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PubMed2000

Thoracic aorta occlusion-reperfusion decreases hemostasis as assessed by thromboelastography in rabbits.

UNLABELLED: Perioperative hemorrhage and thrombosis are serious complications associated with major vascular surgery. We hypothesized that thoracic aortic occlusion-reperfusion in rabbits would adversely affect hemostasis as assessed by thromboelastographic variables (reaction time, alpha angle and G [a measure of clot strength]). Isoflurane-anesthetized rabbits underwent either sham operation (n = 10) or 30 min of aortic occlusion followed by 90 min of reperfusion (n = 10). Blood samples (350 microL) were exposed to 10 microL of either 0.9% NaCl or cytochalasin D (a platelet inhibitor, 10 microM final concentration) and analyzed for 1 h by using thromboelastography after 30 min of postpreparation equilibration and at 30 and 90 min of reperfusion. Aortic occlusion-reperfusion resulted in a significant (P: < 0.05) increase in reaction time, decrease in alpha angle, and decrease in G at 30 and 90 min of reperfusion compared with the sham-operated group. The decrease in hemostatic function after aortic occlusion-reperfusion was observed to the same degree in samples with or without platelet inhibition. There were no significant differences in platelet concentration between the sham-operated and aortic occlusion-reperfusion groups. Aortic occlusion-reperfusion decreased hemostatic function in rabbits primarily by decreasing the coagulation factor-dependent, platelet-independent contribution to clotting. IMPLICATIONS: Thoracic aortic occlusion-reperfusion decreased hemostatic function in rabbits primarily by decreasing the coagulation factor-dependent, platelet-independent contribution to clotting. This decrease in hemostatic function may contribute to hemorrhagic complications associated with major vascular surgery.

Animals↗
PubMed2001

Nitric oxide decreases coagulation protein function in rabbits as assessed by thromboelastography.

Nitric oxide (NO) is administered via infusion of donors such as nitroglycerin or in inhaled form for treatment of ischemia and pulmonary hypertension, respectively. In rabbits, the NO donor, DETANONOate, decreases whole blood clotting function as assessed by thromboelastographic variables (R, reaction time; alpha, angle; and G, a measure of clot strength). I hypothesized that DETANONOate-derived NO would adversely affect coagulation protein and platelet function. Blood obtained from ear arteries of conscious rabbits (n = 8) anticoagulated with sodium citrate. The blood was then incubated with 0 or 10mM DETANONOate for 30 min. After incubation and recalcification, thromboelastography was performed for 60 min under four conditions: 1) 0mM DETANONOate, 2) 0mM DETANONOate with platelet inhibition with cytochalasin D, 3) 10mM DETANONOate, and 4) 10mM DETANONOate with platelet inhibition. DETANONOate significantly (P < 0.05) increased R and decreased alpha and G in samples with or without platelet inhibition, compared with samples not exposed to DETANONOate. Lastly, the percentage of total G (G(T)) attributable to platelet function (G(P)) was significantly more in the absence of DETANONOate (G(P) = 92.3% +/- 1.6%; mean +/- SD) than after exposure to DETANONOate (G(P) = 90.2% +/- 2.3%). DETANONOate-derived NO significantly decreased coagulation protein function and platelet function. Coagulation protein function may be similarly affected in clinical situations involving the administration of NO or NO donors.

Animals↗
PubMed1996

A thromboelastography study on the in vitro effects of L-arginine and L-NG-nitro arginine methyl ester on human whole blood coagulation and fibrinolysis.

The effects of L-arginine and L-NG-nitro arginine methyl ester (L-NAME) on human blood coagulation and fibrinolysis were studied in vitro using computerized thromboelastography and native whole blood. L-Arginine (8-80 microM) prolonged the split point (SP), reaction time (R) and biKoatugulierung time (K); and diminished the angle (alpha), maximum amplitude (MA) and TEG index. L-NAME (0.5-50 microM) shortened SP, R and K and increased alpha, MA and the TEG index in a concentration-dependent manner. Neither L-arginine nor L-NAME had any effect on clot lysis. SP and R indicated the initiation of fibrin-strand formation, therefore L-arginine delayed, while L-NAME promoted the processes leading to fibrin formation. K and alpha reflect the rate of clot formation and involve fibrin build-up and platelets. Thus, L-arginine inhibited and L-NAME enhanced the rate of clot formation. MA (clot strength) involves the integrity of fibrin strands and platelet aggregation, and again L-arginine was inhibitory, while L-NAME enhanced this interaction. The TEG index indicates the coagulability of the sample; L-arginine was anticoagulant while L-NAME had procoagulant effects. These results are consistent with the inhibitory effects of NO on platelet function and of the platelet-aggregating properties of NOS inhibitors. In addition, NO may play an inhibitory role in the process leading to fibrin formation and also on the interactions between platelets and fibrin. Such effects may be important when considering the clinical use of drugs that affect the NO-cGMP pathway.

Adult↗
PubMed2002

Effects of recombinant activated factor VII on coagulation measured by thromboelastography in liver transplantation.

Besides the conventional laboratory tests, thromboelastography (TEG) is used to monitor hemostasis during liver transplantation. A previous pilot study suggested a beneficial effect of recombinant activated factor VII (rFVIIa) on transfusion requirements in liver transplantation. In the present study, we assess the effects of rFVIIa on coagulation variables and TEG. In six study patients, the prothrombin time (PT), the activated partial thromboplastin time (aPTT) and TEG variables [reaction time (r), kinetic time (k), or clot formation time, alpha angle (alpha), and maximal amplitude (MA)] were recorded before and after the administration of a bolus of 80 microg/kg rFVIIa. These patients were compared with six controls who did not receive rFVIIa. In contrast with the control group, a significant shortening of PT (P = 0.028) and aPTT (P = 0.028), r (P = 0.046) and k (P = 0.043) values, and a significant incline of the alpha angle (P = 0.028) were noticed after injection of rFVIIa, whereas MA increased not significantly (P = 0.075). rFVIIa rapidly improved coagulation variables in liver transplant patients including PT and aPTT. Of the TEG variables, r, k and alpha angle significantly improved, and MA showed a trend to increase. These data suggest that rFVIIa not only influences the speed of clot formation, but also the physical properties of the clot, which cannot be detected by routine coagulation tests.

Adult↗
PubMed2004

Thromboelastography with citrated blood: comparability with native blood, stability of citrate storage and effect of repeated sampling.

Thromboelastography (TEG) with recalcified citrate blood is used as an alternative to native blood, but there is insufficient data regarding sample reliability and stability over time. Thus, TEG parameters of freshly drawn native blood were compared with those of recalcified citrated blood without celite in 10 healthy subjects, and the effect of repeated sampling over 240-min storage was evaluated. All TEG parameters following citrate storage remained stable between 30 min [clot formation time (k) = 7.2 +/- 0.6 min; maximum amplitude (ma) = 48.5 +/- 1.9 mm] and 2 h (k = 7.1 +/- 0.6 min; ma = 46.2 +/- 2.5 mm) after initial sampling, but were not comparable with native blood (k = 9.3 +/- 0.7 min; ma = 43.5 +/- 2.5 mm) at any time point. TEG parameters of repeatedly sampled citrated blood had a significant overall hypercoagulable trend throughout 4 h following sampling. In conclusion, in order to achieve reproducible results, citrated blood without celite may be utilized between 30 min and 2 h following sampling, but in normal subjects the TEG parameters following citrate storage are not comparable with native blood, possibly because of incomplete inhibition of the activation of the coagulation cascade. Thus, citrated blood can be used as a surrogate of native blood in assessing coagulation using TEG, but if repeated sampling is used the trend in hypercoagulability must be considered.

Anticoagulants↗
PubMed2004

Clotting parameters and thromboelastography in children with neuromuscular and idiopathic scoliosis undergoing posterior spinal fusion.

STUDY DESIGN: An unblinded comparison of laboratory values between patients with idiopathic and neuromuscular scoliosis. OBJECTIVES: To compare standard tests of coagulation and thromboelastography (TEG) parameters between two groups of patients undergoing posterior spinal fusion (PSF). SUMMARY OF BACKGROUND DATA: Children with neuromuscular scoliosis such as cerebral palsy have more intraoperative blood loss than children with idiopathic scoliosis during PSF. Various reasons suggested for this include nutritional deficiencies, altered tissue integrity, hepatic dysfunction, and use of antiepileptic medications that can cause poor hemostasis and altered coagulation. We have observed alterations in coagulation factor levels in patients with cerebral palsy due to spastic quadriplegia with moderate blood volume loss (25% estimated blood volume). METHODS: In a prospective analysis, we compared standard tests of coagulation (prothrombin time [PT], partial thromboplastin time [PTT], platelet count, fibrinogen levels) and TEG at baseline and at a blood loss of 15% estimated blood volume in patients with idiopathic scoliosis and cerebral palsy undergoing PSF. RESULTS: There were no differences between the groups in terms of gender distribution and age. There was a significant difference between the baseline PT and PTT values, although both groups were within laboratory norms. After 15% blood volume loss, there were differences seen in the PT, PTT, maximum amplitude on the TEG, ionized calcium, and serum magnesium levels (P < 0.05). CONCLUSIONS: Children with cerebral palsy undergoing PSF have increased bleeding that starts earlier in the procedure than it does for patients with idiopathic scoliosis undergoing PSF. We found that, even though children with spastic quadriplegia had baseline PT and PTT values within normal limits, they were significantly different when compared with normal patients.

Adolescent↗
PubMed2006

Global assessment of the coagulation status in type 2 diabetes mellitus using rotation thromboelastography.

Clinical and epidemiologic observations have led to the concept of a procoagulant state in type 2 diabetes. This study aimed to determine the coagulation status in type 2 diabetic patients using rotation thromboelastography (ROTEM), which measures the interactive dynamic coagulation process. For this purpose, 51 (30 women, 21 men) type 2 diabetic patients (mean age, 56.1 years) and 40 age-matched, sex-matched and body-mass-index-matched healthy individuals were enrolled. Twenty-seven of the diabetic group had diabetic vascular complications. ROTEM using different activators for the intrinsic and extrinsic systems of coagulation cascade (intrinsic TEM-INTEM, extrinsic TEM-EXTEM, FIBTEM) was used to measure the coagulation time (CT), clot formation time (CFT), alpha angle (alpha) and maximum clot firmness (MCF). No significant difference was found in the prothrombin time, partial thromboplastin time, thrombin time, fibrinogen and platelet count between the two groups. INTEM-CT and INTEM-CFT and EXTEM-MCF were significantly higher in the diabetic group compared with controls (P = 0.012, P = 0.007 and P = 0.029, respectively). INTEM alpha in the diabetic group was significantly lower than the controls (P = 0.001). All other parameters, including INTEM-MCF, EXTEM-CT, EXTEM-CFT, EXTEM-alpha, FIBTEM-CT, FIBTEM-CFT, FIBTEM-MCF and FIBTEM-alpha, were similar between the two groups. Taking into account these data, we conclude that there is subtle activation of the extrinsic pathway with a concomitant decrement in the intrinsic pathway of the coagulation cascade in type 2 diabetes. The exact underlying mechanisms leading to these changes, and their consequences with regard to diabetic complications, remain to be determined.

Blood Coagulation↗
PubMed2005

Thromboelastography measurements of whole blood from factor VIII-deficient mice supplemented with rFVIII.

The rotational thromboelastography (ROTEG) assay system allows the real-time analysis of clot formation (fibrin formation) in a whole-blood assay format. The ROTEG system provides significant advantages over the current plasma-based assay systems as it includes the important interactions between cellular and plasmatic coagulation factors. We have employed the ROTEG system to characterize clot formation dynamics in factor VIII- deficient mouse whole blood and examined the ability of recombinant FVIII (rFVIII) supplementation to restore the normal phenotype. The ability to generate a clear dose-response relationship by adding rFVIII to FVIII-deficient murine whole blood (FVIII-/-) demonstrates the feasibility of this approach. A dose-response from 1 U to 0.00001 U mL(-1) demonstrates the enhanced sensitivity of the ROTEG system. Further characterization of this experimental approach may provide a potential tool for comparing the activity of FVIII concentrates and/or evaluating FVIII mutants.

Animals↗
PubMed2006

Individualization of bypassing agent treatment for haemophilic patients with inhibitors utilizing thromboelastography.

The treatment of bleeding for haemophilic patients with inhibitors relies on the use of the bypassing agents, recombinant factor VIIa and factor eight inhibitor bypass activity (FEIBA). While both therapies are effective in the majority of bleeding episodes, there is a significant amount of interindividual variability when it comes to the response to therapy. As of yet, there is no reliable laboratory parameter that can predict the response to therapy in the same manner that factor VIII and factor IX levels predict response in non-inhibitor patients. Developing such a laboratory parameter is vital in order to maximize the clinical efficacy of these agents. Thromboelastography (TEG) is a device, which assesses clot formation over time in whole blood and has several characteristics which suggest it may be an effective way to monitor bypass agent therapy. We studied the ability of TEG to individualize the treatment regimens of three patients with high titre inhibitors assessing the response to recombinant factor VIIa, FEIBA, and when both were used sequentially. The TEG allowed for individualization of treatment for each of the three patients and resulted in more effective, convenient and less expensive treatment regimens. We thus believe that TEG is a promising device for monitoring of bypass agent therapy and should be studied further.

Factor VIII↗
PubMed2004

Thromboelastography used to assess coagulation during treatment with molecular adsorbent recirculating system.

Coagulopathy is a life-threatening complication of liver cirrhosis. We describe the effect of molecular adsorbent recirculating system (MARS), a cell-free dialysis technique, on the blood coagulation of cirrhotic patients. From February 2002 to July 2002, nine patients--five males (55.5%) and four females (44.4%), age 47-70 yr (median 56)--underwent 12 courses (4-7 sessions each) of MARS. Patients were treated for the following indications: six (66.6%) acute-on-chronic hepatic failure, three (33.3%) intractable pruritus. Platelet count, prothrombin time (PT), international standardized ratio and thromboelastography were measured before and after each MARS session. Coagulation factors II, V, VII, VIII, IX, X, XI, XII, XIII, von Willebrand, lupus anticoagulant, protein C, protein S, antithrombin III, plasminogen, alpha 2 antiplasmin, D-dimer, fibrin monomers, complement, and C(1) inactivator were measured before and at the end of each MARS treatment. We found a statistically significant difference (p < 0.05) in the platelet count, PT, all the thromboelastograph variables (reaction and constant time, alpha angle, and maximal amplitude), factor VIII, von Willebrand, and D-dimer, when measured before and after MARS. Previous reports have shown amelioration of blood coagulation following MARS treatments. However, we document that MARS induces coagulopathy through a platelet-mediated mechanism, whereby platelet may be mechanically destroyed during the passage of blood through the filters and lines. An alternative postulated mechanism is an immune-mediated platelet disruption - coagulopathy.

Aged↗
PubMed2004

The use of recalcified citrated whole blood -- a pragmatic approach for thromboelastography in children.

BACKGROUND: Thromboelastography (TEG) is an established way of monitoring the coagulation status of children and adults requiring blood products during surgery. Serial measurements are performed using a nearside machine and blood product prescription may be titrated against changes in TEG. There may also be useful applications when the patient is remote from the TEG machine but these are limited because TEG is usually performed on fresh native whole blood within 6 min of venepuncture. Citrated whole blood can be used for TEG if transport time is more than 6 min. We wished to establish whether TEG parameters for citrated whole blood were comparable with those of native whole blood in healthy children. METHODS: Blood was obtained from 14 healthy children undergoing minor surgical procedures, at the time of intravenous cannula insertion for anaesthesia. Each sample was divided: TEG was performed on part of the sample in its fresh native state at 6 min and second portion of the sample was citrated, kept at room temperature and TEG was performed at 30 min after recalcification. RESULTS: There was a significant difference in TEG parameters (r, k, alpha, MA and LY30) for fresh native whole blood and recalcified citrated whole blood (paired t-test). CONCLUSIONS: The normal range for fresh native whole blood TEG parameters is well established, which is routinely used in practice. There was a significant difference between TEG parameters for fresh native whole blood and citrated whole blood. We recommend that a specific normal range be established for citrated whole blood to enable it to be used in clinical practice.

Adolescent↗
PubMed2005

Validation of human recombinant tissue factor-activated thromboelastography on citrated whole blood from clinically healthy dogs.

BACKGROUND: Thromboelastography (TEG) is an analytical method that enables global assessment of hemostatic function in whole blood (WB) with evaluation of both plasma and cellular components of hemostasis. TEG has a largely unused potential in the diagnostic workup and monitoring of dogs with hemostatic disorders and it may be a valuable supplement to traditional coagulation parameters. OBJECTIVES: The objective of this study was to establish a clinically applicable reference interval for a TEG assay using recombinant human tissue factor (TF) as the activator on citrated WB from clinically healthy dogs and to evaluate the stability of citrated WB stored for 30 minutes (T30) and 120 minutes (T120) at room temperature (RT). Additionally, we evaluated the analytical variation in reaction time (R), clotting time (K), angle (alpha), and maximum amplitude (MA). METHODS: Blood was collected from 18 clinically healthy dogs. Duplicate TEG analyses with TF as the activator at a concentration of 1:50,000 were performed on canine citrated WB at T30 and T120. R, K, a, and MAwere analyzed. RESULTS: Mean TEG values at T30/T120 were R = 5.61/4.91 minutes, K = 4.20/3.34 minutes, alpha = 45.33/50.90 degrees , and MA = 47.96/50.19 mm. Significant differences in these values were observed after storage for T30 and T120 at RT, with a tendency towards hypercoagulability at T120. The mean coefficients of variation were low. CONCLUSIONS: Canine citrated WB can be used for TEG analysis with human recombinant TF as the activator when stored at RT for T30 or T120. At both time points, the analytical variation was low, suggesting that TEG analysis may be of value in evaluating dogs with hemostatic disorders. A fixed time point should be chosen for serial measurements.

Analysis of Variance↗
PubMed2000

Comparative in vitro efficacy of different platelet glycoprotein IIb/IIIa antagonists on platelet-mediated clot strength induced by tissue factor with use of thromboelastography: differentiation among glycoprotein IIb/IIIa antagonists.

In the present study, the in vitro efficacy of different platelet glycoprotein IIb/IIIa (GPIIb/IIIa) antagonists on platelet-fibrin-mediated clot strength under shear was compared with the antiaggregatory efficacy by using tissue factor (TF) thromboelastography (TEG). The ability of platelets to augment the elastic properties of blood clots under shear conditions was measured by computerized TEG under conditions of maximal platelet activation accelerated by recombinant TF. Under these conditions, platelets significantly enhance clot strength 8-fold (relative to platelet-free fibrin clots). This effect was inhibited to a different extent by various platelet GPIIb/IIIa receptor antagonists; this inhibition appears to be dependent on the transmission of platelet contractile force to fibrin via the GPIIb/IIIa receptors. The GPIIb/IIIa antagonists with high binding affinity for resting and activated platelets and slow platelet dissociation rates (class I) but not those with fast platelet dissociation rates (class II) demonstrated potent and comparable inhibition of platelet aggregation and TF-TEG clot strength. Platelet GPIIb/IIIa antagonists of class I, such as XV459 (free-acid form of roxifiban), DMP802, XV454, and c7E3, demonstrated comparable inhibitory dose responses of TF-TEG clot strength and platelet aggregation, with an IC(50) of 50 to 70 nmol/L. In contrast, platelet GPIIb/IIIa antagonists from class II, with comparable antiaggregatory efficacy, such as DMP728, YZ202 (free-acid form of orbofiban), YZ211 (free-acid form of sibrafiban), YZ751, and other antagonists, have a much lower efficacy in altering the strength of TF-mediated clot formation (IC(50) >1.0 micromol/L). These data suggest differential efficacy among different GPIIb/IIIa antagonists in inhibiting platelet-fibrin clot retraction despite of equivalent antiaggregatory potency.

Abciximab↗
PubMed2003

Value of thromboelastography in the assessment of platelet function.

Thromboelastography (TEG) is a useful measure of coagulation. Modified TEG (that is with the addition of a GP IIb/IIIa receptor antagonist) has been used to assess the contribution of the fibrinogen-platelet interaction to TEG parameters (in particular the maximum amplitude, MA). Modified TEG was compared with other investigations of platelet function to assess its sensitivity in both normal subjects and in patients with peripheral arterial disease (PAD), a condition associated with activated platelets. Blood was collected from eight healthy subjects and 12 PAD patients. Platelet function was measured by TEG, flow cytometry (using PAC-1, P-selectin, GP IIIa and GP Ib murine antibodies) and platelet aggregometry (spontaneous and ADP-induced) in the presence and absence of tirofiban (a GP IIb/IIIa receptor antagonist). TEG showed a statistically significant reduction in MA with tirofiban at 0.4 mg/L and an increase in k (kinetic time; which indicates how fast clot strength is increasing once clotting starts) at 0.2 and 0.4 mg/L of tirofiban in both healthy subjects and PAD patients. Flow cytometry showed a significant decrease in the PAC-1 binding index (at 0.2 mg/L). This finding was compatible with the significant reductions found in spontaneous and ADP-induced platelet aggregation. However, aggregometry and flow cytometry were more sensitive indicators of platelet inhibition than the TEG parameters. TEG does not provide a comprehensive or sensitive reflection of impaired platelet function. If TEG is used as an index of severely impaired platelet function, we recommend that the k parameter should be used as well as MA. TEG should be supplemented by other methods of platelet function assessment wherever possible.

Adenosine Diphosphate↗
PubMed2005

An in vitro evaluation of standard rotational thromboelastography in monitoring of effects of recombinant factor VIIa on coagulopathy induced by hydroxy ethyl starch.

BACKGROUND: Rotational thromboelastography (ROTEG) has been proposed as a monitoring tool that can be used to monitor treatment of hemophilia with recombinant factor VIIa (rFVIIa). In these studies special non-standard reagents were used as activators of the coagulation. The aim of this study was to evaluate if standard ROTEG analysis could be used for monitoring of effects of recombinant factor VIIa (rFVIIa) on Hydroxy Ethyl Starch-induced dilutional coagulopathy. METHODS: The study was performed in vitro on healthy volunteers. Prothrombin time (PT) and ROTEG analysis were performed after dilution with 33% hydroxy ethyl starch and also after addition of rFVIIa to the diluted blood. RESULTS: PT was impaired with INR changing from 0.9 before dilution to 1.2 after dilution while addition of rFVIIa to diluted blood lead to an overcorrection of the PT to an International Normalized Ratio (INR) value of 0.6 (p = 0.01). ROTEG activated with the contact activator ellagic acid was impaired by hemodilution (p = 0.01) while addition of rFVIIa had no further effects. ROTEG activated with tissue factor (TF) was also impaired by hemodilution (p = 0.01) while addition of rFVIIa lead to further impairment of the coagulation (p = 0.01). CONCLUSIONS: The parameters affected in the ROTEG analysis were Clot Formation Time and Amplitude after 15 minutes while the Clotting Time was unaffected. We believe these effects to be due to methodological problems when using standard activators of the coagulation in the ROTEG analysis in combination with rFVIIa.

Journal Article↗
PubMed2006

Thromboelastography detects inadequate response to abciximab therapy during stent-assisted cerebral aneurysm coil embolization complicated by stroke.

INTRODUCTION: Thromboembolic stroke is the most common severe complication following coil embolization of intracerebral aneurysms, with a 5% incidence of permanent deficits. Despite heparin anticoagulation, rescue therapy with the platelet glycoprotein IIb/IIIa receptor antagonist abciximab may be required. However, we describe a failure of abciximab rescue therapy and discuss the importance of monitoring the variable individual response to abciximab. CASE REPORTS: Two patients underwent stent-assisted cerebral aneurysm coil embolization complicated by thromboembolic stroke. In one patient, abciximab rescue therapy failed and was associated with a poor neurological outcome. Thromboelastography (TEG model 5000; Haemoscope, Skokie, IL) and platelet aggregometry suggested inadequate platelet inhibition, although other tests of platelet function suggested adequate inhibition. CONCLUSION: We describe a failure of regular-dose abciximab rescue therapy for thromboembolic stroke-complicating stent-assisted cerebral aneurysm coil embolization. The use of TEG to individualize abciximab dosing in this setting may improve patient outcome, as it tracks a pattern of coagulation consistent with the clinical picture.

Abciximab↗
PubMed2002

The effects of cardiopulmonary bypass with hollow fiber membrane oxygenator on blood clotting measured by thromboelastography.

In cardiac surgical patients we investigated the effects of cardiopulmonary bypass (CPB) with a hollow fiber membrane oxygenator on blood clotting measured by thromboelastography (TEG). We found only a minimal change in the strength of blood clot described either by the TEG parameter MA (maximum amplitude) or by the shear modulus G calculated from MA. After CPB there was also a significant tendency towards hypercoagulation as defined by shortened parameters R, K and increased a-angle. After comparison with published data obtained in cardiac surgical patients using a bubble oxygenator we conclude that currently used extracorporeal technology exerts a less negative influence on blood clotting than had been conceived previously.

Adult↗