Assessment of three point-of-care platelet function assays in adult trauma patients.

BACKGROUND: Antiplatelet (AP) medication use is common among trauma patients and is associated with poor outcomes. Management options for platelet dysfunction in trauma patients are controversial, expensive, and potentially harmful. Although light transmission platelet aggregometry is considered the standard test to assess platelet function, it is cumbersome and not generally available. Currently, there are no widely accepted platelet function point-of-care tests for acute trauma. STUDY DESIGN: Prospective observational study from 2014 to 2015. Baseline Multiplate aggregometry aspirin area under the platelet aggregation curve (ASPI AUC), Thrombelastography Platelet Mapping percent inhibition of arachidonic acid (TEG-PM AA), and VerifyNow Aspirin Test (ARU) were compared for ability to detect any AP medication use (aspirin or clopidogrel), platelet dysfunction, and identify patients at risk for intracranial hemorrhage (ICH) progression by calculating the area under receiver operating characteristic curves (AUC), sensitivity, specificity, and positive and negative predictive values. Adenosine diphosphate assays were similarly evaluated. RESULTS: Sixty-four patients were enrolled, 25 were taking AP medications. AP patients were older (71.6 versus 35.0 y, P < 0.001) and received more platelet transfusions, but other baseline characteristics were similar. Median ASPI AUC (22.0 versus 53.5 P < 0.001) and VerifyNow ARU (503.5 versus 629.0, P < 0.001) were lower, whereas TEG-PM AA (51.8% versus 18.3%, P < 0.001) was higher in AP patients. Multiplate ASPI AUC, TEG-PM AA percent inhibition, and VerifyNow ARU could identify AP medication use (AUC: 0.90, 0.77, and 0.90, respectively). Adenosine diphosphate assays did not correlate with AP medication use in this population. TEG-PM AA percent inhibition and VerifyNow ARU correlated well with Multiplate ASPI AUC to identify platelet dysfunction (AUC: 0.78, 0.89, respectively). ICH occurred in 29 patients; 12 of which had progression of their injury. ASPI AUC (AUC: 0.50) and VerifyNow ARU (AUC: 0.59) did not correlate, and TEG-PM AA percent inhibition (AUC: 0.66) minimally correlated with progression. CONCLUSIONS: Multiplate, TEG-PM, and VerifyNow are useful point-of-care tests which identify AP medication use and platelet dysfunction in trauma patients. Initial TEG-PM AA percent inhibition may be associated with risk for ICH progression. However, additional large, prospective studies are needed.

Effect of Thoracic Paravertebral Nerve Block on Blood Coagulation in Patients After Thoracoscopic Lobectomy: A Prospective Randomized Controlled Clinical Trial.

PURPOSE: Ultrasound-guided thoracic paravertebral block (TPVB) has become increasingly popular for postoperative analgesia after thoracic surgery. We designed this prospective, randomized, double-blind, placebo-controlled trial to investigate the effect of TPVB on blood coagulation in patients after thoracoscopic lobectomy. PATIENTS AND METHODS: Sixty patients scheduled for thoracoscopic lobectomy were randomly allocated to two groups. Patients underwent ultrasound-guided TPVB with 0.33% ropivacaine (T group) or 0.9% saline (C group) at the end of the surgery under general anesthesia. Patient-controlled intravenous analgesia (PCIA) was administered for both group after the surgery. The primary outcome was the thromboelastogram (TEG) parameters before anesthesia (T0), at the end of operation (T1) and in 1 day (T2) and 2 days (T3) after the operation, the second outcomes were the analgesic effect and the amount of intraoperative opioid consumption, operation time, infusion volume, blood loss and urine volume. RESULTS: The visual analog scale (VAS) scores in group T were lower than group C (P < 0.05). In group T, compared with T0, the R value at T1 and T2 is significantly reduced, and the K value at T1 were significantly shortened, the α-angle and MA value at T1 were significantly increased (P < 0.05). In group C, compared with T0, the R value and K value were significantly shortened, the α-angle and MA value were significantly increased at all postoperative time points (P < 0.05). Compared with group C at the same time point, the R and K values of group T were significantly longer, and the α-angle and MA values were significantly reduced at T2 and T3 points, with statistically significant differences (P<0.05). CONCLUSION: TPVB is beneficial to improve postoperative hypercoagulability and promote postoperative rehabilitation of patients after thoracoscopic lobectomy.

Analysis of thrombelastogram-guided medication in patients with coronary heart disease after percutaneous coronary intervention.

Effects of thrombelastogram-guided (TEG-guided) clopidogrel and aspirin on major adverse cardiovascular events (MACE) after percutaneous coronary intervention (PCI) were investigated. A retrospective analysis was performed on 203 patients undergoing PCI interventional therapy in the Cardiovascular Medicine of Weihai Central Hospital from February 2015 to September 2016. The patients were treated with clopidogrel and aspirin for anti-thrombus therapy. Among them, 104 patients who had TEG detection of anticoagulant effects for guiding medication were the experimental group, and 99 patients without TEG detection for guiding medication the control group. The coagulation function and the platelet inhibition rate of patients after medication were evaluated and compared between the two groups. The incidence of MACE and bleeding events of patients was counted during three months of follow-up. Patients in the experimental group had higher R (coagulation reaction time) value and K (blood clot formation time) value than those in the control group after treatment (P<0.05), and lower MA (maximum amplitude) value than those in the control group (P<0.05). Patients in the experimental group had higher postoperative platelet inhibition rate than those in the control group (P<0.05). Patients in the experimental group had lower incidence of MACE and bleeding events than those in the control group (P<0.05). Coronary heart disease (CHD) patients after PCI with the TEG-guided dose adjustment of clopidogrel have more satisfactory treatment effects than patients without the TEG guidance. TEG makes the treatment of patients more targeted and is worthy of promotion.

Establishment of the Normal Reference Range of Thrombelastogram among the Healthy Population and Pregnants in China.

BACKGROUND: We aimed to establish the reference range of thrombelastogram (TEG) for Chinese healthy volunteers and pregnant women and analyze the influence factors. METHODS: Blood samples were collected from healthy volunteers and pregnant women at five tertiary hospitals (the Third Xiangya Hospital of Central South University, the Second Xiangya Hospital of Central South University, Hunan Provincial People's Hospital, Hunan Cancer Hospital and Changsha Central Hospital) in 2016. The effects of age, gender, blood type, and full-term pregnancy on the reference range of normal TEG for healthy volunteers and pregnant women were studied. The specificity of TEG in detecting coagulation disorder. RESULTS: For healthy volunteers, the normal ranges of TEG parameters were as follows: R, 4.3-9.3 min; K, 1.2-3.2 min; α, 50.2-71.2°; MA, 54.1-71.3 mm; LY30: 0%-2.2%; CI, -3.8-2.4. At least one parameter exceeded the normal range specified by the manufacturer in 20.3% of the healthy volunteers; about 7.6% healthy volunteers were diagnosed as coagulation disorder by the above standards; the specificity of detection was 79.7%. There were significant differences in R, K, α, MA and CI between males and females (P<0.01). For pregnant women, the normal ranges of TEG were as follows: R, 3.9-7.5 min; K, 1.0-2.4 min; α, 57.6-74.9°; MA, 55.7-75.7 mm; LY30, 0%-0.56%; CI, -0.97-3.6. Pregnant women having O blood group had a dramatically prolonged R. Full-term pregnancy had no significant impact on TEG results. CONCLUSION: Compared with pregnant women having non-O blood group, those having O blood group had a dramatically prolonged R and showed greater tendency to hemorrhage during and after parturition.

[Incidence of Lower Limb Deep Venous Thrombosis and Coagulation Status 
in Severe Patients after Thoracic Surgery].

BACKGROUND: The aim of this study was to analyze the incidence of lower limb deep venous thrombosis (DVT) and the corresponding coagulation status in severe patients after thoracic surgery. METHODS: Severe patients after thoracic surgery who received mechanical prophylaxis of lower limb DVT between July 2016 and June 2018 were analysed retrospectively. Their general information, disease species, surgical treatment, and coagulation index were reviewed. RESULTS: Fifty patients were finally included. There were 34 male and 16 female, aging from 22 to 80 years. The incidence of DVT was 22.0%, all of them were isolated calf DVT. The incidence was 29.4% in male patients, while 6.3% in female; 23.5% in malignant diseases and 18.6% in benign. All coagulation index presented no statistical difference between patients with and without DVT, except activated partial thromboplastin time (APTT). CONCLUSIONS: Even on the basis of adequate mechanical prophylaxis, lower limb DVT is common in severe patients after thoracic surgery. Meanwhile, male patients and malignant diseases are more suscepted.

Comparison of Ticagrelor and Clopidogrel for Patients Undergoing Emergency Percutaneous Coronary Intervention.

BACKGROUND: We compared treatments with the antiplatelets ticagrelor and clopidogrel used in patients with acute myocardial infarction (AMI) during the perioperative period for emergency percutaneous coronary intervention (PCI). METHODS: A total of 120 patients were selected and randomly divided into control and observation groups (60 patients in each) from 2014-2016 at The Affiliated Hospital of Qingdao University. The patients in the control group received 300 mg clopidogrel and 300 mg aspirin for oral administration, while those in the observation group were given 180 mg ticagrelor and 300 mg aspirin orally prior to the PCI. During the operation, heparinization and a tirofiban micro-pump were used continuously. RESULTS: Coronary artery and peripheral venous blood were extracted from each patient to obtain various parameters of thrombelastogram (TEG), and the maximum platelet aggregation rates in order to compare antiplatelet effects. Major adverse cardiac events (MACE) were recorded during the following 6-month follow-up. Analysis of the data showed no differences in terms of the time span between medication intake and stent implantation, or the dosage of heparin and tirofiban used between the two groups. Before stent implantation, and 24 and 48 h after the procedure the average R and K values of TEG in coronary artery blood and peripheral venous blood samples in the observation group were longer than those in the control group, while the α angle, MA, CI, MARAA and MARADP values were lower (P<0.05). CONCLUSION: Ticagrelor can improve antiplatelet treatment for patients with AMI during the perioperative period of emergency PCI.

The effects of platelet apheresis on blood saving and coagulation in bilateral total hip replacement: A prospective study on 60 patients.

BACKGROUND: Preoperative platelet rich plasma (PRP) harvest has been used in cardiopulmonary surgery for more than 10 years. There is no previous study dealing with PRP in bilateral total hip replacement. This study was to investigate the effects of PRP on blood saving and blood coagulation function in patients with bilateral total hip replacement. PATIENTS AND METHODS: A prospective, randomized, clinical trial was conducted. Sixty patients were enrolled, including 30 patients undergoing PRP in the PRP group and 30 controls. The surgery time, total transfusion volume, blood loss, allogenic blood transfusion, autologous blood transfusion, urine volume, drainage volume, some blood parameters (including Fibrinogen, D-dimer, Prothrombin time, international normalizedratio, activated partial thromboplastin time, Platelet, Haemoglobin B), thrombelastogram (TEG) and blood-gas parameters were studied in the perioperative stage. The measurement data were analyzed statistically. RESULTS: There was no statistical difference between the two groups in baseline characteristics, surgery time, total transfusion volume, blood loss, autologous blood transfusion, etc. Allogenic blood transfusion in the PRP group was less than the control group with statistical difference (p = 0.024). Fibrinogen in the PRP group was higher than the control group (p = 0.008). Among the TEG indicators, activated clotting time and coagulation time K in the PRP group were less than the control group. Clotting rate and maximum amplitude in the PRP group were higher. The blood-gas parameters presented no statistical difference. CONCLUSION: The results suggested that PRP probably played a positive role in blood coagulation function as well as blood saving in patients with bilateral total hip replacement.

Positive blood alcohol is associated with reduced DVT in trauma.

INTRODUCTION: Trauma patients exhibit a complex coagulopathy which is not fully understood and deep venous thrombosis (DVT) rates remain high. The effects of alcohol (EtOH) consumption on coagulopathy in trauma patients have not been studied. We hypothesized that acute EtOH intoxication would produce a relative hypocoagulable state as measured by thrombelastography (TEG) and would be associated with reduced DVT rates. METHODS: Data were prospectively collected on 213 trauma patients at a level 1 trauma centre and analyzed in a retrospective secondary analysis. Thrombelastography (TEG), standard laboratory tests and ETOH levels were performed. If the level was positive, patients were grouped as EtOH+ and all patients were screened for DVT using a standard protocol. Statistical significance was p<0.05. RESULTS: The EtOH+ group was predominantly male (76%), was younger (p<0.05), had a lower BMI (p<0.05), demonstrated a lower AIS extremity score (p<0.01) and was less likely to have a blunt injury (p<0.01) than the EtOH- group. Gender, ISS and other AIS scores were not significantly different. TEG values in the alcohol group demonstrated a relative hypocoagulable state that was associated with a reduced DVT incidence, 1.4% versus 16.2%, (p<0.01). This difference was not detected with conventional assays. A multivariate logistic regression was performed, controlling for common risk factors for DVT and a positive EtOH level on admission was independently associated with reduced DVT incidence. CONCLUSIONS: Alcohol consumption is associated with a relative hypocoagulable state on TEG that is associated with a decreased DVT incidence. This difference is not detected by conventional assays.

Correction of blood coagulation dysfunction and anemia by supplementation of red blood cell suspension, fresh frozen plasma, and apheresis platelet: results of in vitro hemodilution experiments.

PURPOSE: This study aimed to determine the optimal composition and timing for the administration of blood supplements during in vivo blood transfusion with red blood cells suspension (pRBC), fresh frozen plasma (FFP), and apheresis platelet (PLT) administered for the correction of anemia and coagulation dysfunction caused by in vitro hemodilution. MATERIALS AND METHODS: We collected blood samples from 24 healthy volunteers and prepared various dilutions of whole blood with normal saline: 9:1, 8:2, 7:3, 6:4, 5:5, 4:6, 3:7, 2:8, and 1:9. The diluted blood samples were then supplemented with blood components at various proportions and then analyzed to determine the values of the routine blood indices, coagulation indices, and thromboelastogram measures. RESULTS: At hemodilutions of 40%, 50%, and 60%, the hemoglobin, coagulation indices, and platelet number and function reached critical levels, necessitating supplementation with pRBC, FFP, and PLT, respectively. When hemodilution was 90%, the supplementation required was approximately 1:1.3:0.9 of pRBC/FFP/PLT. CONCLUSION: The use of pRBC, FFP, and PLT in appropriate proportions can correct the blood coagulation dysfunction and anemia caused by in vitro hemodilution, and these proportions can be used as guidelines for in vivo massive transfusion.