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Zou Y, Zeng S, Huang C, Liu L, Li L. The value of fibrinogen combined with D-dimer and neonatal weight in predicting postpartum hemorrhage in vaginal delivery. J Perinat Med 2024; 52:478-484. [PMID: 38414334 DOI: 10.1515/jpm-2023-0351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 02/03/2024] [Indexed: 02/29/2024]
Abstract
OBJECTIVES The purpose of this study was to explore whether fibrinogen (Fib) can be used as a predictor of postpartum hemorrhage (PPH) in parturients with vaginal delivery, and the value of combining Fib with other indexes to predict postpartum hemorrhage in vaginal delivery. METHODS A total of 207 parturients who delivered via vagina were divided into PPH group (n=102) and non-PPH group (n=105). The PPH group was further divided into mild PPH group and severe PPH group. The differences of Fib, platelet (PLT), mean platelet volume (MPV), platelet distribution width (PDW), D-dimer (D-D), hemoglobin (HGB) and neonatal weight (Nw) between the two groups were compared to explore the significance of these indexes in predicting PPH. RESULTS Fib, PLT and PDW in PPH group were significantly lower than those in non-PPH group, while D-D and Nw in PPH group were significantly higher than those in non-PPH group. In the binary logistic regression model, we found that Fib, D-D and Nw were independently related to PPH. The risk of PPH increased by 9.87 times for every 1 g/L decrease in Fib. The cut-off value of Fib is 4.395 (sensitivity 0.705, specificity 0.922). The AUC value of PPH predicted by Fib combined with D-D and Nw was significantly higher than that of PPH predicted by Fib (p<0.05, 95 % CI 0.00313-0.0587). CONCLUSIONS Fib, D-D and Nw have good predictive value for PPH of vaginal delivery, among which Fib is the best. The combination of three indexes of Fib, D-D and Nw can predict PPH more systematically and comprehensively, and provide a basis for clinical prevention and treatment of PPH.
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Affiliation(s)
- Yanke Zou
- Department of Cardiology, Army Medical Center of PLA, Chongqing, P.R. China
| | - Shuai Zeng
- Department of Laboratory Pathology, Unit 32280 of the People's Liberation Army, Leshan City, Sichuan Province, P.R. China
| | - Changxiao Huang
- Department of Obstetrics and Gynecology, Army Medical Center of PLA, Chongqing, P.R. China
| | - Ling Liu
- Department of Health Statistics, Army Military Medical University, Chongqing, P.R. China
| | - Li Li
- Department of Obstetrics and Gynecology, Army Medical Center of PLA, Chongqing, P.R. China
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Dorken-Gallastegi A, Bokenkamp M, Argandykov D, Mendoza AE, Hwabejire JO, Saillant N, Fagenholz PJ, Kaafarani HMA, Velmahos GC, Parks JJ. Optimal dose of cryoprecipitate in massive transfusion following trauma. J Trauma Acute Care Surg 2024; 96:137-144. [PMID: 37335138 DOI: 10.1097/ta.0000000000004060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
BACKGROUND While cryoprecipitate (Cryo) is commonly included in massive transfusion protocols for hemorrhagic shock, the optimal dose of Cryo transfusion remains unknown. We evaluated the optimal red blood cell (RBC) to RBC to Cryo ratio during resuscitation in massively transfused trauma patients. METHODS Adult patients in the American College of Surgeon Trauma Quality Improvement Program (2013-2019) receiving massive transfusion (≥4 U of RBCs, ≥1 U of fresh frozen plasma, and ≥1 U of platelets within 4 hours) were included. A unit of Cryo was defined as a pooled unit of 100 mL. The RBC:Cryo ratio was calculated for blood products transfused within 4 hours of presentation. The association between RBC:Cryo and 24-hour mortality was analyzed with multivariable logistic regression adjusting for the volume of RBC, plasma and platelet transfusions, global and regional injury severity, and other relevant variables. RESULTS The study cohort included 12,916 patients. Among those who received Cryo (n = 5,511 [42.7%]), the median RBC and Cryo transfusion volume within 4 hours was 11 U (interquartile range, 7-19 U) and 2 U (interquartile range, 1-3 U), respectively. Compared with no Cryo administration, only RBC:Cryo ratios ≤8:1 were associated with a significant survival benefit, while lower doses of Cryo (RBC:Cryo >8:1) were not associated with decreased 24-hour mortality. Compared with the maximum dose of Cryo administration (RBC:Cryo, 1:1-2:1), there was no difference in 24-hour mortality up to RBC:Cryo of 7:1 to 8:1, whereas lower doses of Cryo (RBC:Cryo, >8:1) were associated with significantly increased 24-hour mortality. CONCLUSION One pooled unit of Cryo (100 mL) per 7 to 8 U of RBCs could be the optimal dose of Cryo in trauma resuscitation that provides a significant survival benefit while avoiding unnecessary blood product transfusions. LEVEL OF EVIDENCE Prognostic and Epidemiologic; Level IV.
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Affiliation(s)
- Ander Dorken-Gallastegi
- From the Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Hughes MDG, Cussons S, Hanson BS, Cook KR, Feller T, Mahmoudi N, Baker DL, Ariëns R, Head DA, Brockwell DJ, Dougan L. Building block aspect ratio controls assembly, architecture, and mechanics of synthetic and natural protein networks. Nat Commun 2023; 14:5593. [PMID: 37696784 PMCID: PMC10495373 DOI: 10.1038/s41467-023-40921-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 08/16/2023] [Indexed: 09/13/2023] Open
Abstract
Fibrous networks constructed from high aspect ratio protein building blocks are ubiquitous in nature. Despite this ubiquity, the functional advantage of such building blocks over globular proteins is not understood. To answer this question, we engineered hydrogel network building blocks with varying numbers of protein L domains to control the aspect ratio. The mechanical and structural properties of photochemically crosslinked protein L networks were then characterised using shear rheology and small angle neutron scattering. We show that aspect ratio is a crucial property that defines network architecture and mechanics, by shifting the formation from translationally diffusion dominated to rotationally diffusion dominated. Additionally, we demonstrate that a similar transition is observed in the model living system: fibrin blood clot networks. The functional advantages of this transition are increased mechanical strength and the rapid assembly of homogenous networks above a critical protein concentration, crucial for in vivo biological processes such as blood clotting. In addition, manipulating aspect ratio also provides a parameter in the design of future bio-mimetic and bio-inspired materials.
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Affiliation(s)
- Matt D G Hughes
- School of Physics and Astronomy, Faculty of Engineering and Physical Sciences, University of Leeds, Leeds, UK
| | - Sophie Cussons
- Astbury Centre for Structural Molecular Biology, University of Leeds, Leeds, UK
- School of Molecular and Cellular Biology, Faculty of Biological Sciences, University of Leeds, Leeds, UK
| | - Benjamin S Hanson
- School of Physics and Astronomy, Faculty of Engineering and Physical Sciences, University of Leeds, Leeds, UK
| | - Kalila R Cook
- School of Physics and Astronomy, Faculty of Engineering and Physical Sciences, University of Leeds, Leeds, UK
| | - Tímea Feller
- Leeds Institute of Cardiovascular and Metabolic Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Najet Mahmoudi
- ISIS Neutron and Muon Spallation Source, STFC Rutherford Appleton Laboratory, Oxfordshire, UK
| | - Daniel L Baker
- School of Physics and Astronomy, Faculty of Engineering and Physical Sciences, University of Leeds, Leeds, UK
| | - Robert Ariëns
- Leeds Institute of Cardiovascular and Metabolic Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - David A Head
- School of Computing, Faculty of Engineering and Physical Science, University of Leeds, Leeds, UK
| | - David J Brockwell
- Astbury Centre for Structural Molecular Biology, University of Leeds, Leeds, UK
- School of Molecular and Cellular Biology, Faculty of Biological Sciences, University of Leeds, Leeds, UK
| | - Lorna Dougan
- School of Physics and Astronomy, Faculty of Engineering and Physical Sciences, University of Leeds, Leeds, UK.
- Astbury Centre for Structural Molecular Biology, University of Leeds, Leeds, UK.
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Stanford S, Roy A, Cecil T, Hegener O, Schulz P, Turaj A, Lim S, Arbuthnot E. Differences in coagulation-relevant parameters: Comparing cryoprecipitate and a human fibrinogen concentrate. PLoS One 2023; 18:e0290571. [PMID: 37647278 PMCID: PMC10468048 DOI: 10.1371/journal.pone.0290571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 08/09/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND Variable fibrinogen content within cryoprecipitate makes accurate dosing challenging in patients with coagulopathic bleeding, in addition to pathogen transmission risks associated with its administration. Purified and standardized human fibrinogen concentrates (HFCs) represent reliable alternatives. Full cryoprecipitate characterization is required to inform selection of an appropriate fibrinogen source for supplementation therapy. METHODS Extended biochemical comparison of pooled cryoprecipitate and HFC (Fibryga, Octapharma) was performed using commercially available assays to determine levels of variability in cryoprecipitate and HFC. In addition to standard procoagulant factors, measurements included activities of platelet-derived microparticles (PMPs) and plasminogen, and levels of fibrin degradation products. RESULTS Cryoprecipitate contains lower fibrinogen levels than HFC (4.83 vs.19.73 g/L; p<0.001), translating to approximately half the amount of fibrinogen per standard cryoprecipitate dose (two pools, pre-pooled from five donations each) vs. HFC (2.14 vs. 3.95 g; p<0.001). Factor XIII (FXIII) levels were also lower in cryoprecipitate vs. HFC (192.17 vs. 328.33 IU/dL; p = 0.002). Levels of procoagulants in cryoprecipitate, such as von Willebrand Factor (VWF) and factor VIII (FVIII), were highly variable, as was PMP activity. A standard cryoprecipitate dose contains significantly higher levels of measured plasminogen and D-dimer fragments than a standard HFC dose. CONCLUSION The tested HFC is a more reliable fibrinogen and FXIII source for accurate dosing compared with cryoprecipitate. Cryoprecipitate appears considerably less predictable for bleeding management due to wide variation in pro- and anticoagulation factors, the presence of PMPs, and the potential to elevate VWF and FVIII to prothrombotic levels.
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Affiliation(s)
- Sophia Stanford
- Peritoneal Malignancy Institute, Basingstoke and North Hampshire Hospital, Basingstoke, United Kingdom
| | - Ashok Roy
- Peritoneal Malignancy Institute, Basingstoke and North Hampshire Hospital, Basingstoke, United Kingdom
| | - Tom Cecil
- Peritoneal Malignancy Institute, Basingstoke and North Hampshire Hospital, Basingstoke, United Kingdom
| | | | - Petra Schulz
- Octapharma Pharmazeutika Produktionsges.m.b.H., Vienna, Austria
| | - Anna Turaj
- Faculty of Medicine, Centre for Cancer Immunology, University of Southampton, University Hospital Southampton, Southampton, United Kingdom
| | - Sean Lim
- Faculty of Medicine, Centre for Cancer Immunology, University of Southampton, University Hospital Southampton, Southampton, United Kingdom
| | - Emily Arbuthnot
- Peritoneal Malignancy Institute, Basingstoke and North Hampshire Hospital, Basingstoke, United Kingdom
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Zeineddin A, Wu F, Dong JF, Vesselinov R, Neal MD, Corash L, Pati S, Kozar RA. Early lyophilized cryoprecipitate enhances the ADAMTS13/VWF ratio to reduce systemic endotheliopathy and lessen lung injury in a mouse multiple-trauma hemorrhage model. J Trauma Acute Care Surg 2023; 95:S137-S143. [PMID: 37211640 PMCID: PMC10389395 DOI: 10.1097/ta.0000000000004065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 04/22/2023] [Accepted: 05/12/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND Recent studies in severely injured patients suggest an important role of von Willebrand Factor (VWF) and ADAMTS13 in the endotheliopathy of trauma (EoT). We hypothesized that the early use of cryoprecipitate would be effective as an endothelial protector by supplementing physiologic VWF and ADAMTS13 to reverse the EoT. We tested a pathogen-reduced lyophilized cryoprecipitate (LPRC) that could expedite the early administration of cryoprecipitate in the battlefield. METHODS A mouse multiple-trauma model with uncontrolled hemorrhage (UCH) from liver injury was utilized followed by hypotensive resuscitation (mean arterial pressure, 55-60) × 3 hours with lactated Ringer's (LR), fresh frozen plasma (FFP), conventional pathogen-reduced cryoprecipitate (CC), and LPRC. Blood was collected for measurement of syndecan-1, VWF, and ADAMTS13 by ELISA. Lungs were stained for histopathologic injury and syndecan-1 and bronchial alveolar lavage (BAL) fluid harvested for protein as an indicator of permeability. Statistical analysis was by ANOVA followed by Bonferroni correction. RESULTS Following multiple trauma and UCH, blood loss was similar across groups. Mean volume of resuscitation was higher in the LR group compared with the other resuscitation groups. Lung histopathologic injury, syndecan-1 immunostaining and BAL protein were higher with LR compared with resuscitation with FFP and CC, while LPRC further reduced BAL compared with FFP and CC. The ADAMTS13/VWF ratio was significantly lower in LR but improved with FFP and CC, comparable to shams while LPRC further increased this ratio. CONCLUSION The protective effects of CC and LPRC were comparable to FFP in ameliorating the EoT in our murine multiple trauma and UCH model. Lyophilized cryoprecipitate may also provide additional benefit by enhancing the ADAMTS13/VWF ratio. These data provide evidence of the safety and efficacy of LPRC and warrants further investigation for its potential application in military settings once approved for human administration.
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Curry N, Davenport R, Lucas J, Deary A, Benger J, Edwards A, Evans A, Foley C, Green L, Morris S, Thomas H, Brohi K, Stanworth SJ. The CRYOSTAT2 trial: The rationale and study protocol for a multi-Centre, randomised, controlled trial evaluating the effects of early high-dose cryoprecipitate in adult patients with major trauma haemorrhage requiring major haemorrhage protocol activation. Transfus Med 2023; 33:123-131. [PMID: 36321753 DOI: 10.1111/tme.12932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 09/05/2022] [Accepted: 10/03/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVES To describe the protocol for a multinational randomised, parallel, superiority trial, in which patients were randomised to receive early high-dose cryoprecipitate in addition to standard major haemorrhage protocol (MHP), or Standard MHP alone. BACKGROUND Blood transfusion support for trauma-related major bleeding includes red cells, plasma and platelets. The role of concentrated sources of fibrinogen is less clear and has not been evaluated in large clinical trials. Fibrinogen is a key pro-coagulant factor that is essential for stable clot formation. A pilot trial had demonstrated that it was feasible to deliver cryoprecipitate as a source of fibrinogen within 90 min of admission. METHODS Randomisation was via opaque sealed envelopes held securely in participating Emergency Departments or transfusion laboratories. Early cryoprecipitate, provided as 3 pools (equivalent to 15 single units of cryoprecipitate or 6 g fibrinogen supplementation), was transfused as rapidly as possible, and started within 90 min of admission. Participants in both arms received standard treatment defined in the receiving hospital MHP. The primary outcome measure was all-cause mortality at 28 days. Symptomatic thrombotic events including venous thromboembolism and arterial thrombotic events (myocardial infarction, stroke) were collected from randomisation up to day 28 or discharge from hospital. EQ5D-5Land Glasgow Outcome Score were completed at discharge and 6 months. All analyses will be performed on an intention to treat basis, with per protocol sensitivity analysis. RESULTS The trial opened for recruitment in June 2017 and the final patient completed follow-up in May 2022. DISCUSSION This trial will provide firmer evidence to evaluate the effectiveness and cost-effectiveness of early high-dose cryoprecipitate alongside the standard MHP in major traumatic haemorrhage.
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Affiliation(s)
- Nicola Curry
- Oxford UniversityHospitals NHS Foundation Trust, Nuffield Orthopaedic Hospital, Oxford, UK
| | - Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Joanne Lucas
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Alison Deary
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Jonathan Benger
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Antoinette Edwards
- Trauma Audit and Research Network, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Amy Evans
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Claire Foley
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Laura Green
- Blizard Institute, Queen Mary University of London, London, UK
- NHS Blood and Transplant and Bart's Health NHS Trust, London, UK
| | - Stephen Morris
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Helen Thomas
- NHS Blood and Transplant Clinical Trials Unit, Bristol, UK
| | - Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Simon J Stanworth
- NHS Blood and Transplant and Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
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Vermeulen T, Van de Velde M. The role of fibrinogen in postpartum hemorrhage. Best Pract Res Clin Anaesthesiol 2022; 36:399-410. [PMID: 36513434 DOI: 10.1016/j.bpa.2022.10.002] [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: 09/29/2022] [Accepted: 10/10/2022] [Indexed: 11/06/2022]
Abstract
Postpartum hemorrhage (PPH) is the leading cause of maternal death worldwide (WHO), with almost 60000 deaths annually. Pregnancy is a prothrombotic state with increased levels of several coagulation factors to protect the parturient from bleeding problems during delivery. Fibrinogen has a significant role in coagulation and bleeding. Studies have pointed out that lower fibrinogen levels before delivery, but also at the initiation of PPH, are predictive of major hemorrhage. Early, the goal-directed fibrinogen concentrate therapy might be very useful in a subgroup of patients with serious PPH. This review aims to summarize the current literature on fibrinogen during PPH.
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Affiliation(s)
- Tim Vermeulen
- Department of Anaesthesiology, UZ Leuven, Herestraat 49, 3000, Leuven, Belgium.
| | - Marc Van de Velde
- Department of Anaesthesiology, UZ Leuven, Herestraat 49, 3000, Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
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8
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Morrow GB, Feller T, McQuilten Z, Wake E, Ariëns RAS, Winearls J, Mutch NJ, Laffan MA, Curry N. Cryoprecipitate transfusion in trauma patients attenuates hyperfibrinolysis and restores normal clot structure and stability: Results from a laboratory sub-study of the FEISTY trial. Crit Care 2022; 26:290. [PMID: 36163263 PMCID: PMC9511733 DOI: 10.1186/s13054-022-04167-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 09/13/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Fibrinogen is the first coagulation protein to reach critical levels during traumatic haemorrhage. This laboratory study compares paired plasma samples pre- and post-fibrinogen replacement from the Fibrinogen Early In Severe Trauma studY (FEISTY; NCT02745041). FEISTY is the first randomised controlled trial to compare the time to administration of cryoprecipitate (cryo) and fibrinogen concentrate (Fg-C; Riastap) in trauma patients. This study will determine differences in clot strength and fibrinolytic stability within individuals and between treatment arms. METHODS Clot lysis, plasmin generation, atomic force microscopy and confocal microscopy were utilised to investigate clot strength and structure in FEISTY patient plasma. RESULTS Fibrinogen concentration was significantly increased post-transfusion in both groups. The rate of plasmin generation was reduced 1.5-fold post-transfusion of cryo but remained unchanged with Fg-C transfusion. Plasminogen activator inhibitor 1 activity and antigen levels and Factor XIII antigen were increased post-treatment with cryo, but not Fg-C. Confocal microscopy analysis of fibrin clots revealed that cryo transfusion restored fibrin structure similar to those observed in control clots. In contrast, clots remained porous with stunted fibres after infusion with Fg-C. Cryo but not Fg-C treatment increased individual fibre toughness and stiffness. CONCLUSIONS In summary, our data indicate that cryo transfusion restores key fibrinolytic regulators and limits plasmin generation to form stronger clots in an ex vivo laboratory study. This is the first study to investigate differences in clot stability and structure between cryo and Fg-C and demonstrates that the additional factors in cryo allow formation of a stronger and more stable clot.
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Affiliation(s)
- Gael B Morrow
- Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, Oxford, OX3 9DU, UK.
- Aberdeen Cardiovascular and Diabetes Centre, School of Medicine, Medical Sciences and Nutrition, Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK.
| | - Timea Feller
- Leeds Thrombosis Collective, Discovery and Translational Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Zoe McQuilten
- Transfusion Research Unit, Melbourne and Monash Health, Monash University, Melbourne, Australia
| | - Elizabeth Wake
- Trauma Service, Gold Coast University Hospital, Southport, Australia
- School of Medicine and Dentistry, Griffith University, Gold Coast Campus, Southport, Australia
| | - Robert A S Ariëns
- Leeds Thrombosis Collective, Discovery and Translational Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - James Winearls
- School of Medicine and Dentistry, Griffith University, Gold Coast Campus, Southport, Australia
| | - Nicola J Mutch
- Aberdeen Cardiovascular and Diabetes Centre, School of Medicine, Medical Sciences and Nutrition, Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK
| | - Mike A Laffan
- Centre for Haematology, Imperial College London, London, UK
- Oxford Haemophilia and Thrombosis Centre, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Nicola Curry
- Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, Oxford, OX3 9DU, UK
- Oxford Haemophilia and Thrombosis Centre, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Sloos PH, Vulliamy P, van 't Veer C, Gupta AS, Neal MD, Brohi K, Juffermans NP, Kleinveld DJB. Platelet dysfunction after trauma: From mechanisms to targeted treatment. Transfusion 2022; 62 Suppl 1:S281-S300. [PMID: 35748694 PMCID: PMC9546174 DOI: 10.1111/trf.16971] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 05/06/2022] [Accepted: 05/09/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Pieter H. Sloos
- Department of Intensive Care Medicine, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Paul Vulliamy
- Centre for Trauma Sciences, Blizard Institute, Barts and the London School of Medicine and DentistryQueen Mary University of LondonLondonUK
| | - Cornelis van 't Veer
- Center for Experimental and Molecular Medicine, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Anirban Sen Gupta
- Department of Biomedical EngineeringCase Western Reserve UniversityClevelandOhioUSA
| | - Matthew D. Neal
- Pittsburgh Trauma and Transfusion Medicine Research Center and Division of Trauma and Acute Care SurgeryUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Barts and the London School of Medicine and DentistryQueen Mary University of LondonLondonUK
| | - Nicole P. Juffermans
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
- Department of Intensive Care MedicineOLVG HospitalAmsterdamThe Netherlands
| | - Derek J. B. Kleinveld
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
- Department of Intensive Care MedicineErasmus MCRotterdamThe Netherlands
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Clinical Benefits of Early Concurrent Use of Cryoprecipitate and Plasma Compared With Plasma Only in Bleeding Trauma Patients. Crit Care Med 2022; 50:1477-1485. [PMID: 35759689 DOI: 10.1097/ccm.0000000000005596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The effectiveness of cryoprecipitate (Cryo) in trauma has not been well established; the benefits of Cryo might have been overestimated in previous studies since the difference in the total amount of administered clotting factors was not considered. We aimed to evaluate the benefits of the concurrent use of Cryo in combination with fresh frozen plasma (FFP) for bleeding trauma patients. DESIGN Retrospective cohort study. SETTING The American College of Surgeons Trauma Quality Improvement Program database between 2015 and 2019. PATIENTS Patients who received greater than or equal to 5 units of packed RBCs and at least 1 unit of FFP within the first 4 hours after arrival to a hospital were included and dichotomized according to whether Cryo was used within the first 4 hours of hospital arrival. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS The outcomes of patients treated with Cryo and FFP were compared with those treated with FFP only using propensity score-matching analysis. The dose of administered clotting factors in each group was balanced. The primary outcome was inhospital mortality, and the secondary outcome was the occurrence rate of adverse events. A total of 24,002 patients (Cryo+FFP group: 6,018; FFP only group: 17,984) were eligible for analysis, of whom 4,852 propensity score-matched pairs were generated. Significantly lower inhospital mortality (1,959 patients [40.4%] in the Cryo+FFP group vs 2,142 patients [44.1%] in the FFP only group; odds ratio [OR], 0.86; 95% CI, 0.79-0.93) was observed in the Cryo+FFP group; no significant difference was observed in the occurrence rate of adverse events (1,857 [38.3%] vs 1,875 [38.6%]; OR, 1.02; 95% CI, 0.94-1.10). Several sensitivity analyses showed similar results. CONCLUSIONS Cryo use combined with FFP was significantly associated with reduced mortality in bleeding trauma patients. Future randomized controlled trials are warranted to confirm these results.
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Bartoszko J, Martinez-Perez S, Callum J, Karkouti K, Farouh ME, Scales DC, Heddle NM, Crowther M, Rao V, Hucke HP, Carroll J, Grewal D, Brar S, Brussières J, Grocott H, Harle C, Pavenski K, Rochon A, Saha T, Shepherd L, Syed S, Tran D, Wong D, Zeller M. Impact of cardiopulmonary bypass duration on efficacy of fibrinogen replacement with cryoprecipitate compared with fibrinogen concentrate: a post hoc analysis of the Fibrinogen Replenishment in Surgery (FIBRES) randomised controlled trial. Br J Anaesth 2022; 129:294-307. [DOI: 10.1016/j.bja.2022.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 04/16/2022] [Accepted: 05/06/2022] [Indexed: 11/28/2022] Open
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Whyte CS, Rastogi A, Ferguson E, Donnarumma M, Mutch NJ. The Efficacy of Fibrinogen Concentrates in Relation to Cryoprecipitate in Restoring Clot Integrity and Stability against Lysis. Int J Mol Sci 2022; 23:ijms23062944. [PMID: 35328366 PMCID: PMC8949572 DOI: 10.3390/ijms23062944] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 02/25/2022] [Accepted: 03/03/2022] [Indexed: 02/01/2023] Open
Abstract
Loss of fibrinogen is a feature of trauma-induced coagulopathy (TIC), and restoring this clotting factor is protective against hemorrhages. We compared the efficacy of cryoprecipitate, and of the fibrinogen concentrates RiaSTAP® and FibCLOT® in restoring the clot integrity in models of TIC. Cryoprecipitate and FibCLOT® produced clots with higher maximal absorbance and enhanced resistance to lysis relative to RiaSTAP®. The fibrin structure of clots, comprising cryoprecipitate and FibCLOT®, mirrored those of normal plasma, whereas those with RiaSTAP® showed stunted fibers and reduced porosity. The hemodilution of whole blood reduced the maximum clot firmness (MCF) as assessed by thromboelastography. MCF could be restored with the inclusion of 1 mg/mL of fibrinogen, but only FibCLOT® was effective at stabilizing against lysis. The overall clot strength, measured using the Quantra® hemostasis analyzer, was restored with both fibrinogen concentrates but not cryoprecipitate. α2antiplasmin and plasminogen activator inhibitor-1 (PAI-1) were constituents of cryoprecipitate but were negligible in RiaSTAP® and FibCLOT®. Interestingly, cryoprecipitate and FibCLOT® contained significantly higher factor XIII (FXIII) levels, approximately three-fold higher than RiaSTAP®. Our data show that 1 mg/mL fibrinogen, a clinically achievable concentration, can restore adequate clot integrity. However, FibCLOT®, which contained more FXIII, was superior in normalizing the clot structure and in stabilizing hemodiluted clots against mechanical and fibrinolytic degradation.
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Djambas Khayat C, Marchi R, Durual S, Lecompte T, Neerman-Arbez M, Casini A. Impact of fibrinogen infusion on thrombin generation and fibrin clot structure in patients with inherited afibrinogenemia. Thromb Haemost 2022; 122:1461-1468. [PMID: 35045578 DOI: 10.1055/a-1745-0420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Inherited afibrinogenemia is a very rare disease characterized by complete absence of fibrinogen in the circulation and an increased risk in both thrombosis and bleeding. Infusion of fibrinogen concentrate (FC) is the main approach for prevention and management of bleeding; however, it has been reported to carry a thrombotic risk. METHODS We investigated the impact of a standard dose (40-100 mg/kg) of FC infusion on the thrombin generation (TG) parameters and the fibrin clot structure formed in plasma samples of patients with afibrinogenemia. Blood samples were collected from 20 patients before (T0) and 1 hour after infusion of FC (T1). TG was studied with Calibrated Automated Thrombography. Fibrin clot structure was assessed with turbidimetry and scanning electron microscopy (SEM). RESULTS FC infusions (mean Clauss fibrinogen plasma level 1.21 g/L at T1) led to a statistically significant increase in endogenous thrombin potentials (ETP) (p<0.0001) and thrombin peaks (p=0.02). Nevertheless, when compared to healthy controls, patients' T1 lag times were longer (p=0.002), ETP values were lower (p=0.0003), and thrombin peaks were lower (p<00001). All fibrin polymerization parameters (turbidimetry) obtained at T1 were comparable to those of patients with inherited hypofibrinogenemia matched for fibrinogen plasma levels. CONCLUSIONS In summary, fibrinogen infusion with a standard dose of FC increased but did not correct TG and led to formation of fibrin clots similar to those of patients with hypofibrinogenemia. All in all, our results do not support to biological evidence of hypercoagulability induced by FC in patients with afibrinogenemia.
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Affiliation(s)
| | - Rita Marchi
- Department of Genetic Medicine and Development, University of Geneva Faculty of Medicine, Geneve, Switzerland
| | - Stéphane Durual
- University clinics of dental medicine, University of Geneva, Geneva, Switzerland
| | - Thomas Lecompte
- Angiology and Haemostasis Division, University Hospitals of Geneva, Geneva, Switzerland
| | - Marguerite Neerman-Arbez
- Dep Of Genetic Medicine and Development, University of Geneva Medical School, Geneva, Switzerland
| | - Alessandro Casini
- Angiology and Haemostasis Division, University Hospitals of Geneva, Geneva, Switzerland
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Green L, Daru J, Gonzalez Carreras FJ, Lanz D, Pardo MC, Pérez T, Philip S, Tanqueray T, Khan KS. Early cryoprecipitate transfusion versus standard care in severe postpartum haemorrhage: a pilot cluster-randomised trial. Anaesthesia 2021; 77:175-184. [PMID: 34671971 PMCID: PMC9298397 DOI: 10.1111/anae.15595] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2021] [Indexed: 12/15/2022]
Abstract
There is a lack of evidence evaluating cryoprecipitate transfusion in severe postpartum haemorrhage. We performed a pilot cluster‐randomised controlled trial to evaluate the feasibility of a trial on early cryoprecipitate delivery in severe postpartum haemorrhage. Pregnant women (>24 weeks gestation), actively bleeding within 24 h of delivery and who required at least one unit of red blood cells were eligible. Women declining transfusion in advance or with inherited clotting deficiencies were not eligible. Four UK hospitals were randomly allocated to deliver either the intervention (administration of two pools of cryoprecipitate within 90 min of first red blood cell unit requested plus standard care), or the control group treatment (standard care, where cryoprecipitate is administered later or not at all). The primary outcome was the proportion of women who received early cryoprecipitate (intervention) vs. standard care (control). Secondary outcomes included consent rates, acceptability of the intervention, safety outcomes and preliminary clinical outcome data to inform a definitive trial. Between March 2019 and January 2020, 199 participants were recruited; 19 refused consent, leaving 180 for analysis (110 in the intervention and 70 in the control group). Adherence to assigned treatment was 32% (95%CI 23–41%) in the intervention group vs. 81% (95%CI 70–90%) in the control group. The proportion of women receiving cryoprecipitate at any time‐point was higher in the intervention (60%) vs. control (31%) groups; the former had fewer red blood cell transfusions at 24 h (mean difference −0.6 units, 95%CI −1.2 to 0); overall surgical procedures (odds ratio 0.6, 95%CI 0.3–1.1); and intensive care admissions (odds ratio 0.4, 95%CI 0.1–1.1). There was no increase in serious adverse or thrombotic events in the intervention group. Staff interviews showed that lack of awareness and uncertainty about study responsibilities contributed to lower adherence in the intervention group. We conclude that a full‐scale trial may be feasible, provided that protocol revisions are put in place to establish clear lines of communication for ordering early cryoprecipitate in order to improve adherence. Preliminary clinical outcomes associated with cryoprecipitate administration are encouraging and merit further investigation.
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Affiliation(s)
- L Green
- Department of Haematology, Blizard Institute, Queen Mary University of London and NHS Blood and Transplant, London, UK.,Department of Haematology, Barts Health NHS Trust, London, UK
| | - J Daru
- Barts Research Centre for Women's Health, Queen Mary University of London, UK
| | | | - D Lanz
- Barts Research Centre for Women's Health, Queen Mary University of London, UK
| | - M C Pardo
- Department of Statistics and Operational Research, Complutense University of Madrid, Madrid, Spain
| | - T Pérez
- Department of Statistics and Data Science, Complutense University of Madrid, Madrid, Spain
| | - S Philip
- Department of Anaesthesia, Barts Health NHS Trust, London, UK
| | - T Tanqueray
- Department of Obstetrics, Homerton University Hospital NHS Foundation Trust, London, UK
| | - K S Khan
- Department of Preventive Medicine and Public Health, University of Granada, Granada, Spain.,CIBER (Centro de Investigación Biomédica en Red) of Epidemiology and Public Health (CIBERESP), Madrid, Spain
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Curry N. Fibrinogen Replacement in Haemostatic Resuscitation: Dose, Laboratory Targets and Product Choice. Transfus Med Rev 2021; 35:104-107. [PMID: 34565636 DOI: 10.1016/j.tmrv.2021.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 06/05/2021] [Accepted: 06/12/2021] [Indexed: 10/20/2022]
Abstract
Fibrinogen is a key coagulation protein that is necessary for the formation of stable clots. Fibrinogen levels have been reported to be one of the first to fall during major haemorrhage reflecting consumption, dilution and fibrinogenolysis. Its role in acquired major haemorrhage, both in relation to the contribution it plays to the coagulopathy of major bleeding that can exacerbate bleeding and how effective fibrinogen supplementation can be at improving clinical outcomes, has received a great deal of attention over the last 10 - 15 years. This commentary focuses on just three of the more recent publications from the last 5 years that provide some of the evidence behind how we can think about fibrinogen as a haemostatic treatment for acquired major haemorrhage and how we can use the laboratory thresholds to guide therapy.
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Affiliation(s)
- Nicola Curry
- Oxford Haemophilia & Thrombosis Centre, Oxford University Hospitals NHS Foundation Trust, and Oxford University, NIHR BRC Haematology Theme, Oxford, UK.
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Abstract
PURPOSE OF REVIEW Recent advances in the understanding of the pathophysiological processes associated with traumatic haemorrhage and trauma-induced coagulopathy (TIC) have resulted in improved outcomes for seriously injured trauma patients. However, a significant number of trauma patients still die from haemorrhage. This article reviews the role of fibrinogen in normal haemostasis, the effect of trauma and TIC on fibrinogen levels and current evidence for fibrinogen replacement in the management of traumatic haemorrhage. RECENT FINDINGS Fibrinogen is usually the first factor to reach critically low levels in traumatic haemorrhage and hypofibrinogenaemia after severe trauma is associated with increased risk of massive transfusion and death. It is postulated that the early replacement of fibrinogen in severely injured trauma patients can improve outcomes. There is, however, a paucity of evidence to support this, and in addition, there is little evidence to support or refute the effects of cryoprecipitate or fibrinogen concentrate for fibrinogen replacement. SUMMARY The important role fibrinogen plays in haemostasis and effective clot formation is clear. A number of pilot trials have investigated different strategies for fibrinogen replacement in severe trauma. These trials have formed the basis of several large-scale phase III trials, which, cumulatively will provide a firm evidence base to harmonise worldwide clinical management of severely injured trauma patients with major haemorrhage.
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