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Anaesthesia Jan 2015Over the last 10 years, the management of major haemorrhage in trauma patients has changed radically. This is mainly due to the recognition that many patients who are... (Review)
Review
Over the last 10 years, the management of major haemorrhage in trauma patients has changed radically. This is mainly due to the recognition that many patients who are bleeding when they come in to the emergency department have an established coagulopathy before the haemodilution effects of fluid resuscitation. This has led to the use of new terminology: acute traumatic coagulopathy, acute coagulopathy of trauma shock or trauma-induced coagulopathy. The recognition of acute traumatic coagulopathy is important, because we now understand that its presence is a prognostic indicator, as it is associated with poor clinical outcome. This has driven a change in clinical management, so that the previous approach of maintaining an adequate circulating volume and oxygen carrying capacity before, as a secondary event, dealing with coagulopathy, has changed to haemostatic resuscitation as early as possible. While there is as yet no universally accepted assay or definition, many experts use prolongation of the prothrombin time to indicate that there is, indeed, a coagulopathy. Hypoxia, acidosis and hypothermia and hormonal, immunological and cytokine production, alongside consumption and blood loss, and the dilutional effects of resuscitation may occur to varying extents depending on the type of tissue damaged, the type and extent of injury, predisposing to, or amplifying, activation of coagulation, platelets, fibrinolysis. These are discussed in detail within the article.
Topics: Acute Disease; Blood Coagulation Disorders; Humans; Resuscitation; Thrombelastography; Wounds and Injuries
PubMed: 25440402
DOI: 10.1111/anae.12914 -
Heart & Lung : the Journal of Critical... 2021COVID-19-associated coagulopathy (CAC) is a feature of COVID-19 that can lead to various thrombotic complications and death. In this review, we briefly highlight... (Review)
Review
COVID-19-associated coagulopathy (CAC) is a feature of COVID-19 that can lead to various thrombotic complications and death. In this review, we briefly highlight possible etiologies, including direct cytotoxicity caused by the SARS-CoV-2 virus, and the activation of proinflammatory molecules such as cytokines, underlying coagulopathy. Endothelial dysfunction has been highlighted as pivotal, irrespective of the mechanism involved in CAC. Specific features of CAC distinguishing it from disseminated intravascular coagulopathy and sepsis or ARDS-associated coagulopathy have been discussed. We have also highlighted some hematological parameters, such as elevated d-dimers and partial prothrombin and prothrombin times prolongation, which can guide the use of anticoagulation in critically ill patients. We conclude by highlighting the importance of prophylactic anticoagulation in all COVID-19 hospitalized patients and reiterate the need for institution-specific guidelines for anticoagulation COVID-19 patients since individual institutions have different patient populations.
Topics: Anticoagulants; Blood Coagulation Disorders; COVID-19; Fibrin Fibrinogen Degradation Products; Humans; SARS-CoV-2
PubMed: 33524866
DOI: 10.1016/j.hrtlng.2021.01.011 -
Blood May 2018Traumatic brain injury (TBI)-induced coagulopathy is a common and well-recognized risk for poor clinical outcomes, but its pathogenesis remains poorly understood, and... (Review)
Review
Traumatic brain injury (TBI)-induced coagulopathy is a common and well-recognized risk for poor clinical outcomes, but its pathogenesis remains poorly understood, and treatment options are limited and ineffective. We discuss the recent progress and knowledge gaps in understanding this lethal complication of TBI. We focus on (1) the disruption of the brain-blood barrier to disseminate brain injury systemically by releasing brain-derived molecules into the circulation and (2) TBI-induced hypercoagulable and hyperfibrinolytic states that result in persistent and delayed intracranial hemorrhage and systemic bleeding.
Topics: Blood Coagulation; Blood Coagulation Disorders; Blood Coagulation Tests; Blood Platelets; Blood-Brain Barrier; Brain Injuries, Traumatic; Endothelium; Fibrinolysis; Humans; Phenotype; Symptom Assessment
PubMed: 29507078
DOI: 10.1182/blood-2017-11-784108 -
World Journal of Gastroenterology Nov 2021Due to concomitant changes in pro- and anti-coagulant mechanisms, patients with liver dysfunction have a "rebalanced hemostasis", which can easily be tipped toward... (Review)
Review
Due to concomitant changes in pro- and anti-coagulant mechanisms, patients with liver dysfunction have a "rebalanced hemostasis", which can easily be tipped toward either a hypo- or a hypercoagulable phenotype. Clinicians are often faced with the question whether patients with chronic liver disease undergoing invasive procedures or surgery and those having active bleeding require correction of the hemostasis abnormalities. Conventional coagulation screening tests, such as the prothrombin time/international normalized ratio and the activated partial thromboplastin time have been demonstrated to have numerous limitations in these patients and do not predict the risk of bleeding prior to high-risk procedures. The introduction of global coagulation assays, such as viscoelastic testing (VET), has been an important step forward in the assessment of the overall hemostasis profile. A growing body of evidence now suggests that the use of VET might be of significant clinical utility to prevent unnecessary infusion of blood products and to improve outcomes in numerous settings. The present review discusses the advantages and caveats of both conventional and global coagulation assays to assess the risk of bleeding in patients with chronic liver disease as well as the current role of transfusion and hemostatic agents to prevent or manage bleeding.
Topics: Blood Coagulation Disorders; Blood Coagulation Tests; Hemostasis; Humans; Liver Diseases; Thrombelastography
PubMed: 34876789
DOI: 10.3748/wjg.v27.i42.7285 -
Journal of Thrombosis and Haemostasis :... May 2016Severe burn injury is associated with systemic coagulopathy. The changes in coagulation described in patients with severe burns resemble those found patients with sepsis... (Review)
Review
Severe burn injury is associated with systemic coagulopathy. The changes in coagulation described in patients with severe burns resemble those found patients with sepsis or major trauma. Coagulopathy in patients with severe burns is characterized by procoagulant changes, and impaired fibrinolytic and natural anticoagulation systems. Both the timing of onset and the severity of hemostatic derangements are related to the severity of the burn. The exact pathophysiology and time course of coagulopathy are uncertain, but, at least in part, result from hemodilution and hypothermia. As the occurrence of coagulopathy in patients with severe burns is associated with increased comorbidity and mortality, coagulopathy could be seen as a potential therapeutic target. Clear guidelines for the treatment of coagulopathy in patients with severe burns are lacking, but supportive measures and targeted treatments have been proposed. Supportive measures are aimed at avoiding preventable triggers such as tissue hypoperfusion caused by shock, or hemodilution and hypothermia following the usually aggressive fluid resuscitation in these patients. Suggested targeted treatments that could benefit patients with severe burns include systemic treatment with anticoagulants, but sufficient randomized controlled trial evidence is lacking.
Topics: Anticoagulants; Blood Coagulation; Blood Coagulation Disorders; Burns; Coagulants; Fibrinolysis; Hemodilution; Hemostasis; Humans; Recombinant Proteins; Smoke Inhalation Injury
PubMed: 26854881
DOI: 10.1111/jth.13283 -
Annals of the Academy of Medicine,... Apr 2021
Topics: Anticoagulants; Blood Coagulation Disorders; COVID-19; Humans
PubMed: 33990816
DOI: 10.47102/annals-acadmedsg.2021113 -
International Journal of Molecular... Dec 2019Diabetes (both type-1 and type-2) affects millions of individuals worldwide. A major cause of death for individuals with diabetes is cardiovascular diseases, in part... (Review)
Review
Diabetes (both type-1 and type-2) affects millions of individuals worldwide. A major cause of death for individuals with diabetes is cardiovascular diseases, in part since both types of diabetes lead to physiological changes that affect haemostasis. Those changes include altered concentrations of coagulatory proteins, hyper-activation of platelets, changes in metal ion homeostasis, alterations in lipid metabolism (leading to lipotoxicity in the heart and atherosclerosis), the presence of pro-coagulatory microparticles and endothelial dysfunction. In this review, we explore the different mechanisms by which diabetes leads to an increased risk of developing coagulatory disorders and how this differs between type-1 and type-2 diabetes.
Topics: Blood Coagulation; Blood Coagulation Disorders; Diabetes Mellitus, Type 1; Diabetes Mellitus, Type 2; Humans; Lipid Metabolism; Risk Factors
PubMed: 31888259
DOI: 10.3390/ijms20246345 -
Annals of Hepatology Mar 2018Long thought to be hypocoagulable, new evidence suggests cirrhosis patients have "rebalanced" coagulation in the setting of decreased synthesis of both pro- and...
Long thought to be hypocoagulable, new evidence suggests cirrhosis patients have "rebalanced" coagulation in the setting of decreased synthesis of both pro- and anti-coagulant factors. Traditional testing like PT/INR reflects only the decreased synthesis of pro-coagulant factors and thus does not correspond to bleeding or clotting risk in this population. In this review, we discuss the use of viscoelastic testing (VET), an assay of global hemostasis in cirrhosis patients. We describe the technique and interpretation of commercially available VET and assess the application of VET in both transplant and non-transplant cirrhosis populations. VET largely correlates well with traditional testing including platelet count and fibrinogen level, however, is potentially less accurate in patients with low fibrinogen levels. VET may be useful in identifying patients at higher risk of hypercoagulable complications post-transplant and reflects changes in hemostasis in decompensated patients. While VET has been associated with decreased transfusión support in multiple studies, the lack of bleeding in patients who avoided prophylactic transfusion suggests a "rescue" rather than prophylactic approach to transfusion may be ideal and further studies with a "rescue" arm are needed. Additional prospective studies of VET should include clinically relevant endpoints of bleeding and thrombosis.
Topics: Blood Coagulation; Blood Coagulation Disorders; Blood Transfusion; Elasticity; Hemorrhage; Humans; Liver Cirrhosis; Liver Transplantation; Predictive Value of Tests; Reproducibility of Results; Risk Assessment; Risk Factors; Thrombelastography; Treatment Outcome; Viscosity
PubMed: 29469043
DOI: 10.5604/01.3001.0010.8635 -
Annales de Biologie Clinique 2001Primary hemostasis exploration involves many tests, but most of them are highly specialized. Meanwhile, a few simple and reliable assays can make possible a first... (Review)
Review
Primary hemostasis exploration involves many tests, but most of them are highly specialized. Meanwhile, a few simple and reliable assays can make possible a first orientation of the diagnosis in a routine laboratory. This review is organized in four parts. It highlights the importance of pre-analytical steps when exploring hemostasis, especially a carefully conducted clinical history and blood collecting conditions. It first presents the tests involved in the global exploration: the platelet count, the bleeding time, the occlusion time and the prothrombin consumption test. Then, this review presents the tests essential for the diagnosis of thrombocytopenia, von Willebrand disease and platelet disorders. Finally, we discussed about the limits and the future of diagnosis in primary hemostasis, and more particularly about endothelial cells and the adhesion proteins that are implicated.
Topics: Blood Coagulation Disorders; Hematologic Tests; Hemostasis; Humans
PubMed: 11713017
DOI: No ID Found -
Current Gastroenterology Reports Sep 2017Previous perceptions of cirrhosis as a hypocoagulable state have resulted in empirical blood product transfusions prior to invasive procedures. We evaluate... (Review)
Review
PURPOSE OF REVIEW
Previous perceptions of cirrhosis as a hypocoagulable state have resulted in empirical blood product transfusions prior to invasive procedures. We evaluate procedure-related bleeding risks in patients with cirrhosis, assess the utility of conventional and newer global coagulation tests, and explore evidence surrounding prophylactic transfusion strategies.
RECENT FINDINGS
Recent literature supports the concept of a rebalanced, albeit fragile, haemostasis equilibrium in cirrhosis, with a potential hypercoagulable tendency in stable patients. Standard coagulation tests provide a poor reflection of bleeding risks and yet are relied upon for transfusion thresholds. Consequently, a sizeable proportion of patients receive unnecessary blood products. The role of viscoelastic tests to guide transfusions requires further evaluation. In stable cirrhotic patients, procedure-related bleeding rates appear low. Prophylactic transfusion strategies based on arbitrary thresholds lack evidence of clinical benefit. There is a pressing need for point-of-care coagulation tests that represent the complex coagulopathy of cirrhosis and well-powered randomised controlled trials to develop evidence-based pre-procedure transfusion guidelines.
Topics: Blood Coagulation Disorders; Blood Transfusion; Humans; Liver Cirrhosis; Postoperative Hemorrhage
PubMed: 28752476
DOI: 10.1007/s11894-017-0585-6