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PubMed2003

Whole blood coagulation thrombelastographic profiles employing minimal tissue factor activation.

We investigated whole blood coagulation by thrombelastography (TEG) employing activation with minute amounts of tissue factor (TF). Continuous raw data captured were transformed into novel parameters, such as the maximum velocity (MaxVel) and the time to maximum velocity (t,MaxVel) of whole blood clot formation. The courses of the whole blood clot development were very similar to thrombin generation curves reported in plasma. In this assay healthy women (n = 30) showed an earlier onset and an increased coagulation velocity compared to healthy men (n = 30). In patients with severe hemophilia, and persons undergoing thromboprophylaxis, distinctly abnormal coagulation profiles were observed with a decrease in the MaxVel, as well as a prolonged t,MaxVel. Changes appeared to be dependent on the nature and severity of the hemostatic deficit. Preliminary studies in patients substituted with recombinant factor VIIa demonstrated a marked change in the coagulation profile, in which the MaxVel and t,MaxVel shifted towards normal in a dose-dependent way. Data suggest that the whole blood coagulation TEG profile, following activation with minute amounts of TF, may reflect the hemostatic potential in patients suspected of impaired hemostasis.

Adult↗
PubMed2000

Hepatoenteric ischemia-reperfusion increases circulating heparinoid activity in rabbits.

PURPOSE: The purpose of this study was to determine if an increase in circulating heparinoid activity contributes to the hemostatic abnormalities associated with hepatoenteric ischemia-reperfusion. MATERIALS AND METHODS: Anesthetized rabbit (n = 18) underwent thoracic aorta occlusion for 30 minutes with a balloon catheter, followed by 30 minutes of reperfusion. Blood samples were obtained after 30 minutes of equilibration and 30 minutes of reperfusion. Hemostatic function was assessed by changes in the thrombelastographic variables R (reaction time), alpha (a measure of the speed of clot formation), and G (a measure of clot strength). Thrombelastography was performed on blood without platelet inhibition in the presence or absence of heparinase (n = 9 rabbits). Additional samples (n = 9) were exposed to cytochalasin D (platelet inhibitor) with or without heparinase. RESULTS: Compared with preischemic values, blood samples with intact platelet function obtained during reperfusion demonstrated a decrease in hemostatic function evidenced by a significant (P<.05) increase in R, decrease in alpha, and decrease in G. R, alpha, and G values of samples without platelet inhibition exposed to heparinase did not significantly change after ischemia. Blood samples exposed to cytochalasin D displayed a similar pattern. CONCLUSION: An increase in circulating heparinoid activity significantly contributes to the hemostatic disorder associated with hepatoenteric ischemia-reperfusion in rabbits.

Animals↗
PubMed2001

Endogenous heparin decreases the thrombotic response to hemorrhagic shock in rabbits.

PURPOSE: The purpose of this study was to determine if endogenous heparin release would modulate the hemostatic response to hemorrhagic shock in rabbits. MATERIALS AND METHODS: Anesthetized rabbits (n = 13) underwent hemorrhagic shock (MAP 30-40 mm Hg) for 60 minutes. Blood samples obtained before and 60 minutes after hemorrhagic shock had thrombelasto-graphic variables (R, reaction time [min]; angle, alpha [ degrees ]; and G [dynes/cm(2)]) determined. Hemostatic function was assessed by modified thrombelastography under four conditions: (1) unmodified sample; (2) platelet inhibition with cytochalasin D; (3) heparinase I exposure; and (4) platelet inhibition and heparinase I exposure. RESULTS: Thrombelastographic variable values in samples without platelet inhibition or heparinase exposure did not significantly change after hemorrhage (before hemorrhage: R = 22.01 +/- 0.7 min, alpha 43.6 +/- 1.3 degrees, G 7,089 +/- 379 dyne/cm(2); after hemorrhage: R 22.1 +/- 2.4, alpha 41.6 +/- 3.9, G = 5,662 +/- 564; mean +/- SEM). However, blood samples exposed to heparinase after hemorrhage demonstrated enhanced hemostatic function with thrombelastographic values (R = 13.4 +/- 1.5, alpha 56.0 +/- 3.4, G = 7012 +/- 565) significantly different (P <.05) from samples not exposed to heparinase. Samples with platelet inhibition demonstrated a similar pattern. CONCLUSION: Hemorrhagic shock significantly increased circulating endogenous heparin activity, attenuating the thrombotic response to hemorrhage in rabbits. Heparin-mediated regulation of hemostasis may serve as a protective mechanism in shock states.

Analysis of Variance↗
PubMed2002

[Thrombelastographic coagulation analysis following in vitro and in vivo haemodilution with hydroxyethyl starch (HES)].

In the study presented the effects of in vitro hemodilution with HES on coagulation are compared with the effects of in vivo hemodilution using thrombelastography (TEG). The in vivo hemodilution was performed by the i. v. infusion of 1000 ml 6 % solution of hydroxyethyl starch HES (2 formulations with HES 130/0.4 and one formulation with HES 200/0.5) in healthy volunteers during 30 min. The in vitro hemodilution was performed with blood samples taken from the volunteers before the infusion was started. These samples were diluted with HES-solution until the same hemoglobin concentration measured at the end of the infusion was attained. The in vivo TEG-parameters remained in the reference range of the method, however all in vitro TEG-parameters are out of the range of normal values. The isolated interpretation of the in vitro data shows an impairment of blood coagulation. The shortening of the reaction time as an indicator for the initiation of blood clotting points to activated coagulation by in vivo hemodilution with HES, whereas in vitro the prolongation of the reaction time is indicative for retardation of clotting. The evaluation of the TEG-parameters and of other clotting parameters determined prior to the beginning of the infusion, at the end of the infusion and four hours after termination of the infusion of HES 130/0.4 and of HES 200/0.5 to healthy volunteers show alterations of blood coagulation parameters caused mainly by dilutional effects. The more pronounced alterations found in vitro cannot be interpreted as impairment of haemostasis in vivo. On the other hand, the likewise haemodilution in vitro causes an impairment of coagulation. Therefore, the effects of in vitro hemodilution with HES on coagulation differ qualitatively and quantitatively from the effects of in vivo hemodilution.

Adult↗
PubMed1993

Changes in urokinase-type plasminogen activator in orthotopic liver transplantation.

Elevated levels of u-PA Ag and scu-PA preoperatively and before revascularization of the graft are explained by an impaired clearance function by the diseased liver. They are parallel preoperatively and in the beginning of OLT by increased tcu-PA activity. This may reflect a role of the intrinsic fibrinolytic system in the "hyperfibrinolytic state" observed in patients with end stage liver disease. u-PA Ag and scu-PA normalize following reperfusion. The increase in tcu-PA observed during the anhepatic phase coincided with greatly increased fibrinolysis, as demonstrated by thrombelastography. This indicates that u-PA seems to be involved in the development of fibrinolysis during OLT. It had been demonstrated in previous investigations that a significant increase of t-PA activity was seen in the late anhepatic phase leading to an elevated plasmin generation. Since plasmin is a major activator of scu-PA, a t-PA mediated scu-PA activation would explain the concomitant increase in both plasminogen activators.

Aprotinin↗
PubMed2004

Clopidogrel (Plavix) and cardiac surgical patients: implications for platelet function monitoring and postoperative bleeding.

The use of clopidogrel (Plavix), an inhibitor of adenosine diphosphate (ADP)-induced platelet aggregation, has been proven to reduce ischemic events in cardiovascular patients, but little information is available for optimal monitoring of platelet function in patients receiving the drug preoperatively. In the first part of the study we compared different testing modalities (thrombelastography (TEG), platelet aggregometry, and whole blood aggregation) to assess platelet ADP receptor inhibition. Because clopidogrel is a pro-drug, we used an in vitro model of ADP inhibition with 5'-p-fluorosulfonylbenzoyladenosine (FSBA). FSBA at final concentration of 80 microM completely inhibited platelet aggregation but had no effect on TEG maximum amplitude (MA). In the second part of the study, antiplatelet effects of clopidogrel were clinically assessed and correlated to postoperative bleeding in 18 coronary bypass surgery patients. Preoperative TEG results were normal or hypercoagulable in clopidogrel-treated patients, although platelet aggregation responses to ADP were inhibited. Clopidogrel-treated patients who underwent cardiopulmonary bypass had a high incidence (84.6%) of platelet transfusion therapy due to increased chest tube drainage. In conclusion, we have demonstrated that normal preoperative TEG-MA does not preclude clopidogrel-induced ADP receptor blockade; however, TEG can be a reliable monitor for CPB-induced platelet dysfunction related to GPIIb/IIIa. For monitoring clopidogrel, it is necessary to perform more specific platelet function tests (aggregometry or platelet count ratio) using ADP as an activator.

Adenosine↗
PubMed2006

Thromboelastography: potential bedside tool to assess the effects of antiplatelet therapy?

Modified thrombelastography (TEG) is a simple point of care test that provides an overall assessment of ex vivo clot formation and currently has limited clinical application. We evaluated the ability of TEG to assess the effects of antiplatelet therapy on clot formation using a novel assessment parameter (the area under curve). Forty healthy volunteers were divided into four groups of 10. Group A took aspirin 75 mg once daily for 7 days followed by aspirin 75 mg and clopidogrel 75 mg once daily in combination for 7 more days. Blood samples were taken for analysis at day 0 and days 7 and 14. Group B took a single 300 mg dose of aspirin. Group C took 600 mg of clopidogrel only. Group D took 300 mg of aspirin and 600 mg of clopidogrel at the same time. For groups B, C and D blood was taken prior to drug administration and at 2, 6 and 24 h afterwards. Each sample was tested by TEG in four channels following activation using (1) kaolin, (2) activator F (Act F), a direct activator of fibrin, (3) Act F + arachidonic acid (AA) and (4) Act F + adenosine diphosphate (ADP). Parameters measured included the maximum amplitude (MA) of the clot and the area under the TEG-generated curve at 1 h. Significant, time-dependent reductions in MA and area were seen in the AA-activated samples following administration of aspirin in all groups as compared to baseline. By contrast, there were no significant differences in MA or area in the AA-activated samples with clopidogrel alone. Significant reductions were also seen in MA and area in ADP-activated samples from volunteers treated with clopidogrel as compared to baseline. Three out of 10 subjects receiving 600 mg clopidogrel had a reduction in their responses of 30% or less, thus identifying them as relatively resistant to the drug. This study identifies a rapid, reliable method for assessing the time-dependent effects of antiplatelet therapy on clotting using a novel parameter of area of the TEG trace, which could have an important clinical application as a point of care test of efficacy, particularly in the context of acute coronary syndromes and percutaneous coronary intervention.

Adult↗
PubMed1994

Reversal of post-reperfusion coagulopathy by protamine sulphate in orthotopic liver transplantation.

We report details of two liver transplant procedures in which post-reperfusion coagulopathy was reversed by administration of protamine sulphate. Both procedures were uncomplicated until about 30 min after reperfusion of the graft, when the cut surfaces began to ooze blood. Failure of coagulation was confirmed by thrombelastography and in both cases routine coagulation tests revealed a prolonged kaolin cephalin clotting time (KCT). A heparin-like effect was suspected. Protamine sulphate 50 mg was given i.v., resulting in cessation of bleeding and normalization of the thrombelastogram and KCT.

Adult↗
PubMed1998

Reduced quality of clot formation with gelatin-based plasma substitutes.

We have studied, over a wide range of dilutions using techniques of clot weight, thrombelastography and scanning electron microscopy, the physical properties of a blood clot formed in vitro when fresh blood was diluted with gelatin-based colloid solutions compared with crystalloid controls. The colloid solutions tested (3.5% polygeline (Haemaccel) and 4% succinylated gelatin (Gelofusine)) produced clots that had reduced median weight (P < 0.001 and P = 0.018, respectively) and reduced mean shear modulus (P < 0.001) compared with crystalloid controls. Scanning electron microscopy showed that the fibrin formed a less extensive mesh in the presence of the gelatin-based colloids compared with crystalloid. Reduction in clot quality with gelatin-based colloids has not been noted previously and further work is needed to ascertain if this occurs in vivo as these solutions are used frequently in patients who require full haemostatic competence.

Blood Cells↗
PubMed1998

In vivo investigation into the effects of haemodilution with hydroxyethyl starch (200/0.5) and normal saline on coagulation.

We have investigated the effects of haemodilution with either saline or hydroxyethyl starch (200/0.5) (HES) on blood coagulation in healthy volunteers in vivo. Standard haematological tests (packed cell volume (PCV), platelets, prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen, antithrombin III, bleeding time and platelet aggregation), and thrombelastography (TEG) were performed before and after administration of either 0.9% saline 1000 ml or HES 1000 ml i.v. over a 30-min period. Dilution of PCV and platelet concentrations as a result of volume load were 9% in the saline group and 19% in the HES group. Reductions in fibrinogen (18.6% and 28.8%) and antithrombin III (25.5% and 37.8%) were significantly greater than could be explained by haemodilution alone in both groups. Indices of platelet aggregation were significantly enhanced by saline haemodilution, but not by HES, which inhibited epinephrine-induced aggregation and prolonged bleeding time. TEG in the saline group showed significantly shortened r and k times (24% and 26%, respectively), and increased alpha angle (24%) and maximum amplitude (MA, 6%). HES haemodilution decreased MA (11%) but did not affect other TEG variables. We conclude that haemodilution of normal blood exerted a procoagulant effect, possibly by enhancement of thrombin formation. Circulating concentrations of antithrombin III were depleted more than could be explained by haemodilution alone, leading to a hypercoagulable state. This effect was offset by an antiplatelet action of HES, which was not seen with saline. The mechanism is unknown.

Antithrombin III↗
PubMed2000

Anticoagulant-induced pseudothrombocytopenia in a patient presenting for coronary artery bypass grafting.

A 73-yr-old man with severe ischaemic heart disease presented for coronary artery bypass grafting. His preoperative platelet count, obtained from an ethylene diamine tetraacetic acid (EDTA) sampling bottle, was 61 x 10(9) litre-1, but he had no history of bleeding problems. Previous platelet counts demonstrated results ranging from 16 x 10(9) litre-1 to 254 x 10(9) litre-1 with variable degrees of in vitro platelet clumping. Preoperative thrombelastography reflected a normal coagulation profile. The laboratory findings and the absence of a history of haemorrhagic complications suggested a diagnosis of EDTA-dependent pseudothrombocytopenia. We present the perioperative implications of this in vitro phenomenon and methods of detecting the functional and numerical integrity of circulating platelets.

Aged↗
PubMed2002

Effects of a new modified, balanced hydroxyethyl starch preparation (Hextend) on measures of coagulation.

BACKGROUND: Hydroxyethyl starch (HES) may affect blood coagulation. We studied the effects of a modified, balanced, high-molecular weight [mean molecular weight (MW) 550 kDa], high-substituted [degree of substitution (DS) 0.7] HES preparation (Hextend) on coagulation in patients undergoing major abdominal surgery. METHODS: Patients were allocated randomly to receive Hextend) (n=21), lactated Ringer's solution (RL, n=21) or 6% HES with a low MW (130 kDa) and a low DS (0.4) (n=21). The infusion was started after induction of anaesthesia and continued until the second postoperative day to maintain central venous pressure between 8 and 12 mm Hg. Activated thrombelastography (TEG) was used to assess coagulation. Different activators were used (extrinsic and intrinsic activation of TEG) and aprotinin was added to assess hyperfibrinolytic activity (ApTEG). We measured onset of coagulation [coagulation time (CT=reaction time, r)], the kinetics of clot formation [clot formation time (CFT=coagulation time, k)] and maximum clot firmness (MCF=maximal amplitude, MA). Measurements were performed after induction of anaesthesia, at the end of surgery, 5 h after surgery and on the mornings of the first and second days after surgery. RESULTS: Significantly more HES 130/0.4 [2590 (SD 260) ml] than Hextend) [1970 (310) ml] was given. Blood loss was greatest in the Hextend) group and did not differ between RL- and HES 130/0.4-treated patients. Baseline TEG data were similar and within the normal range. CT and CFT were greater in the Hextend) group immediately after surgery, 5 h after surgery and on the first day than in the two other groups. ApTEG MCF also changed significantly in the Hextend) patients, indicating more pronounced fibrinolysis. Volume replacement using RL caused moderate hypercoagulability, shown by a decrease in CT. CONCLUSION: A modified, balanced high-molecular weight HES with a high degree of substitution (Hextend) adversely affected measures of coagulation in patients undergoing major abdominal surgery, whereas a preparation with a low MW and low DS affected these measures of haemostasis less. Large amounts of RL decreased the coagulation time.

Abdominal Neoplasms↗
PubMed2005

Effect of fibrinogen on reversal of dilutional coagulopathy: a porcine model.

BACKGROUND: This study was conducted to determine whether replacement of fibrinogen is useful in reversing dilutional coagulopathy following severe haemorrhage and administration of colloids. METHODS: In 14 anaesthetized pigs, approximately 65% of the estimated blood volume was withdrawn and replaced with the same amount of gelatin solution to achieve dilutional coagulopathy. Animals were randomized to receive either 250 mg kg(-1) fibrinogen (n=7) or normal saline (n=7). A standardized liver injury was then inflicted to induce uncontrolled haemorrhage. Modified thrombelastography and standard coagulation tests were performed at baseline, after blood withdrawal, after dilution, after injection of the study drugs, and on conclusion of the protocol. Further, electron microscopy imaging of the blood clots was performed and blood loss after liver injury was determined. RESULTS: Severely impaired haemostasis was observed after haemodilution with gelatin substitution. With administration of fibrinogen, clot firmness and dynamics of clot formation reached baseline values. Median blood loss following liver injury was significantly less (P=0.018) in the fibrinogen-treated animals (1100 ml; 800-1400 ml) than in the placebo group (2010 ml; 1800-2200 ml). CONCLUSIONS: Replacing 65% of the estimated blood volume with gelatin in swine resulted in dilutional coagulopathy; subsequent fibrinogen administration improved clot formation and reduced blood loss significantly.

Animals↗
PubMed2006

Efficacy of fibrinogen and prothrombin complex concentrate used to reverse dilutional coagulopathy--a porcine model.

BACKGROUND: This study was conducted to assess whether the combined administration of fibrinogen and prothrombin complex concentrate (PCC) enables the reversal of dilutional coagulopathy resulting from intended blood loss and fluid replacement, and whether this treatment reduces further blood loss and mortality. METHODS: In 20 anaesthetized pigs, approximately 65% of the estimated blood volume was withdrawn and replaced with the same amount of hydroxyethyl starch (6% HES 130/0.4) to mimic blood loss and to develop a dilutional coagulopathy. Pigs (randomized) received either fibrinogen (200 mg kg(-1)) and PCC (35 IU kg(-1)) (n=10), or placebo (n=10). Thereafter, a standard liver laceration was performed to induce uncontrolled haemorrhage. The subsequent blood loss and survival time were determined as primary outcome variables. Throughout the experiment serial blood samples were obtained to assess the competence of the haemostatic system using standard coagulation tests, modified Thrombelastograph measurements (ROTEM) and electron microscopy clot imaging. RESULTS: As compared with baseline, after haemodilution both groups showed statistically significant impairment of haemostasis as measured with standard coagulation tests and thrombelastography. These parameters significantly improved after administration of the study drugs while aPPT measurements remained unchanged. Blood loss after liver injury was significantly less in the treatment group as compared with placebo: 240 ml (50-830) vs 1800 ml (1500-2500) (P<0.0001). All treated animals survived, whereas 80% of the placebo group died (P<0.0001). CONCLUSION: During haemodilution, substitution of fibrinogen and PCC causes an enhancement of coagulation and final clot strength. This reversal of dilutional coagulopathy may reduce blood loss and mortality when large amounts of colloids are needed to maintain normovolaemia during huge blood losses.

Animals↗
PubMed1995

Quantification of thrombelastographic changes after blood component transfusion in patients with liver disease in the intensive care unit.

Thrombelastography (TEG) can be used to monitor hemostasis and guide transfusion therapy during orthotopic liver transplantation. However, data are limited regarding the type and quantity of blood components necessary for TEG-guided blood component transfusion in coagulopathic critically ill patients with liver disease. We evaluated changes in four thrombelastogram variables (reaction time, thrombin constant time, alpha angle, and maximum amplitude) in whole blood samples after 74 separate blood component transfusions in 60 critically ill patients with a coagulopathy and liver disease. Only platelets significantly improved TEG variables in patients who received a single type of blood component. Each unit of platelets decreased the reaction and thrombin constant time by 0.43 (P < 0.05) and 0.82 (P < 0.005) min, respectively, increased the alpha angle by 1.5 degrees (P < 0.005), and the maximum amplitude by 1.4 mm (P < 0.005). In patients who received multiple blood components, cryoprecipitate decreased the thrombin constant time by 0.56 min/U (P < 0.05), and each unit of platelets decreased the thrombin constant time by 0.39 min (P < 0.005), and increased the alpha angle and maximum amplitude by 0.63 degrees (P < 0.05) and 0.99 mm (P < 0.005), respectively. We conclude that platelet transfusions, alone or in combination with other blood components, are most effective for improving abnormal TEG variables in coagulopathic critically ill patients with liver disease.

Blood Coagulation Disorders↗
PubMed2001

The influence of intravascular volume therapy with a new hydroxyethyl starch preparation (6% HES 130/0.4) on coagulation in patients undergoing major abdominal surgery.

UNLABELLED: A new hydroxyethyl starch (HES) preparation with a mean molecular weight of 130,000 daltons and a degree of substitution of 0.4 shows favorable pharmacokinetic properties. We conducted a study of the influence of the new HES specification on coagulation and compared it with another colloidal intravascular volume replacement regimen using gelatin. According to a prospective, random sequence, 42 patients undergoing major abdominal surgery received either HES 130/0.4 (n = 21) or gelatin (n = 21) until the first postoperative day (POD) to keep central venous pressure between 10 and 14 mm Hg. From arterial blood samples, standard coagulation variables were measured, and modified thrombelastogram (TEG) measurements using different activators were performed. A total of 2830 +/- 350 mL of gelatin and 2430 +/- 310 mL of HES 130/0.4 were administered until the morning of the first POD. The use of allogeneic blood/blood products and standard coagulation variables did not differ significantly between the two groups. After induction of anesthesia, all TEG data for both groups were within normal range. Coagulation time and maximum clot firmness did not change significantly in any TEG measurements during the study period. The kinetics of clot formation (clot formation time) significantly increased immediately after surgery, but without showing significant group differences. On the morning of the first POD, the clot formation time returned to almost normal levels, except for aprotinin-activated TEG(R). We conclude that administration of moderate doses of the new HES 130/0.4 preparation in patients undergoing major abdominal surgery results in similar coagulation alterations as those after using an established gelatin-based volume-replacement regimen. IMPLICATIONS: We compared the effects of infusion of a new hydroxyethyl starch preparation (6% hydroxyethyl starch; mean molecular weight 130,000 daltons; degree of substitution 0.4) on coagulation with a gelatin-based intravascular volume replacement regimen in patients undergoing major abdominal surgery. After moderate doses of hydroxyethyl starch (2430 +/- 310 mL until the morning of the first postoperative day), coagulation monitoring, including modified thrombelastography, did not show impaired hemostasis.

Abdomen↗
PubMed1989

Intraoperative coagulation changes in children undergoing liver transplantation.

Intraoperative changes in blood coagulation were observed in eight children undergoing liver transplantation using a simplified coagulation profile (prothrombin time [PT], activated partial thromboplastin time [aPTT], and platelet count) and thrombelastography. Preoperatively, PT and aPTT were moderately prolonged (1.5 times control), and platelet count was greater than 100,000/mm3 in all patients but one (91,000/mm3). During the preanhepatic and anhepatic stages, PT, aPTT, reaction time, and coagulation time improved toward normal values, but platelet count and maximum amplitude did not change. Significant changes in coagulation occurred on reperfusion of the grafted liver: PT, aPTT, reaction time, and coagulation time were prolonged, and platelet count, maximum amplitude, and clot formation rate decreased. A heparin effect, which did not require treatment, was seen on reperfusion in four patients. Fibrinolysis occurred during the operation in five patients and was treated with Epsilon-aminocaproic acid (EACA) in one. Blood coagulation improved slowly, and values were close to baseline 90 min after reperfusion. In general, the coagulation changes seen in these children are similar to those in adults but less severe, possibly because of the preponderance of cholestatic disease in children compared with the more common hepatocellular disease in adults.

Aminocaproic Acid↗