Hemostaseological Management of Urological Operations in Patients Taking Aspirin Using the Thrombostat 4000

A clinical study was started in order to examine the suitability of the Thrombostat (in vitro bleeding test) (IVBT) as a diagnostic tool to prevent perioperative bleeding due to aspirin (ASA) and/or platelet function disorders of other origins. This report is based on preliminary data. Eighty three patients who had ingested ASA in the last two weeks and/or with a history of bleeding and/or documented hemorrhagic disorders requiring distinct urological operations, were included in the study. In all patients the IVBT with CaCl2 , in addition to common coagulation tests, were performed. Thirteen patients stopped ASA ingestion until IVBT became normal and did not show any increased bleeding tendency. The residual patients were classified by the various operations. The following operation groups were formed: Male genitals (n = 11), inguinal/suprapubic operations (n = 7), transurethral tumor resections of the bladder (TURB) (n = 17), transurethral prostate resection (TURP) (n = 12), tumor nephrectomy (n = 8), radical prostatectomy (n = 9). Thirty six patients with a history of ASA use, but normal IVBT, served as control group (C). Thirty one patients with a history of ASA ingestion had normal in vivo bleeding times (BT) and abnormal IVBT with CaCl2 (A). Seven patients had a bleeding history and/or documented hemorrhagic disorders (B). None of the patients (A) with abnormal IVBT but normal BT displayed clinically relevant bleeding. However, the blood loss was somewhat higher compared to the controls (C), especially in patients with TURB and radical prostatectomy (not significant). The only real bleeding complication occurred in an ASA patient (TURB), who was subjected to surgery by error. Anesthesia had already started, when abnormality of BT (>15 min) and IVBT (m“infinite ”) were measured. Operative revision was necessary and revealed that the blood loss (>3 L) was based on diffuse microvascular bleeding. The majority of the patients with a bleeding history and/or documented hemorrhagic disorders (B) showed an increased bleeding tendency, which could be managed without relevant blood loss, except in two patients, one with factor XIII deficiency (25%) and ASA intake, and the other with undetected mild congenital platelet disorder (storage pool disease?). The IVBT proved suitable as screening test for platelet function disorders. Major bleeding complications could be prevented by its use. A history of low-dose ASA ingestion without prolongation of BT, but abnormal IVBT, also seemed to increase the bleeding tendency; however, the clinical relevance has to be demonstrated by an extended clinical study.

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Determination and Treatment of Disorders of Primary Haemostasis

Hämostaseologie ◽

10.1055/s-0038-1660415 ◽

1999 ◽

Vol 19 (04) ◽

pp. 168-175 ◽

Cited By ~ 6

Author(s):

M. Weippert-Kretschmer ◽

V. Kretschmer

Keyword(s):

Platelet Function ◽

Bleeding Risk ◽

Bleeding Complications ◽

Bleeding Tendency ◽

Platelet Counts ◽

Platelet Function Disorders ◽

Perioperative Bleeding ◽

Before And After ◽

Low Sensitivity

SummaryPerioperative bleeding complications due to disorders of primary haemostasis are often underestimated. Routine determination of primary haemostasis is still problematic. The in vivo bleeding time (BT) shows low sensitivity and high variability. In this contribution the results and experiences with the IVBT having been obtained in various studies and during 10 years of routine use are reported. Patients and Methods: Blood donors before and after ASA ingestion, patients with thrombocytopenia as well as congenital and acquired platelet function disorders. Monitoring of desmopressin efficacy. IVBT with Thrombostat 4000 (tests with CaCl2 = TST-CaCl2 and ADP = TST-ADP) and PFA-100 (test cartridges with epinephrine = PFA-EPI and ADP = PFA-ADP). Results and Conclusions: IVBT becomes abnormal with platelet counts <100,000/μl. With platelet counts <50,000/μl the results are mostly outside the methodical range. IVBT proved clearly superior to BT in von Willebrand syndrome (vWS). All 16 patients with vWS were detected by PFA-EPI, whereas with BT 7 of 10 patients with moderate and 1 of 6 patients with mild forms of vWS were spotted. The majority of acquired and congenital platelet function disorders with relevant bleeding tendency were detectable by IVBT. Sometimes diagnostic problems arose in case of storage pool defect. Four to 12 h after ingestion of a single dose of 100 mg ASA the TST-CaCl2 became abnormal in all cases, the PFA-EPI only in 80%. However, the ASA sensitivity of TST-CaCl2 proved even too high when looking for perioperative bleeding complications in an urological study. Therefore, the lower ASS sensitivity of the PFA-100 seems to be rather advantageous for the estimation of a real bleeding risk. The good efficacy of desmopressin in the majority of cases with mild thrombocytopenia, congenital and acquired platelet function disorders and even ASS-induced platelet dysfunction could be proven by means of the IVBT. Thus IVBT may help to increase the reliability of the therapy. However, the IVBT with the PFA-100 is not yet fully developed. Nevertheless, routine use can be recommended when special methodical guidelines are followed.

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Protein Z Deficiency in Patients with Bleeding History. Is It a Coagulopathy?.

Blood ◽

10.1182/blood.v120.21.2227.2227 ◽

2012 ◽

Vol 120 (21) ◽

pp. 2227-2227 ◽

Cited By ~ 1

Author(s):

Frauke Bergmann ◽

Andreas Czwalinna ◽

Arndt Groening

Keyword(s):

Platelet Function ◽

Conflicts Of Interest ◽

Factor Xa ◽

Postoperative Hemorrhage ◽

Bleeding Tendency ◽

Normal Range ◽

Protein Z ◽

Platelet Function Disorders ◽

Diagnostic Work ◽

Bleeding History

Abstract Abstract 2227 Introduction: Protein Z (PZ) is a vitamin K-dependent protein. In hemostasis PZ has two functions: together with Factor Xa it forms an inhibiting complex with the PZ- dependent protease-inhibitor and it enhances binding of Thrombin to phospholipid surfaces. Therefore, low PZ levels may induce thrombosis or bleeding. The latter has been questioned by Vasse 2008 and in 1995 Kemkes-Matthes reported in 58% of patients (pts) with a bleeding history PZ deficiency as the only abnormality. Aim of the study: To evaluate if low PZ levels are associated with a bleeding tendency, we reviewed data of pts referred to or laboratory. PZ determination is part of our diagnostic work up, including whole blood count, PT, PTT, VWF/FVIII-complex, FXIII and platelet function studies. Material and Methods: Over a 1 year period we investigated PZ level in 173 pts. PZ concentration was determined by ELISA (Asserachrom Protein Z; Diagnostica Stago), a sandwich immunoassay using a mouse monoclonal antibody against PZ, normal range 1600 – 3300 μg/l, mean 2600 μg/l published by Miletich. Our normal range obtained by 62 donors 990–2490, mean 1740μg/l (+/− 2SD). PZ <1000μg/l is considered to be abnormal. Results: In 75/173 (43%) pts with a bleeding history (e.g. postoperative hemorrhage, epistaxis, menorrhagia) no coagulation abnormality was detected. In 41/98 (42%) low PZ level was the only abnormality (mean PZ 642, range 195–994). 57/98 (58%) were diagnosed with vWD n=17; platelet function disorders n=10 or ASA/drugs causing platelet dysfunction n=20, others n=10. In 21/57 (37%) low PZ level was detected additionally (mean PZ 699μg/l; range 219–949) and in the remaining 36/57 (mean PZ 1689; range 1036–2842). Conclusion: Surprisingly, in 24% of pts with a bleeding history the only abnormality was PZ deficiency. Therefore, we consider PZ determination a useful parameter in patients with a bleeding history after ruling out more common disorders. Low PZ levels may cause a coagulopathy in some pts. Disclosures: No relevant conflicts of interest to declare.

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A Case Report on Glanzmann’s Thrombasthenia: A Rare Platelet Function Disorder

Haematology Journal of Bangladesh ◽

10.37545/haematoljbd201818 ◽

2018 ◽

Vol 2 (02) ◽

pp. 59-60

Author(s):

Farida Yasmin ◽

Md. Anwarul Karim ◽

Chowdhury Yakub Jamal ◽

Mamtaz Begum ◽

Ferdousi Begum

Keyword(s):

Case Report ◽

Platelet Function ◽

The Body ◽

Presenting Symptoms ◽

Glanzmann’S Thrombasthenia ◽

Glanzmann's Thrombasthenia ◽

Platelet Function Disorders ◽

Recurrent Epistaxis ◽

Severe Epistaxis ◽

History Of

Epistaxis in children is one of the important presenting symptoms for attending emergency department in paediatric patients. Recurrent epistaxis is common in children. Although epistaxis in children usually occurred due to different benign conditions, it may be one of the important presenting symptoms of some inherited bleeding disorder. Whereas most bleeding disorders can be diagnosed through different standard hematologic assessments, diagnosing rare platelet function disorders may be challenging. In this article we describe one case report of platelet function disorders on Glanzmann’s thrombasthenia (GT). Our patient was a 10-year old girl who presented to us with history of recurrent severe epistaxis. She had a bruise on her abdomen and many scattered petechiae in different parts of the body. Her previous investigations revealed no demonstrable haemostatic anomalies. After performing platelet aggregation test, she was diagnosed as GT.

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Platelet Disorders

10.2310/im.1410 ◽

2015 ◽

Author(s):

Lawrence L K Leung ◽

James L. Zehnder

Keyword(s):

Platelet Function ◽

Clinical Manifestations ◽

Von Willebrand Disease ◽

Drug Induced ◽

Excessive Bleeding ◽

Vascular Integrity ◽

Patient Reports ◽

Platelet Function Disorders ◽

Hemorrhagic Disorders ◽

Von Willebrand

A bleeding disorder may be suspected when a patient reports spontaneous or excessive bleeding or bruising, often secondary to trauma. Possible causes can vary between abnormal platelet number or function, abnormal vascular integrity, coagulation defects, fibrinolysis, or a combination thereof. This review addresses hemorrhagic disorders associated with quantitative or qualitative platelet abnormalities, such as thrombocytopenia, platelet function disorders, thrombocytosis and thrombocythemia, and vascular purpuras. Hemorrhagic disorders associated with abnormalities in coagulation (e.g., von Willebrand disease and hemophilia) are not covered. An algorithm shows evidence-based practice guidelines for the management of immune thrombocytopenic purpura. Tables list questions regarding bleeding and bruising to ask patients, clinical manifestations of hemorrhagic disorders, typical results of tests for hemostatic function in bleeding disorders, causes of thrombocytopenia, other forms of drug-induced thrombocytopenia, classification of platelet function disorders, and selected platelet-modifying agents. This review contains 1 highly rendered figure, 7 tables, and 82 references.

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Evaluating platelet function disorders in children with bleeding tendency – A single center study

Platelets ◽

10.1080/09537104.2016.1257784 ◽

2017 ◽

Vol 28 (7) ◽

pp. 676-681 ◽

Cited By ~ 3

Author(s):

Osama Tanous ◽

Orna Steinberg Shemer ◽

Joanne Yacobovich ◽

Meira Zoldan ◽

Yoseph Horovitz ◽

...

Keyword(s):

Platelet Function ◽

Bleeding Tendency ◽

Single Center ◽

Platelet Function Disorders ◽

Single Center Study ◽

Center Study

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Incorporation of Evidence Based Guidelines on Bleeding Risk Assessment PRIOR to Ent Surgery into Practice: Real Time Experience

Blood ◽

10.1182/blood-2018-99-118193 ◽

2018 ◽

Vol 132 (Supplement 1) ◽

pp. 4714-4714

Author(s):

Nada Al-Marhoobi ◽

Manar Maktoom ◽

Fatma Bulushi ◽

Mohamed Ebrahim Mohamed Ebrahim Elshinawy ◽

Hanan Nazir ◽

...

Keyword(s):

Bleeding Risk ◽

Bleeding Tendency ◽

Invasive Procedures ◽

Coagulation Profile ◽

Awareness Campaigns ◽

Laboratory Test Results ◽

Coagulation Testing ◽

History Of ◽

British Committee ◽

Bleeding History

Abstract Background: In spite of guidelines recommending the no need for coagulation profile prior to ENT surgeries when challenging history of bleeding is negative, yet surgeons still practice it. Cost and delaying surgeries are major issues faced when insignificant abnormalities are found in the coagulation profile results. In 2008, British Committee for Standards of Hematology has published guidelines (1) on assessing the bleeding risk prior to surgeries or invasive procedures, which stated that the indication for sending a coagulation profile is best based on the bleeding history of the patient. Aim: This study aimed to measure unbiased estimate of hemostatic outcomes in ENT surgeries in relation to coagulation testing. Methods: All patients who underwent ENT surgeries from three tertiary hospitals during the period from 1st July 2016 to 1st January 2017 were enrolled in the study. The retrieved data included gender, age, type of surgery, results of coagulation blood test (if done), other laboratory test results (complete blood count, biochemical profile, etc.), postoperative bleeds, how it was managed, need for blood transfusion and whether the patient required another surgery to stop the bleeding or not. Patients with known bleeding history or previous coagulation derangement were excluded from the study. The primary outcome was post-operative bleeding. Results: The study included data from 730 patients who underwent ENT surgical procedures. They were 432 males and 298 females. Their mean age was 19.6 + 16.92 year. Out the 730 patients, 372 patients were interviewed for a challenging bleeding history alone (group 1) and 358 were interviewed plus a pre-operative coagulation profile check (Group 2). Total of fourteen patients (1.9 %) developed postoperative bleeding. None of them was due to abnormal bleeding tendency and they didn't require any hemostatic support. Six of them bled early (primary hemorrhage) while at the hospital due to surgical reasons (surgical site bleed that required suturing). Eight patients had delayed postoperative bleeds, after being discharged (due to eating hard food/Trauma). Only total of four patients had major bleeds, requiring surgical intervention. Conclusion: Despite guidelines recommending not doing coagulation testing prior to surgeries, many local surgeons still consider preoperative coagulation testing as a standard practice to evaluate the patients bleeding risk prior to any surgical procedure. This has resulted in unnecessary delays in surgeries (reaching up to a year in many patients) besides the parents/patients anxiety and additional total cost. We recommend awareness campaigns for surgeons and adhering to guidelines of taking detailed hemostatic history. Reference: Chee YL1, Crawford JC, Watson HG, Greaves M. Guidelines on the assessment of bleeding risk prior to surgery or invasive procedures. British Committee for Standards in Haematology. Br J Haematol. 2008 Mar;140(5):496-504. Keywords: Coagulation testing, Bleeding History, Surgery Disclosures No relevant conflicts of interest to declare.

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The PFA-100 Does Not Predict Delta-Granule Platelet Storage Pool Deficiencies

Blood ◽

10.1182/blood.v116.21.2518.2518 ◽

2010 ◽

Vol 116 (21) ◽

pp. 2518-2518

Author(s):

Jonathan L Sladky ◽

Jennifer Klima ◽

Linda Grooms ◽

Bryce A Kerlin ◽

Sarah H O'Brien

Keyword(s):

Electron Microscopy ◽

Family History ◽

Platelet Function ◽

Screening Test ◽

P Value ◽

Storage Pool ◽

Platelet Storage ◽

Platelet Function Disorders ◽

History Of ◽

The Relationship

Abstract Abstract 2518 Background: Although delta-granule platelet storage pool deficiencies (δ-PSPDs) are common disorders of platelet function, they are relatively poorly studied and described. One unknown is the relationship between δ-PSPDs and the PFA-100, a screening test originally developed for von Willebrand's disease but now widely used as a general screening test for coagulopathies. Previous studies have suggested that the PFA-100 is less effective in detecting mild platelet function disorders (which include δ-PSPDs) than more severe platelet function disorders. These studies, however, were limited by small numbers of patients with a variety of different platelet function defects. We examined PFA-100 results in a larger pediatric patient population diagnosed specifically with δ-PSPD, and determined the relationship between PFA-100 results and platelet electron microscopy (the standard for diagnosis of δ-PSPDs). Methods: This study is a retrospective medical record review of patients 0 to 18 years of age diagnosed with δ-PSPD at Nationwide Children's Hospital between January 1, 2008 and July 31, 2010. We defined δ-PSPD as patients with an average of fewer than 3.68 delta granules per platelet. We obtained demographic data including age, sex, and family history of bleeding. Lab data was also extracted, including PFA-100 and platelet electron microscopy. We determined the percentage of δ-PSPD patients with an abnormal PFA-100. To examine the correlation between the PFA-100 results and the average number of granules per platelet we used Spearman's Rho as our non-parametric measure of dependence. Results: A total of 88 patients diagnosed with δ-PSPD were included in this study. Of our patient population, 35% were male, and 61% had a first degree family history of easy bruising or bleeding, while only 15% had a family history that was positive specifically for platelet function disorders. The most common symptoms on presentation were easy bruising (56%), epistaxis (39%), oral cavity bleeding (35%) and menorrhagia (30%). Eighty-one of these patients underwent PFA-100 testing, of which 41% had an abnormal CEPI value, 17% had an abnormal CADP value, and 14% had abnormal results for both PFA cartridges. We found no statistical correlation between CEPI closure time and the average number of granules per platelet (rho = 0.0315, p value = 0.7798), nor between CADP closure time and the average number of granules (rho = -0.0095, p value = 0.9328)(Figure). Additionally, the number of bleeding symptoms in each patient was not statistically correlated with CEPI closure times, CADP closure times or platelet EM. Discussion: The PFA-100, which is widely used as a screening test for suspected bleeding disorders, was abnormal in fewer than half of pediatric patients diagnosed with δ-PSPD. We found that PFA-100 results did not correlate with presence or severity of delta-granule platelet storage pool deficiencies as determined by platelet electron microscopy. When evaluating patients with suspected bleeding disorders, PFA-100 testing alone cannot be used to rule out the presence of a δ-PSPD. Disclosures: No relevant conflicts of interest to declare.

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Clinical and Experimental Studies on the Bleeding Tendency During Defibrinogenation Therapy

10.1055/s-0039-1680675 ◽

1977 ◽

Author(s):

S. Ishimaru ◽

K. Furukawa ◽

M. Takahashi ◽

M. Fujimaki ◽

K. Fukutake

Keyword(s):

Platelet Aggregation ◽

Platelet Function ◽

Surgical Procedure ◽

Postoperative Bleeding ◽

Experimental Studies ◽

Bleeding Complications ◽

Fibrinogen Concentration ◽

Bleeding Tendency ◽

Normal Platelet ◽

Normal Limits

Defibrinogenation with thrombin-like enzyme is expected to be a new type of anticoagulant therapy without serious bleeding complications. However, it appears to be dangerous to perform surgical procedure in defibrinogenated state. In order to investigate the causes of the bleeding tendency which occurs during defibrinogenation therapy, the following clinical and experimental studies were undertaken. Ten mongrel dogs were used, the superior caval vein was replaced by expanded polytetrafluoroethylene graft. 50 to 100 μl/kg of batroxobin was administered 2 days prior to the operation. 5 out of 10 dogs died due to bleeding postoperativelly, and the causes of the bleeding seemed to be the decreased fibrinogen concentration and the reduced platelet function. Fifteen patients suffering from peripheral vascular thrombosis were treated with 30 to 60 μl/kg of batroxobin. In 9 patients, urokinase was administered combined with batroxobin. No bleeding complications were observed in these patients. In another 6 patients, surgical procedure was performed after batroxobin administration. Postoperative bleeding was observed in one out of these 6 patients. This patient was operated on after the initial administration of batroxobin. FDP level was 512 μg/ml and ADP induced platelet aggregation was within normal limits, but fibrinogen concentration was unmeasurable at the time of operation. The cause of the bleeding seemed to be the decreased fibrinogen concentration. From these clinical experiences, it is suggested that platelet adhesion to glass and ADP induced platelet aggregation are not influenced by the decreased fibrinogen concentration nor the increased level of FDP during the defibrinogenation therapy with batroxobin. These results indicate that an adequate level of fibrinogen is needed for certain hemostasis besides normal platelet function.

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Platelet Function and Blood Loss after Cardiopulmonary Bypass

10.1055/s-0039-1680412 ◽

1977 ◽

Author(s):

M. D. Rosario ◽

H. Leinberger ◽

A. Suehiro ◽

S. Zeitlin ◽

G. Moore ◽

...

Keyword(s):

Cardiopulmonary Bypass ◽

Blood Loss ◽

Platelet Function ◽

Heart Surgery ◽

Bleeding Time ◽

Open Heart Surgery ◽

Bleeding Tendency ◽

Significant Difference ◽

The Relationship

The relationship between platelet function and bleeding tendency was studied in 42 patients undergoing open heart surgery. Template bleeding time (TBT) and hourly chest tube outflow were measured as indices of bleeding tendency. Platelet function tests included platelet count (PC), aggregation with epinephrine, ADP, and collagen, and a modified platelet slide adhesion test (PSAT) which allowed us to quantitate in vivo the relative amount of more adhesive platelets, i. e., the “spread” forms, as compared to the number of smaller non-adhesive platelets. Post operatively the PC decreased 36% (from 214.1 ± 11.4 K to 136.3 ± 6.8 K, p<0.001) in all patients irrespective of the amount of blood loss. Using the PSAT, the product of the % “spread” forms and the PC showed a significant 57% decrease (from 110.5 ± 7.4 K to 47.4 ± 4.6 K, p<0.001) which was 19% more than the PC decrease implying that the more adhesive platelets had been expended. TBT increased significantly (7.7 ± 0.5 min. to 17.7 ± 1.3 min., p<0.001) and aggregation to epinephrine decreased significantly (60.9 ± 4.8% to 36.0 ± 3.4%, p<0.001), but no significant change was noted with ADP or collagen. There was no significant difference in the above parameters between patients bleeding more than 113 cc/hr. from 1 to 5 hrs. post op (N=14) and those bleeding less (N=28). A second study of 16 patients with bleeders having >1000 cc output in the first 4 hrs. post op showed results similar to the first group comparing pre vs. post and bleeders (N=8) vs. non-bleeders. This study indicates that after cardiopulmonary bypass surgery platelet function is frequently compromised and this dysfunction though probably contributing to a bleeding tendency did not correlate well with the magnitude of blood loss.

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Risks and complications of robot-assisted radical prostatectomy (RARP) in patients receiving antiplatelet and/or anticoagulant therapy: a retrospective cohort study in a single institute

Journal of Robotic Surgery ◽

10.1007/s11701-020-01154-8 ◽

2020 ◽

Author(s):

Masashi Oshima ◽

Satoshi Washino ◽

Yuhki Nakamura ◽

Tsuzumi Konishi ◽

Kimitoshi Saito ◽

...

Keyword(s):

Radical Prostatectomy ◽

Blood Loss ◽

Postoperative Bleeding ◽

Patient Characteristics ◽

Bleeding Complications ◽

Control Group ◽

Control Groups ◽

Robot Assisted ◽

Estimated Blood Loss ◽

Significant Difference

Abstract The objective of the study was to evaluate the risk of bleeding complications in patients undergoing robot-assisted radical prostatectomy (RARP) while taking antiplatelet (AP) and/or anticoagulant (AC) agents. We analyzed the data of 334 patients undergoing RARP from May 2015 to May 2019. Patients were categorized into AP, AC, and control groups; the bleeding complications were compared among them. The end points were the estimated blood loss, decrease in hemoglobin level, and bleeding complications. The patient characteristics did not differ significantly among groups, with the exception of ASA scores, which were significantly higher in the AP and AC groups vs. the control group. The estimated blood loss and hemoglobin decrease were not significantly different between the AP and AC groups and the control group. The frequency of bleeding complications did not differ significantly between the AP and the control groups, but was significantly higher in the AC vs. the control group (4.3% in the AP and 23.5% in the AC group vs. 3.7% in the control group; P = 0.63 and P < 0.01, respectively). There was no significant difference in bleeding complications between the AP continuation (continuation of a single AP) and the AP interruption group or between the heparin bridging and the AC interruption group. All bleeding complications observed in the AC group occurred after resuming AC therapy. RARP can be performed safely with continuation of a single AP, and in patients taking ACs by interrupting these agents or via heparin bridging, without increasing intraoperative bleeding, whereas postoperative bleeding complications may increase after resuming ACs.

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