Screening for hemostasis during hemorrhagic emergencies (original) (raw)
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Indian Journal of Critical Care Medicine
IntroductIon Hemostasis-"hemo" is derived from New Latin which means blood; "stasis" is derived from Greek which means standing still. [1] Three hemostatic systems: Platelets, intact vasculature, and soluble clotting factors, interact effectively to protect humans from clinically significant bleeding. Significant bleeding is rare until two of the three systems malfunction, and then the magnitude of each failure often must be significant. [2] There is a spectrum of diseases or conditions that we come across in a medical intensive care unit (MICU) that present with clinical or laboratory evidence of hemostatic abnormality. A clinician is often stressed when bleeding and coagulation tests are alarmingly on the rise. At times, apprehension may arise from a sense of responsibility for bleeding following procedures or perhaps the fact that hemorrhage is often visible externally. [3] The information gained from a careful history-taking, physical examination, laboratory confirmation of the hemostatic abnormalities, and finally the correct interpretation of these results help in the accurate diagnosis and treatment of these patients admitted in the MICU. These patients are major consumers of blood products, yet their incidence and cause have not been studied in detail. Although studies regarding the proportion of patients in MICU with bleeding, their etiology and prognosis are reported from the western world; [4] there is a paucity of data from Indian centers. Having met with limited Background and Aims: In a medical intensive care unit (MICU), many patients develop hemostatic abnormalities, ranging from abnormal clotting tests to frank bleeding. The aim of this study was to assess the etiology of diseases that present with bleeding, its common bleeding manifestations, incidence, MICU stay, mortality, and transfusion requirements in an Indian setup and also to assess if the Acute Physiology and Chronic Health Evaluation II (APACHE II) score can be used as a predictor for blood transfusion requirements. Materials and Methods: Between July 2013 and August 2014, 200 patients with clinically significant bleeding admitted in the MICU were prospectively evaluated. Detailed history, examination, laboratory investigations, APACHE II score, and requirement of blood products were also noted. The endpoints were discharge or death. Results: The spectrum of diseases that presented with bleeding was 47 patients with malaria (23.5%) followed by 36 acute undifferentiated febrile illness (18.0%), 33 dengue (16.5%), 30 leptospirosis (15.0%), 31 acute fulminant hepatitis (15.5%), 14 sepsis (7.0%), and the rest nine miscellaneous causes. The most common bleeding manifestation observed was hematuria in 62/200 (31%). Among the patients studied, 126 expired (63%) and 74 survived (37%). Of the 200 patients, 48/200 (24%) received packed cells, 78/200 (39%) fresh frozen plasma, and 82/200 (41%) platelets. Conclusions: Tropical diseases formed the majority of admissions with bleeding manifestations. Thrombocytopenia is an important marker to predict mortality and also has a significant association with MICU stay. APACHE II score was found to be a good predictor of blood transfusion requirements.
Common haemostasis issues in major bleeding and critical illness
Clinical Medicine, 2018
Haemostatic abnormalities are common in the critically ill or bleeding patient, including haemorrhage-related coagulopathies, disseminated intravascular coagulation and thrombocytopenia, among other pathologies. In this article we aim to outline some of the causes of these clotting abnormalities, highlighting recent advancements in knowledge and new insights into their clinical management, with the aim of optimising diagnostic and therapeutic strategies. Major haemorrhage Recent years have seen the widespread adoption of major haemorrhage protocols to guide shop-floor clinicians when treating severe bleeding, based around the use of packed red blood cells (PRBCs) and fresh frozen plasma (FFP) delivered in fixed ratios, which aim to treat the coagulopathy that frequently accompanies major bleeding and limit its initial development. An important recent study, the Pragmatic Randomized Optimal
Clinica Chimica Acta, 2019
Background: Both thrombelastography (TEG) and rotational thromboelastometry (ROTEM) have been investigated for diagnosis of coagulopathy and guidance of resuscitation in trauma and surgery. Given similarities between the two systems, it is important to determine whether one is superior to the other and how comparable they are to conventional coagulation tests (CCTs). Therefore, we conducted a comparative study of functional fibrinogen and coagulation assays using TEG and ROTEM and CCTs to determine their capability to monitor coagulation profiles, diagnose coagulopathy and predict blood transfusion requirements in trauma patients. Methods: Blood samples were collected from 45 patients at admission and during 48-h hospitalization as part of a randomized control trial on early fibrinogen replacement in trauma. Functional fibrinogen (FF) TEG, ROTEM FIBTEM and EXTEM, and CCTs were performed and compared. Results: We found significant differences between the placebo and fibrinogen groups over hospitalization time in FF TEG MA, ROTEM CT, MCF and LI30. FF TEG MA and ROTEM FIBTEM MCF mirrored plasma fibrinogen profiles, reached a maximum difference between the two groups 1-3 h after fibrinogen administration. In comparison, CCTs detected minimal hemostatic changes by fibrinogen treatment. TEG and ROTEM showed various degrees of correlations with CCTs. TEG MA and ROTEM MCF provided better predictions for plasma and RBC transfusions than CCTs, but poor accuracy for cryoprecipitate transfusion. Both TEG and ROTEM well predicted hypofibrinogenemia (fibrinogen concentration < 1 g/L), but poorly detected coagulopathy (INR ≥ 1.2). Conclusions: TEG and ROTEM detected increases in clot strength following early use of fibrinogen. ROTEM also detected changes in coagulation time and clot lysis. Both were better than CCTs for monitoring coagulation profiles and predicting transfusion requirements.
Thrombosis and Haemostasis, 2002
A description of the development of a strategy for improving the standardization of coagulation tests and the rationale behind the recommendations that follow are the subject of this position paper. Such an endeavor has been occasioned by the advances in the technology for the diagnosis and therapeutic treatment of hemorrhagic and thromboembolic diseases. These and anticipated further advances make it imperative that the standardization of laboratory tests used in diagnosis and in monitoring therapeutic treatments be the 'state-of-the-art' so that the accuracy, comparability and clinical utility is of the highest order. The complexity of the hemostatic system makes achieving accuracy and comparability among these tests a substantial challenge. Another impetus for improving the comparability of the results from different laboratories throughout the world arises as a consequence of the globalization of the pharmaceutical and medical diagnostic companies that began in the 1990's and is continuing into this, the 21 st century.
Editorial: A New Aera in Hemostasis Diagnostic Begins
This is the first double issue of the NOVA journal Hemostasis Laboratory. Six years ago Hemost Lab started to close a gap in international hemostasis diagnostic. New ultra-specific, ultra-sensitive assay procedures that are the basis for good clinical practice should be described in detail, enabling everybody skilled in the art to reproduce the respective highly relevant results in hemostasis, the system of generation and destruction of thrombi. I am delighted to edit again the present issue of Hemost Lab. This time a) secondary hemostasis, b) tertiary hemostasis, c) Limulus hemostasis are the major focuses. Articles present the enormous importance of up to date measuring the generation of a) thrombin, b) plasmin and singlet oxygen (1 O 2) c) factor Aa. Thrombin generation in vivo is best detected by the systemic F2a-test, in vitro thrombin generation should be performed with the recalcified coagulation activity assay (RECA that measures any pro-thrombotic tendency of plasma, trigge...
International Journal of Contemporary Medical Research [IJCMR]
Introduction: Acquired bleeding disorders are a major cause of mortality, both in the developed and developing countries. An acute haemorrhage should be managed immediately with blood products, factor concentrates or anti-fibrinolytics. Investigations to detect coagulopathies typically include baseline screening tests like prothrombin time, activated partial thromboplastin time, platelet count and fibrinogen level. These tests have a long turn around time which frequently lead to a blinded approach towards blood product support leading to under or over transfusion. In contrast, rotational thromboelastometry (ROTEM) which assesses haemostasis from the start of clot formation to fibrinolysis gives earliest results within ten minutes. This study was done to establish a correlation between ROTEM parameters and standard coagulation profile in the context of acquired bleeding disorders. Material and Methods: A total of 138 subjects-70 patients who presented with acquired bleeding disorders and 68 subjects diagnosed to be normal on the basis of a complete coagulation work up were included as the cases and controls respectively. All samples were subjected to standard coagulation profile and ROTEM analysis which included Clotting Time, Clot Formation Time, Alpha Angle, Maximum Clot Firmness and Maximum Lysis. Results: The Maximum Clot Firmness had a very good co relation with serum fibrinogen levels (k value-0.807; p<0.000; Sensitivity-88%; Specificity-92%), and good correlation with platelet count (k value-0.793; p< 0.000; Sensitivity-86%, Specificity-92%), whereas Clot Formation Time showed moderate correlation with aPTT. Clotting time had a poor correlation with prothrombin time and activated partial thromboplastin time. Conclusion: The achievement of haemostasis is a crucial factor for determining patient outcomes in acquired bleeding disorders. The gold standard test to diagnose coagulopathy is the standard coagulation profile. Rotational thromboelastometry correlates well with standard coagulation parameters. This test which is performed on whole blood showed interpretable results within 10 minutes, whereas standard coagulation profile required an average of 45-75 minutes. In view of the good correlation to the standard coagulation profile, it appears that Rotational Thromboelastometry results can be safely used to implement early transfusion therapy for haemorrhage.
Biochemia Medica, 2018
Introduction: Haemolysis is the leading cause of sample rejection in laboratory haemostasis. Most studies focused on artificially haemolysed samples. The aim of this study was a prospective assessment of spontaneous haemolysis on haemostasis tests, by comparing results of haemolysed (H) versus new, non-haemolysed (NH) specimens, collected within 4hrs. As new coagulometers can identify interfering substances, visual assessment of haemolysis was also compared with instrumental haemolysis index and stratified in subclasses. Materials and methods: Two hundred and sixty nine paired samples were collected and analysed using ACL TOP750-CTS (Instrumentation Laboratory, Bedford, USA), for prothrombin time (PT), activated partial thromboplastin time (aPTT), D-Dimer (DD), fibrinogen (Fib) and antithrombin (AT). Bias between H and NH was calculated and compared with the respective critical difference (CD). Results: Mean bias was-0.1 s for PT (P = 0.057),-1.1 s for aPTT (P < 0.001), 1025 ng/mL for DD (P < 0.001),-0.04 g/L for Fib (P = 0.258) and 1.4% for AT (P = 0.013). Bias exceeding the CD varied according to the method, with larger differences for aPTT (36.1%) and DD (17.1%) and < 8% for PT, Fib and AT. No correlation emerged between free haemoglobin values and difference in haemostasis tests in H and NH samples for any tests. Moderate/severe haemolysis involved > 95% of samples. The agreement between visual assessment and instrumental evaluation of haemolysis was 0.62. Conclusion: Spurious haemolysis deeply influences aPTT and DD, and to a lesser extent AT and Fib. Prothrombin time seems only slightly influenced, suggesting that PT can be accepted also in haemolysed samples. Although a good inter-observer correlation of haemolysis evaluation was found, the instrumental assessment of haemolysis seems recommendable.
American Journal of Obstetrics and Gynecology, 1990
The relationship between hemostatic abnormalities and thrombotic and cardiovascular diseases is summarized. All known congenital and acquired abnormalities in the biochemistry of hemostasis are related to thrombotic and cardiovascular diseases in the way that would be expected on the basis of theories about the role of balances between coagulation and fibrinolysis and between activating and inhibiting factors. Notwithstanding the consistency between theory and observed abnormalities, a causal relationship between biochemical abnormality and clinical symptoms has been proved only in a limited number of situations, and it is possible that certain abnormalities only (or also) mark pathologiC events. The limitations of laboratory diagnosis of hemostatic disorders in relation to hemostasis as a local process are discussed. It is proposed that more attention be paid to methods of evaluating the local aspects, for example, methods that assess reaction products in the circulation and that can provide an averaged message of the local phenomena. In addition, such methods can provide information about the dynamic balances in the hemostatic system, whereas historically more attention has been paid to the static balances in the potential of hemostatic processes. (AM J OasTET GVNECOL 1990;163:305-12.)
Laboratory hemostasis: milestones in Clinical Chemistry and Laboratory Medicine
Clinical Chemistry and Laboratory Medicine, 2000
Hemostasis is a delicate, dynamic and intricate system, in which pro-and anti-coagulant forces cooperate for either maintaining blood fluidity under normal conditions, or else will prompt blood clot generation to limit the bleeding when the integrity of blood vessels is jeopardized. Excessive prevalence of anticoagulant forces leads to hemorrhage, whereas excessive activation of procoagulant forces triggers excessive coagulation and thrombosis. The hemostasis laboratory performs a variety of first, second and third line tests, and plays a pivotal role in diagnostic and monitoring of most hemostasis disturbances. Since the leading targets of Clinical Chemistry and Laboratory Medicine include promotion of progress in fundamental and applied research, along with publication of guidelines and recommendations in laboratory diagnostics, this journal is an ideal source of information on current developments in the laboratory technology of hemostasis, and this article is aimed to celebrate some of the most important and popular articles ever published by the journal in the filed of laboratory hemostasis.