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Patient Assessment
Published in Ian Greaves, Keith Porter, Jeff Garner, Trauma Care Manual, 2021
Ian Greaves, Keith Porter, Jeff Garner
Resuscitation in trauma aims to manage tissue hypoperfusion and prevent the onset of acute coagulopathy. This should be achieved by the infusion of blood products which may be monitored by thromboelastography (see Appendix A). Multiple strategies have been described, but studies suggest that there is a role for permissive hypotension up to 60 minutes post-injury followed by resuscitation with blood and blood products to low normotension.9 As a consequence many patients who arrive in the emergency department will have reached the point in their injury timeline where therapeutic hypotension is no longer appropriate. As described previously, the altered cardiovascular response to haemorrhage following tissue injury means that a significant haemorrhage may have occurred by the time the blood pressure falls, and massive transfusions may be required. It is important to recognize that this fluid resuscitation does not occur in isolation and is part of the damage control resuscitation process of which surgery is a part.10
Liver transplantation
Published in Mark Davenport, James D. Geiger, Nigel J. Hall, Steven S. Rothenberg, Operative Pediatric Surgery, 2020
Caroline Lemoine, Riccardo A. Superina
Complete hemostasis is secured. All anastomoses are checked. Bleeding from the raw cut surface of the segmental graft is controlled by a combination of fibrin glue and other topical hemostatic agents, superficial sutures, and argon beam coagulation. If bleeding is severe or persistent, venous outflow obstruction must be excluded. Otherwise, bleeding at this stage is often secondary to coagulopathy, and thromboelastography may be useful in guiding the use of blood products. Before proceeding with abdominal closure, suturing the remnants of donor and recipient falciform ligaments helps to stabilize the graft and reduce the risk of torsion of the left hepatic vein. The abdominal wall is closed in one layer in an interrupted fashion using absorbable suture, after placing two soft multi-fenestrated large-bore (10 Fr) silicone drains posteriorly in the right upper quadrant by the cut section in cases of a segment/lobe graft, and/or under the porta hepatis when a whole liver graft is used, and a duct-to-duct anastomosis is performed. The skin is closed with metallic staples. A prosthetic patch (e.g. Vicryl•) or skin closure alone (with delayed muscle closure) may occasionally be necessary to avoid an excessively tight abdominal closure.
Systemic care—Renal, hematologic, gastrointestinal
Published in Hemanshu Prabhakar, Charu Mahajan, Indu Kapoor, Essentials of Anesthesia for Neurotrauma, 2018
Panumart Manatpon, Andrew W. Kofke
Conventional blood tests such as PT, PTT, and platelets are generally obtained to diagnose coagulopathy. Recently, thromboelastography (TEG) has been introduced in many clinical situations such as the perioperative periods and after trauma resuscitation. It provides a more comprehensive coagulation evaluation and help tailors specific therapies to individual patients. However, studies of TEG in TBI patients are scanty. A prospective observational study of 169 traumatic intracranial hemorrhage patients demonstrated that TEG values acquired after admission was not related to progression of traumatic intracranial hemorrhage, the need for surgery, and mortality rate.53 Nonetheless, further studies are still needed to validate its use in this context.
Early stage clinical trials for the treatment of hemophilia A
Published in Expert Opinion on Investigational Drugs, 2022
Gianna M Guzzardo, Robert Sidonio, Jr, Michael U Callaghan, Katherine Regling
Mim8 (Novo Nordisk A/S) is a novel, next-generation FVIII mimetic human bispecific antibody [73]. In vitro studies assessed thrombin generation by way of thromboelastography from the plasma of congenital HA patients as well as whole blood from healthy volunteers. Mim8 showed normalization of both thrombin generation and blood clot formation, with approximately 15 times greater potency than emicizumab [74]. Animal models have demonstrated a reduction in bleeding after severe tail-vein transection in HA mice and reported a half-life of 14 days in the cynomolgus monkey [73]. In addition, subcutaneous administration of Mim8 of up to 3 mg/kg/week for 26 weeks exhibited significant PD effects in the aPTT and thrombin generation without signs of thrombi or excessive coagulation system activation [75]. Phase 1, 2, and 3 clinical trials are underway in all age groups with HA with or without inhibitors (NCT05127473, NCT04204408, NCT05053139, NCT05306418) [76,77].
Thromboelastography in the setting of acetaminophen-induced hepatotoxicity
Published in Clinical Toxicology, 2022
Sanjay Mohan, Christian Koziatek, Jordan Swartz, Mary Ann Howland, Mark K. Su
There are several limitations to this study. The retrospective nature and small sample size make it difficult to formulate definitive conclusions about the utility of thromboelastography in this setting. Moreover, our cohort of patients contained a combination of both acute and repeated supratherapeutic APAP ingestions rather than purely acute overdoses. We also do not know the indication for TEG testing or whether patients had TEG testing based on the results of any abnormal coagulation tests. Furthermore, given that n-acetylcysteine artificially increases the INR, this might account for some abnormal INR elevations seen in our cohort and distorts the correlation between INR and TEG [12]. Lastly, only one TEG was obtained for each patient and TEG testing was not protocolized. Future direction should include prospective studies that obtain serial TEGs to better understand its potential role in APAP-induced hepatotoxicity.
Determination of fibrin clot growth and spatial thrombin propagation in the presence of different types of phospholipid surfaces
Published in Platelets, 2021
Ekaterina M. Koltsova, Anna D. Kuprash, Natalya M. Dashkevich, David M. Vardanyan, Artem V. Chernyakov, Maria A. Kumskova, Sukesh C. Nair, Alok Srivastava, Fazoil I. Ataullakhanov, Mikhail A. Panteleev, Anna N. Balandina
Among the laboratory tests that have recently entered clinical practice, thromboelastography/thromboelastometry and thrombin generation tests allow an integrated assessment of the coagulation system. However, none of these tests takes into account the spatial heterogeneity of the activation process and clot growth, whereas it is well known that the coagulation process in the body is fundamentally heterogeneous [1]. Thrombodynamics is a global test for diagnosing coagulation disorders, determining bleeding risks and detecting thrombus formation [2–4]. Unlike other methods used in clinical practice, in which coagulation is activated simultaneously in the whole volume of plasma, this method is based on the principle of local coagulation starting on a flat surface containing a thin layer of tissue factor (TF) and lipids. Therefore, the imitation of vessel wall damage is achieved. Currently, two variations of the Thrombodynamics test have been developed, one of which allows for the detection of spatial thrombin generation in addition to detecting fibrin clot growth.