation with the biology laboratory, these devices should be situated according to the way each centre functions.
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Affiliation(s)
- Stéphanie Roullet
- Inserm U 12-11, service anesthésie-réanimation 1, université de Bordeaux, CHU de Bordeaux, 33000 Bordeaux, France.
| | | | - Brigitte Ickx
- Université Libre de Bruxelles, Erasme University Hospital, Department of Anesthesiology, Brussels, Belgium
| | - Normand Blais
- Hématologie et oncologie médicale, CHUM, Montréal, Canada
| | - Sophie Susen
- Institut d'hématologie et transfusion, CHRU de Lille, 59037 Lille, France
| | - David Faraoni
- Department of Anaesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | | | - Fanny Bonhomme
- Service d'anesthésiologie, hôpital universitaire de Genève, Geneva, Switzerland
| | - Anne Godier
- Service d'anesthésie-réanimation, Fondation Rothschild, 75019 Paris, France
| | - Dominique Lasne
- Laboratoire d'hématologie, hôpital Necker, 75015 Paris, France
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Forkin KT, Colquhoun DA, Nemergut EC, Huffmyer JL. The Coagulation Profile of End-Stage Liver Disease and Considerations for Intraoperative Management. Anesth Analg 2018; 126:46-61. [PMID: 28795966 DOI: 10.1213/ane.0000000000002394] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The coagulopathy of end-stage liver disease results from a complex derangement in both anticoagulant and procoagulant processes. With even minor insults, cirrhotic patients experience either inappropriate bleeding or clotting, or even both simultaneously. The various phases of liver transplantation along with fluid and blood product administration may contribute to additional disturbances in coagulation. Thus, anesthetic management of patients undergoing liver transplantation to improve hemostasis and avoid inappropriate thrombosis in the perioperative environment can be challenging. To add to this challenge, traditional laboratory tests of coagulation are difficult to interpret in patients with end-stage liver disease. Viscoelastic coagulation tests such as thromboelastography (Haemonetics Corporation, Braintree, MA) and rotational thromboelastometry (TEM International, Munich, Germany) have helped to reduce transfusion of allogeneic blood products, especially fresh frozen plasma, but have also lead to the increased use of fibrinogen-containing products. In general, advancements in surgical techniques and anesthetic management have led to significant reduction in blood transfusion requirements during liver transplantation. Targeted transfusion protocols and pharmacologic prevention of fibrinolysis may further aid in the management of the complex coagulopathy of end-stage liver disease.
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Affiliation(s)
- Katherine T Forkin
- From the Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | | | - Edward C Nemergut
- From the Department of Anesthesiology, University of Virginia, Charlottesville, Virginia.,Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Julie L Huffmyer
- From the Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
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Wahlen BM, El-Menyar A, Peralta R, Al-Thani H. World Academic Council of Emergency Medicine Experience Document: Implementation of Point-of-Care Thromboelastography at an Academic Emergency and Trauma Center. J Emerg Trauma Shock 2018; 11:265-270. [PMID: 30568368 PMCID: PMC6262651 DOI: 10.4103/jets.jets_134_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background: We aimed to discuss the initial experience of the implementation of point-of-care thromboelastography (POC-TEG) at the Level 1 Trauma Center of an academic health institution in Qatar. Materials and Methods: A TEG protocol was developed and tailored to our hospital requirements and patient population, after an exhausting review of the literature and international published protocols, including a synthesis of a preexisting TEG protocol from our heart hospital. To successfully achieve the incorporation of point-of-care testing (POCT) in our clinical practice, a multidisciplinary organizational and education approach is required. The education and training of the physicians in this POCT modality during the first 3 months period has been described in detail. Results: A TEG protocol has been developed and implemented according to hospital standards. Ten physicians from the department of trauma surgery have been trained over a 3-month period to perform the daily quality control as well as the patient samples in order to provide a 24/7 service. In patients with major trauma, brain injury, bleeding, sepsis, and coagulopathy are the most important determinants of the clinical course and outcomes. Viscoelastic whole-blood assays have already proved their values in cardiac as well as liver surgery. Therefore, this POCT-directed approach would be considered as a part of the goal-directed management in severe polytrauma patients. Conclusions: Our experience shows that implementation of POC-TEG program is feasible and it is a promising tool in the management of major trauma patients with a potential compromised coagulation. However, further prospective research projects and well-trained personnel still warranted.
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Affiliation(s)
- Bianca M Wahlen
- Department of Anesthesia and Trauma Surgery, Hamad General Hospital, Doha, Qatar
| | - Ayman El-Menyar
- Department of Surgery, Trauma and Vascular Surgery, Clinical Research, Hamad General Hospital, Doha, Qatar.,Department of Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
| | - Ruben Peralta
- Department of Surgery, Trauma Surgery, Hamad General Hospital, Doha, Qatar
| | - Hassan Al-Thani
- Department of Surgery, Trauma and Vascular Surgery, Hamad General Hospital, Doha, Qatar
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46
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Blaine KP, Sakai T. Viscoelastic Monitoring to Guide Hemostatic Resuscitation in Liver Transplantation Surgery. Semin Cardiothorac Vasc Anesth 2017; 22:150-163. [PMID: 29099334 DOI: 10.1177/1089253217739121] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Coagulopathic bleeding must be anticipated during liver transplantation (LT) surgery. Patients with end-stage liver disease (ESLD) often present with disease-related hematologic disturbances, including the loss of hepatic procoagulant and anticoagulant clotting factors and thrombocytopenia. Transplantation surgery itself presents additional hemostatic changes, including hyperfibrinolysis. Viscoelastic monitoring (VEM) is often used to provide targeted, personalized hemostatic therapies for complex bleeding states including cardiac surgery and major trauma. The use in these coagulopathic conditions led to its application to LT, although the mechanisms of coagulopathy in these patients are quite different. While VEM is often used during transplant surgeries in Europe and North America, evidence supporting its use is limited to a few small clinical studies. The theoretical and clinical applications of the standard and specialized VEM assays are discussed in the setting of LT and ESLD.
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Affiliation(s)
- Kevin P Blaine
- 1 Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Tetsuro Sakai
- 2 University of Pittsburgh Medical Center Health System, Pittsburgh, PA, USA
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Chow JH, Lee K, Abuelkasem E, Udekwu OR, Tanaka KA. Coagulation Management During Liver Transplantation: Use of Fibrinogen Concentrate, Recombinant Activated Factor VII, Prothrombin Complex Concentrate, and Antifibrinolytics. Semin Cardiothorac Vasc Anesth 2017; 22:164-173. [DOI: 10.1177/1089253217739689] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Coagulation management, and transfusion practice in liver transplantation (LT) have been evolving in the recent years due to better understanding of coagulation abnormalities in end-stage liver disease, and clinical management of LT patients. Avoidance of allogeneic blood components is feasible in some patients, but multi-modal coagulation therapies may be necessary in others who develop complex coagulopathy due to hemorrhage, hemodilution, hypothermia, and acid-base disturbances. Transfusions of plasma and cryoprecipitate remain to be the mainstay therapy for procoagulant factor replacement during LT. Clinical efficacy and safety of these products are limited by logistic issues (eg, thawing), and mostly noninfectious complications. Considering potential alternatives to conventional transfusion is thus important to improve hemostatic resuscitation in complex LT cases. The present review is mainly focused on procoagulant properties of plasma and platelet transfusion, and currently available plasma-derived and recombinant factor concentrates, and antifibrinolytic agents in LT patients. The role of viscoelastic coagulation tests to guide specific component therapies will be also discussed.
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Affiliation(s)
| | - Khang Lee
- University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Obi R. Udekwu
- University of Maryland School of Medicine, Baltimore, MD, USA
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Bhardwaj V, Malhotra P, Hasija S, Chowdury UK, Pangasa N. Coagulopathies in cyanotic cardiac patients: An analysis with three point - of - care testing devices (Thromboelastography, rotational thromboelastometry, and sonoclot analyzer). Ann Card Anaesth 2017; 20:212-218. [PMID: 28393783 PMCID: PMC5408528 DOI: 10.4103/aca.aca_4_17] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Introduction: In the last few years, viscoelastic point-of-care (POC) coagulation devices such as thromboelastography (TEG), rotational thromboelastometry (ROTEM), and Sonoclot (SON) analyzer have been increasingly used in major surgeries for timely assessment and management of coagulopathies. The aim of the present study was to evaluate coagulation profile of cyanotic cardiac patients with TEG, ROTEM, and SON analyzer. In addition, we assessed the correlation of standard laboratory coagulation tests and postoperative chest drain output (CDO) with the parameters of POC testing devices. Materials and Methods: Thirty-five patients of either gender, belonging to the American Society of Anesthesiologists Grade I–III, and undergoing elective cardiac surgery on cardiopulmonary bypass for cyanotic congenital heart disease were included in this study. To identify possible coagulation abnormalities, blood samples for TEG, ROTEM, SON, and standard laboratory coagulation were collected after induction of anesthesia. The correlations between variables were assessed using Pearson's correlation coefficient. P < 0.05 was considered statistically significant. Results and Discussion: EXTEM clot time (CT) and clot formation time (CFT) were prolonged in 87% and 45% patients whereas INTEM CT and CFT were prolonged in 36% and 73% patients, respectively. FIBTEM maximum clot firmness (MCF) was decreased in 30% patients. We observed significant correlation between fibrinogen concentration and ROTEM FIBTEM MCF (r = 0.94, P < 0.001). The SON platelet function (SON PF) showed good correlation with platelet count (r = 0.85, P < 0.001). We also found significant correlation between preoperative FIBTEM MCF and CDO in first 4 postoperative hours (r = 0.49, P = 0.004) and 24 postoperative hours (r = 0.52, P = 0.005). Receiver operating characteristic analysis demonstrated that SON PF and TEG maximum amplitude are highly predictive of thrombocytopenia below 100 × 109/L (area under the curve [AUC] - 0.97 and 0.92, respectively), while FIBTEM-MCF is highly predictive of hypofibrinogenemia (fibrinogen <150 mg/dL (AUC, 0.99). Conclusion: Cyanotic cardiac patients have preoperative coagulation abnormalities in ROTEM, TEG, and SON parameters. ROTEM FIBTEM is highly predictive of hypofibrinogenemia while SON PF is highly predictive of thrombocytopenia. ROTEM FIBTEM can be studied as a marker of increased postoperative CDO.
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Affiliation(s)
- Vandana Bhardwaj
- Department of Cardiac Anaesthesia, Cardio Thoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Poonam Malhotra
- Department of Cardiac Anaesthesia, Cardio Thoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Suruchi Hasija
- Department of Cardiac Anaesthesia, Cardio Thoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Ujjwal Kumar Chowdury
- Department of Cardio Thoracic Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Neha Pangasa
- Department of Cardiac Anaesthesia, Cardio Thoracic Centre, All India Institute of Medical Sciences, New Delhi, India
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Abstract
Organ transplantation recipients present unusual challenges with regard to blood transfusion. Although this patient population requires a larger proportion of blood product resources, liberal transfusion of allogeneic blood products can lead to a plethora of complications. Recent trends suggest that efforts to minimize bleeding, conserve products, and target transfusion to specific deficits and needs are increasingly becoming the standard practice; these must all occur with optimization of graft function and preservation in mind. With newer monitoring modalities and factor concentrates, the approach toward transfusion and bleeding in organ transplantation has rapidly improved in recent years.
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Affiliation(s)
- Jaswanth Madisetty
- Department of Anesthesiology and Pain Management, William P. Clements University Hospital, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, MC 9202, Dallas, TX 75390, USA
| | - Cynthia Wang
- Department of Anesthesiology and Pain Management, William P. Clements University Hospital, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, MC 9202, Dallas, TX 75390, USA.
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Abuelkasem E, Hasan S, Mazzeffi MA, Planinsic RM, Sakai T, Tanaka KA. Reduced Requirement for Prothrombin Complex Concentrate for the Restoration of Thrombin Generation in Plasma From Liver Transplant Recipients. Anesth Analg 2017; 125:609-615. [DOI: 10.1213/ane.0000000000002106] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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