Preoperative Coagulation Parameters Research Articles

Comparison of coagulation profile and thromboembolic events among patients undergoing spinal surgery before and after COVID-19 pandemic.

Impairment of coagulation parameters and increased rate of thromboembolism are known complications of COVID-19 infection. In this study the coagulation profile and rate of thromboembolic events between two groups of patients who underwent spinal surgery before and after the COVID-19 pandemic was compared. Clinically and laboratory negative for COVID-19 elective patients before (n: 211) and during COVID- 19 pandemic (n: 294) with spinal surgeries were included in this retrospective study. Surgical characteristics, Physiologic parameters, coagulation parameters and thromboembolic events were compared between the two study groups. Preoperative coagulation parameters, including PT, PTT, and INR were significantly increased during the COVID-19 pandemic (P < 0.001. P = 0.001, and P < 0.001, respectively), while the platelet count was significantly reduced (P = 0.04). The same differences were observed between the two study groups after the spinal surgery. In addition, respiratory rate and postoperative bleeding of the first postoperative 24h was significantly more in patients who were operated on during COVID-19 outbreak (P = 0.03 and P = 0.002, respectively). The rate of thromboembolic events was 3.1% during the COVID-19 pandemic (seven PE, one DVT, and one MI) and 0% before that. This difference was statistically significant (P = 0.043). The rate of thromboembolic events seems to be increased during the COVID-19 pandemic. These findings urge more stringent monitoring of the patients' coagulation parameters during the COVID-19 outbreak.

Safety profile of preoperative administration of low-molecular-weight heparin on minimally invasive lung cancer surgery: a randomized controlled trial

BackgroundVenous thromboembolism remains a common but preventable complication for cancerous lung surgical patients. Current guidelines recommend thromboprophylaxis for lung patients at high risk of thrombosis, while a consensus about specific administration time is not reached. This study was designed to investigate the safety profile of preoperative administration of low-molecular-weight-heparin (LMWH) for lung cancer patients.MethodsFrom July 2017 to June 2018, patients prepared to undergo lung cancer surgery were randomly divided into the preoperative LMWH-administration group (PRL) for 4000 IU per day and the postoperative LMWH-administration group (POL) with same dosage, all the patients received thromboprophylaxis until discharge. Baseline characteristics including demographics and preoperative coagulation parameters were analyzed, while the endpoints included postoperative coagulation parameters, postoperative drainage data, hematologic data, intraoperative bleeding volume and reoperation rate.ResultsA total of 246 patients were collected in this RCT, 34 patients were excluded according to exclusion criterion, 101 patients were assigned to PRL group and 111 patients belonged to POL group for analysis finally. The baseline characteristic and preoperative coagulation parameters were all comparable except the PRL group cost more operation time (p = 0.008) and preoperative administration duration was significantly longer (p < 0.001). The endpoints including postoperative day 1 coagulation parameters, mean and total drainage volume, drainage duration, intraoperative bleeding volume and reoperation rate were all similar between the two groups. Moreover, coagulation parameters for postoperative day 3 between the two groups demonstrated no difference.ConclusionPreoperative administration of low-molecular-weight-heparin demonstrated safety and feasibility for lung cancer patients intended to receive minimally invasive surgery.Trial registration: ChiCTR2000040547 (www.chictr.org.cn), 2020/12/1, retrospectively registered.

Bleeding risk of image-guided percutaneous catheter drainage of pyogenic liver abscess in patients with coagulopathy.

Percutaneous catheter drainage (PCD) is the mainstream treatment for pyogenic liver abscess (PLA). However, in some patients with severe coagulopathy, there may increase the risk of bleeding complications related to PCD. Therefore, this study was aimed to evaluate the incidence of bleeding complications of PCD in PLA patients complicated with coagulopathy. Between January 2011 and September 2019, patients diagnosed with PLA who had undergone PCD were selected retrospectively. Based on the preoperative coagulation parameters, the patients were divided into the coagulopathy group (PLT ≤ 50 × 109/L or INR ≥ 1.5) and the normal coagulation group. The major and minor bleeding complications related to PCD were compared between the two groups. The ICU occupancy and mortality rates in the coagulopathy group were assessed and compared with patients of normal coagulation group. A total of 583 PLA patients subjected to PCD were selected. 522 patients were finally included in this study: 64 cases (12.26%) in the coagulopathy group and 458 cases (87.74%) in the normal coagulation group. No major bleeding complications related to PCD was observed. Two patients (0.38%) of minor bleeding complications, one patient in each group, showed no statistically significant difference (0.2% vs.1.6%, P > 0.05). The ICU occupancy rate of coagulopathy group was significantly higher than normal coagulation group (6.2% vs. 0.7%, P < 0.05). No significant difference in mortality rate was noted between the two groups (4.7% vs.1.5%, P > 0.05). The incidence of bleeding complications related to PCD in PLA patients is rare even if complicated with coagulopathy.

Comparison of complete and near-complete endovascular embolization of hypervascular spine tumors with partial embolization.

Preoperative endovascular embolization of hypervascular spine tumors can reduce intraoperative blood loss. The extent to which subtotal embolization reduces blood loss has not been clearly established. This study aimed to elucidate a relationship between the extent of preoperative embolization and intraoperative blood loss. Sixty-six patients undergoing preoperative endovascular embolization and subsequent resection of hypervascular spine tumors were retrospectively reviewed. Patients were divided into 3 groups: complete embolization (n = 22), near-complete embolization (≥ 90% but < 100%; n = 22), and partial embolization (< 90%; n = 22). Intraoperative blood loss was compared between groups using one-way ANOVA with post hoc comparisons between groups. The average blood loss in the complete embolization group was 1625 mL. The near-complete embolization group had an average blood loss of 2021 mL in surgery. Partial embolization was associated with a mean blood loss of 4009 mL. On one-way ANOVA, significant differences were seen across groups (F-ratio = 6.81, p = 0.002). Significant differences in intraoperative blood loss were also seen between patients undergoing complete and partial embolization (p = 0.001) and those undergoing near-complete and partial embolization (p = 0.006). Pairwise testing showed no significant difference between complete and near-complete embolization (p = 0.57). Analysis of a combined group of complete and near-complete embolization also showed a significantly decreased blood loss compared with partial embolization (p < 0.001). Patient age, tumor size, preoperative coagulation parameters, and preoperative platelet count were not significantly associated with blood loss. Preoperative endovascular embolization is associated with decreased intraoperative blood loss. In this series, blood loss was significantly less in surgeries for tumors in which preoperative complete or near-complete embolization was achieved than in tumors in which preoperative embolization resulted in less than 90% reduction of tumor vascular blush. These findings suggest that there may be a critical threshold of efficacy that should be the goal of preoperative embolization.

Preoperative thromboprophylactic administration of low-molecular-weight-heparin significantly decreased the risk of intraoperative bleeding compared with heparin in patients undergoing video-assisted lobectomy for lung cancer.

Due to the threat from venous thromboembolism (VTE) after major thoracic surgery, especially for cancers, guidelines recommend either heparin sodium (unfractionated heparin) or low-molecular-weight-heparin (LMWH) for those patients at high risk of deep vein thrombosis (DVT). However, risk of bleeding remains a major concern for pre-operative administration of anti-coagulation agents. Therefore, this study aimed to compare the bleeding risk of preoperative administration of LMWH and heparin in patients undergoing video-assisted thoracic surgery (VATS) lobectomy for lung cancer. A retrospective, single-center study was designed. A total of 130 patients diagnosed with lung cancer were included from August 2016 to January 2018. These patients were divided into two groups. The preoperative administration of heparin group (PH group) had received heparin 5,000 IU, BID (twice a day) both pre- and post-operatively. And the LMWH group (PL group) had received LMWH 4,000 IU, QD (once a day) both pre- and post-operatively. These anticoagulants would not be ceased until patient was discharged or 24-hour postoperative chest drainage volume exceeded 500 mL. Both preoperative and postoperative coagulation parameters including platelet count (PLT), hemoglobin value (HGB), international normalized ratio (INR), prothrombin time (PT), activated partial thromboplastin time (APTT), fibrinogen (FIB), thrombin time (TT), postoperative drainage parameters and intraoperative bleeding volume were compared. A total of 62 patients were collected in PH group, while 68 patients comprised PL group. Preoperative coagulation parameters, hematologic data and demographic data were comparable. Preoperative duration of two agents (P=0.414), operation time (P=0.155), postoperative HGB (P=0.943), PLT (P=0.244), INR (P=0.469), PT (P=0.651), TT (P=0.407), FIB (P=0.151), drainage duration (P=0.800), duration of heparin and LMWH (P=0.778) were all comparable between the two groups. Compared with PL group, intraoperative bleeding volume (105.11 and 50.26, P<0.001) and postoperative mean drainage volume (251.52 and 216.90 mL, P=0.025) of PH group were significant more. Postoperative APTT (30.17 vs. 28.20 seconds, P=0.022) was significantly longer in PH group. Compared with preoperative administration of heparin, preoperative thromboprophylactic administration of LMWH significantly decreased the risk of intraoperative bleeding in VATS lobectomy.

Prediction of Flap Compromise by Preoperative Coagulation Parameters in Head and Neck Cancer Patients

Studies on coagulation parameters (including activated partial thromboplastin time, prothrombin time, thrombin time, fibrinogen [FIB], platelet count, and D-dimer) in flap compromise are limited. The aim of the present study was to compare coagulation parameter variables in patients with and without flap compromise. In this retrospective cohort study, patients were recruited from the Department of Oral and Maxillofacial Surgery at the Second Xiangya Hospital (Changsha, Hunan, China) from July 2016 through July 2017. The primary predictor variable was a set of coagulation parameters. The primary outcome variable was flap compromise. The other variables were age, gender, tumor stage, smoking, and prior radiotherapy. Descriptive, bivariate, receiver operating characteristic (ROC) curves and regression statistics were computed. Statistical significance was set at less than .05 with 95% reliability. A total of 503 patients with 42 compromised flaps were identified in this study. Venous thrombosis, arterial thrombosis, or no confirmed reason for compromise was observed in 28, 5, or 9 compromised flaps, respectively. Only FIB was associated with flap compromise or venous thrombosis at adjusted analyses, although the predictive values were low at ROC analysis. For patients with D-dimer lower than 0.4μg/mL, the likelihood of venous thrombosis was greater than that for patients with D-dimer of at least 0.4μg/mL (P=.0414). For patients with FIB lower than 3.5g/L, the likelihood of venous thrombosis was greater than that for patients with FIB of at least 3.5g/L (P=.0336). Decreased FIB was associated with a higher rate of flap compromise. In patients with D-dimer lower than 0.4μg/mL or FIB lower than 3.5g/L, the risk of venous thrombosis was higher.

Acute postoperative cervical spinal epidural hematoma.

The aim of this study was to assess the clinical presentation, causes or risk factors, treatment and outcomes of symptomatic acute postoperative cervical spinal epidural hematoma (APCSEH). The study retrospectively reviewed all patients who underwent open cervical spinal surgery between January 1, 2004 and October 31, 2008. Perioperative coagulation parameters, past medical history, age, gender, time to decompression, pre- and postoperative (decompression operation) neurological status, as well as the interval of hematoma formation and level of segments were reviewed. Potential risk factors for extradural hematomas were examined. Patients who were diagnosed with APCSEH underwent immediate surgical drainage of the hematoma. Over 2,338 cervical spinal surgeries were performed by the Orthopedic Spinal Disorder Group in our hospital between 2004 and 2008. Twelve (0.5%) cases of APCSEH were identified. Two-thirds of the patients had history of hypertensive disease or transitory hypertensive status after surgery. No patients had abnormal preoperative coagulation parameters, bleeding diathesis or developed intraoperative coagulopathy. All patients were treated with hematoma evacuation within 2 hours of the ultimately definitive diagnosis of hematoma. Acute postoperative cervical spinal epidural hematoma is a rare cause of postoperative neurological deterioration. Hypertensive disease and the method of multilevel cervical surgery appear to increase bleeding and predict formation of hematoma. Early diagnosis and evacuation of the hematoma can result in resolution of the neurological deficit.

Spinal haematoma after removal of a thoracic epidural catheter in a patient with coagulopathy resulting from unexpected vitamin K deficiency

Postoperative epidural analgesia is effective and widely utilised after major abdominal surgery. Spinal haematoma is a rare and devastating complication after epidural analgesia. Well-established risk factors for the development of spinal haematoma after neuraxial procedures have been documented. We present the case of a patient with normal pre-operative coagulation parameters who developed a spinal haematoma more than 24 h after removal of an epidural catheter; she had been without oral intake for only 4 days during which time she developed vitamin K-deficient coagulopathy. Clinicians should consider pre-operative screening of coagulation (International Normalised Ratio), or giving vitamin K supplementation, before performing neuraxial procedures in patients who are at risk of developing vitamin K deficiency or coagulopathy in the peri-operative period.

Fresh frozen plasma in the pediatric pump prime: a prospective, randomized trial

Background The aim of this study was to determine whether the use of fresh frozen plasma (FFP) in the infant pump prime can avoid dilution of fibrinogen, decrease the need for blood product transfusion after bypass, and decrease exposure to donor blood products. Methods Twenty infants weighing less than 8 kg were prospectively randomized to receive either 1 U of FFP (10 patients) or no FFP (10 patients) in the pump prime. Mean age (4.2 ± 2.8 months), weight (4.3 ± 1.1 kg), total prime volume (641 ± 96 ml), cardiopulmonary bypass time, cross-clamp time, lowest temperature on bypass, and preoperative coagulation parameters did not differ between the two groups. Results At the end of bypass, the mean fibrinogen level was significantly higher in the FFP than the no FFP group (123 ± 20 versus 58 ± 17 mg/dL; p < 0.0001), whereas the mean platelet count did not differ (60 ± 25 versus 52 ± 26 K/mm 3; p = 0.5). Patients in the FFP group received significantly fewer units of cryoprecipitate (0.4 ± 0.8 versus 2.0 ± 0.9 U/patient; p < 0.001), and had a mean total donor exposure of 4.1 ± 1.5 U/patient versus 5.4 ± 1.4 U/patient in the no FFP group ( p = 0.06). The mean chest tube output over the first 24 hours did not differ between groups. Conclusions The use of FFP in the pump prime significantly limited dilutional hypofibrinogenemia, decreased the transfusion of cryoprecipitate after bypass, and tended to decrease the overall mean patient exposure to blood products.

Compensated activation of coagulation in patients with abdominal aortic aneurysm: effects of heparin treatment prior to elective surgery

Elective surgery of abdominal aortic aneurysm (AAA) sometimes leads to excessive bleeding and disseminated intravascular coagulation (DIC), even in patients with normal preoperative coagulation parameters. Coagulation screen, performed routinely before surgery is of limited value in the assessment of compensated activation of the haemostatic system. In this study, we used a number of additional tests (D-dimer, prothrombin fragment 1+2, antithrombin, and activation of fibrinolysis in the platelet poor plasma) for the diagnosis of compensated activation of the haemostatic system in AAA-patients. D-dimer and marker of thrombin generation (prothrombin fragment 1+2) positively correlated with each other (r = 0.768, P < 0.001). Out of 71 AAA patients, 15 patients had normal global coagulation times, but those with a D- dimer concentration above 3000 ng/ml were selected for preoperative low molecular weight heparin (LMWH) treatment. Administration of LMWH diminished coagulation abnormalities (D-dimer and prothrombin fragment 1+2 decreased significantly) and resulted in the increase of platelet number and fibrinogen concentration, indicating their previous consumption. Despite differences in aneurysm diameters between the groups of 15 LMWH treated patients (mean 70.9 +/- 16 mm) and the reference group of 20 untreated AAA patients (mean 52.3 +/- 8.0 mm), intraoperative parameters (operation time, blood loss and transfusion demands) were similar.

Emergency coronary artery bypass grafting: does excessive preoperative anticoagulation increase bleeding complications and transfusion requirements?

Patients requiring urgent surgical revascularization due to unstable coronary artery disease are usually pretreated with multiple antithrombotic drugs. The perioperative risks of this type of treatment were investigated in 123 patients who underwent emergency coronary artery bypass grafting (CABG) at our institution. Eighty-two patients (group A) received heparin and acetylsalicylic acid solely and 41 patients (group B) received additionally ADP-receptor antagonists (82.9%), glycoprotein IIb/IIIa inhibitors (12.2%) or thrombolysis (14.6%) preoperatively. Both groups were similar regarding demographic data and overall clinical status. Preoperative coagulation parameters and intraoperative characteristics were comparable. Blood loss via chest tubes was not significantly different between groups. Transfusion of red blood cells and fresh frozen plasma were slightly, but not significantly increased in group B. Transfusion of pooled platelets was low in general and similar in both groups. Re-exploration rate, medium intensive care unit and hospital stay as well as perioperative mortality were comparable. Excessive antithrombotic pretreatment seems to bear no additional risk in emergency CABG and may be beneficial in this setting.

Mechanical circulatory support and heart transplantation. Pre-operative status and outcome.

Between July 1988 and December 1993, 118 patients waiting for heart transplantation underwent mechanical circulatory support by an extracorporeal, pneumatically driven assist device (the Berlin Heart System) to maintain a sufficient circulation and to restore impaired organ function (109 patients requiring a biventricular assist device [BVAD], 9 patients requiring a left ventricular assist device [LVAD]). Before implantation, all patients were in severe cardiogenic shock, despite maximum inotropic support; all had end organ failure. The aim of a retrospective study in 70 patients (for whom pre-operative parameters were available) was to identify patients who would permit from this procedure and could undergo successful transplantation. After a mean bridging time of 34.8 days, 75 (63.5%) patients underwent transplant, and 52 (44.1%) were discharged. Pre-operative coagulation parameters (fibrinogen, antithrombin III, platelet count, and kinetics) were correlated to post-operative blood loss and outcome. Patients who had no or mild coagulation disorders because of a shorter phase of low cardiac output before implantation of the assist device proved to gain faster restitution of organ function and most underwent transplantation. As a result of these observations, implantation of an assist device before shock-induced coagulopathy could occur allowed a greater number of patients to undergo successful bridging and be discharged after heart transplantation.

Disseminated Intravascular Coagulation During Surgery for Scoliosis

Disseminated intravascular coagulation (DIC) was recently observed intraoperatively in two patients who required correction and stabilization of scoliosis with Harrington instrumentation and spinal fusion. Despite negative bleeding history and normal preoperative coagulation parameters, each patient developed sudden massive bleeding soon after decortication of spinous processes and facet joints. Coagulation profile revealed decreased platelets, plasma coagulation factors, and fibrinogen in association with elevated fibrin split products. Cessation of all bleeding occurred within a few hours. There was rapid correction of the coagulation parameters with blood component replacement therapy, indicating that the defibrination was short-lived and had ceased by the end of surgery. A review of the literature revealed six similar cases of DIC occurring during elective orthopedic surgery, four of which involved spinal arthrodesis and/or bone grafts. We suggest that injury secondary to decortication or chipping at bone can serve as a trigger for defibrination. This type of DIC is self-limited, and ends with completion of the operation. The treatment is blood component replacement. Heparin should be avoided.