Thromboelastography Parameters Research Articles

The predictive role of the nomogram based on clinical characteristics and thromboelastography markers for rebleeding after hypertensive intracerebral hemorrhage

ObjectivesRebleeding after hypertensive intracerebral hemorrhage is a common and serious postoperative complication in neurosurgery, with high mortality and mental disability rates. The aim of this study was to establish a nomogram to analyze the role of thromboelastography in predicting rebleeding after hypertensive intracerebral hemorrhage. Basic methodsWe selected 375 patients with hypertensive intracerebral hemorrhage who underwent surgical treatment in Yuebei People's Hospital of Shaoguan City, Guangdong Province from May 2018 to August 2022, and retrospectively analyzed the relevant data of hypertensive intracerebral hemorrhage patients (including general data and clinical thromboelastography data), and analyzed the factors and thromboelastography parameters that affect rebleeding after surgery (45 cases, defined as re-examination of head CT within 72 h after surgery showed that the hematoma in the surgical area exceeded 20 ml). Main resultsTime from symptom onset to surgery, taking antiplatelet drugs, taking anticoagulant drugs, diabetes mellitus, difficulty in hemostasis during surgery, R value and EPL value in thromboelastography were risk factors for rebleeding after hypertensive intracerebral hemorrhage (P < 0.05). Logistic regression was used to determine the independent risk factors, and based on these risk factors, a nomogram was established and internally validated using a bootstrap method. ROC curve analysis showed that the nomogram model had high diagnostic value for rebleeding after hypertensive intracerebral hemorrhage, with AUC of 0.7314. The calibration curve of the nomogram showed good consistency between the predicted probabilities and the observed values. The decision curve analysis and clinical impact curve also revealed the potential clinical usefulness of the nomogram. ConclusionsThe nomogram based on clinical characteristics and thromboelastography markers may be useful for predicting rebleeding after hypertensive intracerebral hemorrhage.

The effect of ε-aminocaproic acid on blood product requirement, outcome and thromboelastography parameters in severely thrombocytopenic dogs.

No treatment other than platelet administration is known to protect against spontaneous hemorrhage in thrombocytopenic dogs. Primary: determine if treatment with ε-aminocaproic acid (EACA) decreases the requirement for blood transfusions and improves outcome in dogs with severe thrombocytopenia. Secondary: find evidence of hyperfibrinolysis and determine the effect EACA administration on rapid (rTEG) and tissue plasminogen activator-spiked (tPA-rTEG) thromboelastography parameters. Twenty-seven dogs with severe thrombocytopenia were treated with EACA, and data from an additional 33 were obtained from the hospital database as historical control (HC) cohort. Single arm clinical trial with HCs. The EACA group dogs received EACA (100 mg/kg IV followed by a constant-rate infusion [CRI] of 400 mg/kg/24 hours). Thromboelastography before and during EACA infusion, hospitalization days, number of transfusions, and mortality were compared. No difference was found in number of transfusions per dog (median, interquartile range; 1, 0-2.5 vs 0.9, 0-2; P = .5) and hospitalization days (4, 4-6 vs 4.5, 3.75-6; P = .83) between HC and EACA groups, respectively, and no difference in survival was identified by log-rank analysis (P = .15). Maximum amplitude on both rTEG and tPA-rTEG increased after EACA administration (rTEG baseline: 23.6, 9.6-38.9; post-EACA: 27.3, 19.8-43.2; P < .001; tPA-rTEG baseline: 23, 10.9-37.2; post-EACA: 24.7, 16.7-44.8; P < .002). Although EACA increased clot strength, there was no effect on outcome. Treatment with EACA at this dosage cannot be recommended as a routine treatment but may be considered for dogs with severe ongoing hemorrhage.

Prediction of Unexplained Recurrent Miscarriages Using Thromboelastography.

This study investigates the thromboelastography (TEG) changes in patients with unexplained recurrent spontaneous abortion (URSA) to identify effective diagnostic markers for URSA. We retrospectively analyzed 160 URSA patients from the Gynecology Department of the First People's Hospital of Lianyungang (June 2017 - June 2020) and compared them with 190healthy, fertile women without adverse pregnancy histories (control group). TEG parameters were assessed using logistic regression, applying stepwise selection for model optimization. Model performance was evaluated using Receiver Operating Characteristic (ROC) curves, determining sensitivity and specificity. The Youden index identified optimal cut points for predictive probabilities. Significant differences were observed between the URSA and control groups in coagulation reaction time (R), clot formation time (K), clot formation rate (Angle-α), and maximum clot strength (MA) (P<0.05). Multivariable logistic regression identified R, Angle-α, and MA as independent URSA risk factors. The model demonstrated excellent discrimination (AUC: 0.940; 95% CI: 0.918-0.962). The optimal cut point of predictive probability (Youden index) was P=0.355, yielding a sensitivity of 0.925 and specificity of 0.795. URSA patients exhibit a hypercoagulable state even when not pregnant. More research is needed to validate our findings and explore the potential clinical implications of anticoagulants in treating URSA.

Analyzing venous thromboembolism risk in malignant tumors: thromboelastogram and coagulation factors study.

Aim: This retrospective clinical study was designed to examinethe predictive value of thromboelastography (TEG) combined with coagulation function for venous thromboembolism (VTE) in hospitalized patients with cancer. Materials & methods: Among 215 patients admitted between May 2020 and January 2022, 39 (18.14%) were diagnosed with VTE during hospitalization. Results: Significant differences were found in D-dimer, ATIIIand TEG parameters (maximum amplitude and coagulation index) between VTE-positive and VTE-negative patients (p<0.05). Multivariate analysis revealed tumor node metastasis stage, concomitant infection, smoking historyand D-dimer as independently associated with VTE. The constructed model and D-dimerareas under the curve were 0.809 and 0.764, respectively. Conclusion: TEG parameters were not significantly predictive indicators for VTE, with D-dimer remaining a key predictor.

Clinical value of thromboelastography in predicting the risk of recurrence of acute ischemic stroke.

Thromboelastography (TEG) can objectively reflect the formation, development and rupture process of thrombosis in patients, but there are limited data on whether TEG can be used as a predictive tool for recurrence in patients with acute ischemic stroke. To explore the TEG risk of recurrence in patients with acute ischemic stroke predictive value. A total of 441 patients with acute ischemic stroke who met the research criteria in the First Affiliated Hospital of Henan University of Traditional Chinese Medicine from January 2020 to December 2021 were selected as the research objects. TEG was measured in all patients, and the main parameters of TEG (R value, indicating coagulation reaction time; K value and Angle, the rate of blood clot formation; MA value, indicating the maximum amplitude). The primary outcome of this study was ischemic stroke recurrence. Recurrent events included cerebral infarction, cerebral hemorrhage, TIA, and were determined by combining imaging events and clinical events. Logistic regression analysis was used to explore the influencing factors of recurrence in patients with acute ischemic stroke. Fifty-six patients (12.7%) had recurrence. Multivariate Logistic regression analysis showed that: Age [OR = 1.078, 95%CI(1.024, 1.135)], triglyceride [OR = 1.541, 95%CI(1.033, 2.298)], glycosylated hemoglobin [OR = 1.401, 95%CI(1.097, 1.790)], history of hypertension [OR = 16.046, p < 0.05], 95%CI(4.726, 54.489), R value [OR = 0.533, 95%CI(0.351, 0.809)], MA value [OR = 1.399, 95%CI(1.004, 1.949)] were independent influencing factors for hemorrhagic transformation in patients with acute ischemic stroke. TEG has some value in predicting recurrence in patients with acute ischemic stroke, and the MA value in TEG [AUC = 0.806 (95%CI:0.747-0.867), with a sensitivity of 78.6% and a specificity of 70.4%], predicted the most significant efficiency of AIS recurrence.

Nomogram model combined thrombelastography for venous thromboembolism risk in patients undergoing lung cancer surgery.

Background: The aim of this study was to develop a nomogram model in combination with thromboelastography (TEG) to predict the development of venous thromboembolism (VTE) after lung cancer surgery. Methods: The data of 502 patients who underwent surgical treatment for lung cancer from December 2020 to December 2022 were retrospectively analyzed. Patients were then randomized into training and validation groups. Univariate and multivariate logistic regression analyses were carried out in the training group and independent risk factors were included in the nomogram to construct risk prediction models. The predictive capability of the model was assessed by the consistency index (C-index), receiver operating characteristic curves (ROC), the calibration plot and decision curve analysis (DCA). Results: The nomogram risk prediction model comprised of the following five independent risk factors: age, operation time, forced expiratory volume in one second and postoperative TEG parameters k value(K) and reaction time(R). The nomogram model demonstrated better predictive power than the modified Caprini model, with the C-index being greater. The calibration curve verified the consistency of nomogram between the two groups. Furthermore, DCA demonstrated the clinical value and potential for practical application of the nomogram. Conclusion: This study is the first to combine TEG and clinical risk factors to construct a nomogram to predict the occurrence of VTE in patients after lung cancer surgery. This model provides a simple and user-friendly method to assess the probability of VTE in postoperative lung cancer patients, enabling clinicians to develop individualized preventive anticoagulation strategies to reduce the incidence of such complications.

Evaluation of perioperative routine coagulation testing versus thromboelastography for major liver resection - A single-arm, prospective, interventional trial (PORTAL trial).

The International Normalised Ratio (INR), which assesses the loss of procoagulant factors in the extrinsic pathway, fails to evaluate the coagulation abnormalities comprehensively after a major liver resection, which often leads to reduced synthesis of procoagulant and anticoagulant-factors. This study was conducted with an aim to study the trend and compare the results of routine coagulation tests and thromboelastography (TEG) during the perioperative period in patients undergoing major liver resections (≥3 segments). Twenty-five patients who underwent a major liver resection were enrolled. This prospective, single-arm, interventional study was performed with the primary objective of determining the serial changes in conventional coagulation tests and TEG during the perioperative period in patients undergoing major liver resections, at the preincision period, intraoperative period, postoperatively, at 48 h and on the fifth postoperative day. Transfusion requirements of blood components were also assessed with a TEG-guided replacement strategy. Spearman rank-order correlation was used to study the relationships of coagulation tests (both TEG and conventional tests) at each time point. The prothrombin time (PT)-INR was elevated in 14 patients (56%) at the intraoperative, immediate postoperative and 48-h time points in contrast to the TEG parameters, which remained normal in all patients. Blood component transfusion was avoided in 4, 11 and 10 patients at the intraoperative, immediate postoperative and 48-h time points, respectively. International Normalised Ratio overestimates the coagulopathy in patients undergoing major liver resection, and a thromboelastography-guided transfusion strategy reduces overall transfusion requirements.

Thromboelastography (TEG) parameters as potential predictors of malignancy and tumor progression in colorectal cancer

PurposeThe purpose of this study was to investigate the use of thromboelastography (TEG) in patients with colorectal cancer and to examine whether the TEG parameters can be used as potential markers for disease screening and prediction of disease severity.MethodsOne-hundred fifteen healthy controls (HC), 43 patients with benign adenoma (BA), and 387 patients with colorectal cancers (CRC) were included in the study. TEG parameters (reaction time, R; clot kinetics, K; alpha angle, α-angle; maximum amplitude, MA), conventional laboratory parameters, and clinical information were collected and analyzed among the HC, BA, and CRC groups. Receiver operating characteristics (ROC) were used for differential analysis. The correlation between TEG parameters and pathological information of CRC (differentiation degree, vaso-nerve infiltration, TNM stage) was analyzed. The differences in TEG parameters at different stages of disease and pre-/post operation were compared.ResultsShorter K and higher α-angle/MA were found in patients with CRC compared with HC and BA (P < 0.001). TEG parameters demonstrated moderate diagnostic value (distinguish CRC from HC + BA: K-AUC = 0.693, α-angle-AUC = 0.687, MA-AUC = 0.700) in CRC but did not outperform traditional laboratory parameters. TEG hypercoagulability was closely associated with tumor markers (carcinoma embryonic antigen and carbohydrate antigen 19–9) and pathological information (differentiation degree, vaso-nerve infiltration, and TNM stage) (P < 0.05). Trend analysis showed that K decreased, but α-angle/MA increased gradually as the tumor progressed (P < 0.001). K- and α-angle showed slightly better sensitivity in predicting advanced tumors compared to traditional laboratory parameters. In CRC patients, 3–6 months after tumor resection, K [from 1.8 (1.5, 2.3) to 1.9 (1.6, 2.6)], α-angle [from 65.3 (59.0, 68.6) to 63.7 (56.6, 68.5)], and MA [from 61.0 (58.2, 66.0) to 58.9 (55.8, 61.3)] exhibited modest improvements compared to their preoperative values (P < 0.05).ConclusionTEG parameters possess moderate diagnostic value in CRC diagnosis and predicting advanced tumors, and they are closely linked to surgical interventions. Although TEG parameters do not significantly outperform traditional laboratory parameters, they still hold promise as potential alternative indicators in CRC patients.

Global tests in patients with Ph-negative myeloproliferative neoplasms

Introduction: A frequent clinical manifestation of Ph-negative myeloproliferative neoplasms (MPN) is the development of thrombosis. To identify the state of hypercoagulation it is relevant and promising to introduce global tests for evaluating the hemostasis — the thrombin generation test (TGT) and thromboelastography (TEG). Aim: to evaluate the parameters of thrombin generation and thromboelastography in patients with Ph-negative MPN. Material and methods. In total, 62 patients with MNP were included in the study: 27 with polycythemia vera (PV), 14 with essential thrombocythemia (ET) and 21 with primary myelofibrosis (PMF). The control group included 55 practically healthy individuals, comparable in gender and age (19 people in the study of TEG, 36 people in the study of TGT). The TEG was performed using a “TEG 5000” thromboelastograph. TGT was measured with Calibrated Automated Thrombinography. Results: Ly30 and Ly60 in TEG in patients were significantly lower (0.35 (0.20–0.48), 0.00 (0.00–0.40) and 0.00 (0.00 — 0.43) and 3.15 (2.45–3.60), 1.25 (0.10–3.58) and 0.60 (0.00–3.05) respectively), than in the control (1.60 (1.05–2.75) and 6.20 (4.15–8.30), respectively), which indicates the ineffectiveness of fibrinolysis. The values of MA and G in patients with ET and PV significantly exceeded the control (69.15 (67.98–70.78) mm and 65.20 (59.65–63.83) mm versus 62.00 (57.75–6.75) mm and 11.20 (10.60–12.15) din/cm2 and 9.40 (7.40–11.60) din/cm2 versus 8.20 (6.85–8.75) din/cm2, respectively. The most pronounced change in sensitivity to TM was observed in patients with ET (27.94 (17.35–43.58) % and 13.29 (-3.48–23.60) %, respectively; p &lt; 0.05). A significant decrease in ETP was observed in patients with PV and PMF. Conclusion. The study of hemostasis in patients with MPN using TEG and TGT revealed the presence of multidirectional changes associated with the disease. The TEG showed that an increase in the time required for the onset of fibrin formation is combined with increased clot strength and inhibited fibrinolysis, which are risk factors for the development of thromboembolic complications. The study of TGT determined a decrease in the quantitative characteristics of thrombin generation and at the same time the failure of the anticoagulant system of protein C, leading to the development of hypercoagulation.

Thromboelastography characteristics in critically ill patients with liver disease.

The purpose of this study was to determine how thromboelastography (TEG) parameters differ by various clinical conditions that commonly occur in patients with cirrhosis, including sepsis, acute on chronic liver failure (ACLF), alcohol-associated hepatitis (AAH) and portal vein thrombosis (PVT). TEG, a whole blood assay, is used to assess several parameters of coagulation and is becoming increasingly used in clinical practice. This study was a retrospective chart review of 155 patients admitted to the ICU with decompensated cirrhosis from 2017 to 2019. The R time was significantly shorter in patients when they were septic compared to when they were not and longer in patients with vs. without ACLF grade 3. Alpha angle and maximum amplitude was decreased in patients with severe AAH compared to those without severe AAH; and maximum amplitude was increased in patients with acute PVT compared to those with chronic PVT. R time was positively correlated with Chronic Liver Failure Consortium Organ Failure and Chronic Liver Failure Consortium ACLF scores (rho = 0.22, P = 0.020), while alpha angle and maximum amplitude were negatively correlated with MELD-NA. Findings suggest TEG parameters vary in several clinical conditions in patients with decompensated cirrhosis who are admitted to the ICU. Prospective research is needed to confirm our findings and to determine how this knowledge can be used to guide clinical practice, as well as blood product transfusions in the setting of bleeding or prior to invasive procedures.

Coagulation parameters for the differential diagnosis of pancreatic cancer in the early stage: a retrospective study

BackgroundIn recent years, conventional coagulation (CC) and thromboelastography (TEG) parameters have been reported to be closely related to the progression of pancreatic cancer (PC). However, the potential utility of these parameters in differentiating benign and malignant pancreatic diseases is still unclear.ObjectivesA retrospective study was conducted to evaluate the efficacy of coagulation parameters in differentiating pancreatic cancer/early stage pancreatic cancer (EPC, TNM stages I and II) from benign control conditions, and to further explore whether coagulation parameters could improve the differential value of CA199.MethodsReceiver operating characteristic (ROC) curves and logistic regression analysis were used to identify the diagnostic value of each coagulation parameter or combination of parameters.ResultsCompared with benign pancreatic disease (BPD), patients with pancreatic malignant tumors had significant coagulation disorders, specifically manifested as abnormal increases or decreases in several CC and TEG parameters (such as activated partial thromboplastin time (APTT), fibrinogen (FIB), D-dimer (DD2), K time, R time, Angle, maximum amplitude (MA), coagulation index (CI), and Ly30). In the training group, ROC curve showed that FIB, DD2, Angle, MA, and CI had favorable efficacy at differentiating PC or EPC from BPD (for PC, AUC = 0.737, 0.654, 0.627, 0.602, 0.648; for EPC, AUC = 0.723, 0.635, 0.630, 0.614, 0.648). However, several combined diagnostic indicators based on FIB, DD2 and CI failed to outperform the individual coagulation indexes in diagnostic efficiency. Combinations of certain coagulation indexes with CA199 outperformed CA199 alone at identifying PC or EPC, especially FIB + CA199 (for PC, AUC = 0.904; for EPC, AUC = 0.905), FIB + DD2 + CA199 (for PC, AUC = 0.902; for EPC, AUC = 0.900), FIB + CI + CA199 (for PC, AUC = 0.906; for EPC, AUC = 0.906), and FIB + DD2 + CI + CA199 (for PC, AUC = 0.905; for EPC, AUC = 0.900). The results from a validation set also confirmed that these combinations have advantageous diagnostic value for PC and EPC.ConclusionsA significant hypercoagulable state was common in PC. Some CC and TEG parameters are valuable in the differential diagnosis of benign and malignant pancreatic diseases. In addition, coagulation indexes combined with CA199 can further enhance the differential diagnosis efficacy of CA199 in PC and EPC.

Comparison of Rapid-, Kaolin-, and Native-TEG Parameters in Burn Patient Cohorts With Acute Burn-induced Coagulopathy and Abnormal Fibrinolytic Function.

Although use of thromboelastography (TEG) to diagnose coagulopathy and guide clinical decision-making is increasing, relative performance of different TEG methods has not been well-defined. Rapid-TEG (rTEG), kaolin-TEG (kTEG), and native-TEG (nTEG) were performed on blood samples from burn patients presenting to a regional center from admission to 21 days. Patients were categorized by burn severity, mortality, and fibrinolytic phenotypes (Shutdown [SD], Physiologic [PHYS], and Hyperfibrinolytic [HF]). Manufacturer ranges and published TEG cutoffs were examined. Concordance correlations (Rc) of TEG parameters (R, α-angle, maximum amplitude [MA], LY30) measured agreement and Cohen's Kappa (κ) determined interclass reliability. Patients (n = 121) were mostly male (n = 84; 69.4%), with median age 40 years, median TBSA burn 13%, and mortality 17% (n = 21). Severe burns (≥40% TBSA) were associated with lower admission α-angle for rTEG (P = .03) and lower MA for rTEG (P = .02) and kTEG (P = .01). MA was lower in patients who died (nTEG, P = .04; kTEG, P = .02; rTEG, P = .003). Admission HF was associated with increased mortality (OR, 10.45; 95% CI, 2.54-43.31, P = .001) on rTEG only. Delayed SD was associated with mortality using rTEG and nTEG (OR 9.46; 95% CI, 1.96-45.73; P = .005 and OR, 6.91; 95% CI, 1.35-35.48; P = .02). Admission TEGs showed poor agreement on R-time (Rc, 0.00-0.56) and α-angle (0.40 to 0.55), and moderate agreement on MA (0.67-0.81) and LY30 (0.72-0.93). Interclass reliability was lowest for R-time (κ, -0.07 to 0.01) and α-angle (-0.06 to 0.17) and highest for MA (0.22-0.51) and LY30 (0.29-0.49). Choice of TEG method may impact clinical decision-making. rTEG appeared most sensitive in parameter-specific associations with injury severity, abnormal fibrinolysis, and mortality.

Diagnostic Agreement Between TEG5000 and TEG6S in the Assessment of Hemostasis in Pediatric Cardiac Surgery: A Prospective Non-inferiority Study.

Thromboelastography (TEG) is a point-of-care test (POCT) used to analyze the hemostatic properties of whole blood. TEG® 5000and TEG® 6s (Haemonetics Corp, USA) measure the same parameters describing clot viscoelasticity using different methodologies. The purpose of this study was to evaluate agreement between TEG5000 and TEG6s measurements. We analyzed prospectively collected tests resulting from paired blood samples in cardiac surgery pediatric patients at one hour (T0) and 24 h (T1) postoperatively. Each citrated sample was utilized for TEG® 5000 and TEG ®6s. Six specific TEG parameters were analyzed and compared: R kaolin time (RK), R kaolin heparinase (RKH) time, K kaolin time (KK), K kaolin heparinase time KH (KKH), Maximum Amplitude kaolin (MAK), Maximal Amplitude Kaolin Heparinase (MAKH). We enrolled 30 patients. Median (interquartile range) patients' age was 206 (20-597) days. All surgical patients underwent correction except 5 who were palliated. At T0, RK and RKH showed an average (standard deviation) % bias of 15.8 (31) and 16.1 (28), respectively, with similar results at T1. A % bias of -6 (23) and - 6 [15] in MAK was found at T0 and T1, respectively. Similarly, MAKH % bias was 1.5 (22) and 7.6 (29) at T0 and T1, respectively. At both timepoints, low % biases (< ± 6%) were demonstrated in KK and KKH. All parameters showed improved coagulation from T0 to T1, but without significant interaction between type of device and time. Analysis of the entire pool of 60 paired samples showed no agreement in diagnostic performance (within the range vs. outside the range) in 12 (20%), 5 (9.8%), 1 (1.7%), 4 (7.8%), 9 (15%), and 5 (9.8%) cases for RK, RKH, MAK, MAKH, KK and KKH, respectively. We observed substantial agreement in MAK and KK in a cohort of pediatric patients undergoing uncomplicated cardiac surgery. Our findings suggest that TEG®5000 and TEG®6s are interchangeable for assessing these parameters.

Reference Range of Kaolin-Activated Thromboelastography (TEG) Values in Healthy Pet Rabbits (Oryctolagus cuniculus).

Thromboelastography (TEG) is a viscoelastic technique that allows the examination of both cellular and plasma protein clotting factors. Thromboelastography helps to investigate the underlying coagulopathy and to monitor therapeutic modalities. Although viscoelastic techniques have been used in human and veterinary medicine, reference ranges in pet rabbits are missing. The objective of this study is to establish the reference-range values of TEG parameters in healthy pet rabbits. 24 healthy pet rabbits of different breeds were included: 16 crossbreeds, four Californians, two lops, one lionhead, and one angora. Four rabbits were less than one year old and 20 were older than one year. Twelve rabbits were neutered females, 10 neutered males, and two were intact females. Health status was assessed through a physical examination, a complete blood work, and a coagulation profile. A TEG 5000 Thromboelastograph Hemostasis System was used with kaolin-activated citrated whole blood. All samples were analysed 30 min postextraction. The TEG reference ranges were reaction time (R) 1.4-6.9 min; clot formation time (K) 0.8-2.2 min; α angle 65.8-82.2 degrees; maximal amplitude (MA) 53.7-73.5 mm; measure of clot strength/firmness (G-value) 5796.6-13,885.9 dyn/cm2; and percentage of clot lysis in 30 min (LY30%) 0-41.5%. This study provides the reference ranges of TEG in pet rabbits.

Can we predict failure of non-operative management of blunt splenic injuries on arrival? A comparison of predictors of immediate splenectomy versus splenectomy secondary to non-operative management failure

Aims and Background The spleen is the most frequently injured solid organ after blunt trauma and a trial non-operative management (NOM) has become the standard of care in hemodynamically stable patients. It remains uncertain which patients are at increased risk of non-operative management failure (NOMF) at initial presentation. We explored whether clinical variables including the contemporary rotational thromboelastography (ROTEM) parameters are predictive of NOMF. Materials and Methods Data for all adult patients with a blunt splenic injury was collected retrospectively at St. Michael’s Hospital in Toronto, Canada between 2005 and 2021. Those who underwent a splenectomy within 4 hours of presentation were classified as direct operative management (OM), while those who had a splenectomy after 4 hours of observation were classified as NOM failure. Vital signs on arrival and injury characteristics were collected. Logistic regression was used to identify predictors of OM and predictors of NOM failure. Results Seven hundred and seventeen patients were identified with splenic injury during our study period. The median Injury Severity Score (ISS) was 27 (IQR 17–36), and 19% ( n = 134) had a shock index of 1 or more. One hundred and eleven (15.5%) underwent direct operative management. A shock index above 1 and increasing spleen injury severity were strong predictors of patients undergoing direct OM. The remaining 606 patients underwent NOM of which 59% ( n = 357) of these were admitted to the ICU. NOM failure occurred in 7.4% ( n = 45) with a median time to NOM failure of 23 (IQR 8–72) hours. The American Association for the Surgery of Trauma (AAST) spleen injury severity was the major factor significantly associated with NOM failure. Conclusions The only major predictor of NOMF available on arrival is increased spleen injury grade. Other clinical variables such as age, vital signs on arrival, and bloodwork were not significantly able to predict NOM failure. Additional investigation is required to identify novel predictors of NOM failure.

Thromboelastography Parameter and Its Association with Survival of COVID-19 Patients: A Retrospective Cross-Sectional Study

Introduction: Coagulopathy associated with Coronavirus disease 2019 (COVID-19) may cause life-threatening complications, especially in severe or critically ill COVID-19 patients. Thromboelastography (TEG) is an effective, dynamic, and reliable test to assess the complete coagulation process. This study aimed to determine the association between selected TEG parameters and survival in COVID-19 patients. Methods: This study was a retrospective observational study using data from medical records of COVID-19 patients who were hospitalized in Dr. Soetomo Hospital, Surabaya, Indonesia. There were 94 COVID-19 patients consisting of 76 survivors and 18 non-survivors. The association between TEG results and certain TEG parameters with survival status was considered significant if the p-value ≤ 0.05. Results: Increased coagulation activity had a significant association with the survival status of COVID-19 patients (p=0.04). There were no significant differences in all TEG parameters between COVID-19 patients who survived and those who did not survive (p &gt; 0.05). Based on the TEG analysis tree, the most TEG results found were secondary fibrinolysis (21.3%) and fibrinolytic shutdown (24.5%). No significant association was found between the coagulability and fibrinolysis abnormality with the survival status in COVID-19 patients (p &gt; 0.05). Conclusion: There was no significant difference in TEG results between COVID-19 survivors and non-survivors. However, based on the TEG result, an increase in coagulation activity is associated with a lower survival rate. Further study with detailed timing of TEG examination, disease severity and comorbidities stratification in COVID-19 patients may be needed.

Thromboelastography and Traditional Coagulation Testing in Non-ICU-Admitted Patients with Acute Kidney Injury: An Observational Cohort Study

Introduction: This study aimed to elucidate the coagulation disorders in non-ICU patients with acute kidney injury (AKI) and their contribution to clotting-related outcomes of intermittent kidney replacement therapy (KRT). Methods: We included non-ICU-admitted patients with AKI requiring intermittent KRT, clinically having a risk of bleeding and against systemic anticoagulant use during KRT between April and December 2018. The premature termination of treatment due to circuit clotting was considered a poor outcome. We analyzed the characteristics of thromboelastography (TEG)-derived and traditional coagulation parameters and explored the potential-affecting factors. Results: In total, 64 patients were enrolled. Hypocoagulability was detected in 4.7%–15.6% of patients by a combination of the traditional parameters, i.e., prothrombin time (PT)/international normalized ratio, activated partial PT, and fibrinogen. No patient had hypocoagulability observed on TEG-derived reaction time; only 2.1%, 3.1%, and 10.9% of patients had hypocoagulability on TEG-derived kinetic time (K-time), α-angle, and maximum amplitude (MA), respectively, which were also platelet-related coagulation parameters, despite 37.5% of the cohort having thrombocytopenia. In contrast, hypercoagulability was more prevalent, involving 12.5%, 43.8%, 21.9%, and 48.4% of patients on TEG K-time, α-angle, MA, and coagulation index (CI), respectively, although thrombocytosis was only in 1.5% of the cohort. Patients with thrombocytopenia showed lower fibrinogen level (2.6 vs. 4.0 g/L, p = 0.00), α-angle (63.5° vs. 73.3°, p = 0.00), MA (53.5 vs. 66.1 mm, p = 0.00), and CI (1.8 vs. 3.6, p = 0.00) but higher thrombin time (17.8 vs. 16.2 s, p = 0.00) and K-time (2.0 vs. 1.2 min, p = 0.00) than those with a platelet count over 100 × 10⁹/L. 41 patients were treated with heparin-free protocol, and 23 were treated with regional citrate anticoagulation (RCA). The premature termination rate was 41.5% on heparin-free patients, while 8.7% of patients underwent an RCA protocol (p = 0.006). Heparin-free protocol was the strongest adverse factor to poor outcomes. A heparin-free subgroup analysis found that the circuit clotting risk was increased by 61.7% with a 10 × 10⁹/L elevation in platelet count (odds ratio [OR] = 1.617, p = 0.049) and decreased by 67.5% following a second increase of PT (OR = 0.325, p = 0.041). No significant correlation was found between TEG parameters and premature circuit clotting. Conclusions: Most non-ICU-admitted patients with AKI had normal-to-enhanced hemostasis and activated platelet function based on TEG results, as well as a high rate of premature circuit clotting when receiving heparin-free protocol despite thrombocytopenia. Further studies are needed to better determine the use of TEG in respect to management of anticoagulation and bleeding complications in AKI patients with KRT.

The in-vitro influence of urea concentration on thromboelastrography in patients with and without end stage renal disease

BackgroundEnd stage renal disease (ESRD) is associated with platelet dysfunction but also thromboembolic complications. The specific role of increased blood urea nitrogen (BUN) on coagulation is unclear. We aimed to characterize thromboelastography (TEG) parameters from males and females with ESRD and normal kidney function and evaluate if exogenous urea in vitro reproduced those TEG differences. MethodsWe collected blood samples from 20 living kidney donors and 20 kidney recipients. TEG was performed without and with two increasing urea concentrations in vitro. TEG parameters were compared between recipients and donors. ResultsBlood from kidney recipients showed baseline increased maximum amplitude (MA) and shortened time to maximum amplitude (TMA) compared to donors. These differences were not confirmed in females. In all patients, BUN was inversely correlated with TMA (r = −0.342; p = 0.031). In males, BUN and creatinine concentrations showed a direct correlation with MA (0.583; p = 0.007) and an inverse correlation with TMA (r = −0.520; p = 0.019). Urea in vitro decreased R-time (p = 0.005) and increased LY30 (p = 0.009) in donors but not recipients. ConclusionsESRD is associated with increased MA and decreased TMA on TEG. No change in MA was observed with increasing urea concentrations in vitro. Gender-specific variability in TEG parameters were observed.

Establishment and validation of a nomogram based on coagulation parameters to predict the prognosis of pancreatic cancer

BackgroundIn recent years, multiple coagulation and fibrinolysis (CF) indexes have been reported to be significantly related to the progression and prognosis of some cancers.ObjectiveThe purpose of this study was to comprehensively analyze the value of CF parameters in prognosis prediction of pancreatic cancer (PC).MethodsThe preoperative coagulation related data, clinicopathological information, and survival data of patients with pancreatic tumor were collected retrospectively. Mann Whitney U test, Kaplan-Meier analysis, and Cox proportional hazards regression model were applied to analyze the differences of coagulation indexes between benign and malignant tumors, as well as the roles of these indexes in PC prognosis prediction.ResultsCompared with benign tumors, the preoperative levels of some traditional coagulation and fibrinolysis (TCF) indexes (such as TT, Fibrinogen, APTT, and D-dimer) were abnormally increased or decreased in patients with pancreatic cancer, as well as Thromboelastography (TEG) parameters (such as R, K, α Angle, MA, and CI). Kaplan Meier survival analysis based on resectable PC patients showed that the overall survival (OS) of patients with elevated α angle, MA, CI, PT, D-dimer, or decreased PDW was markedly shorter than other patients; moreover, patients with lower CI or PT have longer disease-free survival. Further univariate and multivariate analysis revealed that PT, D-dimer, PDW, vascular invasion (VI), and tumor size (TS) were independent risk factors for poor prognosis of PC. According to the results of modeling group and validation group, the nomogram model based on independent risk factors could effectively predict the postoperative survival of PC patients.ConclusionMany abnormal CF parameters were remarkably correlated with PC prognosis, including α Angle, MA, CI, PT, D-dimer, and PDW. Furthermore, only PT, D-dimer, and PDW were independent prognostic indicators for poor prognosis of PC, and the prognosis prediction model based on these indicators was an effective tool to predict the postoperative survival of PC.

Hemostatic and thromboelastographic parameters in dogs with renal azotemia.

Humans and dogs with azotemia can develop coagulation disorders. Therefore, this study aimed to evaluate the coagulation profiles and thromboelastographic parameters in dogs with acute kidney injury (AKI) and chronic kidney disease (CKD). In this prospective study, 31 client-owned dogs with renal azotemia (creatinine >220 μmol/L) were enrolled. Clinical signs of hemostatic disorders, complete blood count, coagulation profile, D-dimers, thromboelastography, and 28-day survival data were obtained and analyzed using the t-test, Mann-Whitney U test, and Chi-square test. Statistical significance was set at p < 0.05. Seventeen dogs with AKI, 10 with CKD, and four with acute-on-chronic kidney injury (AoC) were enrolled. Ten dogs (AKI, 8/17; CKD, 2/10) had thrombocytopenia. Prothrombin time was prolonged in four dogs with AKI and longer in dogs with AKI than in dogs with CKD (p = 0.004). The activated partial thromboplastin time was prolonged in 23 dogs (AKI, 14/17; CKD, 7/10; AoC, 3/4) and was longer in azotemic dogs than in healthy control dogs (p = 0.003). Thromboelastographic tracings were hypocoagulable in three dogs with AKI and hypercoagulable in 16 dogs (AKI 4/17, CKD 9/10, AoC 3/4). The thromboelastographic values for maximum amplitude (p < 0.001) and global clot strength (p < 0.001) were lower in dogs with AKI than in those with CKD. Hypercoagulable thromboelastographic tracings were observed in dogs with CKD, whereas coagulation times were prolonged in dogs with AKI. However these findings should be validated by further studies.