Is thromboelastography reliable in postpartum coagulopathies? Two case reports and a literature review

2019 ◽  
Vol 9 (1) ◽  
Author(s):  
Elif E. Gultekin-Elbir ◽  
J. Peter R. Pelletier ◽  
Kendra R. Sylvester-Armstrong ◽  
Mehmet R. Genc
Keyword(s):  
Case Reports ◽  
Damage Control ◽  
International Normalized Ratio ◽  
Blood Component ◽  
Reference Ranges ◽  
Coagulation Tests ◽  
Maternal Morbidity And Mortality ◽  
Blood Component Therapy ◽  
Intervention Goal

AbstractPostpartum hemorrhage (PPH) is an underestimated problem in labor and delivery units and remains a leading cause of maternal morbidity and mortality worldwide. Managing PPH starts with immediate recognition and intervention. Goal-directed massive transfusion protocol can be achieved by properly monitoring the maternal coagulation profile during severe obstetric hemorrhage. Conventional coagulation tests (prothrombin time, activated partial thromboplastin time, international normalized ratio, fibrinogen analysis, platelet count) have long turnaround times (occasionally >60 min and provide little information about the in vivo condition of hemostasis) compared to viscoelastic tests (VETs) (available results within 10–30 min). The outcome in actively hemorrhaging patients can be optimized by VETs, including thromboelastography (TEG), rotational thromboelastometry and Sonoclot, providing more individualized blood component therapy compared to traditional 1:1:1 ‘damage control resuscitation’ ratios of blood transfusion strategy. The main limitations of the efficacy of VETs include, but are not limited to, the lack of validation, not having well-established reference ranges for each patient group, results affected by fluid resuscitation regimes and consistent operator proficiency. Although there is limited data with the use of VETs in obstetric patients, the value of VETs is supported by guidelines with increasing evidence. This article will demonstrate two obstetric cases to evaluate the reliability of the TEG in the management of postpartum coagulopathies. The lesson we took from our two cases is presented.

scholarly journals The Utilization of Viscoelastic Testing to Guide Blood Component Therapy and Adjunctive Hemostatic Therapy for Postpartum Hemorrhage: A Narrative Review

2019 ◽  
pp. 272-286
Author(s):  
Baumgartner S ◽  
Shariff F ◽  
Vande Lune SA ◽  
Zackariya N ◽  
Grisoli A ◽  
...  
Keyword(s):  
Postpartum Hemorrhage ◽  
Point Of Care ◽  
Narrative Review ◽  
Blood Component ◽  
Clinical Parameters ◽  
Rotational Thromboelastometry ◽  
Coagulation Tests ◽  
Blood Component Therapy ◽  
History Of ◽  
Hemostatic Therapy

This narrative review discusses the history of the pathophysiologic principles and utilization of point-of-care (POC) viscoelastic tests (VETs) in the definition and treatment of postpartum hemorrhage (PPH). This paper addresses the epidemiology of PPH, describes the hemostatic changes that occur in pregnancy and in PPH, and demonstrates the utilization of viscoelastic testing in the identification and treatment of patients with PPH. Additionally, a description of rotational thromboelastometry (ROTEM) and thromboelastography (TEG), the two most commonly used VETs, is detailed in this paper. VETs have only recently been used to guide blood component therapy (BCT) in trauma in the last decade. The recent increased utilization of VETs to guide BCT in PPH is following a similar trend with a delay of ten years. In a similar fashion to the trauma literature, which expanded greatly within this last decade, the literature concerning the use of VETs in PPH has also increased in the last few years. However, because of differing pathophysiologies associated with the coagulopathy of PPH verses traumatic-induced coagulopathy (TIC), utilization of VETs has been more refined and focused on the VETs’ capacity to determine low fibrinogen and to guide the utilization of blood components and prohemostatic agents. The identification and treatment of PPH depends on clinical parameters, conventional coagulation tests (CCTs) including Clauss fibrinogen, and VETs. Successful treatment of PPH will no doubt include utilization of all three strategies with an increasing utilization of VETs in the future.

Diagnosis and Treatment of Trauma-Induced Coagulopathy by Viscoelastography

2020 ◽  
Vol 46 (02) ◽  
pp. 134-146 ◽  
Author(s):  
Jan Hartmann ◽  
Mark Walsh ◽  
Anne Grisoli ◽  
Anthony V. Thomas ◽  
Faisal Shariff ◽  
...  
Keyword(s):  
Trauma Patient ◽  
Clinical Outcomes ◽  
Blood Product ◽  
Blood Component ◽  
Trauma Resuscitation ◽  
Rotational Thromboelastometry ◽  
Trauma Induced Coagulopathy ◽  
Coagulation Tests ◽  
Blood Component Therapy ◽  
Compare And Contrast

AbstractThis article explores the application of viscoelastic tests (VETs) in trauma-induced coagulopathy and trauma resuscitation. We describe the advantages of VETs over conventional coagulation tests in the trauma setting and refer to previous disciplines in which VET use has reduced blood product utilization, guided prohemostatic agents, and improved clinical outcomes such as the mortality of critically bleeding patients. We describe different VETs and provide guidance for blood component therapy and prohemostatic therapy based on specific VET parameters. Because the two most commonly used VET systems, rotational thromboelastometry and thromboelastography, use different activators and have different terminologies, this practical narrative review will directly compare and contrast these two VETs to help the clinician easily interpret either and use the interpretation to determine hemostatic integrity in the bleeding trauma patient. Finally, we anticipate the future of new viscoelastic technologies that can be used in this setting.

scholarly journals Viscoelastic Hemostatic Assays for Postpartum Hemorrhage

2021 ◽  
Vol 10 (17) ◽  
pp. 3946
Author(s):  
Alyson E. Liew-Spilger ◽  
Nikki R. Sorg ◽  
Toby J. Brenner ◽  
Jack H. Langford ◽  
Margaret Berquist ◽  
...  
Keyword(s):  
Postpartum Hemorrhage ◽  
Point Of Care ◽  
Blood Component ◽  
Surgical Trauma ◽  
Point Of Care Test ◽  
Coagulation Tests ◽  
Blood Component Therapy ◽  
Acute Fatty Liver ◽  
Correct Technique ◽  
Point Of Care Tests

This article discusses the importance and effectiveness of viscoelastic hemostatic assays (VHAs) in assessing hemostatic competence and guiding blood component therapy (BCT) in patients with postpartum hemorrhage (PPH). In recent years, VHAs such as thromboelastography and rotational thromboelastometry have increasingly been used to guide BCT, hemostatic adjunctive therapy and prohemostatic agents in PPH. The three pillars of identifying hemostatic competence include clinical observation, common coagulation tests, and VHAs. VHAs are advantageous because they assess the cumulative contribution of all components of the blood throughout the entire formation of a clot, have fast turnaround times, and are point-of-care tests that can be followed serially. Despite these advantages, VHAs are underused due to poor understanding of correct technique and result interpretation, a paucity of widespread standardization, and a lack of large clinical trials. These VHAs can also be used in cases of uterine atony, preeclampsia, acute fatty liver of pregnancy, amniotic fluid embolism, placental abruption, genital tract trauma, surgical trauma, and inherited and prepartum acquired coagulopathies. There exists an immediate need for a point-of-care test that can equip obstetricians with rapid results on developing coagulopathic states. The use of VHAs in predicting and treating PPH, although in an incipient state, can fulfill this need.

Damage control resuscitation using blood component therapy in standard doses has a limited effect on coagulopathy during trauma hemorrhage

2014 ◽  
Vol 41 (2) ◽  
pp. 239-247 ◽  
Author(s):  
Sirat Khan ◽  
Ross Davenport ◽  
Imran Raza ◽  
Simon Glasgow ◽  
Henry D. De’Ath ◽  
...  
Keyword(s):  
Damage Control ◽  
Blood Component ◽  
Damage Control Resuscitation ◽  
Limited Effect ◽  
Blood Component Therapy

Anticoagulant Properties of Three Mucopolysaccharides Used in Rheumatology

1983 ◽  
Vol 50 (03) ◽  
pp. 652-655 ◽  
Author(s):  
F Bauer ◽  
P Schulz ◽  
G Reber ◽  
C A Bouvier
Keyword(s):  
Factor Xa ◽  
Degenerative Joint Disease ◽  
Joint Disease ◽  
Thrombin Time ◽  
Coagulation Tests ◽  
Amplification System ◽  
Relative Potencies ◽  
In Vivo Administration

SummaryThree mucopolysaccharides (MPS) used in the treatment of degenerative joint disease were compared to heparin to establish their relative potencies on 3 coagulation tests, the aPTT, the antifactor X a activity and the dilute thrombin time. One of the compounds, Arteparon®, was one fourth as potent as heparin on the aPTT, but had little or no influence on the 2 other tests. Further in vitro studies suggested that Arteparon® acted at a higher level than factor Xa generation in the intrinsic amplification system and that its effect was independent of antithrombin III. In vivo administration of Arteparon® confirmed its anticoagulant properties, which raises the question of the clinical use of this MPS.

Systemic hemostatic and hemostasiological effects of fibrin monomer in low dose under warfarin action in experiment

2019 ◽  
Author(s):  
В.М. Вдовин ◽  
А.П. Момот ◽  
Д.А. Орехов ◽  
И.Г. Толстокоров ◽  
В.О. Шевченко ◽  
...  
Keyword(s):  
Liver Injury ◽  
Blood Loss ◽  
Prothrombin Complex Concentrate ◽  
Coagulation Factors ◽  
International Normalized Ratio ◽  
Blood Coagulation Factors ◽  
Circulating Blood Volume ◽  
Hemostatic Effect ◽  
Blood Loss Volume

Введение. Ранее было показано, что фибринмономер (ФМ) в низких дозировках обладает системным гемостатическим действием в условиях дозированной травмы. Авторами выдвинута гипотеза, согласно которой ФМ способен оказывать регулирующее гемостатическое действие in vivo на фоне сниженного гемостатического потенциала. Цель исследования: изучение системных гемостатических и гемостазиологических эффектов ФМ на фоне дозированной травмы печени при гипокоагуляции, обусловленной приемом варфарина. Материалы и методы. В работе использовали 40 кроликов породы Шиншилла. Для индукции кумаринобусловленной гипокоагуляции животным per os вводили варфарин в дозе 0,4 0,5 мг/кг 14 дней до достижения международного нормализованного отношения (МНО) более 2,0. Далее животным в краевую вену уха вводили концентрат факторов протромбино вого комплекса (КФПК) в дозе 40 ЕД/кг, ФМ в дозе 0,25 мг/кг или плацебо. Через 1 ч после введения препаратов наносили травму печени и оценивали кровопотерю (в процентах от объема циркулирующей крови). Исследовали число тромбоцитов, активированное парциальное тромбопластиновое время, МНО, содержание фибриногена и Ддимера, оценивали результаты тромбоэластографии крови. Результаты. Объем кровопотери в группах животных после внутривенного введения ФМ и КФПК на фоне приема варфарина был в 9,1 раза и 6,7 раза меньше, соответственно, по сравнению с группой плацебо, получавшей тот же антикоагулянт. Вместе с тем ФМ не влиял на параметры коагулограммы (отсутствие видимого гемостазиологического эффекта) и тромбоэластограммы, тогда как применение КФПК в качестве антидота варфарина сопровождалось нормализацией параметров тромбоэластометрии и коррекцией гипокоагуляционного сдвига по МНО. Заключение. Установлено, что ФМ способен проявлять свое системное гемостатическое действие в условиях сниженного тромбинообразования, обусловленного нарушением синтеза витамин Кзависимых факторов свертывания крови. Данное действие реализуется без признаков восстановления гемостатического равновесия. Introduction. It was shown earlier that fibrinmonomer (FM) in low doses had a systemic hemostatic effect in a controlled injury condition. The authors suggest that FM is able to exert a regulating hemostatic effect in vivo under reduced hemostatic potential. Aim: to study the systemic hemostatic and hemostasiological effects of FM under controlled liver injury during hypocoagulation caused by warfarin administration. Materials and methods. In this study 40 Chinchilla rabbits were used. For the induction of coumarinmediated hypocoagulation, animals were administered per os warfarin at a dose of 0.4 0.5 mg/kg for 14 days, until an international normalized ratio (INR) was more than 2.0. Subsequently, a prothrombin complex concentrate (PCC) at a dose of 40 U/kg, FM at a dose of 0.25 mg/kg or placebo were administered into the marginal ear vein of the animals. An hour later, a liver injury was inflicted and blood loss was assessed (in percents of the circulating blood volume). The number of platelets, activated partial thromboplastin time, INR, levels of fibrinogen and Ddimer were studied and the results of blood thromboelastography were evaluated. Results. Blood loss volume in animals groups after intravenous administration of FM and PPC, under warfarin reception, was 9.1 times and 6.7 times less, respectively, compared to the placebo group receiving the same anticoagulant. However, FM did not affect on coagulogram parameters (no visible hemostasiological effect) and thromboelastogram, whereas the use of PPC as warfarin antidote was accompanied by the normalization of thromboelastometry parameters and hypocoagulation shift correction according to INR. Conclusion. It was found that FM able to manifest its systemic hemostatic effect in conditions of reduced thrombin formation caused by impaired synthesis of vitamin Kdependent blood coagulation factors. This effect is implemented without any signs of recovery of hemostatic balance.

Assays of fibrin network properties altered by VKAs in atrial fibrillation – importance of using an appropriate coagulation trigger

2015 ◽  
Vol 113 (04) ◽  
pp. 851-861 ◽  
Author(s):  
Michal Ząbczyk ◽  
Margareta Blombäck ◽  
Jacek Majewski ◽  
Grzegorz Karkowski ◽  
Hakan N. Wallen ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Thrombin Generation ◽  
Vitamin K Antagonists ◽  
International Normalized Ratio ◽  
Clot Lysis ◽  
Flow Measurements ◽  
Fibrin Networks ◽  
Fibrin Network ◽  
Long Term Treatment

SummaryAtrial fibrillation (AF) is a prothrombotic condition, involving increased thrombin generation and fibrinogen concentrations. Vitamin K antagonists (VKAs) prevent arterial thromboembolism if optimal anticoagulation is achieved by individualised drug doses, assessed by determining the Prothrombin time-related International Normalized Ratio (Pt-INR). There is evidence that formation of tight-laced fibrin networks is pathogenic in prothrombotic diseases. This study was performed among AF patients, to test whether long-term treatment with VKAs affects the structure of fibrin networks, and whether the effect is altered by employing different coagulation triggers: exogenous thrombin (1 IU/ml), 10 pM tissue factor (TF) or a commercial Pt-INR reagent (containing 400-fold more TF). In the thrombin-based method, fibrin network porosity (scanning electron microscopy) and liquid permeability (flow measurements) correlated inversely to fibrinogen concentrations, while positive correlations to the degree of anticoagulation were shown with the Pt-INR reagent. In the method with 10 pM TF, the two above relationships were detected, though the influence of Pt-INR was more profound than that of fibrinogen concentrations. Moreover, greater shortening of clot lysis time (CLT) arose from more permeable clots. As a coagulation trigger, 10 pM TF vs exogenous thrombin or the Pt-INR reagent is more informative in reflecting the in vivo process from thrombin generation to fibrin formation. Since fibrin network permeability rose in parallel to elevations of INR and shortening of CLT in AF patients, antithrombotic effects on prevention of thrombotic complications may be achieved from impairment of thrombin generation, resulting in formation of permeable clots susceptible to fibrinolysis.

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