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Cardiopulmonary bypass (CPB) coagulopathy increases utilization of allogenic blood/blood products, which can negatively affect patient outcomes. Thromboelastography (TEG) is a point-of-care measurement of clot formation and fibrinolysis. We investigated whether the addition of TEG parameters to a clinically based bleeding model would improve the pr...
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Background:
Early treatment with tranexamic acid reduces deaths due to bleeding after post-partum haemorrhage. We report the prevalence of haematological, coagulation and fibrinolytic abnormalities in Nigerian women with postpartum haemorrhage.
Methods:
We performed a secondary analysis of the WOMAN trial to assess laboratory data and rotational...
Citations
... On the other hand, Terada et al. 2019 found that intraoperative use of TEG-MA, TEG R-time, TEG-K, and TEG α-angle was not predictive of blood loss volume in 50 Japanese cardiac patients [103]. Moreover, another five studies showed that these TEG parameters were not predictive of postoperative bleeding [104][105][106][107][108] or even intraoperative bleeding [109,110]. ...
Assessing coagulation status is essential for prompt intervention to reduce morbidity and mortality related to bleeding and thrombotic complications during the perioperative period. Traditional coagulation tests such as platelet count, activated partial thromboplastin time (aPTT), prothrombin time (PT), international normalized ratio (INR), and activated clotting time (ACT) provide only static evaluation. These tests are not designed for assessment of dynamically changing coagulation conditions during the perioperative time. However, viscoelastic coagulation testing such as thromboelastography (TEG) produces a rapid numerical and graphical representation that helps to detect and direct targeted hemostatic therapy. Searching the literature through PubMed, Medline, Ovid, CINAHL, and ClinicalTrials.gov we retrieved 210 studies, which represent the use of TEG in the perioperative period. The included studies were categorized under various settings such as trauma, obstetrics, orthopedics, intensive care unit (ICU), cardiovascular, transplant, and miscellaneous scenarios. TEG showed promising results in trauma surgeries in predicting mortality, hypercoagulability, and bleeding even when it was compared to conventional methods. TEG was also useful in monitoring anticoagulant therapy in orthopedic and obstetric surgeries; however, its role in predicting thrombotic events, hypercoagulability, or complications was questionable. In ICU patients, it showed promising results, especially in the prediction or improvement of sepsis, coagulopathy, thrombotic events, ICU duration, hospital stay, and ventilator duration. TEG parameters effectively predicted hypercoagulation in transplant surgeries. Regarding cardiovascular surgeries, they were effective in the prediction of the need for blood products, coagulopathy, thrombotic events, and monitoring anticoagulation therapy. More randomized clinical trials comparing TEG parameters with standardized tools are needed to produce robust results to standardize its use in different perioperative settings.
... Although VETs do not predict preoperative bleeding in cardiac surgery, the assays correlate with postoperative bleeding more than platelet count, fibrinogen level, and PT. [42][43][44] VET assays have proven useful to guide platelet and fibrinogen replacement in bleeding patients following CPB. Fibrinogen and platelets are diluted and consumed in the CPB circuit. ...
... For patients undergoing cardiac surgery, VET-guided transfusion algorithms have demonstrated a reduction of red blood cell and platelet transfusion, resulting in a decrease in cost. 50, 69,70,[187][188][189][190] VETs have proven useful in guiding fibrinogen and platelet replacement in patients that experience massive bleeding following cardiopulmonary bypass (CPB). Throughout the course of the CPB circuit, platelets and fibrinogen are largely diluted and then consumed. ...
There has been a significant interest in the last decade in the use of viscoelastic tests (VETs) to determine the hemostatic competence of bleeding patients. Previously, common coagulation tests (CCTs) such as the prothrombin time (PT) and partial thromboplastin time (PTT) were used to assist in the guidance of blood component and hemostatic adjunctive therapy for these patients. However, the experience of decades of VET use in liver failure with transplantation, cardiac surgery, and trauma has now spread to obstetrical hemorrhage and congenital and acquired coagulopathies. Since CCTs measure only 5 to 10% of the lifespan of a clot, these assays have been found to be of limited use for acute surgical and medical conditions, whereby rapid results are required. However, there are medical indications for the PT/PTT that cannot be supplanted by VETs. Therefore, the choice of whether to use a CCT or a VET to guide blood component therapy or hemostatic adjunctive therapy may often require consideration of both methodologies. In this review, we provide examples of the relative indications for CCTs and VETs in monitoring hemostatic competence of bleeding patients.
... Some investigators found that TEG findings were not comparable to traditional tests, [8][9][10] while Shore-Lesserson et al. 4 found TEG to be accurate in assessing coagulability and associated with lower transfusion rates. The effect of TEG-directed transfusions following CPB on long-and short-term clinical outcomes such as infections, immunological reactions, or mortality have yet to be determined. ...
Introduction:
This study aimed to determine if thromboelastography (TEG) is associated with reduced blood product use and surgical reintervention following cardiopulmonary bypass (CPB) compared to traditional coagulation tests.
Methods:
A retrospective review was conducted of 698 patients who underwent CPB at a tertiary-care, community-based, university-affiliated hospital from February 16, 2014 to February 16, 2015 (Period I) and from May 16, 2015 to May 16, 2016 (Period II). Traditional coagulation tests guided transfusion during Period I and TEG guided transfusion during Period II. Intraoperative and postoperative administration of blood products (red blood cells, fresh frozen plasma, platelets, and cryoprecipitate), reoperation for hemorrhage or graft occlusion, duration of mechanical ventilation, hospital length of stay, and mortality were recorded.
Results:
Use of a TEG-directed algorithm was associated with a 13.5% absolute reduction in percentage of patients requiring blood products intraoperatively (48.2% vs. 34.7%, p < 0.001). TEG resulted in a 64.3% and 43.1% reduction in proportion of patients receiving fresh frozen plasma (FFP) and platelets, respectively, with a 50% reduction in volume of FFP administered (0.3 vs. 0.6 units, p < 0.001). Use of TEG was not observed to decrease postoperative blood product usage or mortality significantly. The median length of hospital stay was reduced by one day after TEG guided transfusion was implemented (nine days vs. eight days, p = 0.01).
Conclusions:
Use of TEG-directed transfusion of blood products following CPB appeared to decrease the need for intraoperative transfusions, but the effect on clinical outcomes has yet to be clearly determined.
... However, fibrinogen and other coagulation factors, proteins, and platelets are lost from the blood by the processes of washing and filtering and the concentration of RBCs [60,61]. Retransfusion of large volumes of cell-salvaged blood can induce progressive plasma dilution and impair coagulation [41,50], leading to postoperative bleeding [62]. The extent of these processes varies between different methods and filtration devices [63][64][65][66]. ...
Background: Fibrinogen is a substrate for blood clots formation. In cardiac surgery, a number of different mechanisms lead to a decrease in fibrinogen levels and consequent impaired haemostasis. Patients undergoing cardiac surgery are therefore frequently exposed to blood loss and allogeneic blood transfusion, which are risk factors associated with morbidity and mortality. Thus, particular efforts in fibrinogen management should be made to decrease bleeding and the need for blood transfusion. Therefore, fibrinogen remains an active focus of investigations from basic science to clinical practice. This review aims to summarise the latest evidence regarding the role of fibrinogen and current practices in fibrinogen management in adult cardiac surgery. Methods: The PubMed database was systematically searched for literature investigating the role and disorders of fibrinogen in cardiac surgery and diagnostic and therapeutic procedures related to fibrinogen deficiency aimed at reducing blood loss and transfusion requirements. Clinical trials and reviews from the last 10 years were included. Results: In total, 146 articles were analysed. Conclusion: The early diagnosis and treatment of fibrinogen deficiency is crucial in maintaining haemostasis in bleeding patients. Further studies are needed to better understand the association between fibrinogen levels, bleeding, and fibrinogen supplementation and their impacts on patient outcomes in different clinical settings.
... Thromboelastography (TEG) was used during the study period to guide transfusion of blood products in patients undergoing CABG. It has a role in the routine management of CABG patients to improve clinical outcomes and to reduce potential risks associated with transfusions and total CABG cost [12,13]. Furthermore, TEG-based coagulation management decreases significantly the rates of re-exploration, post-operative thromboembolic events, and acute kidney injury [14]. ...
Background and aim: Cardiac tamponade is a recognized post-cardiac surgery complication,
resulting in increased morbidity and mortality. The 2016 American College of Cardiology and
American Heart Association Guidelines recommended the use of Dual Antiplatelet Therapy (DAPT)in the management of patients undergoing urgent or emergency coronary artery bypass grafting(CABG). The effect of DAPT on cardiac tamponade rates was investigated in comparison to aspirinmonotherapy (AMT).
Materials and methods: Prospectively collected data from a tertiary cardiac surgery center was analyzed to identify the patients who underwent urgent and emergency CABG between January 2015 and January 2018. The patients were categorized as aspirin monotherapy (AMT) and Dual Antiplatelet Therapy (DAPT) groups. The primary outcome was total cardiac tamponade rate and secondary outcomes were length of hospitalization and 30-days and 1-year mortality.
Results: A total of 246 eligible patients were included across both arms and compared for confounding variables. Cardiac tamponade was observed in 9 (7.3%) and 8 (6.5%) of AMT and DAPT groups, respectively (P=0.802). The average hospital stay in days was similar in both groups (AMT=8.4 vs.DAPT=8.1, P=0.82), whereas tamponade patients experienced a significantly longer hospitalization when compared to non-tamponade patients (9.8 vs. 8.1 days, P=0.047). The 30-days and 1-year mortality were similar in both groups and were 0.8% and 1.6%, respectively.
Conclusion: Overall, this study demonstrated that DAPT in urgent or emergency CABG patients is not associated with an increased risk of cardiac tamponade, length of hospital stay or mortality.
... However, this device can cause hemostatic system disorders. This is due to the direct contact between blood and the surface of the appliance, the duration of CPB use, hemodilution, the use of anti-platelets and/or pre-operative anticoagulants, heparinization during [1][2][3] CPB, and hypothermic condition. ...
The use of Cardiopulmonary Bypass (CPB) in adult patients of cardiac surgery disrupts the coagulation system. The mostcommon complication of the coagulation system is bleeding; however, that does not rule out the possibility of a dangeroushypercoagulation condition. A quick and precise coagulation test can provide clues for clinicians to predict futurehemostatic disorders or determine interventional therapy. aPTT and PT are standard laboratory tests, which are limited todetect a deficiency of coagulation factors. Thromboelastography (TEG) test (R time, K time, α angle, MA, and LY30) providesan overview of the entire coagulation and fibrinolysis process with faster results. A 2.7 mL citrate blood sample was takenand tested in a TEG®5000 device, then centrifuged. The plasma was then tested for aPTT and PT using the Sysmex CS-2100idevice. Bleeding volume was measured from chest drain 1-2 hours in the ICU after chest closure in the operating room.Bleeding criteria were as follows: > 1.5 mL/kg/hour for 6 hours consecutively in 24 hours or > 100 mL/hour. The resultsshowed 30 patients with no clinically significant bleeding. A significant correlation was found between PT and bleedingvolume at IV hour (p=0.008, r= 0.472). There was no correlation between aPTT and TEG (R time, K time, α angle, MA, andLY30) with the bleeding volume at I, II, III, and IV hours. There was a hypercoagulation indication of the TEG test of 56.7%,which showed clinical importance for the patient. PT can be used to analyze changes in bleeding volume at IV hour and TEGis more superior to detect hypercoagulability of adult patients after cardiac surgery with CPB.
... or prothrombin time (r = 0.43, P = .02). 26 Despite this most studies have shown that the values obtained are usually still in the normal range, and that the difference between the pre and post-bypass tests, rather than the absolute values obtained, predicts bleeding. 21,25,[27][28][29][30] A change in any of the VHA variables >15% is most often associated with increased risk of bleeding. ...
Bleeding complications are common in cardiac surgery and lead to an increase in morbidity and mortality. This is multifactorial in aetiology including the effects of cardiopulmonary bypass, the drugs given to manipulate the coagulation system and the vascular nature of the surgery itself. Viscoelastic tests provide a point of care, rapid assessment of coagulation which offer the advantage of faster turnaround times and a nuanced view of the elements of the coagulation system allowing targeted therapy to be delivered quickly. Both thomboelastography (TEG)and thromboelastometry (ROTEM) have been recommended for use in cardiac surgery, both have shown a reduction in transfusion and bleeding when used as part of a testing algorithm. They are particularly useful in assessing residual heparinisation and fibrinogen levels. Additionally, TEG allows the evaluation of the effects of anti‐platelet agents on platelet function. This review discusses the mechanisms by which bleeding occurs in cardiac surgery and explores three uses of viscoelastic testing in cardiac surgery: to predict bleeding, to assess platelet function and peri‐operative testing to reduce transfusion
... Thromboelastography is a rapid, pointof-care test and is being increasingly used in cardiac surgery, trauma, and massive transfusions. 6,7 We have previously demonstrated that among patients with decompensated CLD, TEG shows delayed coagulation initiation, weaker clot strength, and impaired fibrinogen function but also decreased clot lysis. 8 However, the relationship between TEG and CCTs in this population remains unknown. ...
Objective:
Thromboelastography (TEG) may provide rapid and clinically important coagulation information in acutely ill patients with chronic liver disease (CLD). Our objective was to describe the relationship between TEG and conventional coagulation tests (CCTs), which has not been previously explored in this population.
Methods:
In acutely ill patients with severe CLD (Child-Pugh score > 9, category C), we conducted a prospective observational study investigating coagulation assessment as measured by both CCTs and TEG. We used quantile regression to explore 30 associations between TEG parameters and corresponding CCTs. We compared TEG and CCT measures of coagulation initiation, clot formation, clot strength, and fibrinolysis.
Results:
We studied 34 patients on a total of 109 occasions. We observed inconsistent associations between TEG and CCT measures of coagulation initiation: TEG (citrated kaolin [CK] assay) standard reaction time and international normalized ratio: R 2 = 0.117 (P = .044). Conversely, there were strong and consistent associations between tests of clot formation: TEG (CK) kinetics time and fibrinogen: R 2 = 0.202 (P < .0001) and TEG (CK) α angle and fibrinogen 0.263 (P < .0001). We also observed strong associations between tests of clot strength, specifically TEG MA and conventional fibrinogen levels, across all TEG assays: MA (CK) and fibrinogen: R 2 = 0.485 (P < .0001). There were no associations between TEG and D-dimer levels.
Conclusions:
In acutely ill patients with CLD, there are strong and consistent associations between TEG measures of clot formation and clot strength and conventional fibrinogen levels. There are weak and/or inconsistent associations between TEG and all other conventional measures of coagulation.
... No transfusion was permitted unless the surgeon gave direct verbal orders. Thromboelastography was not used routinely during the study period given its unclear impact on blood conservation [12]. ...
Background:
Whether there is a cardiac surgical patient population that does not incur harm from blood conservation is unknown. This study aimed to identify patient characteristics associated with patients who safely tolerate blood conservation.
Methods:
We conducted a retrospective review of consecutive patients undergoing isolated coronary artery bypass graft surgery or isolated aortic valve replacement, or concomitant coronary artery bypass graft surgery and aortic valve replacement between 2011 and 2016, during which blood conservation intervention took place. Logistic regression derived from the preintervention cohort was applied to the postintervention cohort to identify patient characteristics associated with those predicted to be transfused in the preintervention era but were not in the postintervention era.
Results:
In this series of 2,701 adult patients undergoing cardiac operations, blood conservation intervention in 2014 led to a 52% reduction in red blood cell transfusion. Between preintervention and postintervention cohorts, there was no significant difference in the measured outcomes. A regression model derived from the preintervention cohort was applied to the postintervention cohort to identify predictors of cohort that do not derive benefit from liberal transfusion. This model demonstrated such patient characteristics to be age more than 75 years (odds ratio [OR] 1.71, 95% confidence interval [CI]: 1.09 to 2.68, p = 0.033), body mass index less than 30 kg/m2 (OR 1.5, 95% CI: 1.02 to 2.20, p = 0.044), lowest intraoperative hematocrit between 22 and 25 (OR 1.77, 95% CI: 1.16 to 2.68, p < 0.001), and cardiopulmonary bypass use (OR 4.50, 95% CI: 2.25 to 9.01, p < 0.001).
Conclusions:
Blood conservation can successfully yield reduction in perioperative blood product use, with associated decrease in the risk of postoperative renal failure. A select patient population who may tolerate blood conservation safely was identified, and that may guide a targeted blood conservation effort.
