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Koller T, Kinast N, Castellanos AG, Garcia SP, Iglesias PP, Vintro XL, Arranz JM, Seto NV, García MVM, Moreno-Castaño AB, Aznar-Salatti J, Albaladejo GE, Diaz-Ricart M. Normalization of blood clotting characteristics using prothrombin complex concentrate, fibrinogen and FXIII in an albumin based fluid: experimental studies in thromboelastometry. Scand J Trauma Resusc Emerg Med 2021; 29:57. [PMID: 33836790 PMCID: PMC8035752 DOI: 10.1186/s13049-021-00867-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 03/15/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Colloid fluids supplemented with adequate combinations of coagulation factor concentrates with the capability to restore coagulation could be a desirable future treatment component in massive transfusion. METHODS Starting from a coagulation factor and blood cell-free albumin solution we added Prothrombin Complex Concentrate, Fibrinogen Concentrate and Factor XIII in different combinations and concentrations to analyze their properties to restore thromboelastometry parameters without the use of plasma. Further analysis under the presence of platelets was performed for comparability to whole blood conditions. RESULTS Albumin solutions enriched with Fibrinogen Concentrate, Factor XIII and Prothrombin Complex Concentrate at optimized concentrations show restoring coagulation potential. Prothrombin Complex Concentrate showed sufficient thrombin formation for inducing fibrinogen polymerization. The combination of Prothrombin Complex Concentrate and Fibrinogen Concentrate led to the formation of a stable in vitro fibrin clot. Fibrinogen and Factor XIII showed excellent capacity to improve fibrin clot firmness expressed as Amplitude at 10 min and Maximal Clot Firmness. Fibrinogen alone, or in combination with Factor XIII, was able to restore normal Amplitude at 10 min and Maximal Clot Firmness values. In the presence of platelets, the thromboelastometry surrogate parameter for thrombin generation (Clotting Time) improves and normalizes when compared to whole blood. CONCLUSIONS Combinations of coagulation factor concentrates suspended in albumin solutions can restore thromboelastometry parameters in the absence of plasma. This kind of artificial colloid fluids with coagulation-restoring characteristics might offer new treatment alternatives for massive transfusion. TRIAL REGISTRATION Study registered at the institutional ethic committee "Institut de Recerca, Hospital Santa Creu i Sant Pau, with protocol number IIBSP-CFC-2013-165.
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Affiliation(s)
- Tobias Koller
- Hospital de la Santa Creu i San Pau, Universidad Autonoma de Barcelona, Departamento de Cirugía, Carrer de Sant Quintí, 89, 08041, Barcelona, Spain.
| | - Nadia Kinast
- Consorci Sanitari Alt Penedés-Garraf, Carrer de l'Espirall, s/n, Vilafranca del Penedés, Spain
| | | | - Sergio Perez Garcia
- Hospital de la Santa Creu i San Pau, Universidad Autonoma de Barcelona, Departamento de Cirugía, Carrer de Sant Quintí, 89, 08041, Barcelona, Spain
| | - Pilar Paniagua Iglesias
- Hospital de la Santa Creu i San Pau, Universidad Autonoma de Barcelona, Departamento de Cirugía, Carrer de Sant Quintí, 89, 08041, Barcelona, Spain
| | - Xavi León Vintro
- Hospital de la Santa Creu i San Pau, Universidad Autonoma de Barcelona, Departamento de Cirugía, Carrer de Sant Quintí, 89, 08041, Barcelona, Spain
| | - Jose Mateo Arranz
- Hospital de la Santa Creu i San Pau, Universidad Autonoma de Barcelona, Departamento de Cirugía, Carrer de Sant Quintí, 89, 08041, Barcelona, Spain
| | - Noelia Vilalta Seto
- Hospital de la Santa Creu i San Pau, Universidad Autonoma de Barcelona, Departamento de Cirugía, Carrer de Sant Quintí, 89, 08041, Barcelona, Spain
| | - Ma Victòria Moral García
- Hospital de la Santa Creu i San Pau, Universidad Autonoma de Barcelona, Departamento de Cirugía, Carrer de Sant Quintí, 89, 08041, Barcelona, Spain
| | - Ana Belén Moreno-Castaño
- Hematopathology, Pathology Department, CDB, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | | | - Gines Escolar Albaladejo
- Hematopathology, Pathology Department, CDB, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Maribel Diaz-Ricart
- Hematopathology, Pathology Department, CDB, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
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Punthakee Z, Iglesias PP, Alonso-Coello P, Gich I, India I, Malaga G, Jover RD, Gerstein HC, Devereaux PJ. Association of preoperative glucose concentration with myocardial injury and death after non-cardiac surgery (GlucoVISION): a prospective cohort study. Lancet Diabetes Endocrinol 2018; 6:790-797. [PMID: 30057170 PMCID: PMC7028328 DOI: 10.1016/s2213-8587(18)30205-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 06/14/2018] [Accepted: 06/28/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND Myocardial injury after non-cardiac surgery (MINS) is the most common perioperative cardiovascular complication and is independently associated with 30-day mortality. We aimed to assess the association between preoperative glucose concentration and postoperative MINS and mortality. METHODS The VISION study is a prospective cohort study done at 12 centres in eight countries. Patients aged 45 years or older who required at least one overnight hospital admission for non-cardiac surgery were enrolled from Aug 6, 2007, to Jan 11, 2011. In the GlucoVISION analysis, we assessed the relations between preoperative casual or fasting glucose concentration and MINS within 3 days after surgery using logistic regression, and 30-day mortality using Cox proportional regression, in people with and without diabetes. FINDINGS 11 954 patients were included in this analysis, of whom 2809 (23%) had diabetes. Within the first three postoperative days, MINS occurred in 813 (7%) patients. 249 (2%) patients died by day 30. More patients with diabetes had MINS (odds ratio [OR] 1·98 [95% CI 1·70-2·30]; p<0·0001), and died (OR 1·41 [1·08-1·86]; p=0·016) than did patients without diabetes. Casual glucose concentrations were associated with MINS in all patients (adjusted OR 1·06 [1·04-1·09] per 1 mmol/L increment in glucose; p=0·0003), and with death in patients without diabetes (adjusted hazard ratio [HR] 1·13 [95% CI 1·05-1·23] per mmol/L; p=0·002). We noted a progressive relation between unadjusted fasting glucose concentration and both MINS (OR 1·14 [1·08-1·20] per mmol/L; p<0·0001), driven by the effect in the subgroup without previous diabetes (pinteraction=0·025), and 30-day mortality (HR 1·10 [1·02-1·19] per mmol/L; p=0·013). For patients without diabetes, casual glucose of more than 6·86 mmol/L and fasting glucose of more than 6·41 mmol/L predicted MINS (OR 1·71 [1·36-2·15]; p<0·0001, and OR 2·71 [1·85-3·98]; p<0·0001, respectively). For patients with diabetes, only casual glucose concentration more than 7·92 mmol/L predicted MINS (OR 1·47 [1·10-1·96]; p=0·0096). INTERPRETATION Preoperative glucose concentration, particularly casual glucose concentration, predicts risk for postoperative cardiovascular outcomes, especially in patients without diabetes. FUNDING Full funding sources listed at the end of the paper (see Acknowledgments).
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Affiliation(s)
- Zubin Punthakee
- McMaster University and Population Health Research Institute, Hamilton, ON, Canada.
| | - Pilar Paniagua Iglesias
- Servicio de Anestesiología y Reanimación, Instituto de Investigación Biomédica (IIB Sant Pau), Barcelona, Spain.
| | - Pablo Alonso-Coello
- Centro Cochrane Iberoamericano, Instituto de Investigación Biomédica (IIB Sant Pau-CIBERESP), Barcelona, Spain
| | - Ignasi Gich
- Department of Clinical Epidemiology and Public Health, HSCSP CIBER de Salud Mental (CIBERSAM), Barcelona, Spain
| | - Inmaculada India
- Servicio de Anestesiología y Reanimación, Instituto de Investigación Biomédica (IIB Sant Pau), Barcelona, Spain
| | | | - Ruben Diaz Jover
- Servicio de Anestesiología y Reanimación, Instituto de Investigación Biomédica (IIB Sant Pau), Barcelona, Spain
| | - Hertzel C Gerstein
- McMaster University and Population Health Research Institute, Hamilton, ON, Canada
| | - P J Devereaux
- McMaster University and Population Health Research Institute, Hamilton, ON, Canada
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Devereaux PJ, Duceppe E, Guyatt G, Tandon V, Rodseth R, Biccard BM, Xavier D, Szczeklik W, Meyhoff CS, Vincent J, Franzosi MG, Srinathan SK, Erb J, Magloire P, Neary J, Rao M, Rahate PV, Chaudhry NK, Mayosi B, de Nadal M, Iglesias PP, Berwanger O, Villar JC, Botto F, Eikelboom JW, Sessler DI, Kearon C, Pettit S, Sharma M, Connolly SJ, Bangdiwala SI, Rao-Melacini P, Hoeft A, Yusuf S. Dabigatran in patients with myocardial injury after non-cardiac surgery (MANAGE): an international, randomised, placebo-controlled trial. Lancet 2018; 391:2325-2334. [PMID: 29900874 DOI: 10.1016/s0140-6736(18)30832-8] [Citation(s) in RCA: 190] [Impact Index Per Article: 31.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 03/23/2018] [Accepted: 03/28/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Myocardial injury after non-cardiac surgery (MINS) increases the risk of cardiovascular events and deaths, which anticoagulation therapy could prevent. Dabigatran prevents perioperative venous thromboembolism, but whether this drug can prevent a broader range of vascular complications in patients with MINS is unknown. The MANAGE trial assessed the potential of dabigatran to prevent major vascular complications among such patients. METHODS In this international, randomised, placebo-controlled trial, we recruited patients from 84 hospitals in 19 countries. Eligible patients were aged at least 45 years, had undergone non-cardiac surgery, and were within 35 days of MINS. Patients were randomly assigned (1:1) to receive dabigatran 110 mg orally twice daily or matched placebo for a maximum of 2 years or until termination of the trial and, using a partial 2-by-2 factorial design, patients not taking a proton-pump inhibitor were also randomly assigned (1:1) to omeprazole 20 mg once daily, for which results will be reported elsewhere, or matched placebo to measure its effect on major upper gastrointestinal complications. Research personnel randomised patients through a central 24 h computerised randomisation system using block randomisation, stratified by centre. Patients, health-care providers, data collectors, and outcome adjudicators were masked to treatment allocation. The primary efficacy outcome was the occurrence of a major vascular complication, a composite of vascular mortality and non-fatal myocardial infarction, non-haemorrhagic stroke, peripheral arterial thrombosis, amputation, and symptomatic venous thromboembolism. The primary safety outcome was a composite of life-threatening, major, and critical organ bleeding. Analyses were done according to the intention-to-treat principle. This trial is registered with ClinicalTrials.gov, number NCT01661101. FINDINGS Between Jan 10, 2013, and July 17, 2017, we randomly assigned 1754 patients to receive dabigatran (n=877) or placebo (n=877); 556 patients were also randomised in the omeprazole partial factorial component. Study drug was permanently discontinued in 401 (46%) of 877 patients allocated to dabigatran and 380 (43%) of 877 patients allocated to placebo. The composite primary efficacy outcome occurred in fewer patients randomised to dabigatran than placebo (97 [11%] of 877 patients assigned to dabigatran vs 133 [15%] of 877 patients assigned to placebo; hazard ratio [HR] 0·72, 95% CI 0·55-0·93; p=0·0115). The primary safety composite outcome occurred in 29 patients (3%) randomised to dabigatran and 31 patients (4%) randomised to placebo (HR 0·92, 95% CI 0·55-1·53; p=0·76). INTERPRETATION Among patients who had MINS, dabigatran 110 mg twice daily lowered the risk of major vascular complications, with no significant increase in major bleeding. Patients with MINS have a poor prognosis; dabigatran 110 mg twice daily has the potential to help many of the 8 million adults globally who have MINS to reduce their risk of a major vascular complication [corrected]. FUNDING Boehringer Ingelheim and Canadian Institutes of Health Research.
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Affiliation(s)
- P J Devereaux
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada.
| | - Emmanuelle Duceppe
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, University of Montreal, Montreal, QC, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Vikas Tandon
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Reitze Rodseth
- Department of Anaesthesia, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Bruce M Biccard
- Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Denis Xavier
- Department of Pharmacology, St John's Medical College and Research Institute, Bangalore, India
| | - Wojciech Szczeklik
- Department of Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Christian S Meyhoff
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | | | - Maria Grazia Franzosi
- Department of Cardiovascular Research, IRCCS Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | | | - Jason Erb
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Patrick Magloire
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - John Neary
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Mangala Rao
- Department of Pharmacology, St John's Medical College and Research Institute, Bangalore, India
| | | | - Navneet K Chaudhry
- Department of Surgery, Christian Medical College Hospital, Ludhiana, India
| | - Bongani Mayosi
- Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Miriam de Nadal
- Department of Anesthesiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | | | - Otavio Berwanger
- Instituto de Ensino e Pesquisa do Hospital do Coração (IEP-HCor), São Paulo, Brazil
| | - Juan Carlos Villar
- Departamento de Investigaciones, Fundación Cardioinfantil-Instituto de Cardiología (Bogotá) and Facultad de Ciencias de la Salud, Universidad Autónoma de Bucaramanga, Colombia
| | - Fernando Botto
- Estudios Clínicos Latinoamérica (ECLA), Rosario and Hospital Austral, Pilar, Argentina
| | - John W Eikelboom
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Anesthesiology Institute, Cleveland, OH, United States
| | - Clive Kearon
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Shirley Pettit
- Population Health Research Institute, Hamilton, ON, Canada
| | - Mukul Sharma
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada
| | - Stuart J Connolly
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada
| | - Shrikant I Bangdiwala
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada
| | | | - Andreas Hoeft
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Salim Yusuf
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada
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