Thrombelastography Parameters Research Articles

The effects of preloading infusion with hydroxyethyl starch 200/0.5 or 130/0.4 solution on hypercoagulability and excessive platelet activation of patients with colon cancer

Hypercoagulability and excessive platelet activation account for a significant percentage of mortality and morbidity in cancer patients. In order to test the hypothesis that preloading infusion (PLI) with 6% hydroxyethyl starch 200/0.5 (HES 200), or 6% hydroxyethyl starch 130/0.4 (HES 130) solution can attenuate the hypercoagulable state and inhibit excessive platelet activation of patients with colon cancer, we selected 35 colon cancer patients undergoing laparoscopic-assisted radical colectomy. They were received randomly a test of 15 ml/kg of either HES 200 (n=17), or HES 130 (n=18) over a 30-min period preoperatively. In addition, fifteen healthy volunteers were selected as normal control group. Coagulation function was assessed by thrombelastography (TEG), platelet glycoprotein IIb/IIIa and CD62P was analyzed by flow cytometry before PLI, the end of PLI, 1 h after PLI, and 1 h after the end of surgery. Results demonstrated that hypercoagulable state indicated by TEG and excessive platelet activation was found in patients with colon cancer. We found that preloading infusion with HES 200/0.5 can inhibit platelet activation, and the two solutions, especially HES 200/0.5, compromised TEG parameters that indicated hypercoagulability of patients with colon cancer during perioperative period.

Differentiation of Enzymatic from Platelet Hypercoagulability Using the Novel Thrombelastography Parameter Delta (Δ)

Thrombelastography (TEG) allows for rapid global assessment of coagulation function. Our previous work demonstrated that a hypercoagulable state identified by TEG's G value was associated with thromboembolic events in a cohort of critically ill surgical patients despite routine chemoprophylaxis. We hypothesized that a hypercoagulable state could be differentiated into enzymatic or platelet etiology through the use of thrombus velocity curves; specifically the time to maximum rate of thrombus generation (TMRTG) and the novel TEG parameter, delta. (Delta) We retrospectively studied 10 critically ill surgical patients receiving thromboprophylaxis for at least 72 h by TEG, using kaolin activated citrated samples. Thrombus velocity curves were plotted for each patient, and delta was calculated as the difference between the TEG parameters R and SP, corresponding to the time to maximum rate of thrombus generation (TMRTG), which reflects the enzymatic contribution to clot formation. The TEG parameter G, (G = 5000 x A/100-A) also was determined for each patient. As G is derived from amplitude (A), it reflects overall net clot strength. A hypercoagulable state was defined as delta < 0.6 min and/or G > 11 dynes/cm(2). A hypercoagulable state was identified via delta in 6 patients (60%); all of whom remained hypercoagulable following heparinase addition, suggesting chemoprophylaxis was ineffective. Of six patients with a hypercoagulable G value, 50% had a normal delta suggesting the presence of platelet hypercoagulability. Delta closely correlated with TMRTG (r = 0.94). However, the varying contribution of platelets to hypercoagulability, was shown by a nonlinear, weak correlation of delta and TMRTG with G (r = 0.11 and r = 0.14, respectively). Delta reflects changes in thrombin generation as measured by TMRTG, allowing for differentiation of enzymatic from platelet hypercoagulability. Future studies will be required to validate these findings.

The effect of unfractionated heparin on thrombelastographic analysis in healthy dogs

To determine the effect of single and multiple doses of SQ heparin (200 U/kg) on the thrombelastogram of healthy dogs. Prospective study. University research facility. Six random-source female dogs. Baseline parameters, including a CBC with platelet count, prothrombin time, activated partial thromboplastin time (aPTT), and antithrombin were performed. Thrombelastography (TEG) and aPTT were performed hourly for 12 hours after unfractionated heparin dosing (200 U/kg, SQ). Anti-Xa activity was assayed at 0, 3, 6, and 8 hours. Heparin was then administered every 8 hours for 3 days. The sampling protocol on Day 4 was identical to Day 1. On Day 1, percentage change from baseline for TEG parameter R, as well as absolute values of K, angle, and maximum amplitude (MA) were evaluated. Statistically significant (P<0.01) prolongation of the R time and a decrease in angle and MA was seen in all dogs by hour 3. R and MA were unmeasurable for most dogs between 3 and 5 hours. All TEG tracings returned to baseline by 12 hours. Day 4 TEG tracings mimicked those on Day 1. Only 1 dog achieved aPTT values outside the reference interval on both days. Anti-Xa activity levels increased on Day 4 but not on Day 1. Based on post hoc in vitro analysis, prolongation of R time occurred at plasma heparin levels as low as 0.075 U/mL, well below the lower limit of detection of the anti-Xa activity level assay. Administration of SQ heparin results in progressive changes in the TEG tracing, with maximal change occurring 3-5 hours after dosing. The extensive prolongation of the R time also indicates that TEG may be too sensitive and limits its utility as a monitoring tool for unfractionated heparin therapy.

Differentiation of Enzymatic from Platelet Hypercoagulability Using the Novel Thrombelastography Parameter Delta (Δ)

Background: Thrombelastography (TEG) allows for rapid global assessment of coagulation function. Our previous work demonstrated that a hypercoagulable state identified by TEG's G value was associated with thromboembolic events in a cohort of critically ill surgical patients despite routine chemoprophylaxis. We hypothesized that a hypercoagulability state could be differentiated into enzymatic or platelet etiology through the use of thrombin velocity generation curves; specifically the time to maximum rate of thrombus generation (TMRTG) and the novel TEG parameter, delta (Δ).

Evaluation of a modified thrombelastography assay initiated with recombinant human tissue factor in clinically healthy horses

Thrombelastography (TEG) is used to evaluate the viscoelastic properties of blood during clotting and provides a global assessment of hemostasis and clot lysis. TEG analysis initiated with recombinant human tissue factor (TF) has not been evaluated in clinically healthy horses. The purpose of this study was to determine whether TEG results are affected by the time elapsed between sampling and analysis (storage time) of equine blood samples and to establish a preliminary equine reference interval for a modified TEG assay, using recombinant human TF to initiate coagulation. Citrated blood samples were obtained from 20 clinically healthy adult horses. Thirteen samples were stored for 30, 60, and 120 minutes at room temperature before TEG analysis. Coagulation was initiated by adding 20 microL of CaCl(2) to 330 microL of blood and 10 microL of diluted recombinant TF for a final dilution of 1:3600. Reaction (R) and clotting (K) times, angle (alpha), and maximum amplitude (MA) were compared between time points. A preliminary reference interval (minimum-maximum values) was determined using data from all 20 horses after 30 minutes of sample storage. There was a significant effect of storage time on R, K, and alpha but not MA. Reference intervals were: R, 3.65-6.4 minutes; K, 1.8-5.45 minutes; alpha, 33.4-66.2 degrees ; MA, 41.2-64.1 mm; lysis at 30 minutes post-MA (LY30), <2.75%; and lysis at 60 minutes post-MA (LY60), 1.55-9.5%. TEG can be performed on equine citrated blood samples using recombinant human TF to activate clot formation. TEG parameters were significantly affected by storage time, suggesting an incomplete inhibition of coagulation in citrated blood.

Coagulopathy and traumatic shock: Characterizing hemostatic function during the critical period prior to fluid resuscitation

Aims Identifying early changes in hemostatic clot function as a result of tissue injury and hypoperfusion may provide important information regarding the mechanisms of traumatic coagulopathy. A combat-relevant swine model was used to investigate the development of coagulopathy during trauma by monitoring hemostatic function during increasing severity of shock. Methods Swine were injured (soft tissue + femur fracture) and hemorrhaged while continuously monitoring Oxygen Debt (OD) by indirect calorimetry at the airway. Hemostatic function was assessed by Thrombelastography (TEG), Prothrombin Time (PT), Partial Thromboplastin Time (PTT), and fibrinogen concentration and compared before hemorrhage (D0) and during shock when OD = 40 and 80 ml/kg. An instrumented sham group was used for comparison. Results N = 23 swine ( N = 18 hemorrhage, N = 5 sham) weighing 45 ± 6 kg were studied after removing an average of 34 ± 14% of blood volume during hemorrhage. Hgb, Hct, platelet counts, PT and PTT did not change with increasing OD ( p < 0.05). Fibrinogen was reduced significantly by OD = 40 ml/kg (mean diff. = −59.9 mg/dl, 95% CI diff. [−95.1, −24.6]). TEG parameters representing clot initiation ( R) and polymerization ( K and Alpha Angle) did not change with increasing OD during shock ( p > 0.053). Clot strength (MA) was reduced in the hemorrhage group by OD = 80 ml/kg (mean diff. = −4.1 mm, 95% CI diff. [−7.4, −0.8]). Conclusion In this swine model of traumatic shock, fibrinogen was significantly reduced and an isolated reduction in clot strength (MA) was found with increasing OD. Fibrinogen consumption and altered platelet function may account for the earliest changes in hemostatic function during traumatic shock.

Early evaluation of acute traumatic coagulopathy by thrombelastography

Posttraumatic coagulopathy is a major cause of morbidity. This prospective study evaluated the thrombelastography (TEG) system and PlateletMapping (Haemoscope Corporation, Niles, Ill) values posttrauma, and it correlated those values with transfusions and fatalities. After institutional review board approval, assays were performed on 161 trauma patients. One citrated blood sample was collected onsite (OS), and 1 citrate and 1 heparinized sample were collected within 1 h of arrival to the emergency department (ED). Paired and unpaired t-testing was performed for nominal data with chi square testing for categorical values. Except for a slight increase in clot strength (maximal amplitude (MA)), there were no significant changes from OS to the ED. None of the TEG parameters were significantly different for the 22 patients who required transfusion. PlateletMapping showed lower platelet adenosine diphosphate (ADP) responsiveness in patients who needed transfusions (MA = 22.7 +/- 17.1 vs MA = 35.7 +/- 19.3, P = 0.004) and a correlation of fibrinogen <100 mg/dL with fatalities (P = 0.013). For the 14 fatalities, TEG reaction (R) time was 3703 +/- 11,618 versus 270 +/- 393 s (P = < 0.001), and MA was 46.4 +/- 22.4 versus 64.7 +/- 9.8 mm (P < 0.001). Hyperfibrinolysis (percent fibrinolysis after 60 min (LY60) >15%) was observed in 3 patients in the ED with a 67% fatality rate (P = < 0.001 by chi-square testing). PlateletMapping assays correlated with the need for blood transfusion. The abnormal TEG System parameters correlated with fatality. These coagulopathies were already evident OS. The TEG assays can assess coagulopathy, platelet dysfunction, and hyperfibrinolysis at an early stage posttrauma and suggest more effective interventions.

Recombinant factor VIIa and fibrinogen display additive effect during in vitro haemodilution with crystalloids

Major blood loss requires fluid resuscitation for maintaining hemodynamic stability. Excessive volume infusions predispose to dilutional coagulopathy through loss, consumption and dilution of cells and proteins involved in haemostasis. Further treatment with fibrinogen concentrate and/or recombinant activated factor VII (rFVIIa) may be initiated, although the haemostatic effects in a situation with haemodilution are not fully detailed. The present study evaluates haemostatic effect of fibrinogen and rFVIIa and their combination in an in vitro model of haemodiluted whole blood with two commonly used crystalloids. Eight healthy, male volunteers were enrolled. Outcome variables were clot initiation, propagation and strength assessed by thrombelastographic parameters: clotting time, clot formation time, maximum velocity, time until maximum velocity, maximum clot firmness evaluated at dilution levels of 0% (control), 10%, 30% and 50% with isotonic saline and Ringer's lactate in a model of tissue factor-activated whole blood. Fibrinogen and rFVIIa were additional final reaction concentrations, reflecting commonly used clinically therapeutic dosages. Dose-dependent coagulopathy developed following haemodilution with isotonic saline and Ringer's lactate, characterised by a prolonged clot initiation, reduced clot propagation and reduced clot strength. Fibrinogen improved clot strength and propagation phase while rFVIIa shortened clot initiation, both with a positive dose dependency. The combination of fibrinogen and rFVIIa displays an additive effect and improves overall in vitro whole blood clot formation in a model of in vitro crystalloid-induced haemodilution.

Thrombelastography in 26 healthy horses with and without activation by recombinant human tissue factor

To develop a standardized technique for thrombelastography (TEG) analysis in healthy adult horses, with and without the ex vivo addition of tissue factor (TF) as an activator. To determine reference intervals for TEG parameters in the horse, and to determine if traditional coagulation tests correlate with TEG. Prospective, observational. Veterinary teaching hospital. Twenty-six healthy adult horses. None. Thrombelastography with (TF-TEG) and without (TEG) the addition of TF performed by 4 operators. Coagulation profiles (prothrombin time, activated partial thromboplastin time, platelet count, fibrinogen, antithrombin, and fibrinogen degradation products) were assessed in a subset of horses. Mean values (SD) for TEG parameters in healthy horses were: reaction time (R)=17.0 minutes (3.0 min), K time (K)=5.8 minutes (2.3 min), clotting rate (Ang)=42 degrees (14 degrees ), maximum clot strength (maximum amplitude [MA])=60.3 mm (5.7 mm), CL30=97.0% (2.0%), LY30=0.8% (0.6%), CL60=92% (5.9%), LY60=3.2% (2.5%). Mean values (SD) for TF-TEG parameters were: R-TF=6.6 minutes (1.4 min), K-TF=3.1 minutes (1.0 min), Ang-TF=50.9 degrees (9 degrees ), MA-TF=62.3 mm (5.1 mm), CL30-TF=97.8% (1.6%), LY30-TF=0.6% (0.5%), CL60-TF=90.8% (4.2%), and LY60-TF=3.6% (1.9%). The addition of TF decreased R and K and increased Ang. TF-TEG had a narrower SD for R, K, Ang, CL60 and LY60 compared with TEG. Interoperator differences were reduced by the addition of TF. Regression analysis indicated a positive relationship between MA and fibrinogen concentrations (P=0.02) and R-TF time and prothrombin time (P=0.03). TF-TEG using the described protocol may minimize variability in data obtained across institutions or users. However, due to the variability associated with different operators, it is recommended that each laboratory set up individual reference intervals with the personnel who will perform the assay, and that the assay protocols and data obtained are compared on a regular basis.

Application of basic and composite thrombelastography parameters in monitoring of the antithrombotic effect of the low molecular weight heparin dalteparin: an in vivo study

BackgroundLow molecular weight heparin (LMWH) is in vast usage for treatment of thromboembolic diseases such as deep venous thrombosis and acute coronary syndromes. There are certain clinical situations where a quick point of care testing of the effect of LMWH would be useful. At this point there are no point of care devices available in the market for monitoring the effect of LMWH. Thrombelastography (TEG) evaluates the viscoelastic properties of blood during coagulation. The clinical application of TEG in monitoring LMWH treatment is not yet well defined. The purpose of this in vivo study was to systematically evaluate the most suitable TEG parameters for evaluation of the antithrombotic effect of LMWH. We furthermore evaluated for the first time the usefulness of the composite TEG parameter the Thrombodynamic Ratio (TDR) in monitoring LMWH treatment.MethodsHealthy male volunteers (n = 7) were injected subcutaneously with the LMWH dalteparin 120 IU/kg. TEG parameters and antifactor Xa levels were measures at baseline, 2, 4, 5 and 24 hours after the injection. Correlation between TEG parameters and antiXa were calculated. The sensitivity and specificity of the TEG parameters for plasma levels of antiXa in the therapeutic range of 0.5 - 1.0 U/ml were calculated.ResultsAll basic TEG parameters correlated significantly with antiXa levels. Among the basic parameters, the TEG reaction time R had the best correlation with antiXa levels with the most favorable combination of sensitivity and specificity for the therapeutic range of antiXa levels (r = 0.82, p < 0.0001, sensitivity 68%, specificity 100%). The composite TEG parameter TDR demonstrated the best correlation with antiXa levels, and an even more favorable combination of sensitivity and specificity compared to any of the basic parameters (r = - 0.87, p < 0.0001, sensitivity 95%, specificity 79%).ConclusionThe TEG reaction time R and TDR are the most suitable TEG parameters for evaluation of the antithrombotic effect of dalteparin with a highly significant correlation with antiXa levels in healthy male volunteers. Measures for uniform clinical use of these parameters are proposed. Larger clinical trials are needed to correlate R and TDR with clinical outcomes.

In vitro chelating, cytotoxicity, and blood compatibility of degradable poly(ethylene glycol)-based macromolecular iron chelators

Desferrioxamine (DFO) is used to treat an excess accumulation of iron in the body and is currently the most commonly used iron chelator for the treatment of ‘iron overload’ disorder. However, the disadvantages of DFO surround its high toxicity and very short plasma half-life. Here, the detailed in vitro evaluation of a novel class of high molecular weight iron chelators based on DFO and polyethylene glycol methacrylate is reported. Reversible addition fragment chain transfer (RAFT) copolymerization afforded polymer conjugates (P-DFO) with well-controlled molecular weight (27–127 kDa) and substitution of DFO (5–26 units per chain) along the copolymer. Human umbilical vein endothelial cell (HUVEC) based cell viability assays showed that the cytotoxicity of P-DFO decreased more than 100-fold at identical concentrations of DFO. The hemocompatibilities of various P-DFO samples were determined by measuring prothrombin time (PT), activated partial thromboplastin time (APTT), thrombelastograph parameters (TEG), complement activation, platelet activation, and red blood cell aggregation. Furthermore, the iron binding properties and chelating efficiency of P-DFO were compared to DFO by measuring the spectral properties upon binding to iron(III), while the prevention of iron(III) mediated oxidation of hemoglobin was also determined. Degradation of the P-DFO conjugates via cleavable ester linkages between the polymer backbone and the PEG side chains was evaluated using gel permeation chromatography (GPC) and NMR. Since the chelating ability of DFO remains intact after conjugation to the copolymer backbone, these macromolecular, blood compatible and degradable conjugates are promising candidates as long circulating, non-toxic iron chelators.

Thrombelastography is Better Than PT, aPTT, and Activated Clotting Time in Detecting Clinically Relevant Clotting Abnormalities After Hypothermia, Hemorrhagic Shock and Resuscitation in Pigs

Hypothermia and hemorrhagic shock contribute to coagulopathy after trauma. In this study, we investigated the independent and combined effects of hypothermia and hemorrhage with resuscitation on coagulation in swine and evaluated clinically relevant tests of coagulation. Pigs (n = 24) were randomized into four groups of six animals each: sham control, hypothermia, hemorrhage with resuscitation, and hypothermia, hemorrhage with resuscitation combined. Hypothermia to 32 degrees C was induced with a cold blanket. Hemorrhage was induced by bleeding 35% of total blood volume followed by resuscitation with lactated Ringer's solution. Coagulation was assessed by thrombin generation, prothrombin time (PT), activated partial thromboplastin time (aPTT), activated clotting time (ACT), and thrombelastography (TEG) from blood samples taken at baseline and 4 hour after hypothermia and/or hemorrhage with resuscitation. Data were compared with analysis of variance. Baseline values were similar among groups. There were no changes in any measurements in the control group. Compared with baseline values, hemorrhage with resuscitation increased lactate to 140% +/- 15% (p < 0.05). Hypothermia decreased platelets to 73% +/- 3% (p < 0.05) with no effect on fibrinogen. Hemorrhage with resuscitation reduced platelets to 72% +/- 4% and fibrinogen to 71% +/- 3% (both p < 0.05), with similar decreases in platelets and fibrinogen observed in the combined group. Thrombin generation was decreased to 75% +/- 4% in hypothermia, 67% +/- 6% in hemorrhage with resuscitation, and 75% +/- 10% in the combined group (all p < 0.05). There were no significant changes in PT or aPTT by hemorrhage or hypothermia. ACT was prolonged to 122% +/- 1% in hypothermia, 111% +/- 4% in hemorrhage with resuscitation, and 127% +/- 3% in the combined group (all p < 0.05). Hypothermia prolonged the initial clotting time (R) and clot formation time (K), and decreased clotting rapidity (alpha) (all p < 0.05). Hemorrhage with resuscitation only decreased clot strength (maximum amplitude [MA], p < 0.05). TEG parameters in the combined group reflected the abnormal R, K, MA, and alpha observed in the other groups. Hypothermia inhibited clotting times and clotting rate, whereas hemorrhage impaired clot strength. Combining hypothermia with hemorrhage impaired all these clotting parameters. PT, aPTT were not sensitive whereas ACT was not specific in detecting these coagulation defects. Only TEG differentiated mechanism related to clotting abnormalities, and thus may allow focused treatment of clotting alterations associated with hypothermia and hemorrhagic shock.

Race and sex differences in thrombogenicity: risk of ischemic events following coronary stenting

Race and sex affect thrombogenicity. We have demonstrated that platelet-fibrin clot characteristics can be used to stratify patients for risk of ischemic events following percutaneous coronary intervention. We investigated race and sex differences in thrombogenicty and the relation to ischemic risk in 252 consecutive African-American and Caucasian men and women undergoing elective percutaneous coronary intervention. Platelet-fibrin clot characteristics were measured using the Thrombelastograph Hemostasis System. The incidence of adverse ischemic events was assessed over a 6-month follow-up period. Overall, 40 ischemic events (15.9%) occurred. Adverse events were higher in African-Americans than Caucasians (P = 0.14), and in women than men (P = 0.004). The incidence was highest in African-American women (37.5%) and lowest in African-American men (6.5%). Measured Thrombelastograph parameters were significantly different between ischemic and nonischemic patients (P < 0.05). African-American women in the ischemic group exhibited higher thrombogenicity than the other race and sex groups (P < 0.05). Multivariate logistic regression identified platelet-fibrin mediated clot strength (relative risk 2.52, P = 0.017) and sex (relative risk 2.56, P = 0.009) as significant independent predictors of ischemic events 6 months postpercutaneous coronary intervention. Thrombogenicity is a novel measurable cardiovascular risk factor that varies by race and sex, is highest in African-American women, and independently predicts the frequency of ischemic events following percutaneous coronary intervention. Point-of-service measurements of platelet-fibrin clot characteristics may lead to more intensified antithrombotic therapy and reduced mortality in selected patients.

New assays for monitoring haemophilia treatment

Precise measurements of factor VIII (FVIII) or factor IX (FIX) activity are believed to be essential for clinical management in haemophilia, although discrepancies between factor levels and clinical severity have been recognized. Clot wave form analysis has demonstrated that different wave form patterns may be evident in severe haemophilia A patients with levels of FVIII activity <1 IU dL(-1), and this might explain, in part, the phenotypic heterogeneity seen in these patients. In addition, the relatively new technique of computer-assisted thrombelastography (TEG), in which coagulation is initiated by tissue factor, has revealed a considerable degree of variability in different patients in the presence FVIII levels, which are sufficient to normalize TEG parameters. In contrast, a global thrombin generation test (TGT) has been proposed as a sensitive and reliable method for assessing overall clotting function in haemophilia patients. Several studies have demonstrated a significant correlation between TGT and FVIII/FIX levels, and these measurements also appear to correlate with the clinical phenotype. The TGT may be very useful, therefore, for evaluating overall haemostasis in different clinical situations, although substantial inter-assay and inter-individual variations have been reported. Both the TEG and TGT have been found to be particularly helpful for monitoring haemostatic therapy with bypassing agents or conventional FVIII or FIX concentrates in patients with inhibitors. These global tests enable the selection of appropriate therapeutic agents in individual circumstances and offer the opportunity to tailor the most effective haemostatic treatment even during severe bleeding or major surgery.

Whole blood coagulation measured by modified thrombelastography (ROTEM) is impaired in infants with congenital heart diseases

Patients with congenital heart disease (CHD) often do have a variety of coagulation abnormalities that results in bleeding diathesis. Our study aimed to determine the impact of cyanosis and CHD on modified thrombelastography parameters, compared with children without CHD. Preoperative blood samples were taken for TEM analyses from a total of 51 infants scheduled for surgery. The following groups were examined: normal patients without CHD, acyanotic patients with acyanotic CHD, and cyanotic patients with CHD and with preoperative hemoglobin values higher than 15 g dl(-1). Mean values of all patient groups as well as all individual values of normal patients were within their normal ranges. Within these limits, however, clots were significantly inferior in cyanotic patients (worse mean values of eight out of 10 measured TEM parameters representing the intrinsic, extrinsic, and plasmatic pathways of coagulation) and in acyanotic patients (two out of 10 TEM parameters). Individually, pathological TEM parameters were found in seven (41%) cyanotic patients (P=0.003; vs. normal patients) and in three (17%) acyanotic patients (P=0.01). More than one abnormal TEM coagulation parameter was found in four patients, all of them cyanotic patients. Hyperfibrinolysis was detected in one patient, a cyanotic patient. The present investigation confirms previous findings that in patients with CHD the heart defect itself compromises coagulation monitored with TEM, but in addition, we demonstrate that cyanosis and/or polycythemia exert the essential negative impact on hemostasis. Preoperative hyperfibrinolysis detected with TEM seems to play no important role.

Fibrinolysis or hypercoagulation during radical prostatectomy? An evaluation of thrombelastographic parameters and standard laboratory tests

Radical prostatectomy is at high risk for intraoperative and postoperative bleeding due to surgical trauma, release of urokinase and tissue type plasminogen activator. We conducted this prospective, observational multi-centre study to assess the degree of systemic fibrinolysis or hypercoagulation in the perioperative period. We studied serial changes in standard laboratory values and in thrombelastographic (TEG; Haemoscope Corporation, Skokie, IL, USA) parameters including lysis at 30 and 60 min (LY-30, LY-60), alpha-angle (alpha) and maximum amplitude. In all, 49 patients undergoing radical retropubic prostatectomy in five Italian University Hospitals were included. Blood samples were taken before surgery (T1), at the removal of the prostate (T2), 4 h after surgery (T3) and then 1 day after surgery (T4). Native blood samples were analysed using a thrombelastograph Haemoscope 5000 (Haemoscope Corporation). We did not see any relevant activation of fibrinolysis during any stage. Intraoperatively, we showed even more activated blood coagulation with consumption of fibrinogen and a reduced TEG percentage clot lysis. Only at the first postoperative sample point we saw a trend towards a more fibrinolytic state indicated by increasing partial thromboplastin time, LY-30 and LY-60 values, and a peak of the fibrin degradation product D-dimers. This is consistent with a normal reaction to the hypercoagulable state before and is unlikely to be due to an intraoperative tissue type plasminogen activator release. We found no evidence of an uncontrolled activation of fibrinolysis on the day after surgery. On the contrary, alpha-values which indicate the rate of clot formation and which increase during hypercoagulation showed the tendency to rise slightly compared with the preoperative value. Neither standard coagulation parameters nor TEG values showed any significant activation of fibrinolysis or of hypercoagulation in the preoperative period. Nevertheless, hypercoagulation seems to have a substantial clinical impact as it has been shown that cardiovascular complications and pulmonary embolism were the most common causes of death after retropubic prostatectomy.

The dynamics of clot formation in fresh‐frozen plasma

Factor VIII (FVIII) levels are used as a quality marker of fresh-frozen plasma (FFP); however, other clotting factors are not routinely measured. We assessed additional haemostatic parameters and the dynamics of coagulation using Thrombelastography (TEG) and a thrombin generation test (TGT). FFP was prepared on the day of donation (Day 0) or after overnight hold at 4 degrees C (Day 1). Factor VIII in Day 1 FFP was 18% lower than in Day 0. TEG parameters in Day 1 FFP were consistent with increased coagulability and did not correlate with altered levels of clotting factors, but were consistent with the increased levels of microparticles seen in the Day 1 samples. TGT studies exhibited increased lag time, time to peak and reduced peak thrombin generation, but no change in endogenous thrombin potential (ETP) on Day 1. There was a weak association between FVIII level and both ETP and peak thrombin (ETP r(s)> or = 0.22, P< or = 0.003; peak thrombin r(s)> or = 0.48, P< or = 0.0001), which was influenced by ABO group, with the lowest levels in group O. We conclude that levels of FVIII do not predict the haemostatic potential of FFP and that there may be a role for alternative technologies in monitoring the quality of FFP.

A Reduction in Clot Formation Rate and Strength Assessed by Thrombelastography Is Indicative of Transfusion Requirements in Patients With Penetrating Injuries

Bleeding is a major cause of death in patients with traumatic injuries. Recently, thrombelastography (TEG) has been suggested as an additional means of evaluating coagulation in trauma patients. We hypothesized that TEG data would aid in defining the coagulopathy of trauma in patients with penetrating traumatic injuries. A retrospective study was performed of patients (n = 44) with penetrating injuries admitted to a combat support hospital during a 2-month period in 2004. Recorded data included standard laboratory data, TEG parameters, and blood product use in the first 24 hours after admission. Values were compared with clinically accepted ranges and those obtained from the Haemoscope Corporation. At admission, International Normalization Ratio, prothrombin time, and partial thromboplastin time were increased in 39% (>or=1.5), 31% (>16 seconds), and 37% (>40 seconds) of patients, respectively, suggesting hypocoagulation, but these variables did not correlate with the use of blood products (p > 0.05). TEG values obtained within 24 hours of admission (6 hours +/- 5.7 hours; median of 4.5 hours) demonstrated hypocoagulation based on delayed propagation of the clot (increased K time and reduced alpha-angle) and decreased clot strength (reduced maximal amplitude [MA]). MA correlated (r = 0.57, p < 0.01) with blood product use as well as platelet count (r = 0.61, p < 0.01). Patients with reduced MA (n = 23) used more blood products and had reduced platelet counts and hematocrit. Thrombelastography was a more accurate indicator of blood product requirements in our patient population than prothrombin time, partial thromboplastin time, and International Normalization Ratio. Thrombelastography enhanced by platelet count and hematocrit can guide blood transfusion requirements.

Thrombelastography for the monitoring of lipopolysaccharide induced activation of coagulation in neonatal cord and adult blood

The haemostatic system of neonates is quantitatively deficient at birth, and many coagulation variables constantly change over the first months of life. During Gram-negative sepsis, lipopolysaccharide (LPS) activates toll-like receptor (TLR) 4 and induces complex responses of immune system and haemostasis. Method: In the present study we compared LPS-induced activation of coagulation in whole blood (WB) samples from healthy adult volunteers and neonatal cord blood. Samples were incubated with LPS or control vehicle (normal saline) for various incubation periods (0–2-3–4 hrs), and coagulation was measured by rotation thrombelastography (Roteg 5, Pentapharm, Munich, Germany), a modification of the original thrombelastography method. The following four standard variables were analyzed: clotting time (CT), clot formation time (CFT), maximal clot formation (MCF), and angle a. Results: In the absence of LPS, CTs and CFTs were significantly shorter in cord than in adult WB samples (572±99 vs. 767±108s, and 225±50 vs. 393±57s). The time course of the LPS-induced interaction in thrombelastography parameters of adult WB and cord WB demonstrates that all parameters (CT, CFT, MCF, and angle a) were affected as the incubation period with LPS (100ng/ml) increased. Reduction of CT due to LPS incubation was significantly higher in cord (81 +/- 5%) than in adult WB samples (70 +/- 8%). Conclusion: In the present study we found in accordance with the clinical experience, a high procoagulant readiness of cord versus adult WB. CTs were significantly shorter in native cord versus adult WB as evaluated by means of TEG. Moreover, shortening of CTs was significantly more pronounced in cord versus adult WB when samples were incubated with LPS indicating a higher sensitivity for coagulopathy in septic neonates. In summary, thrombelastography proved to be a sensitive and reliable tool for the determination of LPS-induced activation of haemostasis in whole blood samples from adults and neonates.

In vitro biological evaluation of high molecular weight hyperbranched polyglycerols

Low molecular weight hyperbranched polyglycerols are highly water soluble and biocompatible polyether polyols, which can be synthesized in a controlled manner with narrow polydispersity. Recently we reported the synthesis and characterization of very high molecular weight ( M n up to 700,000) and narrowly polydispersed polyglycerols which could be potentially used as alternatives to high generation dendrimers which are difficult to make. A detailed biocompatibility testing of these polymers conducted in vitro is reported here. The in vitro studies include hemocompatibility testing for effects on coagulation (prothrombin time (PT), activated partial thromboplastin time (APTT), plasma recalcification time (PRT), thrombelastograph parameters (TEG)), complement activation, platelet activation, red blood cell aggregation and cytotoxicity. Results from these studies show that these high molecular weight polyglycerols are highly biocompatible and are potential candidates for various applications in nanobiotechnology and in nanomedicine. Moreover these polymers are thermally and oxidatively stable.