Coagulation Status Of Patients Research Articles

Comparison of Standard and Global Coagulation Tests in Hemodialysis Patients

Background Chronic kidney disease (CKD) is associated with an increased tendency of bleeding and thrombosis. There are multiple factors that interact with each other to cause either in CKD patients. Conventional or standard coagulation tests (SCT) have several limitations. Global coagulation test (GCT), such as Sonoclot, gives a real-time detailed analysis of coagulation status. Materials and Methods This is a prospective observational cross-sectional study of 50 adult CKD stage 5D (dialysis) patients conducted from January 2020 to January 2022. Clinical details were noted and blood samples were taken for conventional and global coagulation tests prior to dialysis. Correlation between SCT and GCT as well as clinical hemostatic events was analyzed. Results Fifty patients were enrolled. Bleeding and thrombosis occurred in 7 and 5 patients, respectively. There was a significant correlation between some SCT and GCT parameters. None of the SCT parameter derangement was associated with any thrombotic episodes except increased fibrinogen level which was associated with thrombotic events. On the contrary, patients with hypocoagulability according to SCT actually had thrombotic events. Parameters of GCT, such as clot rate, time to peak, and platelet function were significantly associated with thrombotic episodes. Conclusion SCT and GCT parameters do not correlate with each other. SCT is not associated with clinically significant bleeding and thrombotic events. Some GCT parameters are associated with thrombotic events. GCT are real time and are better than SCT to reflect the coagulation status in patients on dialysis.

Clinical Practice Patterns for Transradial Coronary Artery Catheterisation in Australian and New Zealand: Mixed-Methods Survey and Interview Study

While there has been an increase in the use of the transradial approach when performing percutaneous coronary angiography and intervention, there is evidence of variations in international practice. Ensuring that operators' practices are supported by evidence is important to ensure optimal outcomes. Interventional cardiologists and advanced trainees completed a cross-sectional survey followed by semi-structured interviews to map current practices for transradial coronary artery procedures in Australia and New Zealand and explore factors that influence clinical decision-making around procedural practice. The right radial artery was the preferred access site (88%). Over a third (37%) of the participants indicated that they tested the hand circulation pre-procedure. Over a quarter of respondents (28.6%) reported that they would carry out transradial procedures regardless of the patient's coagulation status. Most participants (77.8%) described radial artery spasm in around 10% of transradial procedures performed. Only 62% of participants assessed for radial artery occlusion post-catheterisation. Interview data revealed four themes that guided clinical decision-making, namely (1) Decision-making based on research, (2) Using clinical experience, (3) Being led by their training, and (4) Individual patient factors. This study has demonstrated that despite clinical guidelines, substantial practice variation exists in transradial coronary artery catheterisation across Australia and New Zealand. The variation in practice and factors impacting clinical decision-making highlight a need for future strategies to optimise evidence translation and implementation across clinical settings.

Efficacy and Safety of Bortezomib or Thalidomide Combined with rhEPO in the Treatment of Multiple Myeloma

To explore the efficacy and safety of bortezomib or thalidomide combined with recombinant human erythropoietin (rhEPO) in the treatment of multiple myeloma (MM). A total of 80 patients with MM who were treated in the Second People's Hospital of Wuhu from January 2013 to December 2018 were selected as the research subjects, and they were divided into bortezomib group (n=40) and thalidomide group (n=40) by the simple randomization method. The bortezomib group received bortezomib regimen combined with rhEPO therapy, and the thalidomide group was given thalidomide regimen combined with rhEPO therapy, and all patients were treated for 3 courses with every 3 weeks as a course of treatment. The clinical efficacy after 3 courses of treatment, and tumor-related biochemical indicators [lactate dehydrogenase (LDH), β2-microglobulin (β2-MG), vascular endothelial growth factor (VEGF), apoptosis inhibitory protein Survivin], bone marrow-related indicators [serum M-protein, bone marrow plasma cells, hemoglobin (Hb)] and coagulation function indicators [activated partial thromboplastin time (APTT), prothrombin time (PT), plasminogen activator inhibitor (PAI), total circulating microparticles (TMPs)] before treatment and after 3 courses of treatment were compared between the two groups of patients. The occurrence of adverse reactions during the treatment in the two groups of patients was recorded. After 3 courses of treatment, the ORR rate of 92.5% in bortezomib group was higher than 90.0% in thalidomide group, but the difference was not statistically significant (P >0.05). The levels of LDH, β2-MG, VEGF, Survivin, serum M-protein, bone marrow plasma cells, APTT, PT, PAI and TMPs in the two groups after 3 courses of treatment were significantly lower or shorter than those before treatment, and the above indicators in bortezomib group were significantly lower or shorter than those in thalidomide group (P <0.05). After 3 courses of treatment, the expression level of Hb in the two groups was significantly higher than that before treatment, and the Hb level in bortezomib group was significantly higher than that in thalidomide group (P <0.05). During the treatment process, the incidence rates of adverse reactions in bortezomib group were significantly lower than those in thalidomide group (P <0.05). Thalidomide regimen or bortezomib regimen combined with rhEPO has similar clinical efficacy on MM, but bortezomib regimen combined with rhEPO is more prominent and safer on improving tumor-related biochemical indicators, bone marrow-related indicators and coagulation status in patients with MM.

Rotational Thromboelastometry: Enhancing Hemostasis Monitoring in Anesthesia

Rotational thromboelastometry (ROTEM) is a viscoelastic point-of-care coagulation test that measures the dynamics of clot formation and lysis in whole blood samples. A cylindrical shaft that oscillates while passing through a tiny amount of blood is used in the procedure. Blood exerts increasing pressure on the shaft as it thickens into a clot. We can track the strength of the forming clot over time by measuring this resistance. ROTEM® can provide valuable information about the coagulation status of patients who are at risk of bleeding or thrombosis in various peri-operative settings, such as trauma, obstetrics, cardiac surgery, liver transplantation, and major orthopedic and vascular surgeries. In addition, it can aid in the diagnosis and treatment of peri-operative coagulopathy, reduce unneeded transfusions, and enhance patient outcomes.

Precision medicine in hemostasis: a review of prothrombin complex concentrates and the role of viscoelastic tests in tailoring therapy

This review explores the role of precision medicine in the management of bleeding disorders and anticoagulation therapy, with a focus on the use of visco-elastic tests such as Thromboelastography (TEG) and Rotational Thromboelastometry (ROTEM). These tests provide real-time, dynamic insight into a patient's coagulation status, guiding the choice between three-factor prothrombin complex concentrate (PCC3) and four-factor PCC (PCC4), as well as the use of activated four-factor PCC (FEIBA). The specific ROTEM tests, INTEM and EXTEM, further enhance our understanding of the intrinsic and extrinsic coagulation pathways. Moreover, the use of tranexamic acid (TXA) and fibrinogen, guided by these visco-elastic tests, has shown promise in trauma patients. TXA has been associated with survival benefit when administered immediately or within 3 hours of injury. Fibrinogen, a key factor in clot formation, can be monitored and supplemented as needed to optimize hemostasis. In conclusion, the practice of precision medicine, with the aid of TEG and ROTEM, offers the potential to enhance the safety and efficacy of PCC therapy, TXA administration, and fibrinogen supplementation. These tools are invaluable in tailoring therapy to the specific needs of each patient, potentially optimizing patient outcomes and minimizing the risk of adverse events.

Coagulation management during liver transplantation: monitoring and decision making for hemostatic interventions.

Rebalanced hemostasis describes the precarious balance of procoagulant and antithrombotic proteins in patients with severe liver failure. This review is aimed to discuss currently available coagulation monitoring tests and pertinent decision-making process for plasma coagulation factor replacements during liver transplantation (LT). Contemporary viscoelastic coagulation monitoring systems have demonstrated advantages over conventional coagulation tests in assessing the patient's coagulation status and tailoring hemostatic interventions. There is increasing interest in the use of prothrombin complex and fibrinogen concentrates, but it remains to be proven if purified factor concentrates are more efficacious and safer than allogeneic hemostatic components. Furthermore, the decision to use antifibrinolytic therapy necessitates careful considerations given the risks of venous thromboembolism in severe liver failure. Perioperative hemostatic management and thromboprophylaxis for LT patients is likely to be more precise and patient-specific through a better understanding and monitoring of rebalanced coagulation. Further research is needed to refine the application of these tools and develop more standardized protocols for coagulation management in LT.

Preservation of the immunomodulatory effect of interval hypoxytherapy after coronavirus infection in the long-term period

The new coronavirus infection COVID-19, due to the complex pathogenesis of the disease, systemic impact on organs, the development of complications and persistent disorders after the infection, remains an important medical problem. Every year the number of patients with postcovid syndrome in need of timely and full rehabilitation is increasing. Recently, isolated work began to appear on the use of interval hypoxytherapy for the treatment of patients with coronavirus infection. The purpose of our study was to identify the long-term results of the effect of interval hypoxytherapy on the immunological and coagulation status of patients after suffering coronavirus infection COVID-19. 170 patients aged 45 to 59 years were examined after a moderate coronavirus infection before, after and three months after interval hypoxytherapy. The number of lymphocytes, immunoglobulins A, M, G, E and cytokines (IL-1β, IL-2, IL-4, IL-6, IL-8, IL-10, TNFα) in blood, blood D-dimer, prothrombin time, fibrinogen in blood, antithrombin III, C-reactive was determined protein and ferritin in the blood. The conducted studies revealed changes in immunological reactivity after the coronavirus infection COVID-19, requiring correction. Interval hypoxytherapy had an immunomodulatory effect and led to the normalization of the main immunological parameters, which remained three months after hypoxytherapy: there was a significant (p &lt; 0.05) increase in the number of CD3+T lymphocytes, CD4+T lymphocytes, CD8+T lymphocytes. The improvement in immune status was also evidenced by the normalization of the immunoregulatory index, an increase in the level of immunoglobulins A and G. The decrease in immunoglobulins E in the blood was an indicator of a decrease in the severity of sensitization of the body. The course of hypoxytherapy led to a decrease in the content of pro-inflammatory cytokines: IL-1β, IL-2, IL-6, IL-8, TNFα and an increase in anti-inflammatory cytokines: IL-4 and IL-10 in the blood, which indicated an attenuation of the inflammatory process in the lung tissue and in the body as a whole. Blood ferritin decreased 3 months after hypoxytherapy. As studies have shown, the effect of hypoxytherapy persists for three months after the course of treatment. Thus, interval hypoxytherapy can be recommended for the rehabilitation of patients after a moderate coronavirus infection. A repeated course of hypoxytherapy may be performed three months after the first course of hypoxytherapy.

Global observational survey verifying surgeon utilization of the Validated Intraoperative Bleeding (VIBe) scale for use in clinical practice

Based on US-FDA guidelines to create tools for development and evaluation of medical devices in non-clinical and clinical studies, the Validated Intraoperative Bleeding (VIBe) Scale was developed. The current investigation expands upon the earlier validation study with multi-specialty surgeons to further corroborate these findings and establish feasibility to implement VIBe SCALE into clinical practice and surveys degree of anticipated bleeding across common procedures in multiple surgical disciplines. Following online didactic VIBe SCALE training, participating surgeons graded bleeding in ten porcine model videos corresponding to the original validation study. Surgeon and practice information were collected along with percentage of hemostatic product utilization in surgical procedures, the top three surgical procedures performed in their specialty, together with self-reported percentage of bleeding per VIBe SCALE bleeding grade typically encountered in those procedures. Using a web-based interface, survey data were collected from 585 participating surgeons; 339 (58%) participants were from academic or university setting, 170 (29%) had >20 years of surgical experience, 217 (37%) performed 11-20 surgeries per month. Overall, 125 (21%) surgeons reported conducting up to 10% minimally invasive surgeries in their practice. Total, 334 (57%) participants considered patient's coagulation status while selecting intraoperative adjunctive hemostatic product, if required; majority (n=552 [94%]) considered bleeding intensity important when selecting a hemostatic product intraoperatively. Interobserver concordance for VIBe SCALE of 0.89 (perfect concordance=1.0) as a measure of reproducibility, was achieved. This survey strengthens the findings of the earlier validation study and provides human factors verification of the VIBe SCALE as a relevant tool to evaluate and assess bleeding severity across multiple surgical specialties, while demonstrating the useability in contemporary clinical practice and may facilitate hemostatic product choice.

Association between hypomagnesemia and coagulopathy in sepsis: a retrospective observational study

BackgroundHypomagnesemia reportedly has significant associations with poor clinical outcomes such as increased mortality and septic shock in patients with sepsis. Although the mechanism underlying these outcomes mostly remains unclear, some experimental data suggest that magnesium deficiency could potentiate coagulation activation in sepsis. However, in sepsis, the association between serum magnesium levels and coagulopathy, including disseminated intravascular coagulation (DIC), remains unknown. Thus, we aimed to investigate the relationship between serum magnesium levels and coagulation status and the association between hypomagnesemia and DIC in patients with sepsis.MethodsThis retrospective observational study was conducted at the intensive care unit (ICU) of a university hospital from June 2011 to December 2017. Patients older than 19 years who met the Sepsis-3 definition were included. We categorized patients into three groups according to their serum magnesium levels: hypomagnesemia (< 1.6 mg/dL), normal serum magnesium level (1.6–2.4 mg/dL), and hypermagnesemia (> 2.4 mg/dL). We investigated the association between serum magnesium levels and overt DIC at the time of ICU admission according to the criteria of the International Society on Thrombosis and Haemostasis.ResultsAmong 753 patients included in this study, 181 had DIC, 105 had hypomagnesemia, 552 had normal serum magnesium levels, and 96 had hypermagnesemia. Patients with hypomagnesemia had a more activated coagulation status indicated by lower platelet counts, lower fibrinogen levels, higher prothrombin time-international normalized ratios, higher thrombin-antithrombin complex, and more frequent DIC than those with normal serum magnesium levels and hypermagnesemia (DIC: 41.9% vs. 20.6% vs. 24.0%, P < 0.001). The coagulation status in patients with hypomagnesemia was more augmented toward suppressed fibrinolysis than that in patients with normal serum magnesium levels and hypermagnesemia. Multivariate logistic regression revealed that hypomagnesemia was independently associated with DIC (odds ratio, 1.69; 95% confidence interval, 1.00–2.84; P = 0.048) after adjusting for several confounding variables.ConclusionsPatients with hypomagnesemia had a significantly activated coagulation status and suppressed fibrinolysis. Hypomagnesemia was independently associated with DIC in patients with sepsis. Therefore, the treatment of hypomagnesemia may be a potential therapeutic strategy for the treatment of coagulopathy in sepsis.

Novel Coagulation Test Detects Anticoagulation Resistance and Is Associated With Thrombotic Events in Pediatric Patients Requiring Extracorporeal Membrane Oxygenation.

OBJECTIVES:Bivalirudin, an IV direct thrombin inhibitor, and unfractionated heparin (UFH) are frequently used anticoagulants in the pediatric critical care setting. An accurate, specific, point-of-care test to quantify and detect anticoagulation resistance is not currently available. This study evaluates the ability of a rapid (< 10 min), micro-volume (< 50 uL) coagulation test to detect and quantify the anticoagulation effect of bivalirudin and UFH using a functional, clot time endpoint in pediatric critical care patients.DESIGN:Single-site retrospective laboratory sample analysis and chart review.SETTING:A 105-bed pediatric and cardiac ICUs delivering extracorporeal membrane oxygenation.SUBJECTS:Forty-one citrated, frozen, biobanked plasma specimens comprising 21 with bivalirudin and 20 with UFH from 15 anticoagulated pediatric patients were analyzed. Thirteen patients were on extracorporeal membrane oxygenation, one had a submassive pulmonary embolism, and one was on a left ventricular assist device.INTERVENTIONS:None.MEASUREMENT AND MAIN RESULTS:A Clotting Time Score (CTS) was derived on each sample. The CTS detected patients that had developed a pathologic clotting event with 100% sensitivity and 82% specificity compared with prothrombin time with 25% sensitivity/76% specificity and activated partial thromboplastin time with 0% sensitivity/0% specificity. Additionally, the CTS detected subtherapeutic anticoagulation in response to UFH in patients that were clinically determined to be UFH resistant requiring alternative anticoagulation with bivalirudin.CONCLUSIONS:The CTS appears to be a clinically valuable indicator of coagulation status in patients treated with either UFH or bivalirudin. Results outside of the therapeutic range due to inadequate dosing or anticoagulation resistance appeared to be associated with clot formation. CTS testing may reduce the risk of anticoagulation-related complications via the rapid identification of patients at high risk for pathologic thrombotic events.

The Effect of Nanocurcumin Supplementation on Protein C, Partial Thromboplastin Time, Transforming Growth Factor-β1, and Simplified Acute Physiology Score II in Patients With Systemic Inflammatory Response Syndrome: A Randomized Clinical Trial

Systemic inflammatory response syndrome (SIRS) is a general inflammation that involves many patients’ organs in intensive care units and significantly affects the risk of morbidity and mortality. This study aimed to investigate the effect of nanocurcumin on protein C, partial thromboplastin time (PTT), transforming growth factor-β1 (TGF-β1), and simplified acute physiology score II (SAPS II) in patients with SIRS. In this randomized, clinical trial, 40 SIRS-positive patients were randomly assigned to the intervention group who received 160 mg/day of nanocurcumin and the control group that received routine treatment for 10 days. Before, the 5th and 10th days of the study, the SAPS II questionnaire was completed, and protein C, PTT, and TGF-β1 levels were measured. At the end of the study, the PTT levels in the intervention and control groups increased and decreased, respectively. However, the significant increase of protein C levels was shown only in the intervention group. SAPS II scores were also decreased significantly only in the intervention group. There was no significant difference in serum levels of TGF-β1 in both groups. According to the results of this study, supplementation with nanocurcumin can decrease the SAPS II and improve the coagulation status in patients with SIRS.

The Role of Thromboelastography in Heparin Therapy for COVID-19 Patients

The 2019 coronavirus disease (COVID-19)-associated coagulopathy one of the significant complications often found in hospitalized COVID-19 patients. A hypercoagulable and prothrombotic state characterize coagulopathy with an increased risk of thrombotic events. Abnormal coagulation tests could predict bleeding risk, thrombosis, and disease severity. In addition to increasing the D-dimer, prolonged prothrombin time has decreased survival and increased treatment requirements. Based on laboratory findings, it was reported that 70% of patients with COVID-19 had disseminated intravascular coagulation (DIC) and 30% had thrombosis. Approximately 8% of patients with COVID-19 have hemorrhagic complications, the most common one is gastrointestinal bleeding. Variations in hypercoagulability and bleeding occur in COVID-19 patients. Therefore, the anticoagulant drug should be considered to minimize bleeding risk. An anti-bleeding agent for bleeding complications should be considered for the potential increase of coagulopathy. Thromboelastography (TEG) is a tool that is used to analyze the characteristics of viscoelastic clots, platelet function, and fibrinolysis in whole blood, providing a complete picture of the patient's coagulation status. From various therapeutic guidelines for COVID-19 patients, heparin is used as an anticoagulant drug to prevent thrombosis in COVID-19 patients. Starting from prophylactic doses to therapeutic doses, heparin is used to prevent the severity of COVID-19 patient course. The effect of coagulation on COVID-19 patients varies from no impact to hypercoagulation in TEG results.

PO-694-08 DIFFERENCE IN CLOT KINETICS BETWEEN UNINTERRUPTED AND MINIMALLY-INTERRUPTED ORAL ANTICOAGULATION THERAPY WITH FACTOR XA INHIBITORS

Uninterrupted OAC is the peri-procedural antithrombotic strategy of choice in patients undergoing AF ablation to minimize the incidence of peri-ablation thromboembolic event. With NOACs, a minimally-interrupted strategy (i.e., holding 1 dose) is often employed, but the effects on the coagulation status of patients is unknown. To compare clot kinetics in patients under uninterrupted vs minimally-interrupted oral anticoagulation strategy. We compared the thromboelastographic (TEG) profile of 91 consecutive patients who underwent EP procedures on uninterrupted (n=59) or minimally-interrupted (n=32) factor Xa inhibitors (FXaI). Among other parameters, TEG allows to determine the speed of thrombin generation (reaction time, R), a key step of the enzymatic phase of thrombus formation (figure). See figure. Compared to those with uninterrupted FXaI, patients on a minimally interrupted strategy had shorter R times (6.4±0.9 min vs 7.1±1.5 min; mean Δ -0.7 min, 95% CI -0.1 to -1.2 min). When considering patients on uninterrupted apixaban (n=28), the difference in time between apixaban morning dose and blood testing predicted R times, each hour associated with a decrease in R of approximately 0.2 minutes (β = -0.2; p=0.0074). The rate of thrombin generation is slower in patients under uninterrupted FXaI compared to those following a minimally-interrupted strategy. For those on uninterrupted apixaban, the amount of time passed since the morning dose affects clot kinetics, with possible implications for peri-procedural thromboembolic events.

The Possibilities of Thromboelastography in Assessing Safety of Neuraxial Blocks in Gestational Thrombocytopenia (Clinical Study)

Gestational thrombocytopenia (GT) is the most common type of thrombocytopenia during pregnancy. Unlike other types of thrombocytopenia, it is not accompanied by dysfunction of the cellular component of hemostasis. Currently, a quantitative decrease in platelets in GT is a contraindication to neuraxial blockades (NAB), which significantly reduces the quality of care in childbirth.The aim of the study is to determine the possibility of safe use of neuraxial blockades in gestational thrombocytopenia. A retrospective prospective study involved 70 patients who were performed delivery, depending on obstetric indications, either conservatively or surgically. The patients were divided into two groups. The main group (group No. 1) included 35 patients with gestational thrombocytopenia. The comparison group (group No. 2) consisted of 35 patients with a platelet content above 150×109/l. A comparative intergroup analysis of indicators of a general blood test, coagulogram, thromboelastography with a test for functional fibrinogen before childbirth and 2 days after delivery. The change in platelet content and its effect on the coagulation status of patients during pregnancy were retrospectively analyzed. A comparative assessment of the volume of blood loss during childbirth and the early postpartum period and the risk of complications of neuraxial blockade in patients with and without gestational thrombocytopenia was carried out.It was found that during gestational thrombocytopenia in the perinatal period, there is no decrease in coagulation potential, assessed by the results of coagulography and thromboelastography at a platelet level above 49×109/l. The investigated indicators of hemostasis did not have significant intergroup differences during pregnancy and childbirth. In the group of patients with gestational thrombocytopenia, the volume of blood loss during labor and the postpartum period did not differ from the group without thrombocytopenia, regardless of the method of delivery. The median blood loss after vaginal delivery in group 1 was 225 ml, in group 2 – 250 ml, with abdominal delivery – 572 ml and 386 ml – respectively. In this study, no complications of neuraxial blockade were observed in any of the groups.The results obtained suggest that in patients with gestational thrombocytopenia, even with a significant decrease in platelet content, it is possible to perform neuraxial blockades during labor, taking into account the clinical picture and the absence of coagulation disorders confirmed by thromboelastography.

Changes in Coagulation Status in Patients with β-Thalassemia in Iraq

Background: The pathogenesis β-thalassemia is characterized by anemia resulting from reduced β-globin synthesis with low hemoglobin A (HbA) production and higher production of hemoglobin A2 (HbA2) and fetal hemoglobin (HbF). However, thromboembolic events have been recently identified in patients with β-thalassemia due to hypercoagulable state. Objectives: The aim of this study was to evaluate the levels of some coagulation markers in Iraqi patients with β-thalassemia major and β-thalassemia intermedia. Materials and Methods: The study included three groups. The first group included patients with β-thalassemia major (n = 39), the second group included patients with β-thalassemia intermedia (n = 11), and third group included 20 apparently healthy control subjects. Each of prothrombin time (PT), activated partial thromboplastin time (APTT), antithrombin III (ATIII), and thrombin-antithrombin III (TAT) complex were measured according to the standard protocols. Results: Both PT and APTT in β-thalassemia major and β-thalassemia intermedia were higher than that of the control group with a highly significant difference (P = 0.002), whereas no significant differences were observed between patients with β-thalassemia major and β-thalassemia intermedia. Mean ATIII level was highest in the control group followed by β-thalassemia intermedia and then by β-thalassemia major groups (P &lt; 0.001), whereas mean TAT complex was highest in thalassemia major group followed by β-thalassemia intermedia and then by control groups (P &lt; 0.001). Conclusions: Prolonged PT and APTT in patients with β-thalassemia together with the reduction in the level of anticoagulant factor (ATII) suggest a role for liver impairment; however, the significantly higher TAT complex is suggestive of ongoing activation of coagulation cascade in patients with β-thalassemia.

Epidural analgesia and abnormal coagulation in patients undergoing minimal invasive repair of pectus excavatum.

Background:Epidural analgesia (EA) is effective in patients undergoing minimal invasive repair of pectus excavatum (MIRPE) but is associated with major complications such as epidural hematomas. It is recommended to assess coagulation status in patients receiving anticoagulant therapy prior to EA, although no consensus exists in patients without a history of bleeding tendency or anticoagulant therapy. Thus, the aim of this paper was to assess 1) the prevalence of abnormal routine coagulation parameters, i.e., international normalized ratio (INR) and platelet count, and 2) the safety of EA in patients undergoing MIRPE.Methods:In this retrospective study, we identified 1,973 patients undergoing MIRPE at our center between 2001 and 2019. Complications related to EA were registered for all patients. Information on coagulation parameters was present in 929 patients. Patients with spontaneously elevated INR ≥1.5 were referred for assessment of coagulation factor VII in order to assess the cause of the elevated INR.Results:Of 929 patients with coagulation information available, 18 patients had spontaneously elevated INR ≥1.5 (1.9%). In patients with INR ≥1.5, 12 patients underwent further assessment of factor VII, with all patients having a slightly reduced factor VII close to the lower reference range. The majority of the 1,973 patients undergoing MIRPE received EA (99.6%) with very low complication rates (0.2%) and no incidence of epidural hematomas.Conclusion:In patients undergoing MIRPE, coagulation screening prior to EA should not be mandatory as it revealed no clinically relevant consequences. EA is safe with very low complication rates.

The use of blood components prior to bedside procedures

: A transition from liberal use of transfusions prior to invasive procedures to a thoughtful, restrictive approach to transfusion is underway. This shift is being driven by the publication of very large observational studies showing a very low incidence of bleeding complication from most common procedures (even in the presence of severe thrombocytopenia and abnormal tests of coagulation) in conjunction with an evidence-based 2019 guideline from the Society for Interventional Radiology recommending restrictive use of pre-procedure transfusion. Many common invasive procedures have a major bleeding risk well less than 1% with image-guided techniques. This is excellent for patient care, however prospective randomized trials of transfusion vs. no transfusion before invasive procedures are unattainable, given the studies would require an impracticable sample size due to low event rates and would expose the transfusion group to the harms of transfusion. Indeed, a recent pilot randomized trial not only found challenges with recruitment but high rates of transfusion complications suggesting that transfusion risks currently exceed bleeding risks. Utilization studies find approximately 25% of plasma and 10% of platelets are transfused to patients as prophylaxis for bleeding prevention prior to procedures. This suggests that adherence to restrictive practices could substantially reduce adverse reactions from transfusion, minimize blood product shortages, and minimize delays in procedures for transfusion. In addition to unnecessary transfusions, the unselected use of pre-procedure laboratory testing is unwarranted for all procedures. This testing is expensive, has a low positive predictive value for bleeding complications, and delays procedures unnecessarily. Numerous studies have also shown that the infusion of plasma for mildly elevated international normalized ratio (INR) test results (INR of 1.5–1.9) does not alter the INR and therefore is very unlikely to reduce the bleeding risk. Lastly, the INR does not predict the risk of bleeding and the coagulation status of patients with liver cirrhosis. Many large centers have successfully transitioned to a restrictive use of blood before procedures and published the safety of this approach. This review will provide the evidence to convince others to follow suit.

Coagulation status in patients with pulmonary embolism receiving long-term anticoagulant therapy

Aim. To study the blood coagulation status by various laboratory methods in patients after pulmonary embolism (PE) receiving long-term anticoagulant therapy.Material and methods. The blood of 23 patients with pulmonary embolism, who received long-term anticoagulant therapy, was studied. The study of coagulation profile, D-dimer, thrombodynamics, thromboelastography and thrombin generation test were carried out.Results. The thrombin generation test shows a significant increase in the time of its formation, while the maximum amount of thrombin formed is half that of the reference values. There is a slightly increased median fibrin clot growth rate in the thrombodynamics test — 30,4 gm/min with a normal coagulation rate of 20-29 gm/min. The result of thromboelastography also reflects the blood hypocoagulation, in terms of R, Angle a and CI.Conclusion. Integral methods for assessing the thrombotic readiness in combination with a routine coagulation panel demonstrate a complete picture of blood coagulation potential in patients after pulmonary embolism requiring long-term anticoagulant therapy.

Viscoelastic Monitoring in Liver Transplantation.

Cirrhosis and liver transplantation (LT) surgery are associated with substantial alterations to the patient's coagulation status. Accurate monitoring of these changes during LT can help manage bleeding proactively and potentially reduce transfusion requirements. Unlike conventional coagulation tests (CCTs), viscoelastic monitoring (VEM) can provide an accurate, real-time, point-of-care assessment of coagulation status during LT and hence has become an invaluable tool for anesthetists and intensive care physicians. However, it remains an enigmatic subject for transplantation surgeons who are more conversant with CCTs. This review discusses the principles of VEM, provides a primer to understanding and interpreting its output, and explains how it can be used to make real-world clinical decisions during LT.

The Role of Neutrophil-Lymphocyte Ratio (NLR), Platelet-Lymphocyte Ratio (PLR), and D-Dimer in Predicting the Outcome of Confirmed COVID-19 patients

Background: Cytokine storm or hyperinflammation condition in COVID-19 patients could result in fatal outcomes. Inflammation could also result in coagulation disorders. The Neutrophil-Lymphocyte Ratio (NLR) and Platelet-lymphocyte ratio (PLR) have been known as inflammation markers in several diseases. D-dimer value can be used to assess a patient's coagulation status. Further study on thromboinflammation biomarkers in COVID-19 patients is needed. Therefore, we conducted a study to assess the association between NLR, PLR, and d-dimer on the clinical outcome of confirmed COVID-19 patients at Persahabatan Central Hospital.Methods: Observational cohort retrospective analysis was conducted on 214 medical records of confirmed COVID-19 patients who meet the inclusion criteria in Persahabatan Central Hospital from March to July 2020.Results: The mean patient’s age in this study is 54.35 years, dominated by male patients (60.7%). Most of the patients had normal nutritional status (54.7%). The proportion of patients with comorbidities is 65.4%. The most common comorbid is hypertension, followed by diabetes mellitus. 76.1% of patients have severe-critically ill disease, followed by moderate (20.1%) and mild disease (3.7%) The length of hospitalization median were 12 days. Sixty patients (28%) have died during hospitalization. The median of initial value of NLR, PLR, and d-dimer is 5.75 (0.68–81.5), 243.5 (44.7–1607), and 1140 (190–141300) respectively. We found significant associations between NLR (p = 0.000), PLR (p=0.013) and d-dimer (p = 0.032) on clinical outcome. Conclusion: Initial value of NLR, PLR, and D-dimer of confirmed COVID-19 patients at Persahabatan Central Hospital were associated with clinical outcome.