Prediction of bleeding diathesis in patients undergoing cardiopulmonary bypass during cardiac surgery: viscoelastic measures versus routine coagulation test.
ABSTRACT Severe hemorrhagic tendency often complicates cardiopulmonary bypass (CPB) in cardiac surgery. In this study, we compared the effectiveness of thromboelastography (TEG), Sonoclot (SCT), and routine coagulation test (RCT) in the prediction of coagulation defects.
Forty-three patients undergoing cardiac surgery with CPB were included. Blood for RCT, TEG, and SCT profiles was sampled before systemic heparinization and after protamine administration. Clinically significant bleeding was defined as chest tube drainage in excess of 100 ml/h for 3 consecutive hours or 300 ml/h in 1 h. All coagulation parameters obtained before and after CPB were compared. The sensitivity, specificity, accuracy, false positive, and false negative rate were also calculated and compared.
All coagulation tests were within normal range except higher partial thromboplastin time. Variables which were significantly different from those before CPB included platelet count, fibrinogen level, prothrombin time, and thrombin time in RCT, alpha angle and maximum amplitude in TEG, and R2 and peak time in SCT. In the TEG tracing, all variables had high sensitivity, specificity, and accuracy (average 85.4%, 83%, and 83.5% respectively) and low false positive and negative rate (12.5% and 5% respectively). Although SCT had high sensitivity (76.3%) and low false negative rate (6.5%), its specificity and accuracy were all under 50%.
Our data demonstrated that the TEG monitoring is a useful tool for detecting post-CPB bleeding diathesis and can provide much predictive information. RCT and SCT are of limited value because of higher rate of unreliable results.
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ABSTRACT: In der Herzchirurgie ist der Einsatz der Herz-Lungen-Maschine unerlässlich. Das Problem in der postoperativen Phase besteht darin, dass die Blutgerinnung bei einzelnen Patienten erheblich gestört ist, was zu erhöhtem postoperativen Blutverlust führen kann. Basierend auf der oben beschriebenen Problematik hatte die vorliegende, prospektive, randomisierte Verlaufsuntersuchung zum Ziel, folgende Frage zu klären: Lässt sich mit den Standard- Gerinnungsparametern ATIII, Fibrinogen, PTT, Quick und TZ der postoperative Blutverlust in der Herzchirurgie vorhersagen? Zur Beantwortung dieser Fragen wurden bei 150 herzchirurgischen Patienten zu drei verschiedenen Zeitpunkten die Gerinnungsparameter ATIII, Fibrinogen, PTT, Quick und TZ bestimmt. Bei allen Patienten wurde der postoperative Blutverlust. Für keinen der untersuchten Parameter wurde eine signifikante Korrelation mit dem postoperativen Blutverlust bestimmt.
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ABSTRACT: The thromboelastograph (TEG), a measure of global haemostasis, is routinely used during cardiac and hepatic surgery to optimize blood product selection and usage. It has recently been suggested that it may also be a useful tool to screen patients with hypercoagulable states. Limited published data on performance characteristics has led to speculation regarding its consistency and, therefore, validity of the results. This study was designed to assess the effect of stability of blood samples prior to testing, repeated sampling, intra- and inter-assay variability using the native, celite, tissue factor (TF) and Reopro-modified TEG. Analysis of native and celite samples after storage over 90 min showed a period of instability up to 30 min. Thereafter, all parameters between 30 and 90 min were stable [P = not significant (NS)]. When the same sample was repeatedly assayed, both native and celite TEG parameters showed a significant change towards hypercoagulability (P < 0.01), whereas the TF and Reopro-modified TEG showed no change. Intra- and inter-assay variability on samples tested after 30 min showed excellent reproducibility for all parameters (P = NS). The data suggest that the TEG is a useful tool in haemostasis but requires a formal standard operating procedure to be adopted that takes into account the initial period of sample instability.Blood Coagulation and Fibrinolysis 11/2001; 12(7):555-61. DOI:10.1097/00001721-200110000-00008 · 1.38 Impact Factor
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ABSTRACT: To investigate potential mechanisms for the differences in thromboelastography variables observed between arterial blood samples and venous blood samples. Prospective cohort study. University hospital. Patients undergoing cardiac surgery (n = 33). After the withdrawal of 10 mL of discarded blood (>3 deadspace volumes), 3 blood samples were withdrawn simultaneously from the central venous port of the pulmonary artery catheter (CVP), the radial arterial catheter (ART), and the side port of the 9F sheath introducer (SI). Thromboelastography was done simultaneously on each sample. All thromboelastography analyses were performed with 1% celite and heparinase according to the manufacturer's guidelines. A total of 80 ART, SI, and CVP comparisons were obtained. Mean hematocrit values were not different between sampling sites (27 +/- 4 v 27 +/- 4 v 27 +/- 3). Thromboelastography R time values (mean +/- SD) were CVP, 8 +/- 3; ART, 10 +/- 3; and SI, 13 +/- 5 (p = 0.004). Thromboelastography maximal amplitude (MA) values (mean +/- SD) were CVP, 60.4 +/- 11.7; ART, 56.2 +/- 11.4; and SI, 50.5 +/- 13.2 (p = 0.008). Calculated maximal shear stresses were CVP, 48 dyne/cm(2); ART, 36 dyne/cm(2); and SI, 0.3 dyne/cm(2). Blood samples obtained from the CVP (highest shear stress) resulted in faster (shorter R) and stronger (larger MA) coagulation compared with the arterial site (intermediate shear stress) and sheath introducer (lowest shear stress). These data show that differences exist in thromboelastography values between arterial and venous blood samples and, more importantly, show that the differences observed are not related to differences in oxygen content. These differences seem to be related to differences in catheter lumen diameter and, presumably, shear forces.Journal of Cardiothoracic and Vascular Anesthesia 10/2002; 16(5):551-4. DOI:10.1053/jcan.2002.126946 · 1.48 Impact Factor