Management Of Coagulopathy Research Articles

Targeting microthrombosis and neuroinflammation with vepoloxamer for therapeutic neuroprotection after traumatic brain injury.

Targeting microthrombosis and neuroinflammation with vepoloxamer for therapeutic neuroprotection after traumatic brain injury.

Early haemorrhage control and management of trauma-induced coagulopathy: the importance of goal-directed therapy.

The aim of this study was to discuss the recent developments in trauma-induced coagulopathy and the evolvement of goal-directed therapy. Mortality from major trauma continues to be a worldwide problem, and massive haemorrhage remains a major cause in 40% of potentially preventable trauma deaths. Development of trauma-induced coagulopathy challenges 25-35% of the patients further increasing trauma mortality. The pathophysiology of coagulopathy in trauma reflects at least two distinct mechanisms: Acute traumatic coagulopathy, consisting of endogenous heparinization, activation of the protein C pathway, hyperfibrinolysis and platelet dysfunction, and resuscitation associated coagulopathy. Clear fluid resuscitation with crystalloids and colloids is associated with dilutional coagulopathy and poor outcome in trauma. Haemostatic resuscitation is now the backbone of trauma resuscitation using a ratio-driven strategy aiming at 1:1:1 of red blood cells, plasma and platelets while applying goal-directed therapy early and repeatedly to control trauma-induced coagulopathy. Trauma resuscitation should focus on early goal-directed therapy with use of viscoelastic haemostatic assays while initially applying a ratio 1:1:1 driven transfusion therapy (with red blood cells, plasma and platelets) in order to sustain normal haemostasis and control further bleeding.

Hemostatic Management of Trauma-Induced Coagulopathy.

Trauma-induced coagulopathy is a primary factor in many trauma-related fatalities. Management hinges upon rapid diagnosis of coagulation abnormalities and immediate administration of appropriate hemostatic agents. Use of crystalloids and packed red blood cells has traditionally been the core of trauma resuscitation, but current massive transfusion protocols include combination therapy with fresh frozen plasma and predefined ratios of platelets to packed red blood cells, limiting crystalloid administration. Hemostatic agents such as tranexamic acid, prothrombin complex concentrate, fibrinogen concentrate, and, in cases of refractory bleeding, recombinant activated factor VIIa may also be warranted. Goal-directed resuscitation using viscoelastic tools allows specific component-centered therapy based on individual clotting abnormalities that may limit blood product use and thromboembolic risks and may lead to reduced mortality. Because of the complex management of patients with trauma-induced coagulopathy, critical care nurses must be familiar with the pathophysiology, acute diagnostics, and pharmacotherapeutic options used to treat these patients.

Early fibrinogen-concentrate administration in management of trauma-induced coagulopathy – Authors' reply

Early fibrinogen-concentrate administration in management of trauma-induced coagulopathy – Authors' reply

Hemotherapy algorithm for the management of trauma-induced coagulopathy: the German and European perspective.

This review presents a synopsis of best current knowledge with reference to the updated German and European guidelines and recommendations on the management of severe trauma hemorrhage and trauma-induced coagulopathy as well as a viscoelastic-based treatment algorithm based upon international expert consensus to trigger the administration of hemostatic agents and blood products. Uncontrolled hemorrhage and trauma-induced coagulopathy are the major causes for preventable death after trauma and early detection and aggressive management have been associated with improved outcomes. However, best practice to treat this newly defined entity is still under debate. In the acute phase, the clinical management usually follows the 'Damage Control Resuscitation' concept, which advocates the empiric administration of blood products in predefined and fixed ratios. As an alternative, several European but also a few US trauma centers have instituted the concept of 'Goal-directed Coagulation Therapy' based upon results obtained from early point-of-care viscoelastic testing. Current guidelines urge for the implementation of evidence-based local protocols and algorithms including clinical quality and safety management systems together with parameters to assess key measures of bleeding control and outcome.

Haemotherapy algorithm for the management of trauma-induced coagulopathy: an Australian perspective.

Recent advances in the understanding of the pathophysiological processes associated with traumatic haemorrhage and trauma-induced coagulopathy have resulted in improved outcomes for seriously injured trauma patients. However, a significant number of trauma patients still die from haemorrhage. This article reviews the various transfusion strategies utilized in the management of traumatic haemorrhage and describes the major haemorrhage protocol (MHP) strategy employed by an Australian trauma centre. Few topics in trauma resuscitation incite as much debate and controversy as to what constitutes the 'ideal' MHP. There is a widespread geographical and institutional variation in clinical practice. Three strategies are commonly utilized; fixed ratio major haemorrhage protocol (FRMHP), viscoelastic haemostatic assay (VHA)-guided MHP and hybrid MHP. The majority of trauma centres utilize an FRMHP and there is high-level evidence to support the use of high blood product ratios. It can be argued that the FRMHP is too simplistic to be applied to all trauma patients and that the use of VHA-guided MHP with predominant factor concentrate transfusion can allow rapid individualized interventions. In between these two strategies is a hybrid MHP, combining early FRMHP with subsequent VHA-guided transfusion. There are advantages and disadvantages to each of the various MHP strategies and the evidence base to support one above another with any certainty is lacking at this time. One strategy cannot be considered superior to the other and the choice of MHP is dependent on interpretation of the current literature and local institutional logistical considerations. A number of exciting studies are currently underway that will certainly increase the evidence base and help inform clinical practice.

An algorithm for the management of coagulopathy from postpartum hemorrhage, using fibrinogen concentrate as first-line therapy

BackgroundWe constructed an algorithm for the management of coagulopathy from massive postpartum hemorrhage. Fibrinogen concentrate was administered preferentially, and the dose of both fibrinogen concentrate and fresh frozen plasma given was determined by the plasma fibrinogen concentration and prothrombin time. The efficacy of the algorithm and the amount of fibrinogen concentrate and fresh frozen plasma transfused were determined. MethodsThe study was conducted in a single teaching perinatal center. Nineteen patients were included between April 2011 and March 2014 (patient group). For a historical comparison group, we retrospectively analyzed the records of 19 patients who had been treated for coagulopathy from massive postpartum hemorrhage between April 2006 and March 2011 (control group). ResultsBlood loss was significantly lower in the patient group. No adverse events were associated with this management in either group. The dose of fibrinogen concentrate administered was significantly higher and that of fresh frozen plasma administered was significantly lower in the patient group. ConclusionThis algorithm appeared to help reduce blood loss and the total amount of fresh frozen plasma transfused when treating coagulopathy from postpartum hemorrhage, and may represent another strategy for achieving hemostasis in this setting.

Volume replacement during trauma resuscitation: a brief synopsis of current guidelines and recommendations.

Intravascular volume and fluid replacement are still cornerstones to correct fluid deficits during early trauma resuscitation, but optimum strategies remain under debate. A synopsis of best current knowledge with reference to the following guidelines and recommendations is presented: (1) The European Guideline on Management of Major Bleeding and Coagulopathy following Trauma (fourth edition), (2) S3 Guideline on Treatment of Patients with Severe and Multiple Injuries [English Version of the German Guideline S3 Leitlinie Polytrauma/Schwerverletzten-Behandlung/AWMF Register-Nr. 012/019 sponsored by the German Society for Trauma Surgery/Deutsche Gesellschaft für Unfallchirurgie (DGU)], and (3) S3 Guideline Intravascular Volume Treatment in the Adult [AWMF Register-Nr 001/020 sponsored by the German Society for Anesthesiology and Intensive Medicine/Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI)]. Volume replacement at a reduced level in severely injured and bleeding trauma patients is advocated (permissive hypotension) until the bleeding is controlled. ATLS principles with Hb, BE, and/or lactate can assess perfusion, estimate/monitor the extent of bleeding/shock, and guide therapy. Isotonic crystalloid solutions are first-line and specific recommendations apply for patients with TBI.

Tranexamic acid in the German emergency medical service : Anational survey

Trauma-induced coagulopathy, one of the leading causes of trauma-related death, is detected in about one of four trauma patients upon hospital admission. The current European Management of Major Bleeding and Coagulopathy Following Trauma guidelines, published in 2013, recommend that tranexamic acid (TXA) be administered as early as possible to inhibit hyperfibrinolysis (grade of recommendation (GoR 1A)). Furthermore, it is suggested that protocols for the management of patients with bleeding or showing signs of bleeding include the administration of the first dose of TXA at the site of injury or during transportation to hospital (GoR 2C). There is no current data showing to what extent TXA is used in the pre-hospital settings in Germany. This study aimed to collect data about the availability of TXA in the German emergency medical service (EMS). We tried to determine how many EMS stored and used TXA, under which circumstances the substance was used and whether any standard operating procedures (SOPs) were in use. The study also tried to determine what dosage recommendations exist. Between 1 July and 31 August 2015, atotal of 326 German emergency medical directors (EMDs) were asked to take part in asurvey, which involved answering an online questionnaire. Altogether 163 EMD answered the questionnaire (response rate 50%). The results showed that 52.8% of EMDs stored TXA in their vehicles and 26% planned to do so in the future. The availability of TXA in the EMS has increased since 2010. Most EMDs stated that guidelines were the reason for this. SOPs existed in 17.4%. Dosage recommendations were defined by the EMDs in 76.7%. More than 80% of dosage recommendations followed the European guideline. The survey shows awidespread distribution of TXA in the German EMS, which has significantly increased between 2010 and 2015. However, nationwide distribution has not yet been established. This rise in distribution is interpreted as areaction to national and European guidelines for the management of severe bleeding and trauma care. A remaining question is to determine which patients should be treated with TXA, as hyperfibrinolysis is not detectable at the site of injury.

Noteworthy Literature Published in 2016 for Cardiothoracic Critical Care.

In 2016, demand for the presence of cardiothoracic anesthesiologists outside of the cardiac operating rooms continues to expand. This article is the second in this annual series to review relevant contributions in postoperative cardiac critical care that may impact the cardiac anesthesiologist. We explore the use of extracorporeal membrane oxygenation (ECMO), management of postoperative atrial fibrillation, coagulopathy, respiratory failure, and role of quality in cardiac surgery.

Dealing with Traumatic Coagulopathy: A Long Way to Go

Traumatic coagulopathy is a complicated pathophysiological process. The management of traumatic coagulopathy should cover the whole process from pre-hospital to after discharge. The recommendations on management of coagulopathy following trauma in this guideline are practical, but there are still many circumstances we don’t know how to deal with. To manage traumatic coagulopathy, we believe that there is still a long way to go. Citation: Hua Feng, Tian-Long Wang. Dealing with Traumatic Coagulopathy: A Long Way to Go. J Anesth Perioper Med 2017; 4: 195-7. doi:10.24015/JAPM.2017.0055 This is an open-access article, published by Evidence Based Communications (EBC). This work is licensed under the Creative Commons Attribution 4.0 International License, which permits unrestricted use, distribution, and reproduction in any medium or format for any lawful purpose. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/.

Coagulopathies in cyanotic cardiac patients: An analysis with three point - of - care testing devices (Thromboelastography, rotational thromboelastometry, and sonoclot analyzer).

Introduction:In the last few years, viscoelastic point-of-care (POC) coagulation devices such as thromboelastography (TEG), rotational thromboelastometry (ROTEM), and Sonoclot (SON) analyzer have been increasingly used in major surgeries for timely assessment and management of coagulopathies. The aim of the present study was to evaluate coagulation profile of cyanotic cardiac patients with TEG, ROTEM, and SON analyzer. In addition, we assessed the correlation of standard laboratory coagulation tests and postoperative chest drain output (CDO) with the parameters of POC testing devices.Materials and Methods:Thirty-five patients of either gender, belonging to the American Society of Anesthesiologists Grade I–III, and undergoing elective cardiac surgery on cardiopulmonary bypass for cyanotic congenital heart disease were included in this study. To identify possible coagulation abnormalities, blood samples for TEG, ROTEM, SON, and standard laboratory coagulation were collected after induction of anesthesia. The correlations between variables were assessed using Pearson's correlation coefficient. P < 0.05 was considered statistically significant.Results and Discussion:EXTEM clot time (CT) and clot formation time (CFT) were prolonged in 87% and 45% patients whereas INTEM CT and CFT were prolonged in 36% and 73% patients, respectively. FIBTEM maximum clot firmness (MCF) was decreased in 30% patients. We observed significant correlation between fibrinogen concentration and ROTEM FIBTEM MCF (r = 0.94, P < 0.001). The SON platelet function (SON PF) showed good correlation with platelet count (r = 0.85, P < 0.001). We also found significant correlation between preoperative FIBTEM MCF and CDO in first 4 postoperative hours (r = 0.49, P = 0.004) and 24 postoperative hours (r = 0.52, P = 0.005). Receiver operating characteristic analysis demonstrated that SON PF and TEG maximum amplitude are highly predictive of thrombocytopenia below 100 × 109/L (area under the curve [AUC] - 0.97 and 0.92, respectively), while FIBTEM-MCF is highly predictive of hypofibrinogenemia (fibrinogen <150 mg/dL (AUC, 0.99).Conclusion:Cyanotic cardiac patients have preoperative coagulation abnormalities in ROTEM, TEG, and SON parameters. ROTEM FIBTEM is highly predictive of hypofibrinogenemia while SON PF is highly predictive of thrombocytopenia. ROTEM FIBTEM can be studied as a marker of increased postoperative CDO.

Hemorrhagic shock and trauma: brief review and recommendations for management of bleeding and coagulopathy

Hemorrhagic shock and trauma: brief review and recommendations for management of bleeding and coagulopathy

Chapter 11 - Management of intracerebral hemorrhage

Intracerebral hemorrhage (ICH) is a potentially devastating neurologic injury representing 10-15% of stroke cases in the USA each year. Numerous risk factors, including age, hypertension, male gender, coagulopathy, genetic susceptibility, and ethnic descent, have been identified. Timely identification, workup, and management of this condition remain a challenge for clinicians as numerous factors can present obstacles to achieving good functional outcomes. Several large clinical trials have been conducted over the prior decade regarding medical and surgical interventions. However, no specific treatment has shown a major impact on clinical outcome. Current management guidelines do exist based on medical evidence and consensus and these provide a framework for care. While management of hypertension and coagulopathy are generally considered basic tenets of ICH management, a variety of measures for surgical hematoma evacuation, intracranial pressure control, and intraventricular hemorrhage can be further pursued in the emergent setting for selected patients. The complexity of management in parenchymal cerebral hemorrhage remains challenging and offers many areas for further investigation. A systematic approach to the background, pathology, and early management of spontaneous parenchymal hemorrhage is provided.

Management of trauma-induced coagulopathy (TIC): a synopsis of the updated European trauma guideline

Uncontrolled hemorrhage and trauma-induced coagulopathy (TIC) are still the major causes for preventable death after trauma (1,2). Approximately one out of four severely injured trauma patients admitted to the hospital is bleeding with variable degrees of laboratory coagulopathy (3). Meanwhile, TIC is recognized as an own clinical entity with substantial impact on outcome and survival after trauma (4). There has been speculation about the potential mechanisms underlying TIC but much of the data continues to be rather correlative than causative with robust links still lacking (5).

Chapter 40 - Management of neurologic complications of coagulopathies

Coagulopathy is common in intensive care units (ICUs). Many physiologic derangements lead to dysfunctional hemostasis; these may be either congenital or acquired. The most devastating outcome of coagulopathy in the critically ill is major bleeding, defined by transfusion requirement, hemodynamic instability, or intracranial hemorrhage. ICU coagulopathy often poses complex management dilemmas, as bleeding risk must be tempered with thrombotic potential. Coagulopathy associated with intracranial hemorrhage bears directly on prognosis and outcome. There is a paucity of high-quality evidence for the management of coagulopathies in neurocritical care; however, data derived from studies of patients with intraparenchymal hemorrhage may inform treatment decisions. Coagulopathy is often broadly defined as any derangement of hemostasis resulting in either excessive bleeding or clotting, although most typically it is defined as impaired clot formation. Abnormalities in coagulation testing without overt clinical bleeding may also be considered evidence of coagulopathy. This chapter will focus on acquired conditions, such as organ failure, pharmacologic therapies, and platelet dysfunction that are associated with defective clot formation and result in, or exacerbate, intracranial hemorrhage, specifically spontaneous intraparenchymal hemorrhage and traumatic brain injury.

Preeclampsia in 2017: Obstetric and Anaesthesia Management.

In many centres, anaesthesia now incorporates perioperative medicine. Preeclampsia is a perioperative medical challenge requiring a multi-disciplinary team. New definitions stress the rapid progression of the disease and highlight the importance of early detection. Anaesthesiologists should understand the pathophysiology of the disease and develop the ultrasound skills required to assist in the assessment of disease severity. This facilitates the choice of anaesthesia method and perioperative management in complicated cases. Regional anaesthesia remains central, but there are important developments in the practice of general anaesthesia, if indicated. Appropriate haemodynamic monitoring should be established. Anaesthesiologists should also lead the resuscitation team in the management of cardiorespiratory failure and coagulopathy.

Management of trauma-induced coagulopathy (TIC): a synopsis of the updated European trauma guideline

Management of trauma-induced coagulopathy (TIC): a synopsis of the updated European trauma guideline

Novel Approach to Management of Localised Intravascular Coagulopathy in Extensive Low Flow Venous Malformations Using Rivaroxaban

Introduction: Extensive low flow venous malformations, such as Klippel Trenaunay Syndrome (KTS), are rare conditions. Abnormal blood flow in these structures leads to activation of coagulation, sometimes referred to as localised intravascular coagulopathy (LIC). This results in spontaneous, sometimes painful, thrombus formation and fibrinolysis as indicated by raised D-dimer levels.In some cases the LIC can be so severe that it leads to a consumptive coagulopathy with bleeding complications. It is important to assess for this, particularly as many of these patients undergo corrective surgeries. It has been noted that low fibrinogen and, more recently, low FXIII levels correlate with severity of LIC and bleeding risk in these cases while other coagulation factors and platelet counts seem to be unaffected.There is very little published evidence to help with antithrombotic and haemostatic management of these rare and complex patients. Anticoagulation with low-molecular-weight heparin (LMWH) has been used to reduce LIC and consumptive coagulopathy on a case-by-case basis to either manage thrombotic events or reduce bleeding risk. The main issues with long term use of LMWH are that it can result in reduction of bone density and impact on quality of life due to requirement for daily administration of subcutaneous injections. An oral agent would be preferable but vitamin K antagonists, such as warfarin, have been found to be not as effective. Direct oral anticoagulants (DOACs) are being increasingly used as an alternative anticoagulant in more common conditions, such as atrial fibrillation and venous thromboembolism. These could be a potential alternative in this rare group of patients.Aims: We present the use of direct oral factor Xa inhibitor rivaroxaban (off-label) as a novel treatment option for LIC and consumptive coagulopathy in three patients with extensive low flow venous malformations. Serial measurements of D-dimer, fibrinogen and factor XIII levels were used as surrogate markers for the severity of LIC.Methods: Patients managed with rivaroxaban at our tertiary centre were identified retrospectively by the lead consultant. All had a diagnosis of extensive venous malformation with laboratory features of LIC, defined by at least one of the following parameters: high D-dimer levels, low fibrinogen (Clauss), low FXIII levels with the latter only being monitored for the last two years since its clinical significance was realised. Case notes and laboratory results were reviewed.Results: Three patients fulfilled the inclusion criteria (Table 1). Mean age was 29 years. Two cases had KTS, the third had an extensive low flow venous malformation on the back. All cases received prior LMWH. Rivaroxaban (10-20mg once daily) was administered for between 6 weeks and 23 months.In all patients there was an improvement in laboratory parameters (Table 1). D-dimer levels were reduced by 66, 97 and 69% (Cases 1 - 3 respectively). A low fibrinogen increased by 1.1, 0.5 and 0.6 g/L on rivaroxaban (Cases 1 - 3 respectively), with all patients maintaining a level above 1 g/L. Results for FXIII were only available for Case 3: the level more than doubled on rivaroxaban treatment.All patients had a normal platelet count.In addition good clinical response was observed in the two patients with painful phleboliths and venous thromboembolism.No adverse effects were seen in this small cohort.Conclusions: This is the first case series reporting the successful use of rivaroxaban in extensive low flow venous malformations for the management of LIC and consumptive coagulopathy. Our findings suggest that this novel approach can provide good control of laboratory parameters and clinical symptoms and is more convenient for patients. The optimal dose and duration of therapy remains to be defined. In light of these findings other DOACs may also have a role in the treatment of these conditions. [Display omitted] DisclosuresMathias:Bayer: Speakers Bureau. Drebes:Bayer: Consultancy; Bayer: Other: Educational Grant.

Strategies to Improve Safety and Outcomes Utilizing Systems-Based Hematologists in IVC Filter Placement and Management in an Academic Medical Center

In large academic institutions, there are multiple disciplines and clinical scenarios that may require placement of inferior vena cava filters (IVCF). Both the Society of Interventional Radiology (SIR) and the American College of Chest Physicians (ACCP) have released guidelines for IVCF use, with the ACCP guidelines being more stringent due to the lack of survival benefit supported by level I data. Several publications have reported high rates of retrievable IVCF complications. In response to these risks and low retrieval rates, the U.S. FDA issued an updated safety alert in 2014 recommending that implanting physicians and clinicians responsible for the ongoing care of patients with retrievable IVCF consider removing the filter as soon as protection from pulmonary embolism is no longer needed.A systems-based hematologist (SBH) plays a vital role in navigating the health care system in the use of therapeutic and device agents that crosses multiple disciplines by implementing evidence-based strategies to improve safety and outcomes. Previously, we used our institution's electronic health record (EHR) system to assist in improving the quality of care and reducing the cost of heparin-induced thrombocytopenia management, blood product utilization in cardiac surgery and pre-procedure management of coagulopathy in chronic liver disease (Greenberg et al. Blood. Vol. 126, No. 23; Abstract 4467).As a first step, the purpose of this study was to report our healthcare system use of IVCF to: a) define the scope of practice and b) to identify areas for improvement. We propose a practical plan that will assist in improving clinician performance, patient education, and acute and chronic management of IVCF in a large healthcare network based on our recent success utilizing EHR to manage complex medical care.A retrospective review of all IVCF placement performed between July 2014 and December 2015 was conducted. A total of 181 IVCF were placed; 26 (14.4%) permanent IVCF, 143 (79.0%) retrievable IVCF, 12 (6.6%) unknown. Mean age at IVCF placement was 59.34 years (range: 19 - 85); 46.4% were male. Ninety-six (53.0%) patients had active cancer. Surgical Services and Medical Services requested IVCF placements in 112 (61.9%) patients and 69 (38.1%) patients, respectively. Only 13 (7.2%) patients had a SBH consultation prior to IVCF placement.Per SIR guidelines, 60.2% (n=109) of IVCF were placed for absolute indications, 15.5% (n=28) for relative indications, 14.4% (n=26) prophylactically and 9.9% (n=18) with no clear indications.Of the 143 retrievable IVCF, 21 patients died during their hospitalization or were discharged to hospice. Of the remaining 122 cases, documentation of the presence of an IVCF was present in 107 (87.7%) discharge summaries, and outlined instructions for filter retrieval were seen in 19 (15.6%) cases. Only 29 (23.8%) IVCF were retrieved at a mean interval of 159 days (range: 4-511 days). Of the 21 patients that had IVCF placed prophylactically, only 7 (33.3%) IVCF were retrieved.While many of the retrievable filters were placed because of an absolute contraindication (n=64) or relative indication for high-risk of complication to anticoagulation (n=13), 37 (48.1%) patients were discharged on a regimen of anticoagulant therapy.We performed a root cause analysis and identified that a lack of awareness of IVCF evidence-based indications could have played a role in filter use patterns and the lack of a structured system for IVCF tracking in some clinical services resulted in poor IVCF retrieval rates. We propose a practical plan requiring clinicians requesting for IVCF to check an evidence-based indication via EHR. When an IVCF is placed, the Anticoagulation and Bleeding Management Specialty Nurse maintains a log of these patients and provides them with an Information Sheet that lists the date, indication and type of IVCF, specific instructions on IVCF retrieval, and a follow-up appointment in the Benign Hematology clinic for anticoagulant management. The Information Sheet is uploaded onto EHR for documentation. In conclusion, we identified the scope of practice and areas that could be improved by the adoption of a centralized and coordinated approach to monitor patients with IVCF. This study demonstrates the potential impact that a SBH has on health care delivery in both the inpatient and outpatient settings. DisclosuresNo relevant conflicts of interest to declare.