The prognostic value of thrombelastography in identifying neurosurgical patients with worse prognosis. Blood Coagul Fibrinolysis
Coagulopathy in patients with intracranial haemorrhage or traumatic brain injury (TBI) is associated with clinical deterioration and worse outcome. Whole blood viscoelastic haemostatic assays, like thrombelastography (TEG), might aid conventional coagulation assays in identification of patients with worse prognosis. We performed a review of patients (totalling 78 patients) with primary acute intracranial haemorrhage or isolated TBI admitted to a neurointensive care unit (NICU) for more than 24 h during a period of 9 months, who had TEG analysis performed at admission. Primary outcome was all-cause 30-day mortality, whereas decline in Glasgow Coma Scale (GCS) score at 24 h after admission or death due to cerebral incarceration were secondary outcomes. Patients were defined as hypocoaguable if TEG reaction time was more than 8 min, angle less than 55° and/or maximal amplitude less than 51 mm. Patients were defined hypocoaguable according to conventional coagulation assays if international normalized ratio was more than 1.3, platelet counts less than 100×10/l and/or activated partial thromboplastine time more than 35 s. Eight patients were hypocoaguable by TEG on admission to NICU and had higher 30-day mortality (63% vs. 16%, P=0.008), more often declined in GCS (57% vs. 16%, P=0.02) and expired due to cerebral incarceration (50% vs. 6%, P=0.02). Hypocoagulability by TEG, lower admission GCS and subarachnoid haemorrhage were independently associated with higher 30-day mortality [TEG: odds ratio (OR) 14.8 (2.2-100.1), P=0.006; GCS: OR 1.3 (1.1-1.5), P=0.006; subarachnoid haemorrhage: OR: 5.3 (1.3-22.3), P=0.02]. Only two patients were hypocoaguable by both conventional coagulation assays and TEG. The current data indicate that hypocoagulability by TEG at admission to NICU predicts worse prognosis. Low concordance with conventional coagulation assays indicates that TEG might be valuable in identifying patients with clinically relevant coagulopathy.
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[Show abstract] [Hide abstract] ABSTRACT: Careful course observation is necessary for cases of mild to moderate traumatic brain injury even when disturbed consciousness is mild on admission. This is because delayed enlargement of hematoma and progression of cerebral swelling may occur and result in an emergency craniotomy. Here, we investigated coagulopathy and abnormal fibrinolysis as a predictive factor of “deterioration requiring surgery” in mild to moderate traumatic brain injury.Patients and methodsSixty-one patients with mild to moderate (Glasgow Coma Scale (GCS) score 9–15) traumatic brain injury were admitted between June 2009 and October 2010. There were 54 subjects in the study, excluding those treated with oral antiplatelet agents and anticoagulants. Patients were classified into those with deterioration requiring surgery [op(+)] or those without deterioration requiring surgery [op(−)]. This was based on whether surgical treatment was performed for hematoma expansion, and exacerbated consciousness level within 3 days after admission. Age, GCS score on admission and blood test findings (platelet count, PT-INR, APTT, fibrinogen, FDP, and d-dimer) on admission were compared.ResultsThe op(+) and op(−) groups comprised 7 (13.0%) and 47 patients (87.0%), respectively. Platelet counts (24.8 vs 18.5 × 104/μl) were decreased, and PT-INR (1.0 vs 1.2) was higher in the op(+) group. Specially, APTT (28.6 vs 39.1 s), FDP (28.9 vs 112.9 μg/ml), and d-dimer (17.3 vs 69.6 μg/ml) values were significantly higher in the op(+) group.Conclusions Coagulopathy and abnormal fibrinolysis, which are measurable in routine medical practice, is associated with deterioration requiring surgery in mild to moderate traumatic brain injury, indicating that careful course observation is necessary.
- "Since this monitoring is able to be performed at bedside and repeatedly, we can observe a state of coagulopathy in real time. These values were associated with the clinical outcome in TBI patients [17,18]. In another report, tranexamic acid was administered as antifibrinolytic therapy for the acute phase of trauma expected to cause massive hemorrhage in adults . "
[Show abstract] [Hide abstract] ABSTRACT: Thromboelastography (TEG) is a viscoelastic, whole blood‐based assay that integrates information from both the cellular and soluble components of coagulation, providing a global evaluation of the haemostatic system. This contrasts with the conventional coagulation assays (i.e. platelet count, prothrombin time [PT], activated partial thromboplastin time [aPTT] and fibrinogen concentration [FIB]), which only provide information about one component (e.g. clotting factors in the case of PT and aPTT) of the haemostatic process, requiring the combination of several assays for a complete evaluation of haemostasis. Thromboelastography is an old technology that has been used in human medicine for over 50 years. However, it is relatively new in veterinary medicine and has only been applied to horses in the last 5 years. Clinical applications in human medicine include diagnosis and monitoring of coagulopathies. Currently, extensive research is being carried out to expand the use of TEG in dogs and cats. Therefore, it is expected that the use of this technique will also further expand in horses in the near future. To date, the available studies in the equine species have evaluated TEG in healthy horses, horses with gastrointestinal disease, septic foals, horses with exercise‐induced pulmonary haemorrhage (EIPH) and a filly with Glanzmann's thrombasthenia. The main objective of this review is to introduce the TEG technique to equine clinicians, providing information on how the TEG functions, blood sample collection and processing, variables measured and their interpretations, normal reference values and areas of potential clinical application.
- " diagnosed at admission in general ICU patients and associated with a higher rate of ventilator treatment, higher rate of renal replacement therapy and higher use of blood products. It was also found to be an independent risk factor associated with a more than 3 times increased risk of death within 30 days in these patients (Johansson et al. 2010). Windeløv et al. (2011) showed that neurosurgical patients with hypocoagulation detected by TEG have a worse prognosis and thus TEG has a predictive value in this group of patients. Another recent human study reported a sensitivity of 95.2% and a specificity of 81% for a novel thromboelastographic score to identify overt DIC resulting in a hypocoagulable state"
- "There have been few studies linking the severity of TBI with platelet function [12, 14]. However, a correlation between a GCS <8 and a reduced viscoelastic strength of the thrombus has recently been described [18, 19]. In addition, there is a weak correlation between platelet dysfunction and death due to TBI in multisystem trauma . "