scholarly journals The evolution of clot strength in critically-ill COVID-19 patients: a prospective observational thromboelastography study

2021 ◽  
Vol 19 (1) ◽  
Author(s):  
Colette Neethling ◽  
Gregory Calligaro ◽  
Malcolm Miller ◽  
Jessica J. S. Opie
Keyword(s):  
Critically Ill ◽  
Reference Range ◽  
Maximum Amplitude ◽  
Clot Lysis ◽  
Clot Strength ◽  
Mechanically Ventilated ◽  
Time Points ◽  
Normal Platelet ◽  
Upper Limit ◽  
Intravascular Coagulopathy

Abstract Background Few studies detail the evolution of COVID-19 associated coagulopathy. We performed serial thromboelastography (TEG) and laboratory coagulation studies in 40 critically-ill, mechanically ventilated COVID-19 patients over a 14-day period and analysed differences between 30-day survivors and non-survivors. Methods Single-center prospective, observational study including 40 patients with severe COVID-19 pneumonia admitted to the intensive care unit (ICU) for mechanical ventilation. TEG analysis was performed on days 1, 7 and 14 of ICU admission and laboratory coagulation studies were performed on days 1 and 14. Coagulation variables were evaluated for change over the 14-day observation period. Differences between survivors and non-survivors at 30-days were analysed and compared. Results On admission, TEG maximum amplitude (MA) with heparinase correction was above the upper limit of the reference range in 32 (80%) patients while 33 (82.5%) presented with absent clot lysis at 30 min. The functional fibrinogen MA was also elevated above the upper limit of the reference range in 37 (92.5%) patients. All patients had elevated D-dimer and fibrinogen levels, mildly prolonged prothrombin times (PT), normal platelet counts and normal activated partial thromboplastin times (aPTT). The heparinase MA decreased significantly with time and normalised after 14 days (p = < 0.001) while the increased fibrin contribution to clot strength persisted with time (p = 0.113). No significant differences in TEG analysis were noted between 30-day survivors and non-survivors at all time points. No patients developed disseminated intravascular coagulopathy (DIC) after 14-days, however thrombosis and bleeding were each reported in 3 (7.5%) patients. Conclusion Critically-ill patients with COVID-19 present in a hypercoagulable state characterised by an increased clot strength. This state normalises after 14 days despite a persistently increased fibrin contribution to clot strength. We were unable to demonstrate any significant differences in TEG parameters between 30-day survivors and non-survivors at all time points.

Variability in Perioperative Fasting Practices Negatively Impacts Nutritional Support of Critically Ill Intubated Patients

2017 ◽  
Vol 83 (8) ◽  
pp. 895-900 ◽  
Author(s):  
Molly J. Douglas ◽  
David Ciraulo
Keyword(s):  
Critically Ill ◽  
Trauma Center ◽  
Preoperative Fasting ◽  
National Guidelines ◽  
Mechanically Ventilated ◽  
Upper Limit ◽  
Level I ◽  
Anesthetic Complications ◽  
American Society ◽  
American Society Of Anesthesiologists

The aim of the study was to quantify nutritional losses related to pre- and postoperative fasts in critically ill intubated patients and to explore whether shorter fasts are safe and appropriate in this population. A retrospective review of mechanically ventilated adults undergoing surgery more than 24 hours after admission to a Level I trauma center over 15 months was done, which yielded 132 procedures and 81 unique patients. Ninety per cent of preoperative periods and 43 per cent of postoperative periods were affected by nonmedical barriers to feeding. Eighty-two per cent of gastrically fed nonemergent cases were fasted for longer than the 6-hour American Society of Anesthesiologists guideline, whereas 91 per cent of emergent cases had shorter fasts. There were no anesthetic complications, placing an upper limit of 6 per cent on the rate of aspiration for fasts shorter than six hours (95% confidence). Forty-three per cent of cases did not resume tube feeds within 90 minutes postoperatively, and only 37 per cent had a documented justification for delay. Intubated patients were frequently fasted preoperatively for longer than recommended and postoperatively for longer than medically indicated. No complications were observed with shorter-than-guideline fasts. This strengthens the evidence that “standard” preoperative fasting is unnecessary and deleterious in many critically ill intubated patients. New protocols and national guidelines are needed to ensure adequate nutrition.

Abstract 338: Impact of No-Flow Time on the Coagulopathy of Prolonged Cardiac Arrest

Circulation ◽  
2018 ◽  
Vol 138 (Suppl_2) ◽  
Author(s):  
Pavel Hala ◽  
Matias Caceres ◽  
Aaron Prater ◽  
Jensyn VanZalen ◽  
Joshua Jung ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Maximum Amplitude ◽  
Flow Time ◽  
Clot Formation ◽  
Clot Lysis ◽  
Clot Strength ◽  
Consumptive Coagulopathy ◽  
Pathologic Features ◽  
Angle Alpha ◽  
The Impact

Introduction: Prolonged cardiac arrest (CA) eligible for ECPR has pathologic features that are more pronounced than CA durations in which ROSC is typically achieved. One such feature is consumptive coagulopathy resulting in microvascular thrombosis and no-reflow. In this study we examined the impact of no-flow time on CA coagulopathy during prolong CPR in swine Hypothesis: No-flow time amplifies the coagulopathy of prolonged cardiac arrest. Methods: Animals were anesthetized and instrumented for hemodynamic monitoring. After 4 or 8 min of untreated ventricular fibrillation (groups CA-4 and CA-8, n=5/group), goal-directed CPR was initiated and continued for a total arrest time of 45 minutes. Viscoelastic properties of clot formation and fibrinolysis were measured by TEG in whole blood at baseline and at the end of resuscitation protocol. Rate of fibrin activation (Angle alpha), Maximum amplitude (MA), Time to MA (TMA), and reduction of clot after 30 min (CL30) were measured to describe coagulation status. Results: TEG showed reduction in clot strength after the CPR protocol. For groups CA-4 and CA-8, Alpha declined from 71(4) to 55(7) and from 68(5) to 51(9) deg, MA reduced from 75(2) to 58(7) and from 73(3) to 53(11) mm and TMA prolonged from 21(2) to 27(4) and from 20(4) to 25(2) min. CL30 increased from 95(2) to 97(2) and from 96(2) to 100(1) % (all p<0.05). Clot lysis was more reduced in CA-8 (p<0.05) but other parameters did not significantly vary between groups. Overall, platelets declined from 328(86) to 138(81) thousands/mm3 while hematocrit increased (all p<0.01). Conclusion: In this clinically relevant model of prolonged CA with consumptive coagulopathy, the reduction of clot formation and clot strength after 45 minutes of CA and CPR was not significantly different with 4 and 8 min no-flow time. However, clot lysis was more reduced after 8-min no-flow. Further studies are needed to determine the impact of no-flow time on CA coagulopathy at the microvascular level.

scholarly journals Pediatric Multi-Organ Dysfunction Syndrome: Analysis by an Untargeted “Shotgun” Lipidomic Approach Reveals Low-Abundance Plasma Phospholipids and Dynamic Recovery over 8-Day Period, a Single-Center Observational Study

Nutrients ◽  
2021 ◽  
Vol 13 (3) ◽  
pp. 774
Author(s):  
Mara L. Leimanis-Laurens ◽  
Karen Ferguson ◽  
Emily Wolfrum ◽  
Brian Boville ◽  
Dominic Sanfilippo ◽  
...  
Keyword(s):  
Mass Spectrometry ◽  
Intensive Care ◽  
Critically Ill ◽  
Organ Dysfunction ◽  
Lipid Profiles ◽  
Critically Ill Children ◽  
P Value ◽  
Time Points ◽  
Logistic Organ Dysfunction ◽  
Multi Organ Dysfunction Syndrome

Lipids are molecules involved in metabolism and inflammation. This study investigates the plasma lipidome for markers of severity and nutritional status in critically ill children. Children with multi-organ dysfunction syndrome (MODS) (n = 24) are analyzed at three time-points and cross-referenced to sedation controls (n = 4) for a total of N = 28. Eight of the patients with MODS, needed veno-arterial extracorporeal membrane oxygenation (VA ECMO) support to survive. Blood plasma lipid profiles are quantified by nano-electrospray (nESI), direct infusion high resolution/accurate mass spectrometry (MS), and tandem mass spectrometry (MS/MS), and compared to nutritional profiles and pediatric logistic organ dysfunction (PELOD) scores. Our results show that PELOD scores were not significantly different between MODS and ECMO cases across time-points (p = 0.66). Lipid profiling provides stratification between sedation controls and all MODS patients for total lysophosphatidylserine (lysoPS) (p-value = 0.004), total phosphatidylserine (PS) (p-value = 0.015), and total ether-linked phosphatidylethanolamine (ether-PE) (p-value = 0.03) after adjusting for sex and age. Nutrition intake over time did not correlate with changes in lipid profiles, as measured by caloric and protein intake. Lipid measurement in the intensive care environment shows dynamic changes over an 8-day pediatric intensive care unit (PICU) course, suggesting novel metabolic indicators for defining critically ill children.

scholarly journals Fibrinogen Replacement Therapy for Traumatic Coagulopathy: Does the Fibrinogen Source Matter?

2021 ◽  
Vol 22 (4) ◽  
pp. 2185
Author(s):  
Gael B. Morrow ◽  
Molly S. A. Carlier ◽  
Sruti Dasgupta ◽  
Fiona B. Craigen ◽  
Nicola J. Mutch ◽  
...  
Keyword(s):  
Coagulation Factors ◽  
Clot Lysis ◽  
Strongly Correlated ◽  
Good Recovery ◽  
Fibrinogen Concentrate ◽  
Clot Strength ◽  
Coagulation Protein ◽  
Low Levels ◽  
Fibrinogen Replacement Therapy ◽  
Traumatic Coagulopathy

Fibrinogen is the first coagulation protein to reach critically low levels during traumatic haemorrhage. There have been no differential effects on clinical outcomes between the two main sources of fibrinogen replacement: cryoprecipitate and fibrinogen concentrate (Fg-C). However, the constituents of these sources are very different. The aim of this study was to determine whether these give rise to any differences in clot stability that may occur during trauma haemorrhage. Fibrinogen deficient plasma (FDP) was spiked with fibrinogen from cryoprecipitate or Fg-C. A panel of coagulation factors, rotational thromboelastography (ROTEM), thrombin generation (TG), clot lysis and confocal microscopy were performed to measure clot strength and stability. Increasing concentrations of fibrinogen from Fg-C or cryoprecipitate added to FDP strongly correlated with Clauss fibrinogen, demonstrating good recovery of fibrinogen (r2 = 0.99). A marked increase in Factor VIII, XIII and α2-antiplasmin was observed in cryoprecipitate (p < 0.05). Increasing concentrations of fibrinogen from both sources were strongly correlated with ROTEM parameters (r2 = 0.78–0.98). Cryoprecipitate therapy improved TG potential, increased fibrinolytic resistance and formed more homogeneous fibrin clots, compared to Fg-C. In summary, our data indicate that cryoprecipitate may be a superior source of fibrinogen to successfully control bleeding in trauma coagulopathy. However, these different products require evaluation in a clinical setting.

scholarly journals Etiology, incidence, and outcomes of patient–ventilator asynchrony in critically-ill patients undergoing invasive mechanical ventilation

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Yongfang Zhou ◽  
Steven R. Holets ◽  
Man Li ◽  
Gustavo A. Cortes-Puentes ◽  
Todd J. Meyer ◽  
...  
Keyword(s):  
Risk Factors ◽  
Mechanical Ventilation ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Invasive Mechanical Ventilation ◽  
Surgical Intensive Care ◽  
Mechanically Ventilated ◽  
History Of ◽  
Training Background ◽  
The Relationship

AbstractPatient–ventilator asynchrony (PVA) is commonly encountered during mechanical ventilation of critically ill patients. Estimates of PVA incidence vary widely. Type, risk factors, and consequences of PVA remain unclear. We aimed to measure the incidence and identify types of PVA, characterize risk factors for development, and explore the relationship between PVA and outcome among critically ill, mechanically ventilated adult patients admitted to medical, surgical, and medical-surgical intensive care units in a large academic institution staffed with varying provider training background. A single center, retrospective cohort study of all adult critically ill patients undergoing invasive mechanical ventilation for ≥ 12 h. A total of 676 patients who underwent 696 episodes of mechanical ventilation were included. Overall PVA occurred in 170 (24%) episodes. Double triggering 92(13%) was most common, followed by flow starvation 73(10%). A history of smoking, and pneumonia, sepsis, or ARDS were risk factors for overall PVA and double triggering (all P < 0.05). Compared with volume targeted ventilation, pressure targeted ventilation decreased the occurrence of events (all P < 0.01). During volume controlled synchronized intermittent mandatory ventilation and pressure targeted ventilation, ventilator settings were associated with the incidence of overall PVA. The number of overall PVA, as well as double triggering and flow starvation specifically, were associated with worse outcomes and fewer hospital-free days (all P < 0.01). Double triggering and flow starvation are the most common PVA among critically ill, mechanically ventilated patients. Overall incidence as well as double triggering and flow starvation PVA specifically, portend worse outcome.

scholarly journals Selection strategy for sedation depth in critically ill patients on mechanical ventilation

2021 ◽  
Vol 21 (S2) ◽  
Author(s):  
Longxiang Su ◽  
Chun Liu ◽  
Fengxiang Chang ◽  
Bo Tang ◽  
Lin Han ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Dimensionality Reduction ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Latent Profile Analysis ◽  
Profile Analysis ◽  
Mechanically Ventilated ◽  
Mechanically Ventilated Patients ◽  
Sedation And Analgesia ◽  
Ventilated Patients

Abstract Background Analgesia and sedation therapy are commonly used for critically ill patients, especially mechanically ventilated patients. From the initial nonsedation programs to deep sedation and then to on-demand sedation, the understanding of sedation therapy continues to deepen. However, according to different patient’s condition, understanding the individual patient’s depth of sedation needs remains unclear. Methods The public open source critical illness database Medical Information Mart for Intensive Care III was used in this study. Latent profile analysis was used as a clustering method to classify mechanically ventilated patients based on 36 variables. Principal component analysis dimensionality reduction was used to select the most influential variables. The ROC curve was used to evaluate the classification accuracy of the model. Results Based on 36 characteristic variables, we divided patients undergoing mechanical ventilation and sedation and analgesia into two categories with different mortality rates, then further reduced the dimensionality of the data and obtained the 9 variables that had the greatest impact on classification, most of which were ventilator parameters. According to the Richmond-ASS scores, the two phenotypes of patients had different degrees of sedation and analgesia, and the corresponding ventilator parameters were also significantly different. We divided the validation cohort into three different levels of sedation, revealing that patients with high ventilator conditions needed a deeper level of sedation, while patients with low ventilator conditions required reduction in the depth of sedation as soon as possible to promote recovery and avoid reinjury. Conclusion Through latent profile analysis and dimensionality reduction, we divided patients treated with mechanical ventilation and sedation and analgesia into two categories with different mortalities and obtained 9 variables that had the greatest impact on classification, which revealed that the depth of sedation was limited by the condition of the respiratory system.

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