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George CE, Saunders CV, Morrison A, Scorer T, Jones S, Dempsey NC. Cold stored platelets in the management of bleeding: is it about bioenergetics? Platelets 2023; 34:2188969. [PMID: 36922733 DOI: 10.1080/09537104.2023.2188969] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
When platelet concentrates (PCs) were first introduced in the 1960s as a blood component therapy, they were stored in the cold. As platelet transfusion became more important for the treatment of chemotherapy-induced thrombocytopenia, research into ways to increase supply intensified. During the late 1960s/early 1970s, it was demonstrated through radioactive labeling of platelets that room temperature platelets (RTP) had superior post-transfusion recovery and survival compared with cold-stored platelets (CSP). This led to a universal switch to room temperature storage, despite CSP demonstrating superior hemostatic effectiveness upon being transfused. There has been a global resurgence in studies into CSP over the last two decades, with an increase in the use of PC to treat acute bleeding within hospital and pre-hospital care. CSP demonstrate many benefits over RTP, including longer shelf life, decreased bacterial risk and easier logistics for transport, making PC accessible in areas where they have not previously been, such as the battlefield. In addition, CSP are reported to have greater hemostatic function than RTP and are thus potentially better for the treatment of bleeding. This review describes the history of CSP, the functional and metabolic assays used to assess the platelet storage lesion in PC and the current research, benefits and limitations of CSP. We also discuss whether the application of new technology for studying mitochondrial and glycolytic function in PC could provide enhanced understanding of platelet metabolism during storage and thus contribute to the continued improvements in the manufacturing and storage of PC.
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Affiliation(s)
- Chloe E George
- Component Development & Research, Welsh Blood Service, Talbot Green, Llantrisant, UK
| | - Christine V Saunders
- Component Development & Research, Welsh Blood Service, Talbot Green, Llantrisant, UK
| | - Alex Morrison
- Scottish National Blood Transfusion Service, Jack Copland Centre, Research Avenue North, Heriot-Watt University, Edinburgh, UK
| | - Tom Scorer
- Centre of Defence Pathology, Royal Centre of Defence Medicine, Birmingham, UK and
| | - Sarah Jones
- Centre for Bioscience, Manchester Metropolitan University, Manchester, UK
| | - Nina C Dempsey
- Centre for Bioscience, Manchester Metropolitan University, Manchester, UK
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2
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Short KM, Estiarte MA, Pham SM, Williams DC, Igoudin L, Dash S, Sandoval N, Datta A, Pozzi N, Di Cera E, Kita DB. Discovery of novel N-acylpyrazoles as potent and selective thrombin inhibitors. Eur J Med Chem 2023; 246:114855. [PMID: 36462436 DOI: 10.1016/j.ejmech.2022.114855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 10/08/2022] [Accepted: 10/08/2022] [Indexed: 01/04/2023]
Abstract
Direct oral anticoagulants (DOACs), which includes thrombin and factor Xa inhibitors, have emerged as the preferred therapeutics for thrombotic disorders, penetrating a market previously dominated by warfarin and heparin. This article describes the discovery and profiling of a novel series of N-acylpyrazoles, which act as selective, covalent, reversible, non-competitive inhibitors of thrombin. We describe in vitro stability issues associated with this chemotype and, importantly, demonstrate that N-acylpyrazoles successfully act in vivo as anticoagulants in basic thrombotic animal models. Crucially, this anticoagulant nature is unaccompanied by the higher bleeding risk profile that has become an undesirable characteristic of the DTIs and factor Xa inhibitors. We propose that the N-acylpyrazole chemotype shows intriguing promise as next-generation oral anticoagulants.
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Affiliation(s)
- Kevin M Short
- Verseon, 47071 Bayside Parkway, Fremont, CA, 94538, USA.
| | | | - Son M Pham
- Verseon, 47071 Bayside Parkway, Fremont, CA, 94538, USA
| | | | - Lev Igoudin
- Verseon, 47071 Bayside Parkway, Fremont, CA, 94538, USA
| | - Subhadra Dash
- Verseon, 47071 Bayside Parkway, Fremont, CA, 94538, USA
| | | | - Anirban Datta
- Verseon, 47071 Bayside Parkway, Fremont, CA, 94538, USA
| | - Nicola Pozzi
- Department of Biochemistry and Molecular Biology, Edward A. Doisy Research Center, Saint Louis University School of Medicine, 1100 South Grand Blvd., St. Louis, MO, 63104, USA
| | - Enrico Di Cera
- Department of Biochemistry and Molecular Biology, Edward A. Doisy Research Center, Saint Louis University School of Medicine, 1100 South Grand Blvd., St. Louis, MO, 63104, USA
| | - David B Kita
- Verseon, 47071 Bayside Parkway, Fremont, CA, 94538, USA
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3
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Thrombin generation and bleeding in cardiac surgery: a clinical narrative review. Can J Anaesth 2020; 67:746-753. [PMID: 32133581 DOI: 10.1007/s12630-020-01609-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 01/20/2020] [Accepted: 01/21/2020] [Indexed: 12/27/2022] Open
Abstract
This narrative review discusses the role of thrombin generation in coagulation and bleeding in cardiac surgery, the laboratory methods for clinical detection of impaired thrombin generation, and the available hemostatic interventions that can be used to improve thrombin generation. Coagulopathy after cardiopulmonary bypass (CPB) is associated with excessive blood loss and adverse patient outcomes. Thrombin plays a crucial role in primary hemostasis, and impaired thrombin generation can be an important cause of post-CPB coagulopathy. Existing coagulation assays have significant limitations in assessing thrombin generation, but whole-blood assays designed to measure thrombin generation at the bed-side are under development. Until then, clinicians may need to institute therapy empirically for non-surgical bleeding in the setting of normal coagulation measures. Available therapies for impaired thrombin generation include administration of plasma, prothrombin complex concentrate, and bypassing agents (recombinant activated factor VII and factor eight inhibitor bypassing activity). In vitro experiments have explored the relative potency of these therapies, but clinical studies are lacking. The potential incorporation of thrombin generation assays into clinical practice and treatment algorithms for impaired thrombin generation must await further clinical development.
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Bontekoe IJ, van der Meer PF, Korte D. Thromboelastography as a tool to evaluate blood of healthy volunteers and blood component quality: a review. Vox Sang 2019; 114:643-657. [DOI: 10.1111/vox.12823] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 05/16/2019] [Accepted: 06/12/2019] [Indexed: 12/27/2022]
Affiliation(s)
| | | | - Dirk Korte
- Sanquin Blood Supply Amsterdam The Netherlands
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5
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Pohlman TH, Fecher AM, Arreola-Garcia C. Optimizing transfusion strategies in damage control resuscitation: current insights. J Blood Med 2018; 9:117-133. [PMID: 30154676 PMCID: PMC6108342 DOI: 10.2147/jbm.s165394] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
From clinical and laboratory studies of specific coagulation defects induced by injury, damage control resuscitation (DCR) emerged as the most effective management strategy for hemorrhagic shock. DCR of the trauma patient who has sustained massive blood loss consists of 1) hemorrhage control; 2) permissive hypotension; and 3) the prevention and correction of trauma-induced coagulopathies, referred to collectively here as acute coagulopathy of trauma (ACOT). Trauma patients with ACOT have higher transfusion requirements, may eventually require massive transfusion, and are at higher risk of exsanguinating. Distinct impairments in the hemostatic system associated with trauma include acquired quantitative and qualitative platelet defects, hypocoagulable and hypercoagulable states, and dysregulation of the fibrinolytic system giving rise to hyperfibrinolysis or a phenomenon referred to as fibrinolytic shutdown. Furthermore, ACOT is a component of a systemic host defense dysregulation syndrome that bears several phenotypic features comparable with other acute systemic physiological insults such as sepsis, myocardial infarction, and postcardiac arrest syndrome. Progress in the science of resuscitation has been continuing at an accelerated rate, and clinicians who manage catastrophic blood loss may be incompletely informed of important advances that pertain to DCR. Therefore, we review recent findings that further characterize the pathophysiology of ACOT and describe the application of this new information to optimization of resuscitation strategies for the patient in hemorrhagic shock.
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Affiliation(s)
- Timothy H Pohlman
- Department of Surgery, Lutheran Hospital of Indiana, Fort Wayne, IN, USA,
| | - Alison M Fecher
- Department of Surgery, Lutheran Hospital of Indiana, Fort Wayne, IN, USA
| | - Cecivon Arreola-Garcia
- Department of Surgery, Section of Acute Care Surgery, Indiana University Health, Indianapolis, IN, USA
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6
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Schneider T, Siegemund T, Siegemund R, Petros S. Thrombin generation and rotational thromboelastometry in the healthy adult population. Hamostaseologie 2017; 35:181-6. [DOI: 10.5482/hamo-14-08-0033] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Accepted: 12/05/2014] [Indexed: 11/05/2022] Open
Abstract
SummaryPublished data on thrombin generation variables and their correlation with thrombo - elastometry in the healthy population are scarce. This study aimed at assessing thrombin generation in adults and its correlation to classical rotational thromboelastometry (ROTEM).Thrombin generation was measured in platelet-poor plasma from healthy volunteers using the calibrated automated thrombogram (CAT) with 1 and 5 pmol/l tissue factor final concentration. Lag time, thrombin peak, time to thrombin peak and endogenous thrombin potential (ETP) were analyzed. ROTEM was performed without activator (NATEM) and data for clotting time, alpha angle, clot formation time and maximum clot firmness were correlated with those of thrombin generation.Altogether 132 persons (72 men, 60 women; median age: 48.0 years) were included. There was a positive non-linear correlation for age versus lag time (p < 0.001) and time to peak (p = 0.001), and almost linear correlation for age versus thrombin peak (p = 0.024) and ETP (p = 0.001), although with a moderate regression slope. Regarding ROTEM, there was a positive correlation between age and maximum clot firmness and alpha angle (p = 0.001), but a negative correlation between age and clotting time (p = 0.039). Comparing both assays, thrombin peak and ETP measured with a final tissue factor concentration of 5 pmol/l correlated significantly with alpha angle and maximum clot firmness.The age-related changes in CAT and ROTEM variables among adults are not linear. There is a significant correlation, although with a moderate slope, between data from CAT measured with 5 pmol/l tissue factor and ROTEM.
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Rieg A, Rossaint R, Braunschweig T, Spronk H, ten Cate H, van Oerle R, Tolba R, Honickel M, Grottke O. Prothrombin complex concentrate reduces blood loss and enhances thrombin generation in a pig model with blunt liver injury under severe hypothermia. Thromb Haemost 2017; 106:724-33. [DOI: 10.1160/th11-02-0101] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2011] [Accepted: 07/18/2011] [Indexed: 01/05/2023]
Abstract
SummaryAlthough prothrombin complex concentrate (PCC) is increasingly used for the treatment of trauma-induced coagulopathy, few studies have investigated the impact and safety of PCC for this indication. The present study was performed to assess PCC for treatment of coagulopathy after blunt liver injury under severe hypothermia. Coagulopathy in 14 anaesthetised pigs was induced by haemodilution. Subsequently, standardised blunt liver injury was induced under severe hypothermia (32.8–33.2°C). Animals were randomised to receive either PCC (35 IU kg-1) or saline (control). Coagulation was assessed over the following 2 hours by thromboelastometry and thrombin generation. Internal organs were examined to determine presence of emboli. The administration of PCC showed a significant reduction in blood loss (p=0.002 vs. controls) and a significant increase in the rate of survival (p=0.022 vs. controls). Plasma thrombin generation in the PCC group increased considerably above baseline levels, with significant increases in peak thrombin levels and endogenous thrombin potential versus controls throughout the follow-up period. In addition, PT decreased significantly in the PCC group versus the control group. However, only slight improvements in thromboelastometry variables were observed. Histology showed an equal degree of liver injury in both groups, and no thromboembolism. In severely hypothermic pigs, the application of PCC corrected trauma-induced coagulopathy and reduced blood loss. Thus, the infusion of PCC might be a reasonable approach to reduce the need for blood cell transfusion in trauma. Furthermore, the impact and safety of PCC application can be monitored through thrombin generation and thromboelastometry under hypothermia.Note: This study was performed at the RWTH Aachen University Hospital, Pauwelsstrasse 30, D-52074 Aachen, Germany.
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Le Quellec S, Paris M, Nougier C, Sobas F, Rugeri L, Girard S, Bordet JC, Négrier C, Dargaud Y. Pre-analytical effects of pneumatic tube system transport on routine haematology and coagulation tests, global coagulation assays and platelet function assays. Thromb Res 2017; 153:7-13. [DOI: 10.1016/j.thromres.2016.12.022] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 12/05/2016] [Accepted: 12/23/2016] [Indexed: 11/30/2022]
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Jansohn E, Bengzon J, Kander T, Schött U. A pilot study on the applicability of thromboelastometry in detecting brain tumour-induced hypercoagulation. Scandinavian Journal of Clinical and Laboratory Investigation 2017; 77:289-294. [DOI: 10.1080/00365513.2017.1306877] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Thrombelastography detects dabigatran at therapeutic concentrations in vitro to the same extent as gold-standard tests. Int J Cardiol 2016; 208:14-8. [DOI: 10.1016/j.ijcard.2016.01.148] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Revised: 01/05/2016] [Accepted: 01/06/2016] [Indexed: 11/21/2022]
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Rasmussen KC, Højskov M, Johansson PI, Kridina I, Kistorp T, Salling L, Nielsen HB, Ruhnau B, Pedersen T, Secher NH. Impact of Albumin on Coagulation Competence and Hemorrhage During Major Surgery: A Randomized Controlled Trial. Medicine (Baltimore) 2016; 95:e2720. [PMID: 26945358 PMCID: PMC4782842 DOI: 10.1097/md.0000000000002720] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
For patients exposed to a massive blood loss during surgery, maintained coagulation competence is important. It is less obvious whether coagulation competence influences bleeding during elective surgery where patients are exposed to infusion of a crystalloid or a colloid. This randomized controlled trial evaluates whether administration of 5% human albumin (HA) or lactated Ringer solution (LR) affects coagulation competence and in turn blood loss during cystectomy due to bladder cancer. Forty patients undergoing radical cystectomy were included to receive either 5% HA (n = 20) or LR (n = 20). Nineteen patients were analyzed in the HA group and 20 patients in the lactated Ringer group. Blinded determination of the blood loss was similar in the 2 groups of patients: 1658 (800-3300) mL with the use of HA and 1472 (700-4330) mL in the lactated Ringer group (P = 0.45). Yet, by thrombelastography (TEG) evaluated coagulation competence, albumin affected clot growth (TEG-angle 69 ± 5 vs 74° ± 3°, P < 0.01) and strength (TEG-MA: 59 ± 6 vs 67 ± 6 mm, P < 0.001) more than LR. Furthermore, by multivariate linear regression analyses reduced TEG-MA was independently associated with the blood loss (P = 0.042) while administration of albumin was related to the changes in TEG-MA (P = 0.029), aPPT (P < 0.022), and INR (P < 0.033). This randomized controlled trial demonstrates that administration of HA does not affect the blood loss as compared to infusion of LR. Also the use of HA did not affect the need for blood transfusion, the incidence of postoperative complications, or the hospital in-stay. Yet, albumin decreases coagulation competence during major surgery and the blood loss is related to TEG-MA rather than to plasma coagulation variables.
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Affiliation(s)
- Kirsten C Rasmussen
- From the Department of Anesthesiology (KCR, MH, IK, TK, HBN, BR, NHS); Department of Urology (LS); Center of Head and Orthopaedic Surgery (TP); Rigshospitalet, University of Copenhagen; Department of Transfusion Medicine, Rigshospitalet and Department of Surgery, Denmark, and University of Texas Health Medical School, Houston, TX, USA (PIJ)
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12
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Rasmussen KC, Hoejskov M, Johansson PI, Kridina I, Kistorp T, Salling L, Nielsen HB, Ruhnau B, Pedersen T, Secher NH. Coagulation competence for predicting perioperative hemorrhage in patients treated with lactated Ringer's vs. Dextran--a randomized controlled trial. BMC Anesthesiol 2015; 15:178. [PMID: 26646213 PMCID: PMC4672483 DOI: 10.1186/s12871-015-0162-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 12/02/2015] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Perioperative hemorrhage may depend on coagulation competence and this study evaluated the influence of coagulation competence on blood loss during cystectomy due to bladder cancer. METHODS Forty patients undergoing radical cystectomy were included in a randomized controlled trial to receive either lactated Ringer's solution or Dextran 70 (Macrodex ®) that affects coagulation competence. RESULTS By thrombelastography evaluated coagulation competence, Dextran 70 reduced "maximal amplitude" (MA) by 25 % versus a 1 % reduction with the administration of lactated Ringer's solution (P <0.001). Blinded evaluation of the blood loss was similar in the two groups of patients - 2339 ml with the use of Dextran 70 and 1822 ml in the lactated Ringer's group (P = 0.27). Yet, the blood loss was related to the reduction in MA (r = -0.427, P = 0.008) and by multiple regression analysis independently associated with MA (P = 0.01). Thus, 11 patients in the dextran group (58 %) developed a clinical significant blood loss (>1500 ml) compared to only four patients (22 %) in the lactated Ringer's group (P = 0.04). CONCLUSIONS With the use of Dextran 70 vs. lactated Ringer's solution during cystectomy, a relation between hemorrhage and coagulation competence is demonstrated. Significant bleeding develops based on an about 25 % reduction in thrombelastography determined maximal amplitude. A multivariable model including maximal amplitude discriminates patients with severe perioperative bleeding during cystectomy. TRIAL REGISTRATION The study was accepted on January 7(th), 2013 at www.clinicaltrialsregister.eu EudraCT 2012-005040-20.
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Affiliation(s)
- Kirsten C Rasmussen
- Departments of Anesthesiology, Transfusion Medicine, University of Copenhagen, Copenhagen, Denmark. .,Departments of Urology and Centre for Head and Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark. .,Department of Anesthesiology, Rigshospitalet 2043, Blegdamsvej 9, DK-2100, Copenhagen Ø, Denmark.
| | - Michael Hoejskov
- Departments of Anesthesiology, Transfusion Medicine, University of Copenhagen, Copenhagen, Denmark. .,Departments of Urology and Centre for Head and Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Per I Johansson
- Departments of Anesthesiology, Transfusion Medicine, University of Copenhagen, Copenhagen, Denmark. .,Departments of Urology and Centre for Head and Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Irina Kridina
- Departments of Anesthesiology, Transfusion Medicine, University of Copenhagen, Copenhagen, Denmark. .,Departments of Urology and Centre for Head and Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Thomas Kistorp
- Departments of Anesthesiology, Transfusion Medicine, University of Copenhagen, Copenhagen, Denmark. .,Departments of Urology and Centre for Head and Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Lisbeth Salling
- Departments of Anesthesiology, Transfusion Medicine, University of Copenhagen, Copenhagen, Denmark. .,Departments of Urology and Centre for Head and Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Henning B Nielsen
- Departments of Anesthesiology, Transfusion Medicine, University of Copenhagen, Copenhagen, Denmark. .,Departments of Urology and Centre for Head and Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Birgitte Ruhnau
- Departments of Anesthesiology, Transfusion Medicine, University of Copenhagen, Copenhagen, Denmark. .,Departments of Urology and Centre for Head and Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Tom Pedersen
- Departments of Anesthesiology, Transfusion Medicine, University of Copenhagen, Copenhagen, Denmark. .,Departments of Urology and Centre for Head and Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Niels H Secher
- Departments of Anesthesiology, Transfusion Medicine, University of Copenhagen, Copenhagen, Denmark. .,Departments of Urology and Centre for Head and Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
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Abstract
PURPOSE OF REVIEW Bleeding in trauma carries a high mortality and is increased in case of coagulopathy. Our understanding of hemostasis and coagulopathy has improved, leading to a change in the protocols for hemostatic monitoring. This review describes the current state of evidence supporting the use of viscoelastic hemostatic assays to guide trauma resuscitation. RECENT FINDINGS Viscoelastic hemostatic assays such as thrombelastography and rotational thrombelastometry have shown to reduce bleeding, transfusion of fresh frozen plasma and platelets, and possibly mortality in different surgical populations. In trauma care, viscoelastic hemostatic assays allows for rapid and timely identification of coagulopathy and individualized, goal-directed transfusion therapy. As part of the resuscitation concept, viscoelastic hemostatic assays seem to improve outcome also in trauma; however, there is a need for randomized clinical trials to confirm this. SUMMARY We are moving toward avoiding coagulopathy by individualized, goal-directed transfusion therapy, using viscoelastic hemostatic assays to guide ongoing resuscitation of actively bleeding patients in a goal-directed manner.
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14
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Monitoring of dabigatran anticoagulation and its reversal in vitro by thrombelastography. Int J Cardiol 2014; 176:794-9. [DOI: 10.1016/j.ijcard.2014.07.084] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Revised: 06/26/2014] [Accepted: 07/26/2014] [Indexed: 11/18/2022]
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15
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Coagulation competence and fluid recruitment after moderate blood loss in young men. Blood Coagul Fibrinolysis 2014; 25:592-6. [DOI: 10.1097/mbc.0000000000000114] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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16
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Hall CA, Lydon HL, Dalton CH, Chipman JK, Graham JS, Chilcott RP. Development of haemostatic decontaminants for the treatment of wounds contaminated with chemical warfare agents. 1: Evaluation ofin vitroclotting efficacy in the presence of certain contaminants. J Appl Toxicol 2014; 35:536-42. [DOI: 10.1002/jat.3019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Revised: 03/21/2014] [Accepted: 03/22/2014] [Indexed: 11/07/2022]
Affiliation(s)
- Charlotte A. Hall
- CBRN & Chemical Toxicological Research Group, Centre for Radiation; Chemical and Environmental Hazards, Health Protection Agency; Chilton UK
- School of Biosciences; University of Birmingham; Birmingham UK
| | - Helen L. Lydon
- CBRN & Chemical Toxicological Research Group, Centre for Radiation; Chemical and Environmental Hazards, Health Protection Agency; Chilton UK
- School of Biosciences; University of Birmingham; Birmingham UK
| | - Christopher H. Dalton
- School of Biosciences; University of Birmingham; Birmingham UK
- Biomedical Sciences; Dstl Porton Down; Salisbury UK
| | - J. K. Chipman
- School of Biosciences; University of Birmingham; Birmingham UK
| | - John S. Graham
- Medical Toxicology Branch Analytical Toxicology Division; US Army Medical Research Institute of Chemical Defense; Aberdeen Proving Ground MD 21010 USA
| | - Robert P. Chilcott
- CBRN & Chemical Toxicological Research Group, Centre for Radiation; Chemical and Environmental Hazards, Health Protection Agency; Chilton UK
- Department of Pharmacy; University of Hertfordshire; Hatfield UK
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Moore HB, Moore EE, Chin TL, Gonzalez E, Chapman MP, Walker CB, Sauaia A, Banerjee A. Activated clotting time of thrombelastography (T-ACT) predicts early postinjury blood component transfusion beyond plasma. Surgery 2014; 156:564-9. [PMID: 24882760 DOI: 10.1016/j.surg.2014.04.017] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Accepted: 04/14/2014] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Rapid thrombelastography (rTEG) has been advocated as a point-of-care test to manage trauma-induced coagulopathy. rTEG activated clotting time (T-ACT) results become available much sooner than other rTEG values, thus offering an attractive tool to guide blood component transfusion in a hemorrhagic shock. We hypothesize that patients with a prolonged T-ACT require replacement of platelets (Plts) and cryoprecipitate (Cryo) in addition to plasma to correct trauma-induced coagulopathy. METHODS A prospective trauma registry was reviewed for patients with an r-TEG available within 3 hours of injury. Blood was collected via a standardized protocol for rTEG. Patients were stratified into quartiles: low (T-ACT <113 seconds), mild (T-ACT 113-120 seconds), moderate (T-ACT 121-140 seconds), and severe (T-ACT >140 seconds). Transfusion requirements were evaluated during the first 6 hours after injury. RESULTS A total of 114 patients were included. Median age was 39 years, injury severity score 20, base-deficit 10, and mortality rate 13%. T-ACT cohorts had similar age (P = .11), injury severity score (P = .55), and base deficit (P = .38). An T-ACT >140 seconds predicted a lower angle (median 57 vs 70, P < .000) and maximum amplitude (46 vs 60, P = .002), and patients received more Cryo (0.5 vs 0, P ≤ .000) and Plts (1 vs 0, P = .006). CONCLUSION Injured patients requiring resuscitation with blood transfusion that have a T-ACT >140 seconds are polycoagulopathic and may benefit from early Cryo and Plts.
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Affiliation(s)
| | - Ernest E Moore
- University of Colorado, Aurora, CO; Denver Health Medical Center, Denver, CO
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18
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Hydroxyethyl starch reduces coagulation competence and increases blood loss during major surgery: results from a randomized controlled trial. Ann Surg 2014; 259:249-54. [PMID: 24100337 DOI: 10.1097/sla.0000000000000267] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE This study evaluated whether administration of hydroxyethyl starch (HES) 130/0.4 affects coagulation competence and influences the perioperative blood loss. BACKGROUND Artificial colloids substitute blood volume during surgery; with the administration of HES 130/0.4 (Voluven, Fresenius Kabi, Uppsala, Sweden) only a minor effect on coagulation competence is expected. METHODS Eighty patients were scanned for enrollment in the study, and 40 patients fulfilled the inclusion criteria. Two patients withdrew their consent to participate in the study, and 5 patients were excluded. Thus, 16 patients were randomized to receive lactated Ringer's solution and 17 to receive HES 130/0.4. RESULTS Among the patients receiving HES 130/0.4, thrombelastography indicated reduced clot strength (P < 0.001) and blinded evaluation of the perioperative blood loss was 2.2 (range 0.5 to 5.0) versus 1.4 (range 0.5 to 2.4) L in the patients who received HES 130/0.4 or lactated Ringer, respectively (P < 0.038). The patients in the lactated Ringer's group, however, received more fluid (P < 0.0001) than those in the HES 130/0.4 group. There was no significant difference between the 2 groups with regard to frequency of reoperations or the length of hospital stay, but use of HES 130/0.4 was both more expensive and less efficacious than the use of lactated Ringer. CONCLUSIONS Administration of HES 130/0.4 reduced clot strength and perioperative hemorrhage increased by more than 50%, while administration of lactated Ringer's solution provoked an approximately 2.5 times greater positive volume balance at the end of surgery.
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Hanel RM, Chan DL, Conner B, Gauthier V, Holowaychuk M, Istvan S, Walker JM, Wood D, Goggs R, Wiinberg B. Systematic evaluation of evidence on veterinary viscoelastic testing Part 4: Definitions and data reporting. J Vet Emerg Crit Care (San Antonio) 2014; 24:47-56. [DOI: 10.1111/vec.12145] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Accepted: 11/15/2013] [Indexed: 12/28/2022]
Affiliation(s)
- Rita M. Hanel
- From the Department of Clinical Sciences; College of Veterinary Medicine; North Carolina State University; Raleigh NC 27607
| | - Daniel L. Chan
- Clinical Science and Services; The Royal Veterinary College; University to London; North Mymms; Hertfordshire UK AL9 7TA
| | - Bobbi Conner
- Department of Small Animal Clinical Sciences; College of Veterinary Medicine; University of Florida; Gainesville FL 32608
| | - Vincent Gauthier
- Department of Clinical Studies; Ontario Veterinary College; University of Guelph; Guelph ON N1L 1G6
| | - Marie Holowaychuk
- Department of Clinical Studies; Ontario Veterinary College; University of Guelph; Guelph ON N1L 1G6
| | | | - Julie M. Walker
- Department of Medical Sciences; School of Veterinary Medicine; University of Wisconsin-Madison; Madison WI
| | - Darren Wood
- Department of Pathobiology; Ontario Veterinary College; University of Guelph; Guelph ON N1L 1G6
| | - Robert Goggs
- Department of Clinical Sciences; College of Veterinary Medicine; Cornell University; Ithaca NY 14853
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Goggs R, Brainard B, de Laforcade AM, Flatland B, Hanel R, McMichael M, Wiinberg B. Partnership on Rotational ViscoElastic Test Standardization (PROVETS): Evidence-based guidelines on rotational viscoelastic assays in veterinary medicine. J Vet Emerg Crit Care (San Antonio) 2014; 24:1-22. [DOI: 10.1111/vec.12144] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Accepted: 11/15/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Robert Goggs
- From the Department of Clinical Sciences; College of Veterinary Medicine; Cornell University; Ithaca NY 14853
| | - Benjamin Brainard
- Department of Small Animal Medicine & Surgery, College of Veterinary Medicine; University of Georgia; Athens GA 30602
| | - Armelle M. de Laforcade
- Department of Clinical Sciences; Tufts Cummings School of Veterinary Medicine; North Grafton MA 01536
| | - Bente Flatland
- Department of Pathobiology, College of Veterinary Medicine; University of Tennessee; Knoxville TN 37996
| | - Rita Hanel
- Department of Clinical Sciences, College of Veterinary Medicine; NC State University; Raleigh NC 27607
| | - Maureen McMichael
- Department of Veterinary Clinical Medicine, College of Veterinary Medicine; University of Illinois; Urbana IL 61801
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Comparison between human and porcine thromboelastograph parameters in response to ex-vivo changes to platelets, plasma, and red blood cells. Blood Coagul Fibrinolysis 2013; 24:818-29. [DOI: 10.1097/mbc.0b013e3283646600] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Comparison of in vitro responses to fresh whole blood and reconstituted whole blood after collagen stimulation. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2013; 12:50-5. [PMID: 24333065 DOI: 10.2450/2013.0303-12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Accepted: 06/10/2013] [Indexed: 11/21/2022]
Abstract
BACKGROUND In patients who have large bleeds, there is a tendency to transfuse more plasma and platelets than recommended in earlier guidelines, and accordingly many hospitals now provide "transfusion packages" with an intended red cell:platelet:plasma ratio of 1:1:1. The purpose of this study was to investigate in vitro functions of transfusion packs compared with fresh whole blood. MATERIAL AND METHODS "Reconstituted whole blood" was prepared with the same ratio of red cells, platelets and plasma as used in local transfusion packages. The aggregation and thrombin-antithrombin complex formation responses to collagen stimulation of this reconstituted whole blood were compared with those of fresh whole blood. The storage time of red cells and platelets was varied in a systematic manner, giving nine different compositions of reconstituted whole blood that simulated transfusion packs. RESULTS The responses varied significantly between whole blood and reconstituted whole blood -and between the reconstituted whole blood of different compositions. A significant decrease (p<0.005) in collagen-induced platelet count reduction was seen with increasing platelet and red blood cell age. Thrombin-antithrombin complex formation peaked in studies with platelets stored for 5 days. The red cells stored for the longest time induced the greatest thrombin-antithrombin complex formation. Fresh whole blood gives more consistent responses, and the aggregation response to collagen is stronger than in reconstituted whole blood. DISCUSSION Our results indicate that in vitro responses of reconstituted whole blood vary substantially according to how long the red cells and platelets are stored for. As the responses obtained by testing whole blood are more consistent and usually stronger, the alternative use fresh whole blood in special conditions should not be excluded without further consideration.
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Clinical markers of the hypercoagulable state by rotational thrombelastometry in obese patients submitted to bariatric surgery. Surg Endosc 2013; 28:543-51. [PMID: 24043645 DOI: 10.1007/s00464-013-3203-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Accepted: 08/23/2013] [Indexed: 12/18/2022]
Abstract
BACKGROUND Metabolic and inflammatory disturbances associated with obesity are considered important trigger factors for venous thromboembolism (VTE). Identification of clinical markers indicating a hypercoagulability state could define a group of high-risk patients in the surgical setting. This study aimed to identify these markers using rotational thrombelastometry (ROTEM) analysis, an established method for hemostasis testing that can detect hyperfunctional stages of the clotting process. METHODS From June to December 2010, this study investigated 109 consecutive obese patients (28 women and 22 men, mean age 46 years, body mass index 46.6 ± 7 kg/m(2)) with no history of VTE who were candidates for bariatric surgery. Preoperative clinical and metabolic characteristics and ROTEM analysis were recorded. Hypercoagulable risk was defined when patients showed a clot strength (G) of ≥11 dynes/cm(2). RESULTS Of the 109 patients, 20 (18%) were hypercoagulable according to ROTEM analysis. Metabolic/inflammatory biomarkers such as leptin, C-reactive protein, fibrinogen levels, and platelet count were significantly higher in the high-risk patients. In the multivariate analysis, fibrinogen was an independent predictor of G ≥ 11 dynes/cm(2) [odds ratio (OR) 2.92, 95 % confidence interval (CI) 1.80-5.21, p = 0.023]. After adjustment to other data, only waist circumference affected the prediction [OR 4.42, 95 % CI 2.27-6.71, p = 0.009]. Receiver operating characteristic curve analysis showed that 3.95 g/l was the best cutoff point for fibrinogen predictability (sensitivity 100 %, specificity 41%). CONCLUSION A hypercoagulability state in obese patients is associated with central obesity and high fibrinogen levels, which should be considered clinical hallmarks of this state. More aggressive perioperative prophylaxis for VTE should be recommended when these hallmarks are present in obese patients.
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Sølbeck S, Ostrowski SR, Johansson PI. A review of the clinical utility of INR to monitor and guide administration of prothrombin complex concentrate to orally anticoagulated patients. Thromb J 2012; 10:5. [PMID: 22546056 PMCID: PMC3413545 DOI: 10.1186/1477-9560-10-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2011] [Accepted: 04/30/2012] [Indexed: 01/21/2023] Open
Abstract
Background and objectives The number of patients treated with oral anticoagulation (OAC) is increasing and these patients are monitored by International Normalized Ratio (INR). Bleeding complications are common and we speculate if this is related to the limitation of INR only reflecting the initiation steps of the haemostatic process. The objective of the present review was to reassess the evidence for using INR as a tool to guide administration of prothrombin complex concentrates (PCC) to OAC patients. A Medline and Cochrane database search was conducted using the following keywords: prothrombin complex concentrate, reversal of oral anticoagulation and international normalized ratio (INR). Thirty-three articles were contracted and a total of ten studies were eligible after applying inclusion and exclusion criteria encompassing only 339 patients. No consensus regarding optimal target INR value to aim for when reversing OAC was found. In three of the studies it was reported that patients reaching their target INR continued to bleed, whereas three studies reviewed reported good haemostatic response also in patients that did not reach their target INR. The present review found limited evidence for the usefulness of INR as a tool to monitor and guide reversal of OAC induced coagulopathy in patients with PCC, which is expected given that it is a plasma-based assay only reflecting a limited part of the haemostatic process.
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Affiliation(s)
- Sacha Sølbeck
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet University of Copenhagen, Blegdamsvej 9, DK-2100, Copenhagen, Denmark.
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Johansson PI, Sølbeck S, Genet G, Stensballe J, Ostrowski SR. Coagulopathy and hemostatic monitoring in cardiac surgery: an update. SCAND CARDIOVASC J 2012; 46:194-202. [PMID: 22375889 DOI: 10.3109/14017431.2012.671487] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES Cardiac surgery with cardiopulmonary bypass (CPB) causes severe derangements in the hemostatic system, which in turn puts the patient at risks of microvascular bleeding. Excessive transfusion and surgical re-exploration after cardiac surgery are potentially associated with a number of adverse outcomes including increased mortality. DESIGN This review describes coagulopathies occurring in cardiac surgery and the monitoring of these. Viscoelastic hemostatic assays (VHA) have routinely been used in cardiac surgery for more than 25 years and at least 16 studies (involving more than 3250 patients, including three randomized controlled trials) have compared VHA to routine coagulation tests (RCoT) with regards to their ability to predict bleeding and re-do surgery and also with regards to transfusion requirements secondary to hemostatic therapy based on VHA vs. RCoT. RESULTS All 16 studies demonstrated superiority with VHA as compared to RCoT both in predicting bleeding and need for re-do surgery and in reducing the total amount of blood transfusions by employing goal-directed administration of blood products based on VHA as compared RCoT based therapy or at the clinicians discretion. CONCLUSIONS The different types of coagulopathies observed in patients undergoing cardiac surgery requires adequate and timely hemostatic therapy and real-time monitoring with WHA such as TEG/ROTEM and whole blood platelet aggregometry.
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Affiliation(s)
- Pär I Johansson
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, University of Copenhagen, Denmark.
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Shenkman B, Livnat T, Misgav M, Budnik I, Einav Y, Martinowitz U. The in vivo effect of fibrinogen and factor XIII on clot formation and fibrinolysis in Glanzmann's thrombasthenia. Platelets 2012; 23:604-10. [PMID: 22273510 DOI: 10.3109/09537104.2011.642031] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Glanzmann's thrombasthenia (GT) is characterized by increased bleeding risk. The treatment options in GT are limited. The aim of this study was to test the effect of GT blood supplementation with fibrinogen and factor XIII on thrombin generation, blood clotting, and fibrinolysis. Whole blood samples of GT patients and normal donors treated with eptifibatide (GT model) were subjected to clotting by CaCl(2) and tissue factor. Thrombin generation was measured in platelet-rich plasma. Clot formation and tPA-induced fibrinolysis were evaluated in whole blood by rotation thromboelastometry (ROTEM). Blood was supplemented with fibrinogen (3 g/L) and/or FXIII (2 IU/mL). Thrombin generation analysis of blood derived from GT model and GT patients revealed decreased endogenous thrombin potential and peak height and extended lag time compared to control. However, this method was not sensitive to blood spiking with fibrinogen and FXIII. ROTEM revealed lower maximum clot firmness (MCF) and area under curve (AUC) in the blood of GT model and GT patients. In the absence of exogenous tPA, blood spiking with fibrinogen markedly enhanced clot quality while FXIII had no effect. Combination of fibrinogen and FXIII did not add to the effect of fibrinogen. In contrast, by the addition of tPA, both fibrinogen and FXIII separately and, to more extent, in combination enhanced clot quality as well as resistance against tPA-induced fibrinolysis (increasing MCF, AUC, and lysis onset time). In conclusion, fibrinogen and FXIII exerted stimulation of blood clotting and inhibition of fibrinolysis. Treating normal blood with eptifibatide mimics the changes of coagulopathy in GT blood.
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Affiliation(s)
- Boris Shenkman
- Institute of Thrombosis & Hemostasis and the National Hemophilia Center, Chaim Sheba Medical Center, Tel-Hashomer, Israel.
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Davenport R, Khan S. Management of major trauma haemorrhage: treatment priorities and controversies. Br J Haematol 2011; 155:537-48. [PMID: 22017416 DOI: 10.1111/j.1365-2141.2011.08885.x] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
The severely injured trauma patient often arrives in the emergency department bleeding, coagulopathic and in need of a blood transfusion. The diagnosis and management of these patients has vastly improved with a better understanding of acute traumatic coagulopathy (ATC). In the emergency setting, traditional laboratory coagulation screens are of limited use in the diagnosis and management of life-threatening bleeding. Whole blood assays, such as thrombelastography (TEG) and rotational thrombelastometry (ROTEM) provide a rapid evaluation of clot formation, strength and lysis. Rapid diagnosis of ATC and aggressive haemostatic transfusion strategies utilizing early high doses of plasma are associated with improved outcomes in trauma. At present there is no accurate guide for transfusion in trauma, therefore blood and clotting products are administered on an empiric basis. Targeted transfusion therapy for major trauma haemorrhage based on comprehensive and rapid measures of coagulation e.g. TEG/ROTEM may lead to improved outcomes while optimizing blood utilization. Evidence for the clinical application of TEG and ROTEM in trauma is emerging with a number of studies evaluating their ability to diagnose coagulopathy early and facilitate goal-directed transfusion. This review explores current controversies and best practice in the diagnosis and management of major haemorrhage in trauma.
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Affiliation(s)
- Ross Davenport
- Trauma Sciences, Blizard Institute, Bart's and the London School of Medicine & Dentistry, Queen Mary University of London, London, UK.
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Moroff G, Kurtz J, Seetharaman S, Skripchenko A, Awatefe H, Thompson-Montgomery D, Myrup A, Wagner SJ. Comparative in vitro evaluation of apheresis platelets stored with 100% plasma or 65% platelet additive solution III/35% plasma and including periods without agitation under simulated shipping conditions. Transfusion 2011; 52:834-43. [PMID: 22014086 DOI: 10.1111/j.1537-2995.2011.03390.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND A comparative study evaluated the retention of apheresis platelet (A-PLT) in vitro properties prepared with PLT additive solution (PAS)-III or 100% plasma and stored with continuous agitation (CA) and without continuous agitation (WCA). STUDY DESIGN AND METHODS PLTs collected with the Amicus cell separator (Fenwal, Inc.) were utilized to prepare two matched components, each with approximately 4 × 10(11) PLTs. In the primary study, one component contained 65% PAS-III/35% plasma and the other 100% plasma. Four storage scenarios were used, one with CA and three with periods without agitation under simulated shipping conditions. In vitro assays were used early and after 5 days of storage. RESULTS pH levels after 5 days with CA were less with PAS-III components than 100% plasma components, with levels always above 6.6 in any component. With CA, a number of other variables were reduced even early during storage with PAS-III including morphology, extent of shape change, hypotonic stress response, adhesion, and aggregation. Storage WCA resulted in only a limited increase in the magnitude of the assay differences between PAS-III and 100% plasma components. Periods WCA did not reduce the pH below 6.6. The thromboelastograph variable associated with the strengthening of clots by PLTs was essentially comparable with PAS-III and plasma components throughout storage with CA or WCA. CONCLUSION The data indicate that a 100% plasma medium provides for better retention of specific in vitro PLT properties, with CA and WCA, although the clinical significance of these in vitro decrements due to PAS-III is unknown.
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Affiliation(s)
- Gary Moroff
- American Red Cross Biomedical Services and Holland Laboratory, Rockville, Maryland 20855, USA
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Wagner SJ, Seetharaman S, Kurtz J. Comparison of the in vitro storage properties of Amicus apheresis platelets collected using single- and double-needle procedures from the same donors. Transfusion 2011; 52:524-8. [DOI: 10.1111/j.1537-2995.2011.03320.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Sweeney J, Kouttab N, Kurtis J. Stored red blood cell supernatant facilitates thrombin generation. Transfusion 2011; 49:1569-79. [PMID: 19413726 DOI: 10.1111/j.1537-2995.2009.02196.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Observational studies have reported that patients transfused with red blood cells (RBCs) have a worse clinical outcome than untransfused patients and that storage age of RBCs at the time of transfusion may be an independent predictor of this adverse clinical outcome. STUDY DESIGN AND METHODS Eight RBC concentrates in additive solution were studied over an 8-week storage period. The RBC supernatant was ultracentrifuged to concentrate microvesicles (RCMVs). RCMVs were studied by flow cytometry to identify phosphatidylserine (PS)-expressing RCMVs and in a thromboelastograph (TEG) using a modified assay to detect a thrombin facilitation effect. RESULTS For all products, the percentage of RCMVs that exhibited PS expression on Day 1 was 50 ± 13%, which increased with storage, and on Day 31 was 90 ± 4%. After 31 days, four of the eight products showed a thrombin facilitation effect as evidenced by a shortening of the TEG reaction (R) time of 1.3 ± 1.1 minutes, which persisted to Day 41. Data are the mean ± 1 SD. This TEG R shortening effect was neutralized by annexin V. No such effect was observed on, or before, Day 21. CONCLUSIONS Some stored RBCs release RCMVs, which express PS and are capable of facilitating thrombin generation in vitro. This provides a possible mechanism by which stored RBCs could promote adverse thrombotic or inflammatory effects.
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Affiliation(s)
- Joseph Sweeney
- Transfusion Services, The Miriam Hospital, 164 Summit Avenue, Providence, RI 02906, USA.
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The influence of platelets, plasma and red blood cells on functional haemostatic assays. Blood Coagul Fibrinolysis 2011; 22:167-75. [DOI: 10.1097/mbc.0b013e3283424911] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Johansson PI. Goal-directed hemostatic resuscitation for massively bleeding patients: the Copenhagen concept. Transfus Apher Sci 2010; 43:401-405. [PMID: 20951650 DOI: 10.1016/j.transci.2010.09.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Continued hemorrhage remains a major cause of mortality in massively transfused patients, many of whom develop coagulopathy. A review of transfusion practice for these patients at our hospital revealed that a significant proportion received suboptimal transfusion therapy. Survivors had higher platelets count than non-survivors. METHODS For massively transfused patients with hemodynamic instability, we introduced the concept of transfusion packages comprising five units of red blood cells, five units of fresh frozen plasma and two units of platelet concentrates. Thrombelastogram analysis was validated for routine laboratory use and implemented in the blood bank for monitoring coagulopathy and guiding transfusion therapy. Anaesthetists at our hospital were trained in functional haemostasis management based on analysis of thrombelastograms. RESULTS Intraoperative administration of transfusion packages for patients operated on for a ruptured abdominal aortic aneurysm was associated with a reduction in mortality from 56% to 34% (p = 0.02). When comparing massively transfused patients treated with hemostatic control resuscitation, i.e., transfusion package therapy during hemodynamic instability and thromboelastogram--monitored and guided transfusion therapy, with controls treated in accordance with existing transfusion guidelines, mortality was reduced from 31% to 20% (p = 0.002). CONCLUSION The initiative from the blood bank, i.e., transfusion packages for patients with uncontrollable bleeding and based on the thromboelastogram when hemodynamic control is established, has improved the transfusion practice and survival in massively transfused patients at our hospital.
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Affiliation(s)
- Pär I Johansson
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, University of Copenhagen, Denmark.
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Abstract
Haemorrhage remains a major cause of potentially preventable deaths. Trauma and massive transfusion are associated with coagulopathy secondary to tissue injury, hypoperfusion, dilution and consumption of clotting factors and platelets. Concepts of damage control surgery have evolved, prioritizing the early control of the cause of bleeding by non-definitive means, while haemostatic control resuscitation seeks early control of coagulopathy. Haemostatic resuscitation provides transfusions with plasma and platelets in addition to red blood cells (RBCs) in an immediate and sustained manner as part of the transfusion protocol for massively bleeding patients. Transfusion of RBCs, plasma and platelets in a similar proportion as in whole blood prevents both hypovolaemia and coagulopathy. Although an early and effective reversal of coagulopathy is documented, the most effective means of preventing coagulopathy of massive transfusion remains debated and randomized controlled studies are lacking. Results from recent before-and-after studies in massively bleeding patients indicate that trauma exsanguination protocols involving the early administration of plasma and platelets are associated with improved survival. Furthermore, viscoelastic whole blood assays, such as thrombelastography (TEG)/rotation thromboelastometry (ROTEM), appear advantageous for identifying coagulopathy in patients with severe haemorrhage, as opposed to conventional coagulation assays. In our view, patients with uncontrolled bleeding, regardless of its cause, should be treated with goal-directed haemostatic control resuscitation involving the early administration of plasma and platelets and based on the results of the TEG/ROTEM analysis. The aim of the goal-directed therapy should be to maintain a normal haemostatic competence until surgical haemostasis is achieved, as this appears to be associated with reduced mortality.
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Affiliation(s)
- P I Johansson
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
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Ostrowski SR, Bochsen L, Windeløv NA, Salado-Jimena JA, Reynaerts I, Goodrich RP, Johansson PI. Hemostatic function of buffy coat platelets in additive solution treated with pathogen reduction technology. Transfusion 2010; 51:344-56. [PMID: 20723169 DOI: 10.1111/j.1537-2995.2010.02821.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Pathogen reduction technologies (PRTs) may influence the hemostatic potential of stored platelet (PLT) concentrates. To investigate this, buffy coat PLTs (BCPs) stored in PLT additive solution (SSP+) with or without Mirasol PRT treatment (CaridianBCT Biotechnologies) were compared by functional hemostatic assays. STUDY DESIGN AND METHODS We performed in vitro comparison of PRT (PRT-BCP) and control pooled-and-split BCPs (CON-BCP) after 2, 3, 6, 7, and 8 days' storage. Hemostatic function was evaluated with thrombelastography (TEG) and impedance aggregometry (Multiplate), the latter also in a sample matrix (Day 2) with or without addition of red blood cells (RBCs), control plasma, and/or PRT-treated plasma. RESULTS PRT treatment of 8-day-stored BCPs influenced clot formation (TEG) minimally, with reductions in maximum clot strength (maximum amplitude, p = 0.014) but unchanged initial fibrin formation (R), clot growth rate (α), and fibrinolysis resistance. In the absence of RBCs and plasma, PRT impaired aggregation (Multiplate) in stored BCPs, with reduced aggregation against thrombin receptor activating peptide-6 (p < 0.001), collagen (p = 0.014), adenosine 5'-diphosphate (p = 0.007), and arachidonic acid (p = 0.070). Addition of RBCs and PRT-treated or untreated plasma to PRT-BCP and CON-BCP, respectively, enhanced aggregation in both groups. CONCLUSIONS Mirasol PRT treatment of BCPs had a minimal influence on clot formation, whereas aggregation in the absence of RBCs and plasma was significantly reduced. Addition of RBCs and plasma increased agonist-induced responses resulting in comparable aggregation between PRT-BCP and CON-BCP. The clinical relevance for PLT function in vivo of these findings will be investigated in a clinical trial.
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Affiliation(s)
- Sisse R Ostrowski
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
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Fischer-Nielsen A, Stissing T, Maansson C, Joergensen BG. Pressure-aided transfusion of platelets: does it affect the platelets? Transfusion 2010; 50:361-5. [DOI: 10.1111/j.1537-2995.2009.02396.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Hemostatic strategies for minimizing mortality in surgery with major blood loss. Curr Opin Hematol 2009; 16:509-14. [DOI: 10.1097/moh.0b013e32833140fc] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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McQuay N, Cipolla J, Franges EZ, Thompson GE. The use of recombinant activated factor VIIa in coagulopathic traumatic brain injuries requiring emergent craniotomy: is it beneficial? J Neurosurg 2009; 111:666-71. [DOI: 10.3171/2009.4.jns081611] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The role of recombinant activated factor VII (rFVIIa) in traumatic brain injury (TBI) has not been well established. This study evaluates the outcomes of using rFVIIa as first-line therapy in patients with a severe TBI requiring emergent craniotomy that are coagulopathic.
Methods
The authors retrospectively reviewed patients admitted between 2003 and 2006 to a Level I trauma center with a severe TBI requiring an emergency craniotomy. Eighteen patients with coagulopathy that was corrected using rFVIIa were identified. Variables evaluated included age, injury severity score, head abbreviated injury score, Glasgow Coma Scale score, international normalized ratio, time to operation, operative procedure, thromboembolic events, and death.
Results
The cohort consisted of 18 patients, predominantly male (55.6%) with a mean age of 80.5 years. The most common mechanism of injury was a fall. Coagulopathy was due to premorbid anticoagulants in 50% of the cohort. Time from admission to operation was 130 minutes. Coagulopathy reversal was complete in all 18 cases (100%). A high mortality rate (55.6%) was attributed to a high incidence of withdrawal of care (50%). The incidence of thromboembolic events was low (5.6%). Survivors, when compared with nonsurvivors, had a > 3-fold increase in postoperative Glasgow Coma Scale score for similar preoperative scores. A good functional outcome was achieved in 75% of survivors with a mean follow-up period of 4.2 months.
Conclusions
The use of rFVIIa in the correction of coagulopathy in patients having sustained severe TBI requiring emergency craniotomy appears to be safe and effective even among the elderly. This allows a shorter transit time to craniotomy. Its effects on mortality and long-term neurological outcome requires further investigation prospectively.
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Affiliation(s)
- Nathaniel McQuay
- 1Department of Surgery, University of Pennsylvania Health System, Trauma/Critica Division, St. Luke's Hosptial; and
| | - James Cipolla
- 1Department of Surgery, University of Pennsylvania Health System, Trauma/Critica Division, St. Luke's Hosptial; and
| | - Eleanor Z. Franges
- Department of Neurosurgery, St. Luke's Hospital, Bethlehem, Pennsylvania
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Johansson PI, Stissing T, Bochsen L, Ostrowski SR. Thrombelastography and tromboelastometry in assessing coagulopathy in trauma. Scand J Trauma Resusc Emerg Med 2009; 17:45. [PMID: 19775458 PMCID: PMC2758824 DOI: 10.1186/1757-7241-17-45] [Citation(s) in RCA: 199] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2009] [Accepted: 09/23/2009] [Indexed: 11/14/2022] Open
Abstract
Death due to trauma is the leading cause of lost life years worldwide, with haemorrhage being responsible for 30-40% of trauma mortality and accounting for almost 50% of the deaths the initial 24 h. On admission, 25-35% of trauma patients present with coagulopathy, which is associated with a several-fold increase in morbidity and mortality. The recent introduction of haemostatic control resuscitation along with emerging understanding of acute post-traumatic coagulability, are important means to improve therapy and outcome in exsanguinating trauma patients. This change in therapy has emphasized the urgent need for adequate haemostatic assays to monitor traumatic coagulopathy and guide therapy. Based on the cell-based model of haemostasis, there is emerging consensus that plasma-based routine coagulation tests (RCoT), like prothrombin time (PT) and activated partial thromboplastin time (APTT), are inappropriate for monitoring coagulopathy and guide therapy in trauma. The necessity to analyze whole blood to accurately identify relevant coagulopathies, has led to a revival of the interest in viscoelastic haemostatic assays (VHA) such as Thromboelastography (TEG) and Rotation Thromboelastometry (ROTEM). Clinical studies including about 5000 surgical and/or trauma patients have reported on the benefit of using the VHA as compared to plasma-based assays, to identify coagulopathy and guide therapy. This article reviews the basic principles of VHA, the correlation between the VHA whole blood clot formation in accordance with the cell-based model of haemostasis, the current use of VHA-guided therapy in trauma and massive transfusion (haemostatic control resuscitation), limitations of VHA and future perspectives of this assay in trauma.
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Affiliation(s)
- Pär I Johansson
- Section for Transfusion Medicine, Regional Blood Bank, Rigshospitalet, University of Copenhagen, Denmark
| | - Trine Stissing
- Section for Transfusion Medicine, Regional Blood Bank, Rigshospitalet, University of Copenhagen, Denmark
| | - Louise Bochsen
- Section for Transfusion Medicine, Regional Blood Bank, Rigshospitalet, University of Copenhagen, Denmark
| | - Sisse R Ostrowski
- Section for Transfusion Medicine, Regional Blood Bank, Rigshospitalet, University of Copenhagen, Denmark
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Wallin O, Söderberg J, Grankvist K, Jonsson PA, Hultdin J. Preanalytical effects of pneumatic tube transport on routine haematology, coagulation parameters, platelet function and global coagulation. Clin Chem Lab Med 2008; 46:1443-9. [DOI: 10.1515/cclm.2008.288] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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