1
|
Hanley C, Callum J, Karkouti K, Bartoszko J. Albumin in adult cardiac surgery: a narrative review. Can J Anaesth 2021; 68:1197-1213. [PMID: 33884561 DOI: 10.1007/s12630-021-01991-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 03/03/2021] [Accepted: 03/04/2021] [Indexed: 02/06/2023] Open
Abstract
PURPOSE Intravascular fluids are a necessary and universal component of cardiac surgical patient care. Both crystalloids and colloids are used to maintain or restore circulating plasma volume and ensure adequate organ perfusion. In Canada, human albumin solution (5% or 25% concentration) is a colloid commonly used for this purpose. In this narrative review, we discuss albumin supply in Canada, explore the perceived advantages of albumin, and describe the clinical literature supporting and refuting albumin use over other fluids in the adult cardiac surgical population. SOURCE We conducted a targeted search of PubMed, Embase, Medline, Web of Science, ProQuest Dissertations and Theses Global, the Cochrane Central Register of Controlled trials, and the Cochrane Database of Systematic Reviews. Search terms included albumin, colloid, cardiac surgery, bleeding, hemorrhage, transfusion, and cardiopulmonary bypass. PRINCIPAL FINDINGS Albumin is produced from fractionated human plasma and imported into Canada from international suppliers at a cost of approximately $21 million CAD per annum. While it is widely used in cardiac surgical patients across the country, it is approximately 30-times more expensive than equivalent doses of balanced crystalloid solutions, with wide inter-institutional variability in use and no clear association with improved outcomes. There is a general lack of high-quality evidence for the superiority of albumin over crystalloids in this patient population, and conflicting evidence regarding safety. CONCLUSIONS In cardiac surgical patients, albumin is widely utilized despite a lack of high- quality evidence supporting its efficacy or safety. A well-designed randomized controlled trial is needed to clarify the role of albumin in cardiac surgical patients.
Collapse
Affiliation(s)
- Ciara Hanley
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Jeannie Callum
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre, Toronto, ON, Canada
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
| | - Keyvan Karkouti
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, 200 Elizabeth Street 3EN-464, Toronto, ON, M5G 2C4, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Justyna Bartoszko
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, 200 Elizabeth Street 3EN-464, Toronto, ON, M5G 2C4, Canada.
| |
Collapse
|
2
|
Getrajdman C, Sison M, Lin HM, Katz D. The impact of crystalloid versus colloid on coagulation as measured by thromboelastometry in term parturients: an in vitro study. J Matern Fetal Neonatal Med 2021; 35:6876-6883. [PMID: 34015981 DOI: 10.1080/14767058.2021.1929157] [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] [Indexed: 10/21/2022]
Abstract
OBJECTIVE A pilot study to examine the impact of crystalloid versus albumin hemodilution in vitro on coagulation using thromboelastometry in pregnant patients. METHODS This prospective, observational pilot study included seventy-six pregnant patients at term (≥37 weeks) without history of bleeding or clotting disorder or on anticoagulation. Blood was collected and diluted with either Plasma-Lyte or albumin at the following levels: 0%, 20%, 25%, 30%, 35%, 40%, 45%, 55%, 60%, 65%, 70%, 75%, 80%. Thromboelastometry was performed to assess for coagulation changes. RESULTS There was a small, statistically significant difference in the FIBTEM A5 between the Plasma-Lyte and albumin samples. However, the predicted probability of coagulopathy, using FIBTEM A5 less than 12 mm, was not different between the groups at any dilution. There was no difference in EXTEM clotting time at low-moderate levels of hemodilution. At dilutions above 40%, the albumin group had a significantly greater prolongation in clotting time compared to the Plasma-Lyte group. CONCLUSION When albumin is used at low-moderate levels of hemodilution in vitro in parturients there is no additional risk of coagulopathy compared to hemodilution with crystalloid. Given that colloids are frequently used to restore intravascular volume during massive hemorrhage, these results support that during early stages of hemorrhage, albumin may not contribute to additional coagulopathy beyond that of hemodilution, although further in vivo studies are needed.
Collapse
Affiliation(s)
- Chloe Getrajdman
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Matthew Sison
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Hung-Mo Lin
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Daniel Katz
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| |
Collapse
|
3
|
Schneck E, Muelich M, Markmann M, Edinger F, Cooper N, Moeller A, Bein G, Hecker A, Koch C, Sander M, Wolff M. Combined Administration of Fibrinogen and Factor XIII Concentrate Does Not Improve Dilutional Coagulopathy Superiorly Than Sole Fibrinogen Therapy: Results of an In-Vitro Thrombelastographic Study. J Clin Med 2021; 10:jcm10102068. [PMID: 34065924 PMCID: PMC8150940 DOI: 10.3390/jcm10102068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 05/04/2021] [Accepted: 05/07/2021] [Indexed: 11/16/2022] Open
Abstract
The early administration of fibrinogen has gained wide acceptance for the treatment of major hemorrhage, whereas the substitution of coagulation factor XIII (FXIII) is only supported by a low level of evidence. This study aimed to answer the question of whether a combined therapy of fibrinogen/FXIII substitution performs superiorly to sole fibrinogen administration in the treatment of dilutional coagulopathy. An in-vitro model of massive transfusion was used to compare the effect of combined fibrinogen/FXIII administration to that of sole fibrinogen therapy for the treatment of dilutional coagulopathy. For this purpose, the blood of red blood cell concentrates, fresh frozen plasma, and platelet concentrates were reconstituted in a ratio of 4:4:1, and then diluted with gelatin by 20% and 40%, respectively. Clot formation and stability were analyzed by thrombelastography. Both sole fibrinogen therapy (equivalent to 50 mg/kg) and the combined administration of fibrinogen (equivalent to 50 mg/kg) and FXIII (equivalent to 75 International Units (IU)/kg) increased fibrinogen-dependent mean clot firmness independently of the degree of dilution (20% dilution: 7 (6.3–7.8) mm; 20% dilution fibrinogen: 13.5 (13–17.3) mm; 20% dilution fibrinogen/FXIII: 16.5 (15.3–18.8) mm; 40% dilution: 3 (2–3.8) mm; 40% dilution fibrinogen: 8 (7–11.3) mm; 40% dilution fibrinogen/FXIII: 10 (8.3–11.8) mm; all p < 0.01). However, no differences were identified between the two treatment arms. Compared to fibrinogen therapy, no beneficial effect of the combined administration of fibrinogen and FXIII for the treatment of dilutional coagulopathy was detected in this in-vitro massive transfusion model. The result was independent of the degree of dilution.
Collapse
Affiliation(s)
- Emmanuel Schneck
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, 35392 Giessen, Germany; (M.M.); (M.M.); (F.E.); (C.K.); (M.S.); (M.W.)
- Correspondence: ; Tel.: +49-641-985-44401
| | - Marcus Muelich
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, 35392 Giessen, Germany; (M.M.); (M.M.); (F.E.); (C.K.); (M.S.); (M.W.)
| | - Melanie Markmann
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, 35392 Giessen, Germany; (M.M.); (M.M.); (F.E.); (C.K.); (M.S.); (M.W.)
| | - Fabian Edinger
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, 35392 Giessen, Germany; (M.M.); (M.M.); (F.E.); (C.K.); (M.S.); (M.W.)
| | - Nina Cooper
- Institute for Clinical Immunology and Transfusion Medicine, Justus Liebig University, 35392 Giessen, Germany; (N.C.); (A.M.); (G.B.)
| | - Annette Moeller
- Institute for Clinical Immunology and Transfusion Medicine, Justus Liebig University, 35392 Giessen, Germany; (N.C.); (A.M.); (G.B.)
| | - Gregor Bein
- Institute for Clinical Immunology and Transfusion Medicine, Justus Liebig University, 35392 Giessen, Germany; (N.C.); (A.M.); (G.B.)
| | - Andreas Hecker
- Department of General & Thoracic Surgery, University Hospital of Giessen, 35392 Giessen, Germany;
| | - Christian Koch
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, 35392 Giessen, Germany; (M.M.); (M.M.); (F.E.); (C.K.); (M.S.); (M.W.)
| | - Michael Sander
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, 35392 Giessen, Germany; (M.M.); (M.M.); (F.E.); (C.K.); (M.S.); (M.W.)
| | - Matthias Wolff
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, 35392 Giessen, Germany; (M.M.); (M.M.); (F.E.); (C.K.); (M.S.); (M.W.)
| |
Collapse
|
4
|
Kammerer T, Hulde N, Speck E, Hübner M, Crispin A, Zwissler B, Conzen P, von Dossow V, Schäfer ST, Hofmann-Kiefer K, Rehm M. Effects of balanced hydroxyethyl starch 6% (130/0.4) and albumin 5% on clot formation and glycocalyx shedding: Subgroup analysis of a prospective randomized trial. Thromb Res 2019; 183:111-118. [DOI: 10.1016/j.thromres.2019.10.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 09/13/2019] [Accepted: 10/21/2019] [Indexed: 12/22/2022]
|
5
|
Abstract
Background: Dextran-70 is a more potent plasma volume expander than albumin but use has been hampered because of its antithrombotic properties. However, also albumin has antithrombotic properties and little is known about relative effects of these two colloids on coagulation in vivo when controlling for differences in efficacy as plasma volume expanders. Aim: Compare effects of dextran-70 and albumin on coagulation at a dose resulting in equal plasma volume expansion. Methods: Guinea pigs were subjected to a 25 mL/kg hemorrhage during 20 min and randomized to resuscitation with either 6% dextran-70 at a dose of 15 mL/kg or 5% albumin at a dose of 25 mL/kg (n = 14 in each group) during 30 min starting 1 h of shock. Blood samples were collected at the completion of resuscitation and at 4 h. Plasma volume was measured using 125I-albumin and the effect on coagulation was evaluated using whole blood thrombelastography (TEG), measurement of plasma fibrinogen and von Willebrand factor (vWF) concentrations and vWF glycoprotein 1b (GP1b) A activity. Results: Plasma volumes after resuscitation were similar in the groups at both time points. Dextran-70 resulted in a transient prolongation of TEG clot amplification time (K) at the completion of resuscitation compared with albumin. TEG clot initiation (R) and strength (MA) did not differ between the treatments at any of the time points. Albumin reduced vWF concentrations to a larger extent than dextran at both time points, whereas no difference in vWF GP1bA activity or in plasma fibrinogen and could be detected. Conclusion: In equipotent doses with regard to plasma volume expansion, dextran-70 transiently prolongs clot amplification time more than albumin whereas dextran-70 reduces plasma vWF concentrations less than albumin.
Collapse
|
6
|
Palmaers T, Hinsenkamp J, Krämer E, Leffler A, Flentje M, Sieg L, Eismann H. Albumin combined with Mannitol impairs whole blood coagulation and platelet function in vitro. J Neurosurg Sci 2019; 65:634-641. [PMID: 31079437 DOI: 10.23736/s0390-5616.19.04679-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The indication of hydroxyethyl starch is currently under critical discussion and albumin 5% (ALB) has an increasing use in the operating theatre. Therefore, ALB is routinely used in neurosurgical procedures and often combined with mannitol 20% (MAN). Purpose of this in vitro study was to determine the influence of the combination of MAN and ALB on blood coagulation and platelet function. METHODS 22 healthy volunteers were included into this study and 21 analysed. Blood was obtained and diluted into five groups: (1) 7% dilution with MAN, (2) 10% dilution with ALB (3) 17% dilution with isotonic balanced electrolyte solution, (4) 17% dilution with MAN + ALB and (5) undiluted blood as control group (CON). Rotational thrombelastometry via ROTEM® (EXTEM, FIBTEM-Test) and thrombocyte aggregometry via Multiplate® (ASPI, ADP and TRAP-test) were used to detect differences within the intervention groups and compared to the control group. RESULTS The maximum clot firmness in the FIBTEM test decreased under the normal range with the combination of MAN+ALB: 8mm (5.5-11) compared to CON: 15mm (12.5-20), p<0.05. Platelet function (ADP-test) showed significant decreases for ALB: 51 AUC (40-84) and MAN+ALB: 54 AUC (41-68) compared to CON: 92 AUC (75-101), p<0.05. Except in clotting time all other EXTEM tests of MAN+ALB subgroup showed significant impairment on blood coagulation compared to the control group. CONCLUSIONS In this in vitro study clinically relevant dilutions of MAN+ALB showed a significant inhibition of blood coagulation and platelet function. Further in vivo studies are necessary to confirm these results.
Collapse
Affiliation(s)
- Thomas Palmaers
- Department of Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - Julia Hinsenkamp
- Department of Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - Elke Krämer
- Department of Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - Andreas Leffler
- Department of Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - Markus Flentje
- Department of Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - Lion Sieg
- Department of Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - Hendrik Eismann
- Department of Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany -
| |
Collapse
|
7
|
High-dose Factor XIII administration induces effective hemostasis for trauma-associated coagulopathy (TAC) both in vitro and in rat hemorrhagic shock in vivo models. J Trauma Acute Care Surg 2019; 85:588-597. [PMID: 29851904 DOI: 10.1097/ta.0000000000001998] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Trauma-associated coagulopathy (TAC) is an early and primary complication in severe trauma patients. Factor XIII (FXIII) is reported to stabilize a clot in the late phase of the coagulation cascade. The goal of this study was to investigate whether the administration of FXIII improves the condition of TAC both in vitro and in vivo. METHODS We evaluated the effects of different doses, including a very high dose of FXIII (3.6-32.4 IU/mL) on tissue-plasminogen activator-induced hyperfibrinolysis and the combined condition of dilutional coagulopathy and tissue-plasminogen activator-induced hyperfibrinolysis in vitro. The coagulation status was analyzed by rotational thromboelastometry (ROTEM) and Sonoclot. Then, we evaluated the effect of high-dose FXIII (300 IU/kg) for severe coagulopathy in vivo using a rat liver trauma model in which coagulopathy similar to TAC was observed. Survival time and the amount of intra-abdominal bleeding of rats were measured, and a coagulation test was also performed. Histologic evaluations of rats' lung and kidney after FXIII administration were completed. RESULTS High-dose FXIII significantly improved clot strength as well as increased resistance to hyperfibrinolysis in vitro which was confirmed by ROTEM. Platelet function on Sonoclot was significantly increased by FXIII in a dose-dependent manner. Factor XIII significantly decreased the total amount of bleeding and prolonged the survival time compared to control (control vs FXIII: 108.9 ± 11.4 vs 32.6 ± 5.5 mL/kg; p < 0.001; 26.0 ± 8.8 vs 120 minutes, p < 0.001) in a rat model. Rotational thromboelastometry parameters and platelet function on Sonoclot were significantly improved in the FXIII (+) group compared to control. No adverse effects of FXIII were detected histologically. CONCLUSION Factor XIII not only generated stable clot resistance to hyperfibrinolysis but also enhanced platelet function by facilitating clot retraction. High-dose FXIII administration therapy has significant clinical impact for severe trauma accompanied with TAC. STUDY TYPE Human in vitro and rat in vivo experimental study.
Collapse
|
8
|
Imbrizi MR, Magro DO, Secundo TDML, Cunha-Silva M, Kotze PG, Montes CG, Almeida JRDS, Cabral VLR. Hypoalbuminemia as a risk factor for thromboembolic events in inflammatory bowel disease inpatients. Intest Res 2019; 17:63-69. [PMID: 30678446 PMCID: PMC6361029 DOI: 10.5217/ir.2018.00077] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Accepted: 10/03/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND/AIMS Inflammatory bowel disease (IBD) are chronic entities characterized by local and systemic inflammation and may be associated with thrombosis. The aim of this study was to identify the prevalence of thromboembolic events (TEE) in hospitalized IBD patients and identify risk factors for their occurrence. METHODS This retrospective, single-center study included patients treated at a Brazilian IBD referral unit between 2004 and 2014. Patients hospitalized for more than 48 hours due to active IBD and who did not receive prophylaxis for TEE during hospitalization were included. Patients were allocated to 2 groups: those with TEE up to 30 days or at the time of hospitalization (TEE-group) and patients without TEE (control-group). Clinical and laboratory characteristics were evaluated. RESULTS Of 53 patients evaluated, 69,8% with Crohn's disease (CD) and 30.2% with ulcerative colitis (UC). The prevalence of TEE 30 days before or during hospitalization was 15.1%, with 10.8% in CD and 25% in UC. In the TEE group, mean serum albumin was 2.06 g/dL versus 3.30 g/dL in the control group. Patients with albumin levels below 2.95 g/dL (43.18%) had a higher risk of developing TEE (relative risk, 1.72; 95% confidence interval, 1.17-2.53) (P<0.001). CONCLUSIONS Albumin levels were significantly lower in patients with TEE, and hypoalbuminemia was considered a risk factor for the development of TEE in this population.
Collapse
Affiliation(s)
- Marcello Rabello Imbrizi
- Gastroenterology Unit, Department of Internal Medicine, Department of Surgery, University of Campinas (UNICAMP), Campinas, Brazil
| | - Daniela Oliveira Magro
- Colorectal Surgery Unit, Department of Surgery, University of Campinas (UNICAMP), Campinas, Brazil
| | - Tirzah de Mendonça Lopes Secundo
- Gastroenterology Unit, Department of Internal Medicine, Department of Surgery, University of Campinas (UNICAMP), Campinas, Brazil
| | - Marlone Cunha-Silva
- Gastroenterology Unit, Department of Internal Medicine, Department of Surgery, University of Campinas (UNICAMP), Campinas, Brazil
| | - Paulo Gustavo Kotze
- Colorectal Surgery Unit, IBD Outpatients Clinic, Cajuru University Hospital, Catholic University of Parana (PUCPR), Curitiba, Brazil
| | - Ciro Garcia Montes
- Gastroenterology Unit, Department of Internal Medicine, Department of Surgery, University of Campinas (UNICAMP), Campinas, Brazil
| | - Jazon Romilson de Souza Almeida
- Gastroenterology Unit, Department of Internal Medicine, Department of Surgery, University of Campinas (UNICAMP), Campinas, Brazil
| | - Virgínia Lúcia Ribeiro Cabral
- Gastroenterology Unit, Department of Internal Medicine, Department of Surgery, University of Campinas (UNICAMP), Campinas, Brazil
| |
Collapse
|
9
|
Sigurjonsson J, Hedman D, Bansch P, Schött U. Comparison of dextran and albumin on blood coagulation in patients undergoing major gynaecological surgery. Perioper Med (Lond) 2018; 7:21. [PMID: 30202516 PMCID: PMC6126009 DOI: 10.1186/s13741-018-0100-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 07/30/2018] [Indexed: 01/28/2023] Open
Abstract
Background Hydroxyethyl starches have been withdrawn from the European market. In Sweden, dextran was the main colloid until 2000, when starches overtook the market. After the recent 6S-trial, it was suggested that dextran could be reinstituted, but concerns for greater coagulopathy, bleeding and anaphylaxis still remain. An experimental study from our department indicated that isovolemic substitution of dextran-70 did not derange the von Willebrand function more than albumin 5%, considering the fact that dextran is hyperoncotic in comparison to albumin 5% and, therefore, induces a greater plasma volume expansion and thereby a greater dilutional coagulopathy. Methods Eighteen patients undergoing major gynaecological surgery were assigned to receive either 5% albumin or 6% dextran-70 with 9 patients in each group. Standard coagulation tests, including prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen and platelet count, viscoelastic coagulation test thromboelastometry (ROTEM) and the Multiplate platelet aggregation test were used to test for coagulation defects at different time points perioperatively. Blood loss, blood loss replacement data and haemodynamic parameters were retrieved from anaesthetic and postoperative charts. A local departmental fluid and transfusion/infusion protocol assured haemoglobin > 90 g/l and mean arterial pressure > 65 mmHg with Ringer’s acetate in addition to the colloid use. Results There were no differences in demographic data between the groups. The tissue factor-activated (EXTEM) clot-structure parameter ROTEM A10 was decreased significantly in the dextran group as compared to the albumin group after the infusion of 500 ml of either colloid solution. The PT and aPTT were significantly prolonged, and the platelet count decreased postoperatively in the dextran group, whereas albumin only deranged fibrinogen levels as compared to preoperative levels. There were no differences in Multiplate platelet aggregometry, amount of haemorrhage or transfusion of blood components between the groups. Conclusions Standard plasma-based coagulation tests, platelet count and whole blood viscoelastic clot structure are affected by 6% dextran-70 to a greater extent than by 5% albumin, but platelet aggregation is not. Future studies should use more advanced haemodynamic monitoring to assess isovolemic plasma volume expansion with dextran and whether this affects haemostasis to a lesser degree.
Collapse
Affiliation(s)
- Johann Sigurjonsson
- 1Department of Anaesthesia and Intensive Care, Institution of Clinical Science Lund, Medical Faculty, Lund University, Lund, Sweden
| | - David Hedman
- 2Department of Anaesthesia and Intensive Care, Skåne University Hospital Lund, SE-221 85 Lund, Sweden
| | - Peter Bansch
- 1Department of Anaesthesia and Intensive Care, Institution of Clinical Science Lund, Medical Faculty, Lund University, Lund, Sweden.,2Department of Anaesthesia and Intensive Care, Skåne University Hospital Lund, SE-221 85 Lund, Sweden
| | - Ulf Schött
- 1Department of Anaesthesia and Intensive Care, Institution of Clinical Science Lund, Medical Faculty, Lund University, Lund, Sweden.,2Department of Anaesthesia and Intensive Care, Skåne University Hospital Lund, SE-221 85 Lund, Sweden
| |
Collapse
|
10
|
Paar M, Rossmann C, Nusshold C, Wagner T, Schlagenhauf A, Leschnik B, Oettl K, Koestenberger M, Cvirn G, Hallström S. Anticoagulant action of low, physiologic, and high albumin levels in whole blood. PLoS One 2017; 12:e0182997. [PMID: 28800610 PMCID: PMC5553770 DOI: 10.1371/journal.pone.0182997] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 07/27/2017] [Indexed: 01/01/2023] Open
Abstract
Albumin is the most abundant plasma protein. Critical illness is often associated with altered, predominately decreased, serum albumin levels. This hypoalbuminaemia is usually corrected by administration of exogenous albumin. This study aimed to track the concentration-dependent influence of albumin on blood coagulation in vitro. Whole blood (WB) samples from 25 volunteers were prepared to contain low (19.3 ± 7.7 g/L), physiological (45.2 ± 7.8 g/L), and high (67.5 ± 18.1 g/L) levels of albumin. Haemostatic profiling was performed using a platelet function analyzer (PFA) 200, impedance aggregometry, a Cone and Platelet analyzer (CPA), calibrated automated thrombogram, and thrombelastometry (TEM). Platelet aggregation-associated ATP release was assessed via HPLC analysis. In the low albumin group, when compared to the physiological albumin group, we found: i) shortened PFA 200-derived closure times indicating increased primary haemostasis; ii) increased impedance aggregometry-derived amplitudes, slopes, ATP release, as well as CPA-derived average size indicating improved platelet aggregation; iii) increased TEM-derived maximum clot firmness and alpha angles indicating enhanced clot formation. TEM measurements indicated impaired clot formation in the high albumin group compared with the physiological albumin group. Thus, albumin exerted significant anticoagulant action. Therefore, low albumin levels, often present in cancer or critically ill patients, might contribute to the frequently occurring venous thromboembolism.
Collapse
Affiliation(s)
- Margret Paar
- Institute of Physiological Chemistry, Medical University of Graz, Graz, Austria
| | - Christine Rossmann
- Institute of Physiological Chemistry, Medical University of Graz, Graz, Austria
| | - Christoph Nusshold
- Institute of Physiological Chemistry, Medical University of Graz, Graz, Austria
| | - Thomas Wagner
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Graz, Graz, Austria
| | | | - Bettina Leschnik
- Department of Pediatrics, Medical University of Graz, Graz, Austria
| | - Karl Oettl
- Institute of Physiological Chemistry, Medical University of Graz, Graz, Austria
| | | | - Gerhard Cvirn
- Institute of Physiological Chemistry, Medical University of Graz, Graz, Austria
- * E-mail:
| | - Seth Hallström
- Institute of Physiological Chemistry, Medical University of Graz, Graz, Austria
| |
Collapse
|
11
|
Lawrence MJ, Marsden N, Kaczynski J, Davies G, Davies N, Hawkins K, Perumal S, Brown MR, Morris K, Davidson SJ, Williams PR, Evans PA. An Investigation Into the Effects of In Vitro Dilution With Different Colloid Resuscitation Fluids on Clot Microstructure Formation. Anesth Analg 2017; 123:1081-1088. [PMID: 27636739 DOI: 10.1213/ane.0000000000001536] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Balancing the beneficial effects of resuscitation fluids against their detrimental effect on hemostasis is an important clinical issue. We aim to compare the in vitro effects of 3 different colloid resuscitation fluids (4.5% albumin, hydroxyethyl starch [Voluven 6%], and gelatin [Geloplasma]) on clot microstructure formation using a novel viscoelastic technique, the gel point. This novel hemorheologic technique measures the biophysical properties of the clot and provides an assessment of clot microstructure from its viscoelastic properties. Importantly, in contrast to many assays in routine clinical use, the measurement is performed using unadulterated whole blood in a near-patient setting and provides rapid assessment of coagulation. We hypothesized that different colloids will have a lesser or greater detrimental effect on clot microstructure formation when compared against each other. METHODS Healthy volunteers were recruited into the study (n = 104), and a 20-mL sample of whole blood was obtained. Each volunteer was assigned to 1 of the 3 fluids, and the sample was diluted to 1 of 5 different dilutions (baseline, 10%, 20%, 40%, and 60%). The blood was tested using the gel point technique, which measures clot mechanical strength and quantifies clot microstructure (df) at the incipient stages of fibrin formation. RESULTS df and clot mechanical strength decrease with progressive dilution for all 3 fluids. A significant reduction in df from baseline was recorded at dilutions of 20% for albumin (P < .0001), 40% for starch (P < .0001), and 60% for gelatin (P < .0001). We also observed significant differences, in terms of df, when comparing the different types of colloid (P < .0001). We found that albumin dilution produced the largest changes in clot microstructure, providing the lowest values of df (= 1.41 ± 0.061 at 60% dilution) compared with starch (1.52 ± 0.081) and gelatin (1.58 ± 0.063). CONCLUSIONS We show that dilution with all 3 fluids has a significant effect on coagulation at even relatively low dilution volumes (20% and 40%). Furthermore, we quantify, using a novel viscoelastic technique, how the physiochemical properties of the 3 colloids exert individual changes on clot microstructure.
Collapse
Affiliation(s)
- Matthew James Lawrence
- From the *NISCHR Haemostasis Biomedical Research Unit, Morriston Hospital, Abertawe Bro Morgannwg University Health Board, Swansea, United Kingdom; †NISCHR Biomedical Research Unit, Medical School, Swansea University, Swansea, United Kingdom; ‡The Welsh Centre for Burns and Plastic Surgery, Abertawe Bro Morgannwg University Health Board, Morriston Hospital, Swansea, United Kingdom; §Department of Surgery, Morriston Hospital, Abertawe Bro Morgannwg University Health Board, Swansea University, Swansea, United Kingdom; ∥Emergency Department, Morriston Hospital, Abertawe Bro Morgannwg University Health Board, Swansea, United Kingdom; ¶Centre of Complex Fluids, College of Engineering, Swansea University, Swansea, United Kingdom; #School of Applied Science, University of Wales Institute Cardiff, Cardiff, United Kingdom; and **Department of Haematology, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
12
|
Comparison of citrated and fresh whole blood for viscoelastic coagulation testing during elective neurosurgery. Thromb Res 2017; 156:73-79. [PMID: 28601642 DOI: 10.1016/j.thromres.2017.05.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 05/11/2017] [Accepted: 05/29/2017] [Indexed: 12/24/2022]
Abstract
BACKGROUND Previous viscoelastic haemostatic tests studies have often indicated a hypercoagulative test signal with citrated blood, which could influence clinical decision makings. PURPOSE The aim of this study was to compare fresh and citrated whole blood using two non-automated viscoelastic ROTEM and Sonoclot tests. Our hypothesis was that citrated blood would demonstrate a hypercoagulative response in this setting, not tested before. METHODS Perioperative viscoelastic coagulation changes were evaluated with a ROTEM and Sonoclot in 38 patients undergoing elective brain tumor surgery. The citrated samples were recalcified with CaCl2. Wilcoxon nonparametric-paired tests and Bland-Altman plots were performed to compare the fresh and citrated blood analyses. RESULTS The citrated blood showed a hypercoagulative response in ROTEM NATEM-clot formation time and α-angle, Sonoclot-clot rate and platelet function, as compared to fresh blood (p<0.0001). CONCLUSIONS Fresh whole blood may theoretically reflect in vivo haemostasis more closely than citrated analyses, which indicated a hypercoagulative response as compared to the fresh whole blood analyses Bland-Altman plots also indicated that ROTEM reference ranges in patients undergoing brain surgery should be redefined. Future studies must establish the correlation between viscoelastic test results using fresh or citrate anticoagulated blood and clinical outcomes, such as bleeding, transfusion or reoperation for postoperative haematoma.
Collapse
|
13
|
Winstedt D, Solomon C, Hillarp A, Lundahl T, Schött U. Intraoperative Hydroxyethyl Starch and its Effects on Different Fibrinogen Measurements. Clin Appl Thromb Hemost 2016; 22:641-7. [DOI: 10.1177/1076029616632904] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Intravenous fluids with synthetic colloids such as hydroxyethyl starch (HES) are known to interfere with plasma fibrinogen concentration measurements. The aim of this study was to evaluate the effects of an HES solution on fibrinogen measurements in a clinical setting. Methods: The study was performed in patients who received at least 1 L of HES during intracranial tumor resection surgery. Blood samples were drawn before the start of surgery (baseline), after infusion of 1 L of HES, and at later time points. The fibrinogen concentration was measured using 3 different methods: (a) enzyme-linked immunosorbent assay (ELISA), (b) Clauss method with a photometric readout, and (c) Clauss method with an electromechanical readout. In addition, the fibrin-based clot quality was evaluated with the thromboelastometric FIBTEM test. Results: Forty patients were enrolled, and 25 patients were included in the analysis. The fibrinogen concentrations at baseline were 2.2, 2.3, and 2.6 g/L and after 1 L of HES 1.6, 1.7, and 1.9 g/L as measured by ELISA, the photometric test, and the electromechanical test, respectively. The electromechanical Clauss test measured significantly higher concentrations at these time points. The relative decrease, however, was comparable between methods (31%, 29%, and 25%, respectively) but significantly lower than the 44% relative decrease with FIBTEM maximum clot firmness. Conclusion: Despite providing different fibrinogen concentration values at baseline, the relative decrease in fibrinogen concentration after HES infusion was comparable among the 3 tests. In contrast, fibrin-based clot quality was more affected than fibrinogen concentration tests by HES infusion.
Collapse
Affiliation(s)
- Dag Winstedt
- Department of Anaesthesia and Intensive Care, Skåne University Hospital Lund, Lund, Sweden
- Division of Anaesthesia and Intensive Care, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Cristina Solomon
- Department of Anaesthesiology, Perioperative Medicine and General Intensive Care, Paracelsus Medical University, Salzburg, Austria
- CSL Behring, Marburg, Germany
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Research Centre, Vienna, Austria
| | - Andreas Hillarp
- Division of Anaesthesia and Intensive Care, Department of Clinical Sciences, Lund University, Lund, Sweden
- Clinical Chemistry and Transfusion Medicine, Halland County Hospital, Sweden
| | - Tom Lundahl
- Division of Anaesthesia and Intensive Care, Department of Clinical Sciences, Lund University, Lund, Sweden
- Clinical Chemistry and Transfusion Medicine, Halland County Hospital, Sweden
| | - Ulf Schött
- Department of Anaesthesia and Intensive Care, Skåne University Hospital Lund, Lund, Sweden
- Division of Anaesthesia and Intensive Care, Department of Clinical Sciences, Lund University, Lund, Sweden
| |
Collapse
|
14
|
Cross-Sectional Guidelines for Therapy with Blood Components and Plasma Derivatives: Chapter 5 Human Albumin - Revised. Transfus Med Hemother 2016; 43:223-32. [PMID: 27403094 PMCID: PMC4924448 DOI: 10.1159/000446043] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 01/12/2016] [Indexed: 12/21/2022] Open
Abstract
Chapter 5 'Human Albumin' that was suspended on January 10, 2011 has been completed and updated in the present version.
Collapse
|
15
|
Elvstam O, Berntorp E, Schött U. ROTEM monitoring of activated and non-activated prothrombin complex concentrate correction of dilutional coagulopathy. Scand J Clin Lab Invest 2016; 76:202-7. [DOI: 10.3109/00365513.2015.1137347] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
16
|
Nicińska B, Pluta J, Kosieradzki M, Lągiewska B, Wasiak D, Lazowski T, Chmura A, Trzebicki J. The effects of in vitro hemodilution and fibrinogen concentrate substitution on thromboelastometry analysis in patients qualified for liver transplantation - preliminary results. Transplant Proc 2015; 46:2758-61. [PMID: 25380911 DOI: 10.1016/j.transproceed.2014.09.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Dilutional coagulopathy might cause life-threatening hemorrhages in liver transplantation. Liver insufficiency is usually accompanied by alteration in fibrinogen (Fib) synthesis, which is one of the main clotting factors providing appropriate hemostasis. Intraoperative hemodilution results in further Fib concentration reduction enhancing coagulopathy and blood loss. Exogenous Fib substitution might prevent this. METHODS A prospective study with a control group was designed. The study group consists of patients with cirrhosis who qualified for liver transplantation. Inclusion and exclusion criteria were strictly established. The blood collected from participants was diluted up to 30% and 60% with crystalloid (saline) or colloid (hydroxyethyl starch) in 2 parallel series. The first series consisted of diluted blood, the second of diluted blood with Fib concentrate. Thromboelastometry tests were performed on every blood sample. After collecting data from the first 12 participants, we performed a preliminary analysis. RESULTS The maximum clot formation (MCF) in the EXTEM test decreased with progressive blood dilution in both study arms. The MCF values were lower than 35 mm in every diluted blood sample of the study group. The recovery of decreased MCF after Fib concentrate substitution was observed in both groups. The improvement in clot formation was also expressed as amplitude of clot firmness in the 10th minute (A10) in the FIBTEM test. CONCLUSIONS Clot formation is disturbed more profoundly by hemodilution in cirrhotic patients. Fib concentrate substitution might be effective in the management of dilutional coagulopathy.
Collapse
Affiliation(s)
- B Nicińska
- Department of Anesthesiology and Intensive Care Unit, Medical University of Warsaw, Clinical Hospital Dzieciątka Jezus, Warsaw, Poland
| | - J Pluta
- Department of Anesthesiology and Intensive Care Unit, Medical University of Warsaw, Clinical Hospital Dzieciątka Jezus, Warsaw, Poland
| | - M Kosieradzki
- Department of General Surgery and Transplantology, Transplantation Institute, Medical University of Warsaw, Clinical Hospital Dzieciątka Jezus, Warsaw, Poland
| | - B Lągiewska
- Department of General Surgery and Transplantology, Transplantation Institute, Medical University of Warsaw, Clinical Hospital Dzieciątka Jezus, Warsaw, Poland
| | - D Wasiak
- Department of Surgical and Transplant Nursing, Medical University of Warsaw, Poland
| | - T Lazowski
- Department of Anesthesiology and Intensive Care Unit, Medical University of Warsaw, Clinical Hospital Dzieciątka Jezus, Warsaw, Poland
| | - A Chmura
- Department of General Surgery and Transplantology, Transplantation Institute, Medical University of Warsaw, Clinical Hospital Dzieciątka Jezus, Warsaw, Poland
| | - J Trzebicki
- Department of Anesthesiology and Intensive Care Unit, Medical University of Warsaw, Clinical Hospital Dzieciątka Jezus, Warsaw, Poland.
| |
Collapse
|
17
|
Solomon C, Ranucci M, Hochleitner G, Schöchl H, Schlimp CJ. Assessing the Methodology for Calculating Platelet Contribution to Clot Strength (Platelet Component) in Thromboelastometry and Thrombelastography. Anesth Analg 2015; 121:868-878. [PMID: 26378699 PMCID: PMC4568902 DOI: 10.1213/ane.0000000000000859] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2015] [Indexed: 12/28/2022]
Abstract
The viscoelastic properties of blood clot have been studied most commonly using thrombelastography (TEG) and thromboelastometry (ROTEM). ROTEM-based bleeding treatment algorithms recommend administering platelets to patients with low EXTEM clot strength (e.g., clot amplitude at 10 minutes [A10] <40 mm) once clot strength of the ROTEM® fibrin-based test (FIBTEM) is corrected. Algorithms based on TEG typically use a low value of maximum amplitude (e.g., <50 mm) as a trigger for administering platelets. However, this parameter reflects the contributions of various blood components to the clot, including platelets and fibrin/fibrinogen. The platelet component of clot strength may provide a more sensitive indication of platelet deficiency than clot amplitude from a whole blood TEG or ROTEM® assay. The platelet component of the formed clot is derived from the results of TEG/ROTEM® tests performed with and without platelet inhibition. In this article, we review the basis for why this calculation should be based on clot elasticity (e.g., the E parameter with TEG and the CE parameter with ROTEM®) as opposed to clot amplitude (e.g., the A parameter with TEG or ROTEM®). This is because clot elasticity, unlike clot amplitude, reflects the force with which the blood clot resists rotation within the device, and the relationship between clot amplitude (variable X) and clot elasticity (variable Y) is nonlinear. A specific increment of X (ΔX) will be associated with different increments of Y (ΔY), depending on the initial value of X. When calculated correctly, using clot elasticity data, the platelet component of the clot can provide a valuable insight into platelet deficiency in emergency bleeding.
Collapse
Affiliation(s)
- Cristina Solomon
- From the CSL Behring, Marburg, Germany; Department of Anesthesiology, Perioperative Care and General Intensive Care, Paracelsus Medical University, Salzburg University Hospital, Salzburg, Austria; Ludwig Boltzmann Institute for Experimental and Clinical Traumatology and AUVA Research Centre, Vienna, Austria; Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, IRCCS Policlinico, San Donato, Milan, Italy; CSL Behring, Vienna, Austria and Department of Anesthesiology and Intensive Care, AUVA Trauma Hospital of Salzburg, Austria
| | - Marco Ranucci
- From the CSL Behring, Marburg, Germany; Department of Anesthesiology, Perioperative Care and General Intensive Care, Paracelsus Medical University, Salzburg University Hospital, Salzburg, Austria; Ludwig Boltzmann Institute for Experimental and Clinical Traumatology and AUVA Research Centre, Vienna, Austria; Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, IRCCS Policlinico, San Donato, Milan, Italy; CSL Behring, Vienna, Austria and Department of Anesthesiology and Intensive Care, AUVA Trauma Hospital of Salzburg, Austria
| | - Gerald Hochleitner
- From the CSL Behring, Marburg, Germany; Department of Anesthesiology, Perioperative Care and General Intensive Care, Paracelsus Medical University, Salzburg University Hospital, Salzburg, Austria; Ludwig Boltzmann Institute for Experimental and Clinical Traumatology and AUVA Research Centre, Vienna, Austria; Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, IRCCS Policlinico, San Donato, Milan, Italy; CSL Behring, Vienna, Austria and Department of Anesthesiology and Intensive Care, AUVA Trauma Hospital of Salzburg, Austria
| | - Herbert Schöchl
- From the CSL Behring, Marburg, Germany; Department of Anesthesiology, Perioperative Care and General Intensive Care, Paracelsus Medical University, Salzburg University Hospital, Salzburg, Austria; Ludwig Boltzmann Institute for Experimental and Clinical Traumatology and AUVA Research Centre, Vienna, Austria; Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, IRCCS Policlinico, San Donato, Milan, Italy; CSL Behring, Vienna, Austria and Department of Anesthesiology and Intensive Care, AUVA Trauma Hospital of Salzburg, Austria
| | - Christoph J. Schlimp
- From the CSL Behring, Marburg, Germany; Department of Anesthesiology, Perioperative Care and General Intensive Care, Paracelsus Medical University, Salzburg University Hospital, Salzburg, Austria; Ludwig Boltzmann Institute for Experimental and Clinical Traumatology and AUVA Research Centre, Vienna, Austria; Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, IRCCS Policlinico, San Donato, Milan, Italy; CSL Behring, Vienna, Austria and Department of Anesthesiology and Intensive Care, AUVA Trauma Hospital of Salzburg, Austria
| |
Collapse
|
18
|
Li N, Statkevicius S, Asgeirsson B, Schött U. Effects of different colloid infusions on ROTEM and Multiplate during elective brain tumour neurosurgery. Perioper Med (Lond) 2015; 4:9. [PMID: 26425342 PMCID: PMC4589068 DOI: 10.1186/s13741-015-0019-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 09/22/2015] [Indexed: 03/28/2023] Open
Abstract
Background The European Medicines Agency does not recommend the use of hydroxyethyl starch-based volume replacement solutions in critically ill patients due to an increased risk of renal failure. However, this recommendation is questionable for its perioperative use. Several recent randomised controlled studies do not indicate a risk for renal failure—not even after high-risk surgery. Human albumin is used in our neurointensive care unit as a part of the “Lund concept” of brain injury resuscitation, and albumin has been introduced in elective neurosurgery instead of starch. The aim of our prospective unblinded observational cohort study was to compare the degree of dilutive coagulopathy after albumin and starch intra-operative fluid therapy. Methods Thirty-nine patients undergoing elective brain tumour surgery with craniotomy received either 130/0.42 hydroxyethyl starch or 5 % albumin infusions. The first 18 patients received starch, whereas the rest received albumin. Rotational thromboelastometry with ROTEM and platelet aggregometry with Multiplate were performed before surgery, after the first and second consecutive colloid infusions (250/500 ml albumin or 500/1000 ml starch) and at the end of surgery. Results Both intra- and inter-group comparisons showed more deranged ROTEM parameters after the higher doses of starch. Multiplate detected changes only in the albumin group after 500-ml infusion. Blood los did not differ between groups, nor did haemoglobin preoperatively or at end of surgery. Lower volumes of albumin were required to maintain stable intra-operative haemodynamic parameters; 250/500 ml albumin corresponded to 500/1000 ml starch. Conclusions Hydroxyethyl starch affected coagulation at lower volumes, with a more prominent effect on clot structure at the end of surgery, corroborating previous research. Only albumin decreased platelet aggregation, and 5 % albumin had a more potential volume effect than 130/0.42 hydroxyethyl starch.
Collapse
Affiliation(s)
- N Li
- Department of Medicine, Växjö County Hospital, Växjö, Sweden
| | - S Statkevicius
- Department of Anaesthesia and Intensive Care, Lund University and Skane University Hospital, Lund, S-22185 Sweden
| | - B Asgeirsson
- Department of Anaesthesia and Intensive Care, Lund University and Skane University Hospital, Lund, S-22185 Sweden
| | - U Schött
- Department of Anaesthesia and Intensive Care, Lund University and Skane University Hospital, Lund, S-22185 Sweden
| |
Collapse
|
19
|
Pathirana S, Wong G, Williams P, Yang K, Kershaw G, Dunkley S, Kam PCA. The Effects of Haemodilution with Albumin on Coagulation in Vitro as Assessed by Rotational Thromboelastometry. Anaesth Intensive Care 2015; 43:187-92. [DOI: 10.1177/0310057x1504300207] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We investigated the in vitro viscoelastic changes of progressive haemodilution with 4% albumin compared with normal saline (NS) using rotational thromboelastometry (ROTEM®, Pentapharm Co., Munich, Germany). Whole blood samples obtained from 20 healthy volunteers were diluted in vitro with 4% albumin or NS by 10%, 20% and 40%. Fibrinogen concentration and ROTEM® (EXTEM [screening test for the extrinsic haemostasis system], FIBTEM [EXTEM-based assay for the fibrin part of the clot]) variables including coagulation time, clot formation time (CFT), α-angle, maximum clot firmness and lysis index were measured in the undiluted sample and at each degree of haemodilution. There was no significant difference in fibrinogen concentration at equivalent haemodilutions with normal saline and 4% albumin solutions. Forty percent haemodilution with albumin significantly prolonged coagulation time (EXTEM P=0.007, FIBTEM P=0.0001) and significantly decreased lysis index (FIBTEM P=0.009) compared with NS. A significant decrease in maximum clot firmness from undiluted measurements ( P=0.05) was observed at lower haemodilutions with albumin (20% with EXTEM, 10% with FIBTEM) compared with NS (40% with EXTEM and FIBTEM). The adverse effects of large degrees of haemodilution with 4% albumin solution are in excess of what can be explained by haemodilution alone. This study suggests that large degrees of haemodilution with albumin impair fibrinogen activity to a greater extent than equivalent degrees of haemodilution with NS.
Collapse
Affiliation(s)
- S. Pathirana
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, New South Wales
| | - G. Wong
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, New South Wales
| | - P. Williams
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, New South Wales
| | - K. Yang
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, New South Wales
| | - G. Kershaw
- Department of Haematology, Royal Prince Alfred Hospital, Camperdown, New South Wales
| | - S. Dunkley
- Department of Haematology, Royal Prince Alfred Hospital, Camperdown, New South Wales
| | - P. C. A. Kam
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, New South Wales
| |
Collapse
|
20
|
Tynngård N, Lindahl TL, Ramström S. Assays of different aspects of haemostasis - what do they measure? Thromb J 2015; 13:8. [PMID: 25688179 PMCID: PMC4329663 DOI: 10.1186/s12959-015-0036-2] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Accepted: 01/12/2015] [Indexed: 12/25/2022] Open
Abstract
Haemostasis is a complex process affected by many factors including both cellular and plasma components. It is a multistep process starting with platelet adhesion to damaged endothelium and ending in clot fibrinolysis. There are several methods available to study different aspects of haemostasis including adhesion, aggregation, coagulation and fibrinolysis. This review describes the different methods, what aspects of haemostasis they measure and their limitations. Methods discussed include methods to study adhesion (e.g. PFA-100, cone and platelet(let) analyzer and perfusion chambers) and aggregation (e.g. Multiplate, VerifyNow and Plateletworks). Furthermore the principles behind viscoelastic haemostatic assays are presented as well as methods that can analyse aspects of haemostasis in plasma or platelet-rich-plasma samples (thrombin generation, overall haemostasis potential and Thrombodynamics Analyzer).
Collapse
Affiliation(s)
- Nahreen Tynngård
- Department of Clinical Chemistry, and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden ; Department of Clinical Immunology and Transfusion Medicine, and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Tomas L Lindahl
- Department of Clinical Chemistry, and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Sofia Ramström
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| |
Collapse
|
21
|
WINSTEDT DAG. Viscoelastic haemostatic assays and fibrinogen concentration tests during haemodilution. Acta Anaesthesiol Scand 2015. [DOI: 10.1111/aas.12478] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- DAG WINSTEDT
- Section of Anaesthesiology and Intensive Care; Faculty of Medicine; Clinical Sciences Lund; 22185 Lund Sweden
| |
Collapse
|
22
|
Winstedt D, Thomas OD, Nilsson F, Olanders K, Schött U. Correction of hypothermic and dilutional coagulopathy with concentrates of fibrinogen and factor XIII: an in vitro study with ROTEM. Scand J Trauma Resusc Emerg Med 2014; 22:73. [PMID: 25510409 PMCID: PMC4272532 DOI: 10.1186/s13049-014-0073-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Accepted: 11/26/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Fibrinogen concentrate treatment can improve coagulation during massive traumatic bleeding. The aim of this in vitro study was to determine whether fibrinogen concentrate, or a combination of factor XIII and fibrinogen concentrates, could reverse a haemodilution-induced coagulopathy during hypothermia. METHODS Citrated venous blood from 10 healthy volunteers was diluted in vitro by 33% with 130/0.42 hydroxyethyl starch (HES) or Ringer's acetate (RAc). The effects of fibrinogen concentrate corresponding to 4 gram per 70 kg, or a combination of the same dose of fibrinogen with factor XIII (20 IU per kg), were measured using rotational thromboelastometry (ROTEM). The blood was analysed at 33°C or 37°C with ROTEM EXTEM and FIBTEM reagents. Clotting time (CT), clot formation time (CFT), alpha angle (AA) and maximal clot formation (MCF) were recorded. RESULTS Fibrinogen with or without factor XIII improved all ROTEM parameters in either solution irrespective of temperature, with the exception of EXTEM-AA and EXTEM-CFT in HES haemodilution. Fibrinogen increased FIBTEM-MCF more in the samples diluted with RAc than HES, particularly in presence of factor XIII. CONCLUSIONS Fibrinogen improved in vitro haemodilution-induced coagulopathy at both 33°C and 37°C, though more efficiently after crystalloid than HES haemodilution. Factor XIII had an additional effect on FIBTEM-MCF, but only after crystalloid dilution.
Collapse
Affiliation(s)
- Dag Winstedt
- Faculty of Medicine, Lund University, Lund, Sweden.
- Department of Anaesthesia and Intensive Care, Skåne University Hospital Lund, Lund, 221 85, Sweden.
| | - Owain D Thomas
- Faculty of Medicine, Lund University, Lund, Sweden.
- Department of Paediatric Anaesthesia and Intensive Care, Skåne University Hospital Lund, Lund, 221 85, Sweden.
| | - Fredrik Nilsson
- Research and Development Centre, Skåne, Skåne University Hospital Lund, Lund, 221 85, Sweden.
| | - Knut Olanders
- Faculty of Medicine, Lund University, Lund, Sweden.
- Department of Anaesthesia and Intensive Care, Skåne University Hospital Lund, Lund, 221 85, Sweden.
| | - Ulf Schött
- Faculty of Medicine, Lund University, Lund, Sweden.
- Department of Anaesthesia and Intensive Care, Skåne University Hospital Lund, Lund, 221 85, Sweden.
| |
Collapse
|
23
|
Moret E, Jacob MW, Ranucci M, Schramko AA. Albumin—Beyond Fluid Replacement in Cardiopulmonary Bypass Surgery. Semin Cardiothorac Vasc Anesth 2014; 18:252-9. [DOI: 10.1177/1089253214535667] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Maintaining vascular barrier competence, preventing interstitial edema, and keeping microcirculation intact is crucial to achieve an optimal outcome in cardiopulmonary bypass surgery (CPB). Blood contact with roller pumps and foreign surfaces during CPB induces shear stress and a pressure drop across the pump boot that leads to transient systemic activation of the inflammatory and hemostatic systems. Moreover, patients after CPB often need volume resuscitation using the smallest possible amount of colloid solution because of fluid overload. For this purpose, human-derived albumin may be preferred over synthetic colloids because CPB priming with albumin preserves oncotic pressure, prevents platelet adhesion, and likely induces less consumption of coagulation factors. In patients with increased bleeding or renal failure, albumin is a safe alternative because of its minimal side effects. Large, randomized clinical trials comparing the benefit of albumin versus other fluids are warranted in the future to define albumin’s distinct role in select high-risk surgical populations.
Collapse
Affiliation(s)
- Enrique Moret
- Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | | | | | | |
Collapse
|
24
|
Abstract
BACKGROUND Within the framework of a risk assessment procedure the Committee for Risk Assessment of Pharmacovigilance (PRAC) of the European Medicines Agency (EMA) came to the conclusion that the benefits of hydroxylethyl starch infusion solutions (HES) no longer outweighed the risks and on 14 June 2013 recommended that approval should be suspended. Until the procedure has finally been concluded, which could last several months, the Federal Institute for Drugs and Medical Products (BfArM) has recommended that HES should not be used. AIM The aim of this article is to present the data situation in the most objective and compact way and to ultimately give the reader the foundations in order to be able to form a personal opinion. In addition an attempt will be made to describe a concept how infusion therapy can be carried out without using hydroxyethyl starch (HES). MATERIAL AND METHODS The background to this decision is given based on a review of the literature and the relevance for intensive care, emergency and perioperative medicine is assessed. Furthermore, a concept of infusion therapy without hydroxyethyl starch is formulated also based on the results of current studies. RESULTS For infusion regimens without HES it should be noted that gelatin represents a considerable risk for anaphylactic reactions, that transfer of the new variants of Creutzfeldt-Jacob disease (bovine spongiform encephalopathy BSE) cannot fundamentally be excluded and that some evidence has been found that gelatin can cause kidney injury, probably in a similar way to HES. With respect to the cost-benefit analysis of infusion solutions, blood loss in adults of approximately 1-1.5 l can be substituted by balanced crystalloids (basic therapy 4-5 times compared to the amount of blood lost). For larger blood losses small amounts of hyperoncotic albumin solution (20 %) or alternatively 5 % albumin solution can be used. The 20 % albumin solution seems to have some advantages because it has a higher volume effect (approximately 200 %) and can be more favourable for the fluid balance than 5 % albumin solution. Blood losses greater than 2-3 l normally also require administration of blood products (e.g. fresh frozen plasma FFP and erythrocyte concentrates EC). CONCLUSIONS The third generation HES solutions cannot be completely replaced by other colloids and in future crystalloids will more strongly again broadly form the basis for infusion therapy. In this aspect balanced crystalloids have priority with respect to the acid-base equilibrium. The history of HES has impressively shown that infusion therapy must be adjusted on a scientifically founded basis, whether in intensive care medicine, perioperative or emergency medicine. Large prospective studies with clinically relevant endpoints are urgently needed.
Collapse
|
25
|
Boisramé-Helms J, Boivin A, Delabranche X, Meziani F. Albumine humaine comme traitement adjuvant du sepsis et du choc septique : mythe et réalité. MEDECINE INTENSIVE REANIMATION 2014. [DOI: 10.1007/s13546-013-0834-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
26
|
Thomas OD, Gustafsson A, Schött U. Rotational thromboelastometry and multiple electrode platelet aggregometry in four patients with abnormal routine coagulation studies before removal of epidural catheters after major surgery: a case series and research study. J Med Case Rep 2013; 7:282. [PMID: 24377397 PMCID: PMC3892080 DOI: 10.1186/1752-1947-7-282] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 08/29/2013] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Routine coagulation tests have a low predictability for perioperative bleeding complications, and spinal hematoma after removal of epidural catheters is very infrequent. Thromboelastometry and point-of-care platelet aggregometry may improve hemostatic monitoring but have not been studied in the context of safety around epidural removal. METHODS Twenty patients who received an epidural catheter for major thoracoabdominal and abdominal surgery were included prospectively. In addition to routine coagulation tests, rotational thromboelastometry and multiple electrode platelet aggregometry were carried out. RESULTS A coagulation deficit was suggested by routine coagulation tests on the intended day of epidural catheter removal in four out of 20 patients. Prothrombin time-international normalized ratio was elevated to 1.5 in one patient (normal range: 0.9 to 1.2) while rotational thromboelastometry and multiple electrode platelet aggregometry parameters were within normal limits. Activated partial thromboplastin time was elevated to 47 to 50 seconds in the remaining three patients (normal range 28 to 45 seconds). Rotational thromboelastometry showed that one of the patients' results was due to heparin effect: the clotting time with the HEPTEM® activator was 154 seconds as compared to 261 seconds with INTEM. The three remaining patients with prolonged routine coagulation test results had all received over 1L of hydroxyethyl starch (Venofundin®) and thrombosis prophylaxis with low-molecular-weight heparin (enoxaparin). Rotational thromboelastometry and multiple electrode platelet aggregometrygave normal or hypercoagulative signals in most patients. CONCLUSIONS This case series is new in that it examines rotational thromboelastometry and multiple electrode platelet aggregometry postoperatively in the context of epidural analgesia and shows that they may be clinically useful. These methods should be validated before they can be used for standard patient care.
Collapse
Affiliation(s)
- Owain D Thomas
- Department of Anaesthesia and Intensive Care, Skåne University Hospital, S-22185 Lund, Sweden
- Faculty of Medicine, University of Lund, Lund, Sweden
| | | | - Ulf Schött
- Department of Anaesthesia and Intensive Care, Skåne University Hospital, S-22185 Lund, Sweden
- Faculty of Medicine, University of Lund, Lund, Sweden
| |
Collapse
|
27
|
Kind SL, Spahn-Nett GH, Emmert MY, Eismon J, Seifert B, Spahn DR, Theusinger OM. Is Dilutional Coagulopathy Induced by Different Colloids Reversible by Replacement of Fibrinogen and Factor XIII Concentrates? Anesth Analg 2013; 117:1063-71. [DOI: 10.1213/ane.0b013e3182a52876] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
28
|
Song JG, Jeong SM, Jun IG, Lee HM, Hwang GS. Five-minute parameter of thromboelastometry is sufficient to detect thrombocytopenia and hypofibrinogenaemia in patients undergoing liver transplantation. Br J Anaesth 2013; 112:290-7. [PMID: 24065728 DOI: 10.1093/bja/aet325] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Early detection of coagulopathy is important to prevent bleeding during liver transplantation (LT). Rotation thromboelastometry (ROTEM(®)) provides the earliest parameter of clot amplitudes at 5 min (A5). We evaluated whether A5 correlates with platelet count (PLT) and fibrinogen concentration (Fib) and can predict thrombocytopenia and hypofibrinogenaemia in hypocoagulable patients undergoing living-donor LT (LDLT). METHODS A total of 3446 retrospective ROTEM(®) measurements, including 1139 EXTEM, 1182 INTEM, and 1125 FIBTEM, with simultaneously measured PLT and Fib, were analysed during LDLT in 239 patients. The correlations between A5 and maximum clot firmness (MCF) index, PLT, and Fib were calculated. Receiver operating characteristic analysis with area under the curve (AUC) was used to assess A5 thresholds predictive of PLT and Fib. RESULTS The median PLT was 47 000 mm(-3) and the median Fib was 100 mg dl(-1) during LDLT. The A5 parameters of EXTEM (A5EXTEM) and INTEM (A5INTEM) were highly correlated with MCF (r=0.96 and r=0.95, respectively), PLT (r=0.76 and r=0.77, respectively), and Fib (r=0.63 and r=0.64, respectively). A5 of FIBTEM (A5FIBTEM) was also correlated with MCF (r=0.91) and Fib (r=0.75). A5EXTEM thresholds of 15 and 19 mm predicted PLT<30 000 mm(-3) (AUC=0.90) and <50 000 mm(-3) (AUC=0.87), respectively, whereas A5FIBTEM 4 mm predicted Fib<100 mg dl(-1) (AUC=0.86). Biases from A5EXTEM and A5FIBTEM to their MCFs were 16.4 and 1.3 mm, respectively. CONCLUSIONS A5 as an early variable of clot firmness is effective in detecting critically low PLT and Fib. A5 can therefore be a reliable fast index guiding transfusion therapy in hypocoagulable patients undergoing LDLT.
Collapse
Affiliation(s)
- J-G Song
- Department of Anaesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | | | | | | | | |
Collapse
|
29
|
Hanna J, Winstedt D, Schött U. Fibrinogen and FXIII dose response effects on albumin-induced coagulopathy. Scandinavian Journal of Clinical and Laboratory Investigation 2013; 73:553-62. [DOI: 10.3109/00365513.2013.821710] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
|