Coagulation Derangements Research Articles

Oral anticoagulation and clinical outcomes in COVID-19: An Italian multicenter experience

BackgroundSince the body of evidence addressing the coagulation derangements caused by Coronavirus disease (COVID-19) has been constantly growing, we investigated whether pre-hospitalization oral anticoagulation (OAC) or in-hospital heparin treatment could have a protective role among COVID-19 patients. MethodIn this cohort study, consecutive COVID-19 patients admitted to four different Italian Institutions were enrolled. Baseline demographic, clinical, laboratory, and radiological characteristics, as well as in-hospital treatment and outcomes were evaluated. The primary outcome was mortality. ResultsA total of 844 COVID-19 patients were enrolled as study cohort, n = 65 (7.7%) taking OACs prior to hospitalization. Regarding clinical outcomes, OAC patients developed acute hypoxemic respiratory failure (AHRF) more frequently than non-OAC patients as well as presenting a higher mortality rate (44.6% vs 19.8%, p < 0.001). At overall multivariate logistical regression, use of heparin (n = 394, 46.6%) was associated with a better chance of survival to hospital discharge (OR 0.60 [0.38–0.94], p < 0.001), in particular in patients with AHRF, with no association found with the use of OACs. In a sub-analysis, the highest mortality rate was found for AHRF patients when heparin was not administered. ConclusionIn our cohort, OACs appeared to be ineffective in reducing mortality rate, while heparin resulted to be a useful treatment when lung disease was sufficiently severe, potentially suggesting a crucial role of microthrombosis in severe COVID-19. Due to the relatively small number of COVID-19 patients treated with OACs included in our analysis and their higher number of comorbidities, larger studies are needed in order to confirm our findings.

Predicting Disease Severity and Outcome in COVID-19 Patients: A Review of Multiple Biomarkers.

An abundance of clinical reports focused on specific laboratory parameters have been reported on coronavirus disease 19 (COVID-19), but a systematic analysis synthesizing these findings has not been performed. To review and summarize the current available literature on the predictive role of various biomarkers in COVID-19 patients. A literature search was performed using databases including PubMed, medRxiv, and bioRxiv. A total of 72 papers were reviewed, including 54 peer-reviewed papers and 18 non-peer-reviewed preprints. Although the markers are considered nonspecific, acute-phase reactants, including C-reactive protein (CRP), ferritin, serum amyloid A (SAA), and procalcitonin, were reported as sensitive markers of acute COVID-19 disease. Significantly elevated white blood cell count; marked lymphopenia; decreased CD3, CD4, or CD8 T-lymphocyte counts; high neutrophil count; thrombocytopenia; and markedly elevated inflammatory biomarkers were associated with severe disease and the risk of developing sepsis with rapid progression. Trends observed by serial laboratory measurements during hospitalization, including progressive decrease of lymphocyte count, thrombocytopenia, elevated CRP, procalcitonin, increased liver enzymes, decreased renal function, and coagulation derangements, were more common in critically ill patient groups and associated with a high incidence of clinical complications. Elevated interleukin 6 level and markedly increased SAA were most often reported in severely and critically ill patients. Indicators of systemic inflammation, such as neutrophil to lymphocyte ratio, systemic immune-inflammation index, or COVID-19 Severity Score, may be used to predict disease severity, outcome, and mortality. Interpretation of the data reported in the studies reviewed here is limited because of the study design (mostly retrospective), limited sample size, and a lack of defined clinical criteria.

Characterizing Early Inpatient Death After Trauma

BackgroundThere is a paucity of data to predict early death or futility after trauma. The objective of this study was to characterize the laboratory values, blood product administration, and hospital disposition for patients with trauma who died within 72 h of admission. MethodsAll deaths within 72 h of admission over a 5-y period at a level I trauma center were reviewed. Blood transfusion within the first 4 h of arrival and patient disposition from the emergency department to the operating room (OR), surgical intensive care unit, or the neuroscience intensive care unit (NSICU) were analyzed. Kaplan-Meier curves were generated to determine time to death. ResultsA total of 622 subjects were identified; 39.5% died in the emergency department, 10.6% went directly to the OR, 13.6% were admitted to the surgical intensive care unit, and 29.7% admitted to the NSICU. Of these subjects, 201 (32.2%) patients received blood within the first 4 h. By 24 h, early blood transfusion was associated with more rapid death for patients who were admitted to the NSICU (80% versus 60% mortality, P = 0.01) but not for patients taken directly to the OR (80% versus 70% mortality, P = 0.2). Admission coagulopathy by international normalized ratio (P < 0.01), but not anemia (P = 0.64) or acidosis (P = 0.45), correlated with a shorter time to death. In contrast, laboratory values obtained at 4 h after admission did not correlate with time to death. ConclusionsOur data demonstrate that admission coagulation derangement and need for early blood product transfusion are the two factors most associated with early death after injury, particularly in those patients with traumatic brain injury. These data will help construct future models for futility of continued care in patients with trauma.

Case Report: Management of Pit Viper Envenoming without Antivenom: A Case Series.

Pit viper envenoming is common in the hilly and the Himalayan regions of Nepal. Antivenom present in Nepal is unlikely to neutralize the venom of these pit vipers, although it has been used often by the healthcare providers in the clinical practice. Here, we report 15 cases of snakebite with a deranged coagulation profile. All patients recovered from envenoming on conservative management and without the administration of antivenom.

COAGULATION PROFILE IN CASES OF SNAKE BITES.

Introduction Snake bite is an important occupational and rural hazard because India had always been a land of Exotic snakes. India is inhabited by more than 60 species of venomous snakes. Objectives 1) To study the coagulation profile in cases of snake bites. 2) To study different clinical manifestation in cases of snake bites. 3) To correlate severity of clinical findings with the results of coagulation profile. Methods- The current studyis a two year cross sectional study, study includes snake bite coming to tertiary care hospital during the period two years. A written informed assent was taken from all the cases remembered for the examination for the treatment, investigations and research purpose. Results- In the current study, during the period of two years, a total 165 study subjects, 91 (55.2%) patients had vasculotoxic bite, Mean age in the current investigation was 34.7 years. The male to female proportion in the current study was 1.6:1. Farmers were affected more with 111 (70.2%) Majority of the cases were admitted within 6 hours of snake bite comprising of 85 (53.8%) cases.Local pain was symptom observed in 133 (84.2%) cases followed by swelling at the site of bite which comprised of 127 (80.4%) cases. The most common presentation of envenomation seen in 60 (65.9%) cases, 20 minute whole blood clotting test (WBCT) in 53 (58.2%) vasculotoxicstudy subjects. APTT was increased in 67 (73.6%) out of 91 vasculotoxic snake bite ases. Bleeding time was increased in 13 (14. 28%) out of 91 vasculotoxicstudy subjects. Thrombocytopenia was seen in 26 (28.6%) out of 91 vasculotoxicstudy subjects. Acute renal failure developed in 11 out of16 cases. Thus, clinical severity is well correlated with the deranged coagulation profile and increased hospital stay. There was no mortality reported in our study. Conclusions Coagulation tests should be routinely performed on all patients presenting to the emergency department with complaints of snake bite, as early detection of coagulopathy reduces the morbidity and prevents the mortality in vasculotoxicstudy subjects.

Pathophysiology of the Venous Thromboembolism Risk in Preeclampsia.

Preeclampsia complicates up to 8% of pregnancies and is a leading cause of fetomaternal morbidity andmortality. Treatment options are limited, with supportive care and delivery of the placenta representing the cornerstone of current management strategies. Derangements in blood coagulation are wellrecognised in this disorder and appear to favour an increased risk of venous thromboembolism among affected women. This risk appears to be most significant in the postpartum period. The mechanisms underlying this increased thrombosis risk remain to be fully elucidated although increased expression of procoagulant factors, endothelial dysfunction, attenuation of endogenous anticoagulant activity and increased platelet activity have been implicated in the prothrombotic tendency. Preeclampsia is also occasionally complicated by life-threatening haemorrhagic events and current evidence suggests that in some severe manifestations of this disease a coagulopathy with a clinical bleeding tendency may be the predominant haemostatic abnormality. Identifying affected women at significant risk of thrombosis and managing the competing thrombotic and haemorrhagic risks continue to be a significant clinical challenge. Derangements in blood coagulation are also implicated in the pathogenesis of preeclampsia; however, the role of antiplatelet or anticoagulant drugs in the prevention and treatment of this disorder remains a source of considerable debate. In addition, the potential role of specific haemostatic markers as diagnostic or screening tools for preeclampsia has also yet to be determined. Further characterisation of the underlying molecular mechanisms would likely be of major translational relevance and could provide insights into the pathogenesis of this disease as well as the associated haemostatic dysfunction.

Thromboelastometry Variables in Neonates with Perinatal Hypoxia.

Perinatal hypoxia is associated with an increased risk of coagulation disorders by enhancing the consumption of platelets and some clotting factors due to the associated severe hypoxemia, acidemia, and compromised oxygen and blood supply to the neonatal liver and bone marrow. Thromboelastometry (TEM), which estimates the dynamics of blood coagulation, may represent an attractive tool for studying the coagulation status of these neonates. We aimed at assessing the hemostatic profile of neonates with perinatal hypoxia using the standard extrinsically activated TEM (ex-TEM) assay. In total, 164 hospitalized neonates with perinatal asphyxia and/or fetal distress comprised the study subjects, and 273 healthy neonates served as controls. Ex-TEM assay was performed, SNAPPE (Score for Neonatal Acute Physiology Perinatal Extension) was calculated, and clinical findings and laboratory results were recorded in all study subjects. Hypoxic neonates expressed a prolonged clotting time (CT) and clot formation time (CFT) and reduced amplitude at 10 minutes (A10), α-angle, and maximum clot firmness compared with healthy neonates. Furthermore, asphyxiated neonates had a significantly prolonged CT and CFT and reduced A10 and α-angle compared with neonates with fetal distress. Hypoxic neonates demonstrate a hypocoagulable ex-TEM profile relative to healthy neonates, indicating a potential role of TEM in the early detection of coagulation derangement in perinatal hypoxia.

Management of Multi Organ Dysfunction in Neonatal Encephalopathy.

Neonatal Encephalopathy (NE) describes neonates with disturbed neurological function in the first post-natal days of life. NE is an overall term that does not specify the etiology of the encephalopathy although it often involves hypoxia-ischaemia. In NE, although neurological dysfunction is part of the injury and is most predictive of long-term outcome, these infants may also have multiorgan injury and compromise, which further contribute to neurological impairment and long-term morbidities. Therapeutic hypothermia (TH) is the standard of care for moderate to severe NE. Infants with NE may have co-existing immune, respiratory, endocrine, renal, hepatic, and cardiac dysfunction that require individualized management and can be impacted by TH. Non-neurological organ dysfunction not only has a negative effect on long term outcome but may also influence the efficacy of treatments in the acute phase. Post resuscitative care involves stabilization and decisions regarding TH and management of multi-organ dysfunction. This management includes detailed neurological assessment, cardio-respiratory stabilization, glycaemic and fluid control, sepsis evaluation and antibiotics, seizure identification, and monitoring and responding to biochemical and coagulation derangements. The emergence of new biomarkers of specific organ injury may have predictive value and improve the definition of organ injury and prognosis. Further evidence-based research is needed to optimize management of NE, prevent further organ dysfunction and reduce neurodevelopmental impairment.

Commentary on: Comparison of three transfusion protocols prior to central venous catheterization in patients with cirrhosis: A randomized controlled trial

Commentary on: Comparison of three transfusion protocols prior to central venous catheterization in patients with cirrhosis: A randomized controlled trial

The Developing Balance of Thrombosis and Hemorrhage in Pediatric Surgery: Clinical Implications of Age-Related Changes in Hemostasis.

Bleeding and thrombosis in critically ill infants and children is a vexing clinical problem. Despite the relatively low incidence of bleeding and thrombosis in the overall pediatric population relative to adults, these critically ill children face unique challenges to hemostasis due to extreme physiologic derangements, exposure of blood to foreign surfaces and membranes, and major vascular endothelial injury or disruption. Caring for pediatric patients on extracorporeal support, recovering from solid organ transplant or invasive surgery, and after major trauma is often complicated by major bleeding or clotting events. As our ability to care for the youngest and sickest of these children increases, the gaps in our understanding of the clinical implications of developmental hemostasis have become increasingly important. We review the current understanding of the development and function of the hemostatic system, including the complex and overlapping interactions of coagulation proteins, platelets, fibrinolysis, and immune mediators from the neonatal period through early childhood and to young adulthood. We then examine scenarios in which our ability to effectively measure and treat coagulation derangements in pediatric patients is limited. In these clinical situations, adult therapies are often extrapolated for use in children without taking age-related differences in pediatric hemostasis into account, leaving clinicians confused and impacting patient outcomes. We discuss the limitations of current coagulation testing in pediatric patients before turning to emerging ideas in the measurement and management of pediatric bleeding and thrombosis. Finally, we highlight opportunities for future research which take into account this developing balance of bleeding and thrombosis in our youngest patients.

An audit of the use of blood components in acute systemic infections and its correlation with clinical outcome

Blood components, especially plasma, are excellent volume expanders but increased osmotic loads draw volume into the intravascular space resulting in volume overload, particularly in patients with cardiac and renal insufficiency. In addition, allogeneic blood transfusion exposes the recipient to large amounts of alloantigen which can create a variety of immunological responses including allo-immunisation and down regulation of immune response. All children between the age of 1 year to 15 years admitted to PICU at our teaching Hospital over a 24 month period with acute systemic infections were evaluated. In our study, of the total of 178 cases, seventy two cases (40%) received fresh frozen plasma for deranged coagulation profile which was considered as an appropriate indication. Eighty two cases (46%) received fresh frozen plasma for hypotension and thirty one cases (17%) for low serum albumin which were both considered as inappropriate indications.Clinical outcome in these two groups of patients showed that there was no significant difference in duration of hospital stay. There was an increase incidence of mortality in children who received FFP for inappropriate indications, though it was not statistically significant (P=0.375). It was also noted that a statistically significant increase in morbidity in the form of increased requirement of ventilatory support for the inappropriately transfused group (P=0.008) was seen in our study.

Lupus anticoagulant- hypoprothrombinemia syndrome detected in a patient with systemic lupus erythematosus with lupus nephritis

Systemic lupus erythematosus is well known to cause renal and haematological manifestations. Here we present a young female presenting with nephrotic syndrome fulfilling criteria for systemic lupus erythematosus found to have lupus anticoagulant hypoprothrombinemia syndrome on the evaluation for deranged coagulation profile. Prompt immunosuppressive therapy resulted in both renal and haematological resolution.

Coagulation abnormalities in dengue and dengue haemorrhagic fever patients.

The aim of this study was to assess abnormality of coagulation and anticoagulation parameters in dengue fever patients and the impact of these tests on the management of patients. Dengue fever is endemic in Pakistan with seasonal rise in cases. Morbidities and mortalities are proportionately reported to be increasing and associated with disseminated intravascular coagulation resulting in haemorrhagic or thrombotic manifestations in patients having deranged coagulation profiles. This observational and descriptive study was conducted on confirmed Dengue patients at the National Institute of Blood Diseases during the years 2013 to 2016. Patients of all age groups were included in this study. Results were analysed by SPSS version 23. A total of 200 patients were selected with the mean age being 28.68 years (±13.28) and male predominance (147/200). The mean platelet count, haemoglobin and haematocrit at base line for bleeders and non-bleeders showed significant results, where platelet count at baseline for bleeders was 24 000, whereas for non-bleeders it was 29 000 and it showed significant correlation with bleeding (P-value .027). Platelets were transfused to 76 (38%) patients. However, none of the specialised haemostasis parameters beside the platelet count correlated with bleeding, requiring platelet transfusions. Our study showed a significant association of platelet counts, haemoglobin and haematocrit with bleeding. It can be concluded that coagulation and anticoagulation profiles will not benefit the management of dengue patients and in countries like Pakistan, it will only add to the economic burden on the patients.

Bleeding and Thrombotic Outcomes in Anticoagulant Free Extracorporeal Membrane Oxygenation (ECMO) in Adults: A Systematic Review

Background: Extra Corporeal Membrane Oxygenation (ECMO) is being used with increasing frequency in critically ill patients requiring cardiopulmonary life-support. The combined effects of critical illness, ECMO use, and systemic anticoagulation to prevent circuit thrombosis, induces a complex milieu of coagulation, fibrinolytic and platelet derangements. Both bleeding and clotting are expectedly the most frequent and dangerous complications of ECMO; in patients with active or high risk of major bleeding, the prospect of anticoagulation-free ECMO is attractive, although data is limited on the safety and efficacy of this practice. In order to better define the safety of anticoagulation-free ECMO, we performed the following systematic review. Methods: We searched Ovid Medline for publications reporting use of ECMO without therapeutic-dose systemic anticoagulation of any kind for a minimum of 24 hours in adult patients, between the years 1977 to 2019. Studies using general venous thromboembolism prophylaxis were included. We included randomized control trials, cohort studies, case series, and case-control studies that contained sufficient patient-level data. Preclinical studies, meta-analyses, systematic reviews, narrative reviews, and reports involving patients under 18 years of age were excluded. Outcomes of interest collected included all bleeding and thrombotic events involving the patient or circuitry. Results: 443 studies were identified through our search. After removal of duplicates, 441 records were screened. After exclusion, 23 full-text articles were assessed for eligibility. 2 of the full text articles were further excluded due to ambiguity regarding the time patients were off of anticoagulation. 21 studies were ultimately included in the systematic review. These included 8 case series and 13 individual case reports. All were single center studies. Data for a total of 154 patients among all 21 studies analyzed were reviewed. 96 adults were treated with veno-venous (vv) ECMO, and 58 were treated with veno-arterial (va) ECMO. Indications for ECMO included acute respiratory distress syndrome, diffuse alveolar hemorrhage, traumatic brain injury, intra-cranial hemorrhage, and lung transplant. Median total time on anticoagulant-free ECMO was 11.85 days among individual case reports, and 7.03 days for patients included in case series. Of the 154 patients, 9 (5.8%) had new, severe bleeding events, 13 (8.4%) experienced minor bleeding, and 15 (9.7%) were re-explored for bleeding. No new cases of intracranial hemorrhage were seen during ECMO without systemic anticoagulation. 15 patients (9.5%) developed circuitry thrombosis, and 6 (3.9%) developed systemic venous or arterial thrombosis. Full results are listed in Table 1. Conclusions: Our systematic review found that anticoagulant-free ECMO was associated with relatively low rates of major bleeding, circuitry and patient thrombosis; the frequency of these events (5.8%, 9.5%, 3.9%, respectively) is similar, if not lower, than historically-reported rates in ECMO with anticoagulation (at least 16%, 10% and 18%, respectively). Of note, no new instances of intracranial hemorrhage were found, which is crucially important given the high associated mortality. Though based on a small number of patients, our review is valuable as it provides a new perspective on the prevailing theory that systemic anticoagulation is an absolutely necessary component of ECMO to prevent thrombosis. Evolving ECMO technology and improved overall care of critically-ill patients may be contributing to a less thrombotic blood microenvironment, which is typically attributed to inflammation, contact pathway and platelet activation. We acknowledge several limitations of our review, including the identification and inclusion of only non-randomized, retrospective studies, variable definitions and reporting of thrombotic and bleeding events, and likely non-negligible differences in ECMO technology, all of which precludes any definitive conclusions. Our findings are, however, hypothesis-generating; prospective, randomized trials would help better clarify the safety and efficacy of ECMO without anticoagulation, and address a unmet medical need by refining anticoagulation indications for critically ill patients on ECMO. Disclosures Shatzel: Aronora, Inc.: Consultancy.

Puerperal sepsis and multiple organ dysfunctions caused by group A streptococcus

Background: Child fever or puerperal sepsis is a significant cause of maternal morbidity and mortality. It is a preventable maternal postpartum complication.1 Group A streptococcus (GAS) infection remains a significant cause for postpartum sepsis as it causes septic shock and multiple organ dysfunction (MODS). There has been a resurgence of severe puerperal GAS infections over the past two decades, although rare, it must be recognized early and treated aggressively. GAS is a common bacteria causing necrotizing fasciitis (NEF) in our region,2 but it caused NEF in only one postpartum patient which is a rarity.3,4,5 We report a case of puerperal GAS infection-causing NEF where the patient underwent multiple surgical debridements complicated with septic shock and MODS, and had a fairly positive outcome.Case presentation: A 26-year old female presented to the emergency department 5 days postpartum with fever, tachycardia, tachypnea, borderline blood pressure, vaginal discharge, and severe pain in the right leg. Her physical examination revealed reddish discoloration of the right lower leg, which was edematous, warm, and extremely tender. The episiotomy wound looked dirty and infected. She had leukocytosis (29.2 × 103/μL), thrombocytopenia (44 × 103/μL), C-Reactive protein was elevated (322 mg/L), and serum lactic acid was 3.8 mmol/L. Her hepatic and renal parameter were elevated. She had a deranged coagulation profile. Post-partum sepsis was suspected and blood cultures were done. She was started on Tazocin® (Tazobactum+piperacillin), supplemented with oxygen, and resuscitated with intravenous fluids.She was immediately taken for emergency surgical intervention, right leg debridement, and fasciotomy with exploration of the episiotomy wound was performed. Surgical findings were dirty colored fluid collection and loss of facial resistance which corroborated with NEF. Necrotic tissues were sent for histopathology and cultures, and clindamycin was started. Intraoperatively the patient became unstable, requiring double vasopressor (noradrenaline and vasopressin) to maintain the hemodynamics. Postoperatively the patient was kept sedated and ventilated in the intensive care unit (ICU). She required four debridements in the next two days despite which her right leg was not improving. Magnetic resonance imaging showed necrotizing fasciitis of the right thigh and leg. Tissue biopsy confirmed the diagnosis. Her blood and tissues showed growth of group A streptococcus. With family agreement, she underwent above right knee amputation, lateral and medial thigh compartment fasciotomy, and debridement on day five. She was oozing from the fasciotomy wounds and needed resuscitation with blood and blood products. She started to show signs of improvement and was weaned off from vasopressors and ventilator. Hepatic and renal functions improved (Figure 1 and Table 1). She was extubated on day 12, awake, hemodynamically stable, tolerated oral feeding, and was transferred to the surgical ward on day 19. She was discharged home on day 24 and was followed in surgical outpatient clinics.Conclusion: Despite developments in infection control and strict aseptic precautions, GAS puerperal sepsis remains a potentially life-threatening infection especially when they present with rare conditions like NEF in the postpartum period. Early diagnosis, aggressive surgical management, and supportive medical care are important for a positive outcome.

Coagulation abnormalities, bleeding, thrombosis, and management of patients with acute liver failure in Australia and New Zealand.

To study the management of coagulation and hematological derangements among severe acute liver failure (ALF) patients in Australia and New Zealand liver transplant intensive care units (ICUs). Analysis of key baseline characteristics, etiology, coagulation and hematological tests, use of blood products, thrombotic complications, and clinical outcomes during the first ICU week. We studied 62 ALF patients. The first day median peak international normalized ratio was 5.5 (inter-quartile range [IQR] 3.8-8.7), median longest activated partial thromboplastin time was 62s (IQR 44-87), and median lowest fibrinogen was 1.1 (IQR 0.8-1.6) g/L. Fibrinogen was only measured in 85% of patients, which was less than other tests (P<0.0001). Median initial lowest platelet count was 83 (IQR 41-122)×109 /L. Overall, 58% of patients received fresh frozen plasma, 40% cryoprecipitate, 35% platelets, and 15% prothrombin complex concentrate. Patients with bleeding complications (19%) had more severe overall hypofibrinogenemia and thrombocytopenia. Thrombotic complications were less common (10% of patients), were not associated with consistent patterns of abnormal hemostasis, and were not immediately preceded by clotting factor administration and half occurred only after liver transplantation surgery. In ALF patients admitted to dedicated Australia and New Zealand ICUs, fibrinogen was measured less frequently than other coagulation parameters but, together with platelets, appeared more relevant to bleeding risk. Blood products and procoagulant factors were administered to most patients at variable levels of hemostatic derangement, and bleeding complications were more common than thrombotic complications. This epidemiologic information and practice variability provide baseline data for the design and powering of interventional studies.

22 Thromboelastography Detects Coagulopathy Faster than Standard Coagulation Studies in Simulated Pit Viper Envenomation

Venomous snakebites pose a significant risk of morbidity and mortality in rural and austere environments, so it is not surprising that the World Health Organization recently set a goal of reducing snakebite deaths by half by 2030. Many of these envenomations are due to pit vipers, leading to severe hematologic derangements, such as venom-induced consumptive coagulopathy (VICC). Immediacy in detection of envenomations is crucial for ameliorating morbidity and mortality, but diagnosis of envenomization can be challenging, requiring access to clinical laboratory facilities. Further, the laboratory-based evaluations of coagulation function take more than an hour to conduct. In contrast, thromboelastography (TEG) is promising as a rapid, portable, bedside test of coagulation that produces meaningful results in less than 15 minutes. Therefore, the primary objective of this study was to assess the efficacy of TEG compared to standard lab tests in detecting pit viper venom at increasing concentrations. Blood samples drawn from 19 healthy adult volunteers were mixed with varying concentrations of western diamond back rattlesnake (Crotalus atrox) venom (none, 0.5%, 1%, 2%, 33%, 66%, and 100% of LD50), then assessed with standard laboratory-based tests of coagulation function (labs), including prothrombin time (PT), partial thromboplastin time (PTT), international normalized ratio (INR), D-dimer, and Fibrinogen, as well as with TEG measures of reaction time (R), amplification (K), rate of clot formation (Angle), and clot strength (MA). Data were analyzed as changes from baseline and categorized as percent of samples out of normal physiologic range, then analyzed using ANOVA and binomial statistics at the p<.05 threshold for statistical significance. TEG and standard labs were both excellent (100%) at detecting higher concentrations of venom (33%, 66%, 100%), save D-dimer. Importantly, at low venom concentration levels (0.5%, 1%, 2%), the TEG measures of R, K, alpha, and MA were similar to laboratory-based evaluations of PT and INR at detecting venom, and were significantly superior to PTT, D-dimer, and Fibrinogen. TEG provides a sensitive, real-time quantitative evaluation of coagulation derangements during simulated pit viper envenomation that is faster than standard laboratory tests. TEG was sensitive at low venom concentrations, outperforming multiple traditional laboratory evaluations of VICC. While the present study was limited to in vitro analyses, our findings suggest that TEG is a fast, effective, and portable point-of-care testing modality to assist the emergency physician community to rapidly and accurately diagnose patients stricken with venomous snake bites.

STUDY TO DETERMINE THE FETAL AND MATERNAL OUTCOME IN ACUTE VIRAL HEPATITIS

Acute viral hepatitis is the commonest cause of jaundice in pregnant women with clinical evidence of hepatitis with HEV being the predominant cause. Acute viral hepatitis is a systemic infection caused by six distinct types of viruses A, B, C, D, E and G. The present study was a prospective observational study done in the Department of Obstetrics and Gynaecology, Patna Medical College &amp; Hospital, Patna over a 2 years period with 100 pregnant patients suffering from acute viral hepatitis. This study was conducted to know the prevalence, obstetric complications and maternal, perinatal outcome in pregnant women presenting with acute viral hepatitis. In our setup most common cause of acute viral hepatitis with adverse fetomaternal outcome was found to be with Hepatitis E .HBV was found to be the 2rd most common etiological factor followed by HAV. Adverse fetomaternal outcome like abortion, preterm, LBW, IUGR, IUD, higher NICU admissions, coagulation derangement, PPH, hepatic encephalopathy were mostly associated with HEV infection. Acute viral hepatitis was associated with a maternal mortality of 17% mostly attributable to HEV infection. In a developing country like India, awareness of pregnant women about viral hepatitis, regular ANC care, cost effectiveness and easy accessibility to health care system and treatment plays a key role in improving the current situation.&#x0D; Keywords: Viral hepatitis, Maternal, Fetal, Pregnancy

In vitro anticoagulant effect of Crassocephalum crepidioides leaf methanol extract and fractions on human blood.

BackgroundBlood coagulation is a rapid and efficient process that produces clot formation which requires regulation. A derangement of blood coagulation is a feature of many disease conditions. This study investigated the in vitro effects of Crassocephalum crepidioides Benth S. Moore leaf methanol (crude) extract and its partitioned solvent fractions on blood coagulation of Healthy human volunteers.MethodsThe secondary metabolites from dried and ground C. crepidioides leaves were extracted with 70% methanol, and the concentrated crude extract was subsequently subjected to solvent partitioning with Hexane, Ethyl acetate, and Butanol. Varying concentrations (5–20 mg/mL) of the extract and fractions were tested in vitro on blood coagulation profile; clotting time (CT), prothrombin time (PT), and activated partial thromboplastin time (aPTT) of apparently healthy human volunteers, while phytochemical characterization of the Hexane fraction was done by gas chromatography-mass spectrometry (GC-MS).ResultsC. crepidioides leaf methanol extract and fractions significantly (P<0.05) prolonged the clotting time, prothrombin and activated partial thromboplastin times in the blood obtained from the volunteers. The highest prolongation effect was recorded with the Hexane fraction at concentration of 10mg/mL. GC-MS analysis of the Hexane fraction indicated the presence of phytochemicals such as unsaturated fatty acids and esters, phenolic compounds, flavonoids, and coumarin-related compounds known to exhibit antiaggregant, antiplatelet and antimicrobial activities.ConclusionThese results showed that C. crepidioides possesses bioactive components with anticoagulant properties which may be exploited in the treatment of blood coagulation disorders.

Coagulation Profile in neonates with perinatal asphyxia

Background: Perinatal Asphyxia refers to a condition during the first and second stage of labour in which impaired gas exchange leads to fetal acidosis, hypoxemia and hypercarbia. It accounts for about 23 per cent of the four million newborn deaths worldwide.Methods: To estimate the magnitude of coagulation derangement in babies who suffered birth asphyxia and compare it with non-asphyxiated controls.Results: There were 61.9% and 64 % males in both the groups outnumbering females suggesting that the health care seeking behavior for male children is more than for their female counterparts. Birth weight and mode of delivery are comparable in both the groups. PT and APTT were significantly higher in the asphyxiated babies than in their respective control group. It may be noted , however, that PT and APTT values were higher in the control group also, when compared with the reference values. This may indicate that the hemostatic mechanisms are already compromised in the newborns and perinatal asphyxia further augment the situation tilting it in favour of bleeding. Thrombocytopenia is observed in the asphyxiated group which may be due to placental insufficiency. Severe bleeding is significant in asphyxiated group as compared to the control.Conclusion: Dyscoagulation should be considered in all asphyxiated babies, and they may present with clinically significant bleeding, which may require fresh frozen plasma to restore and maintain their coagulation status.