Coagulation Tests In Patients Research Articles

Extremely elevated international normalized ratio in a patient using dabigatran etexilate: a case report

Background: We present the case of a patient who was administered dabigatran and showed an extremely elevated prothrombin time-international normalized ratio (PT-INR).Case report: A 79-year-old man was referred due to PT-INR 12.6. The patient was taking 110 mg of dabigatran twice daily in capsule form. On admission, blood urea nitrogen level was 23 mg/dL, creatinine was 1.51 mg/dL, and the estimated glomerular filtration rate was 44.8 mL/min/1.73 m2. Coagulation tests revealed PT 96.8 seconds, PT-INR 12.46, and activated partial thromboplastin time 125.5 seconds. Dabigatran was discontinued, PT-INR on the day after admission was 8.96. PT-INR recovered to 1.61 on the fourth day without any treatment.Conclusion: The PT-INR was not directly correlated with dabigatran activity. Regular monitoring of coagulation was not necessary in all patients taking dabigatran. However, it may be useful to regularly perform coagulation tests in patients with renal impairment or in those at a high risk of bleeding.

A243 THROMBOELASTOGRAPHY-GUIDED COAGULOPATHY CORRECTION IN CIRRHOTIC PATIENTS DECREASES BLOOD PRODUCT TRANSFUSION: A SYSTEMATIC REVIEW AND ANALYSIS

Abstract Background Patients with cirrhosis are a risk factor for coagulopathy and bleeding complications. Thromboelastography (TEG) guided therapy is available to rapidly assess and guide blood product transfusion in this population. Purpose This study aims to determine if TEG-guided therapy is able to decrease the administration of blood products and reduce adverse events such as bleeding and mortality compared to standard coagulation testing (SCT). Method We performed a systematic review and meta-analysis of literature in PubMed, EMBASE, and The Cochrane Library and pooled six randomized-controlled trials comparing thromboelastography versus standard coagulation testing in patients with cirrhosis. A total of six studies were pooled (n= 386). Primary outcomes were mean platelet transfusion units and fresh frozen plasma (FFP) transfusion units. Secondary outcomes were mortality and bleeding events. Result(s) Compared to SCT, there was a significant standard mean decrease in platelet (P<0.00001) and FFP (P<0.00001) administration compared to TEG perioperatively prior to a liver transplant. However, there was no significant difference in the pooled odds ratio between TEG and SCT in patients receiving both platelets and FFP (OR 1.40 [95% Cl 0.61-3.23, P=0.42]). Recurrent variceal bleeding was significantly reduced in the TEG group compared to SCT for platelet transfusion (OR 0.05 [95% Cl 0.01-0.20, P<0.0001]) or FFP transfusions (OR 0.18 [95% Cl 0.05-0.63, P=0.007]). With regards to the 5-day, 28-day, 42-day, and 90-day mortality, there was no significant difference between the pooled odds ratio between the TEG and SCT groups (OR 0.69 [95% Cl 0.47-1.02, P=0.06]). The 24-hour, 48-hour, 5-day, and 42-day rebleeding rates were significantly lower in TEG versus SCT groups (OR 0.50 [95% Cl 0.29-0.85, P = 0.01)]. Conclusion(s) The use of TEG-guided therapy favors a reduction in platelet and FFP transfusion compared to SCT in patients with cirrhosis. Additionally, TEG-guided therapy is able to improve patient care by reducing the rebleeding rate of patients with cirrhosis compared to SCT. However, this same effect was not seen for mortality. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

The importance of laboratory parameters in predicting the severity of coronavirus disease-19 cases

This literature review is aimed at exploring the significance of laboratory parameters in the follow-up of the coronavirus disease-19, which is the latest global biohazard for humanity. Laboratory parameters were classified under three main headings. These headings were hematological tests, inflammatory parameters and coagulation parameters. It has been determined that low lymphocyte count, which is one of the hematological tests, is a condition seen at every stage of the disease. High neutrophil counts are evident in worsening the course of the disease. The neutrophil/lymphocyte ratio increases with increasing disease severity. Low platelet levels may also be observed. It has been determined that high C-reactive protein (CRP) levels can be seen at every stage of the disease. In addition, as the prognosis of the illness worsened, C-reactive protein levels were found to increase more. Increased prothrombin time and high D-dimer values are evident in coagulation tests in patients with severe coronavirus disease-19. In addition, increased ferritin and procalcitonin levels are observed as the illness course worsens. As a result, lymphocytopenia and increased CRP levels come to the fore in the illness course. When the illness becomes more aggressive, prothrombin time, neutrophil/lymphocyte ratio, neutrophil count, D-dimer, ferritin and procalcitonin levels draw attention.

Associations of Thrombocytopenia, Transaminase Elevations, and Transfusion With Laboratory Coagulation Tests in Women With Preeclampsia: A Cross-sectional Study

(Int J Obstet Anesth. 2021;46:102972) Preeclampsia is associated with increased incidence of thrombocytopenia (TCP) and coagulopathy, causing concern about obstetric hemorrhage [postpartum hemorrhage (PPH)] and spinal-epidural hematoma with neuraxial procedures. In the absence of other contraindications, a patient with a platelet count >70×109/L and normal platelet function should be a candidate for a neuraxial procedure. Coagulation testing is not routine in preeclamptic women. Previous data and guidelines on the relationship between coagulation testing and risk of complications from neuraxial procedures are inconsistent. This study aimed to better understand the use of coagulation testing in patients with preeclampsia.

Investigation of the Molecular Mechanism of Coagulopathy in Severe and Critical Patients With COVID-19.

Coagulopathy is a frequently reported finding in the pathology of coronavirus disease 2019 (COVID-19); however, the molecular mechanism, the involved coagulation factors, and the role of regulatory proteins in homeostasis are not fully investigated. We explored the dynamic changes of nine coagulation tests in patients and controls to propose a molecular mechanism for COVID-19-associated coagulopathy. Coagulation tests including prothrombin time (PT), partial thromboplastin time (PTT), fibrinogen (FIB), lupus anticoagulant (LAC), proteins C and S, antithrombin III (ATIII), D-dimer, and fibrin degradation products (FDPs) were performed on plasma collected from 105 individuals (35 critical patients, 35 severe patients, and 35 healthy controls). There was a statically significant difference when the results of the critical (CRT) and/or severe (SVR) group for the following tests were compared to the control (CRL) group: PTCRT (15.014) and PTSVR (13.846) (PTCRL = 13.383, p < 0.001), PTTCRT (42.923) and PTTSVR (37.8) (PTTCRL = 36.494, p < 0.001), LACCRT (49.414) and LACSVR (47.046) (LACCRL = 40.763, p < 0.001), FIBCRT (537.66) and FIBSVR (480.29) (FIBCRL = 283.57, p < 0.001), ProCCRT (85.57%) and ProCSVR (99.34%) (ProCCRL = 94.31%, p = 0.04), ProSCRT (62.91%) and ProSSVR (65.06%) (ProSCRL = 75.03%, p < 0.001), D-dimer (p < 0.0001, χ 2 = 34.812), and FDP (p < 0.002, χ 2 = 15.205). No significant association was found in the ATIII results in groups (ATIIICRT = 95.71% and ATIIISVR = 99.63%; ATIIICRL = 98.74%, p = 0.321). D-dimer, FIB, PT, PTT, LAC, protein S, FDP, and protein C (ordered according to p-values) have significance in the prognosis of patients. Disruptions in homeostasis in protein C (and S), VIII/VIIIa and V/Va axes, probably play a role in COVID-19-associated coagulopathy.

Reflex factor coagulation testing in patients with an unexplained prolonged aPTT: An institutional retrospective review.

We aim to determine the clinical utility of reflex coagulation investigations (RCI) for prolonged lupus insensitive activated partial thromboplastin time (aPTT) at our institution. We retrospectively reviewed all potential RCI (lupus insensitive aPTT of ≥32s) from April 2014 to June 2019. Our diagnostic algorithm requires completion of RCI only if samples had no interfering medications to explain a prolonged aPTT and were either from a preoperative sample or from a patient presenting with unexplained bleeding. Appropriate RCI samples undergo further investigations with one-stage factor activity testing for factors 8(FVIII), 9(FIX), and 11(FXI) reflexively. Data were obtained through electronic medical records to capture clinical characteristics, laboratory findings, prophylactic hemostatic replacement, and bleeding outcomes. Three thousand and three hundreds seventeen samples from 2940 distinct patients were considered as potential RCI during the study period. 263/3317 (8%) samples had RCI completed. Of those, 55/263 (21%) had abnormal factor testing, with the majority from preoperative setting (43/55; 78%). 5/43 (12%) patients were referred to hematology for preoperative evaluation. 5/43 patients received preoperative hemostatic support. A total of 5 patients (5/43) developed postop bleeding. Six patients (6/55) had RCI for unexplained bleeding, and five patients (83%) had a newly identified clinically significant bleeding disorder. Reflex coagulation investigations benefited patients presenting with unexplained bleeding as this expedited the diagnosis and management of clinically significant bleeding disorders. RCI for preoperative evaluation infrequently led to additional hemostatic support/referral to hematology. The lack of additional workup for an abnormal factor activity level suggests laboratory alert fatigue as a potential contributory factor.

Rotational thromboelastometry and conventional coagulation tests in patients undergoing major cardiac or aortic surgery: a retrospective single-center cohort study

Algorithms for treatment of diffuse bleeding in cardiac surgery are based on intervention thresholds of coagulation tests, such as rotational thromboelastometry (ROTEM) or conventional laboratory tests. The relationship between these two approaches is unclear in patients with increased risk of coagulation abnormalities. We retrospectively analyzed the data of 248 patients undergoing major cardiac and/or aortic surgery. ROTEM and conventional laboratory tests were performed simultaneously after termination of cardiopulmonary bypass and protamine administration to investigate the extrinsic and intrinsic system, and to determine deficiencies in platelets and fibrinogen. We evaluated the association between ROTEM and conventional tests by linear regression analysis and compared the frequency of exceeding established thresholds for clinical intervention. Significant linear associations between ROTEM 10 min after the start of coagulation, and plasma fibrinogen concentration or platelet count (FIBTEM A10, R2 = 0.67, p < 0.001; EXTEM A10, R2 = 0.47, p < 0.001) were obtained. However, the 95% prediction intervals exceeded clinically useful ranges (92–233 mg/dL fibrinogen at the intervention threshold of FIBTEM A10 = 10 mm; 14 × 103–122 × 103/µL platelets at the intervention threshold of EXTEM A10 = 40 mm). The association between EXTEM and INR (R2 = 0.23), and INTEM and aPTT (R2 = 0.095) was poor. The frequency of exceeding intervention thresholds and, consequently, of triggering treatment, varied markedly between ROTEM and conventional tests (p < 0.001 for all comparisons). The predictability of conventional coagulation test results by ROTEM is limited, thus hampering the interchangeability of methods in clinical practice.

Complex analysis of coagulation tests in patients undergoing the combination of hemostatic and antithrombotic therapy following large joint arthroplasty

Aim. To assess the dynamics of coagulation parameters and the influence of its initial values on the development of postoperative thrombohemorrhagic complications in male and female patients undergoing large joint arthroplasty and received combination hemostatic and anticoagulant therapy.&#x0D; Methods. A retrospective analysis of the medical records (n=253) of patients with arthroplasty, were divided into two groups based on the time differences between prescription of hemostatic and anticoagulation therapy. The first group includes 145 patients (57.31%, 112 women and 33 men) with time differences 17 h, and the second group includes 108 patients (42.68%, 78 women and 30 men) with time differences 1824 h. The dynamics of coagulation test results were analyzed, and the influence of its initial value on the risk of postoperative thrombosis or bleeding was assessed.&#x0D; Results. Thrombohemorrhagic complications were recorded in 27 (10.67%) patients, of which 22 (81.48%) were observed in group 1. In the first group, thrombosis developed in regimens with tranexamic acid (p=0.038) with 2.2 times higher incidence than in group 2 (p=0.023). The risk of thrombosis of women in the group 1 was increased by an initially low level of international normalized ratio [relative risk (RR) 13.333, p=0.00032] and activated partial thromboplastin time (RR=5.8, p=0.037). The risk of bleeding in group 1 increased by an increasing preoperative level of activated partial thromboplastin time (RR=18, p=0.0012 and RR=28, p=0.00022, respectively) for all patients and by a decreasing fibrinogen level (RR=23.25, p=0.00065) and platelets count (RR=10.2, p=0.038) for women.&#x0D; Conclusion. To minimize the risks of thrombosis and bleeding after arthroplasty, especially in patients with initial deviations of hemostasis parameters from the norm, and, in particular, when using tranexamic acid as a hemostatic agent, it is recommended to observe the time interval between hemostatic and anticoagulant pharmacotherapy for at least 18 hours.

Whole-Blood Capillary Tube Clotting Time as a Possible Predictor of Hypertensive Disorders in Pregnancy

Background: Hypertensive disorders in pregnancy (HDP) are associated with coagulation abnormalities. However, results of standard coagulation tests in patients with HDP have been inconsistent. Aim: The aim of this study was to determine mean clotting time (CT) in subjects with HDP attending antenatal clinic at Murtala Muhammad specialist Hospital Kano, Nigeria and to assess CT as a possible predictor of HDP. Materials and Methods: Eighty-four HDP subjects and equal number of normotensive pregnant women were recruited for the study. Blood pressure was measured according to standard protocol. Urinalysis was performed using urine test strips (Medi-Test Combi 9®). Whole-blood CT was determined using capillary tube method. Hypertensive disorders in pregnancy were defined according to the report of National high blood pressure education program working group on high blood pressure in pregnancy. Data were analyzed using IBM SPSS version 23.0. Chi-square test of association and independent t test were used to determine association and difference between categorical and quantitative variables respectively. Pearson’s correlation was used to determine relationship between quantitative variables.

Hot topics in coagulation testing: Important considerations for testing children for bleeding/thrombotic disorders.

The accurate use and interpretation of diagnostic investigations are essential for safe and effective patient care. Appropriate application and interpretation of coagulation testing can be challenging, and many controversies exist relating to the standardization of testing procedures, the application of relevant tests to different patient populations and the interpretation of test results. We present a list of the most prominent controversies in coagulation testing and have selected three specific examples (age-appropriate reference ranges, therapeutic anticoagulation monitoring and tests of thrombin generation) for closer discussion, highlighting examples with a paediatric framework. We discuss the limitations of discrete age-partitioned reference intervals, given the established principle of developmental haemostasis; the difficulties in establishing normative data across different laboratories; important pre-analytical variables affecting coagulation testing; the challenges in interpreting APTT and anti-Xa assays for monitoring unfractionated heparin therapy in different clinical situations; and the limitations in interpreting tests of thrombin generation due to current available thrombin-specific substrates and the complicating factor of variable alpha2-macroglobulin levels. These controversies are demonstrated using paediatric examples, but raise important implications for coagulation testing in patients of all ages and highlight the pressing need for further research in these areas.

Diagnostic and predictive value of white blood cell count, erythrocyte sedimentation rate, and coagulation tests in patients with blunt head trauma

Introduction: Head trauma is the third leading cause of death and one of the most common causes of referral to the emergency department. Prognosis in these patients identifies individuals at higher risk and provides them with faster and more complete treatment, so it is of particular importance. The aim of this study is to evaluate the diagnostic and predictive value of white blood cell (WBC) count, erythrocyte sedimentation rate (ESR), and coagulation tests in the outcome of patients with blunt head trauma. Methods: In this retrospective study, 91 patients referred to the emergency department of Imam Reza hospital of Tabriz, with a complaint of DAI type of blunt head trauma, were enrolled in a complete and sequential study during the first six months of the year 2017. The patientswere divided into two groups according to good or poor prognosis and their association with leukocytosis status and other paraclinical factors at the baseline. Results: The final outcome in high consciousness group was 13.3% need for intubation,26.7% need for surgery, 50% improvement without complications, and 10% mortality. In the low consciousness group, 16.7% required intubation, 20.0% required surgery, 10% had no complications, and 53.3% experienced mortality. The significance level of the chi-squaretest was 0.001. Independent t test results showed that the WBC and ESR values in the lowconsciousness group were significantly higher than the high consciousness group. But the international normalized ratio (INR) in the high consciousness group was significantly higher than the low consciousness group (P&lt;0.05). Conclusion: There is a significant relationship between severity of injury and leukocytosis, ESRelevation, and related coagulopathy after major trauma.

Comparison of Thromboelastography and Conventional Coagulation Tests in Patients With Severe Liver Disease.

Objective:Thromboelastography (TEG) may provide rapid and clinically important coagulation information in acutely ill patients with chronic liver disease (CLD). Our objective was to describe the relationship between TEG and conventional coagulation tests (CCTs), which has not been previously explored in this population.Methods:In acutely ill patients with severe CLD (Child-Pugh score > 9, category C), we conducted a prospective observational study investigating coagulation assessment as measured by both CCTs and TEG. We used quantile regression to explore 30 associations between TEG parameters and corresponding CCTs. We compared TEG and CCT measures of coagulation initiation, clot formation, clot strength, and fibrinolysis.Results:We studied 34 patients on a total of 109 occasions. We observed inconsistent associations between TEG and CCT measures of coagulation initiation: TEG (citrated kaolin [CK] assay) standard reaction time and international normalized ratio: R 2 = 0.117 (P = .044). Conversely, there were strong and consistent associations between tests of clot formation: TEG (CK) kinetics time and fibrinogen: R 2 = 0.202 (P < .0001) and TEG (CK) α angle and fibrinogen 0.263 (P < .0001). We also observed strong associations between tests of clot strength, specifically TEG MA and conventional fibrinogen levels, across all TEG assays: MA (CK) and fibrinogen: R 2 = 0.485 (P < .0001). There were no associations between TEG and D-dimer levels.Conclusions:In acutely ill patients with CLD, there are strong and consistent associations between TEG measures of clot formation and clot strength and conventional fibrinogen levels. There are weak and/or inconsistent associations between TEG and all other conventional measures of coagulation.

Congenital structural and functional fibrinogen disorders: a primer for internists.

Congenital qualitative and quantitative fibrinogen disorders represent heterogeneous rare abnormalities caused by mutations in one of the 3 genes encoding individual fibrinogen polypeptide chains, located on chromosome 4q28. It is estimated that congenital fibrinogen disorder accounts for 8% of rare coagulation factor deficiencies. Most of congenital fibrinogen disorders are suspected in individuals with bleeding tendency or coincidentally discovered, for instance prior to surgery. Fibrinogen disorders could be also found in patients with thrombotic events, impaired wound healing, and recurrent spontaneous abortions. Afibrinogenemia manifests as mild to severe bleeding, while hypofibrinogenemia is often asymptomatic. Dysfibrinogenemia, a qualitative fibrinogen disorder, is associated with bleeding, thrombosis, or with no symptoms. Recent recommendations issued by the International Society on Thrombosis and Haemostasis in 2018 do not encourage routine evaluation of thrombin time or other coagulation tests in patients with suspected congenital fibrinogen disorders, highlighting the value of fibrinogen antigen measurement and genetic analysis, added to the key finding, that is, reduced fibrinogen concentration determined with a coagulometric assay. The current review summarizes practical issues in diagnostic workup and clinical management of patients with afibrinogenemia, hypofibrinogenemia, dysfibrinogenemia, and hypodysfibrinogenemia from a perspective of internists who may encounter patients with reduced fibrinogen concentration in everyday practice. Despite the fact that hematologists are in front line for the management of patients with bleeding tendency, internists should be aware of the clinical and laboratory findings in patients with inherited fibrinogen disorders including the risk of thromboembolism and management prior to invasive procedures.

Rotational thromboelastometry alongside conventional coagulation testing in patients with Crimean–Congo haemorrhagic fever: an observational cohort study

SummaryBackgroundData describing the coagulopathy of Crimean–Congo haemorrhagic fever are scarce. We did rotational thromboelastometry (ROTEM) and conventional coagulation testing in patients with Crimean–Congo haemorrhagic fever to increase our understanding of the coagulopathy of this infectious disease.MethodsWe did a prospective observational cohort study of adults aged 18 years and older and admitted to hospitals with PCR-confirmed Crimean–Congo haemorrhagic fever in Samsun and Tokat, Turkey. Demographic, clinical, and laboratory data were collected and blood samples for ROTEM analysis and coagulation testing were drawn at admission and during hospital admission and convalescence (up to 30 days after onset of illness). For the ROTEM analysis we recorded the following extrinsically activated ROTEM (EXTEM S) variables, with normal ranges indicated: clotting time (38–79 s), clot formation time (34–159 s), amplitude at 10 min after clotting time (43–65 mm), maximum clot firmness (50–72 mm), and maximum lysis (>15% at 1 h). The following fibrin-specific ROTEM (FIBTEM S) variables were also recorded: amplitude at 10 min after clotting time (normal range 7–23 mm) and maximum clot firmness (9–25 mm). Disease severity was assessed by Swanepoel criteria, severity grading score (SGS), and the severity scoring index (SSI), with mild disease defined as meeting no Swanepoel criteria, graded mild by SSI, and graded low risk by SGS.FindingsBetween May 27, 2015, and Aug 2, 2015, 65 patients with confirmed Crimean–Congo haemorrhagic fever were recruited and had blood taken at 110 time points. Most were male (40 [62%] of 65) with mild disease (49 [75%] of 65). Haemorrhage occurred in 13 (20%; 95% CI 11·1–31·8) of 65 patients and 23 (35%) of 65 received blood products (15 received fresh frozen plasma and eight received red blood cell concentrates), and 21 patients received platelet transfusions. At admission, the following EXTEM S variables differed significantly between mild cases and moderate to severe cases: median clotting time 56 s (range 42–81; IQR 48–64) versus 69 s (range 48–164; IQR 54–75; p=0·01); mean amplitude at 10 min after clotting time 45·1 mm (SD 7·0) versus 33·9 mm (SD 8·6; p<0·0001); median clot formation time 147 s (range 72–255; IQR 101–171) versus 197 s (range 98–418; IQR 156–296; p=0·006); and maximum clot firmness 54·4 mm (SD 7·2) versus 45·1 mm (SD 12·5; p=0·003). The EXTEM S variables were compared at different time points; maximum clot firmness (p=0·024) and amplitude at 10 min after clotting time (p=0·090) were lowest on days 4–6 of illness. We found no significant differences in FIBTEM variables between mild and moderate to severe cases (median amplitude at 10 min, 13 mm [range 8–20; IQR 11–15] vs 12 mm [range 6–25; IQR 10–15; p=0·68]; and median maximum clot firmness, 15 mm [range 9–60; IQR 13–21] vs 17 mm [range 7–39; IQR 13–23; p=0·21]); and no hyperfibrinolysis (maximum lysis >15%).InterpretationCoagulopathy of Crimean–Congo haemorrhagic fever is related to defects in clot development and stabilisation that are more marked in severe disease than in mild disease. The combination of normal and slightly deranged coagulation screens and FIBTEM results with the absence of hyperfibrinolysis suggests that the coagulopathy of Crimean–Congo haemorrhagic fever relates to platelet dysfunction.FundingWellcome Trust, UK Ministry of Defence, and National Institute for Health Research Health Protection Research Unit.

Coagulation Testing in Patients Taking Direct Oral Anticoagulants

Coagulation Testing in Patients Taking Direct Oral Anticoagulants

Rivaroxaban: One For All, All For One

For the past 10 years, the introduction of rivaroxaban in clinical practice has produced dramatic changes in lives of patients affected by thrombotic disorders. In this review, we discuss rivaroxaban’s pharmacokinetic properties, focusing on the issues of interactions with other drugs and on the appropriate clinical use of coagulation tests in patients treated with this drug. We also examine the many clinical scenarios in which rivaroxaban was tested. In particular, results of studies on venous thromboembolism (VTE) prevention in orthopaedic surgery, deep vein thrombosis (DVT) and pulmonary embolism (PE) acute and long-term treatment with a focus on cancer patients, stroke prevention in atrial fibrillation (AF) with a special mention for cardioversion and trans-catheter ablation and atherosclerotic cardiovascular disease are presented. Our objective is to provide a summary of the evidence in order for the physician to be able to critically apply this information to patients’ management in everyday clinical practice.

Choosing Wisely Canada-Top Five List in Hepatology: Official Position Statement of the Canadian Association for the Study of the Liver (CASL) and Choosing Wisely Canada (CWC)

Introduction and aim. The prevalence and incidence of chronic liver disease is increasing resulting, in substantial direct and indirect medical costs. Overuse of investigations, treatments and procedures contribute to rising health care costs and can expose patients to unnecessary harm and delay in receiving care. The Choosing Wisely Canada (CWC) campaign has encouraged professional societies to develop statements that are directly actionable by their members in an effort to promote higher-value health care that will lead to downstream effect on how other practitioners make decisions.Material and methods. The Canadian Association for the Study of the Liver (CASL) established its Choosing Wisely top five list of recommendations using the framework put forward by CWC. CASL convened a task force that developed a list of draft recommendations and shared this with CASL membership electronically with eventual ranking of the top five recommendations by consensus at Canadian Digestives Disease Week (CDDW) 2017. Following revisions, the CASL Executive Committee endorsed the final list, which was disseminated online by CWC (July 2017).Results. The top five recommendations physicians and patients should question include: 1) Don’t order serum ammonia to diagnose or manage hepatic encephalopathy (HE). 2) Don’t routinely transfuse fresh frozen plasma, vitamin K, or platelets to reverse abnormal tests of coagulation in patients with cirrhosis prior to abdominal paracentesis, endoscopic variceal band ligation, or any other minor invasive procedures. 3) Don’t order HFE genotyping based on serum ferritin values alone to diagnose hereditary hemochromatosis. 4) Don’t perform computed tomography (CT) or magnetic resonance imaging (MRI) routinely to monitor benign focal liver lesions. 5) Don’t repeat hepatitis C viral load testing in an individual who has established chronic infection, outside of anti-viral treatment.Conclusion. The Choosing Wisely recommendations will foster patient-physician discussions, reduce unnecessary treatment and testing, avert adverse effects from testing and treatment along with reducing medical expenditure in hepatology.

Correlation of early ROTEM parameters with conventional coagulation tests in patients with chronic liver disease undergoing liver transplant.

Background and Aims:Viscoelastic tests such as rotational thromboelastometry (ROTEM) provide a quick and holistic assessment of coagulation status to guide transfusion during liver transplant (LT). Conventional coagulation tests (CCTs) measure single parameters in isolation, and also the results are delayed hampering management of patients during surgery. We evaluated the correlation of early ROTEM-derived parameters with CCTs and also assessed the ability of ROTEM-derived parameters to predict thrombocytopaenia and hypofibrinogenaemia during LT in patients with end-stage liver disease (ESLD).Methods:This retrospective study was carried out in 100 patients with decompensated ESLD undergoing LT. Correlation between CCTs and ROTEM parameters was analyzed. Receiver operating characteristic curves with area under the curve were used to determine the cut-off values of A5 andA10 on EXTEM and FIBTEM.Results:The values of A5EXTEM and A10EXTEM highly correlated with fibrinogen levels and platelet count, whereas A5FIBTEM and A10FIBTEM correlated well with fibrinogen levels. A5EXTEM<21 mm and A10EXTEM<28 mm correlated with a platelet count <75,000 mm−3, whereas A5EXTEM<18 mm and A10EXTEM<25 mm correlated with a platelet count <50,000 mm−3. Fibrinogen levels <100 mg/dL better correlated with A5FIBTEM<5 mm, A10FIBTEM<6 mm, A5EXTEM<21 mm and A10EXTEM<30 mm.Conclusion:Early ROTEM parameters A5 and A10 of both EXTEM and FIBTEM had an excellent correlation with thrombocytopaenia and hypofibrinogenaemia and may potentially guide early transfusion of relevant blood products during LT.

An introduction to point-of-care testing in extracorporeal circulation and LVADs.

There is a delicate balance between bleeding and clotting in patients on circuits such as ventricular assist devices or extracorporeal membrane oxygenation. Traditional coagulation tests, prothrombin time, activated partial thromboplastin time, and anti-factor Xa levels, are used to monitor patients on these devices. However, turnaround times and inability to assess global hemostasis, including platelets and fibrinogen have contributed to a recognition that faster, accurate, and more informative coagulation tests are needed. Activated clotting time is used to monitor heparin in patients on circuits and has the advantages of being a near-patient point-of-care test. However, its utility is limited to heparin monitoring. Viscoelastic tests (thromboelastometry and thromboelastography) are global, whole-blood coagulation tests, and whole-blood platelet aggregometry evaluates platelet function. Ideally, these tests can ensure that patients are within the therapeutic range of their antithrombotic medications, identify patients at risk for hemorrhagic or thrombotic complications, and guide management of acute bleeding complications. This ideal is currently hampered by a lack of studies that delineate clear ranges that are clinically relevant. Future research is needed to better understand the optimal use of point-of-care coagulation testing in patients on extracorporeal circuits and ventricular assist devices.

Comparison of Rapid Centrifugation Technique with Conventional Centrifugation for Prothrombin Time (PT) and Activated Partial Thromboplastin Time (APTT) Testing.

Prothrombin Time (PT) and activated partial thromboplastin time (APTT) are frequently performed coagulation tests in patients with coagulation disorders especially in critical care areas and in monitoring patients on anticoagulation therapy. In coagulation testing, sample processing especially centrifugation is one of the most critical steps that affect turnaround time(TAT). This study was carried out over a period of 1year. Three hundred paired samples from patients sent for PT and APTT estimation were included. One sample was centrifuged in a regular bench top centrifuge at 1500g for 20min. The other sample was divided into two polypropylene aliquots and centrifuged in a microcentrifuge at 13000g for 3min. The plasma obtained from both methods was tested for PT and APTT using the automated method on STA Compact coagulometer (Stago) using commercial thromboplastin STAR-NeoplastineR C1 Plus and phospholipid (cephalin), STAR-C K PRESTR 5 respectively. Data were analyzed using descriptive statistics, Student t test, correlation coefficient and Bland-Altman plots. Mean PT, INR and APTT forboth centrifugation methods was comparable with no statistically significant difference (p > 0.05). PT, INR and APTT also showed good correlation (r > 0.98) when compared between the two methods of centrifugation. Bland-Altman comparison between rapid and conventional methods of centrifugation for PT, INR and APTT also showed acceptable agreement. Rapid centrifugation technique for routine coagulation testing can be used safely with a significant reduction in the TAT. This can benefit patients in critical care settings and those on outpatient oral anticoagulant therapy.