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1.
Arq. bras. med. vet. zootec. (Online) ; 73(2): 335-342, Mar.-Apr. 2021. tab, ilus
Article in English | LILACS, VETINDEX | ID: biblio-1248935

ABSTRACT

This study aimed to identify, by means of thromboelastometry assessment, altered thrombotic risk in dogs with primary and secondary IMHA by E. canis infection after initiating the immunosuppressive therapy with mycophenolate mofetil. The animals' screening was based on complete blood count (CBC), biochemical and urine tests. Dogs with moderate to severe anemia (hematocrit ≤ 25%) which showed symptoms of immune-mediated hemolysis, such as spherocytosis, positive saline agglutination, bilirubinuria and/or hemoglobinuria, were included. Blood and urine samples were collected at two different moments. The first sample (M1) was collected at the time of diagnosis, when hematocrit was lower or equal to 25% before treatment with mycophenolate mofetil (Accord ®); the second sample (M2) was collected after treatment with mycophenolate mofetil, when hematocrit was greater or equal to 30%. Five out of the twelve animals selected died before the end of the study. No reduction in thrombotic risk was observed in the animals treated with mycophenolate mofetil. The animals that presented hypocoagulation at the time of diagnosis showed the worst prognosis, and their reticulocyte count displayed a better prognostic value than their erythrocytes count at the time of diagnosis.(AU)


O objetivo deste estudo foi esclarecer se há alteração do risco trombótico em cães com anemia hemolítica imunomediada primária e secundária a E.canis, avaliado por meio da tromboelastometria, após início de tratamento com micofenolato de mofetila. A seleção dos animais foi baseada na avaliação de hemograma, exame bioquímico e urinálise. Cães com anemia moderada a severa (hematócrito ≤ 25%), com sinais de hemólise imunomediada, como esferocitose, aglutinação em salina positivo, bilirrubinúria e/ ou hemoglobinúria, foram incluídos. As amostras de sangue e urina foram coletadas em dois momentos diferentes. A primeira amostra (M1) foi coletada no momento do diagnóstico, quando o hematócrito era igual ou inferior a 25%, sem fazer uso do micofenolato de mofetila (Accord®), e o segundo momento (M2), após tratamento com micofenolato de mofetila, quando o hematócrito era igual ou maior que 30%. Doze animais foram selecionados, cinco morreram antes do término do estudo. Não houve diminuição do risco trombótico entre os animais tratados com micofenolato de mofetila; os animais que apresentaram menor coagulabilidade apresentaram pior prognóstico, e a contagem de reticulócitos apresentou melhor valor prognóstico do que a contagem de hemácias no momento do diagnóstico.(AU)


Subject(s)
Animals , Dogs , Immunosuppressive Agents/therapeutic use , Anemia, Hemolytic/complications , Anemia, Hemolytic/veterinary , Mycophenolic Acid/analysis , Mycophenolic Acid/adverse effects , Thrombelastography/veterinary , Ehrlichia canis , Erythrocyte Count/veterinary , Hemostasis
2.
Rev. colomb. anestesiol ; 49(1): e600, Jan.-Mar. 2021. graf
Article in English | LILACS, COLNAL | ID: biblio-1149800

ABSTRACT

Abstract Introduction Glanzmann thromboasthenia is a rare congenital bleeding disorder caused by a mutation in platelet glycoprotein α-IIb and β3 encoding genes (ITGA2B; 607759 and ITGB3; 173470) in chromosomes I7q21.31 and 17q21.32, respectively, which results in a qualitative or quantitative alteration of the platelet integrin αIIbβ3 (glycoprotein IIb/IIIa) receptor. Glanzmann thromboasthenia is classified as type I when less than 5% of glycoprotein αIIbβ3 is expressed, and as type II when more than 5% is expressed. Case presentation Description of the perioperative management of a 13-year-old female patient with Glanzmann thromboasthenia who underwent endoscopic anterior bilateral ethmoidectomy. Management was centered on prophylactic platelet transfusion plus the use of tranexamic acid, as well as thromboelastographic determination of hemostasis. There were no bleeding complications during or after the procedure. Conclusiones Pediatric patients with Glanzmann thromboasthenia are at a high risk of perioperastive bleeding. Platelet transfusion is the best prophylactic and therapeutic alternative; however, even in the absence of anti-platelet antibodies, it may not be effective, and viscoelastic testing must be used for assessment during the surgical procedure in order to improve patient safety.


Resumen Introducción La trombastenia de Glanzmann es un trastorno hemorrágico congénito infrecuente, causado por mutación en los genes que codifican las glucoproteínas plaquetarias α-IIb (ITGA2B; 607759) y β3 (ITGB3; 173470) en los cromosomas I7q2i.3i y I7q2i.32, respectivamente, alterando cualitativa o cuantitativamente al receptor plaquetario de integrina αIIbβ3 (glucoproteína IIb/IIIa). La trombastenia de Glanzmann se clasifica como tipo I cuando se expresa menos del 5 % de la glucoproteína αIIbβ3 y como tipo II, cuando es mayor al 5 %. Presentación del caso Se describe el manejo perioperatorio de una paciente de 13 años de edad con trombastenia de Glanzmann, sometida a etmoidectomía anterior bilateral endoscópica. El manejo se centró en la transfusión profiláctica de plaquetas y ácido tranexámico, así como en la evaluación de la hemostasia con tromboelastografía. No hubo complicaciones hemorrágicas durante y después del procedimiento. Conclusiones Los pacientes pediátricos con trombastenia de Glanzmann tienen alto riesgo de hemorragia perioperatoria. La transfusión de plaquetas es la mejor alternativa profiláctica y terapéutica; sin embargo, incluso en ausencia de anticuerpos antiplaquetarios, puede no ser efectiva y debe evaluarse mediante pruebas viscoelásticas durante los procedimientos quirúrgicos para mejorar la seguridad del paciente.


Subject(s)
Humans , Female , Adolescent , Thrombasthenia , Factor VIIa , Thrombelastography , Platelet Transfusion , Factor VII Deficiency , Genetic Diseases, Inborn
3.
Article in Chinese | WPRIM | ID: wpr-880166

ABSTRACT

OBJECTIVE@#To explore the effects of hematocrit (HCT) on the parameters of thromboelastography (TEG) in healthy adults, so as to judge coagulation and fibrinolysis more accurately.@*METHODS@#Three hundred and ninety-three healthy adults examined in Chengdu 363 Hospital Affiliated to Southwest Medical University from May 2018 to May 2019 were selected. HCT and TEG were detected at the same time. The differences of TEG parameters between the high HCT group and the low HCT group were compared. The correlation between HCT and TEG parameters was analyzed. The differences of TEG parameters between the healthy adults in Plateau and plain areas were compared.@*RESULTS@#Among the parameters of TEG, R and K in high HCT group were significantly higher, and Angle, MA and CI were significantly lower than those in low HCT group, which showed statistically significance (P0.05). R and K positively correlated with HCT (r=0.112, 0.517, P=0.027, 0.000), and Angle, MA and CI negatively correlated with HCT (r=-0.490, -0.408, -0.414, P=0.000). LY30 and EPL not correlated with HCT (P>0.05). HCT in plateau area was significantly higher than that in plain area (P0.05).@*CONCLUSION@#The difference of HCT may affect the values of R, K, Angle, MA and CI in TEG parameters. R and K positively correlate with HCT, while Angle, MA and CI negatively correlate with HCT. It is suggested that a suitable TEG reference range for the local population should be established, in plateau area especially K, Angle, MA and CI, which will be more conducive to the accurate evaluation of patients' coagulation and fibrinolysis status.


Subject(s)
Adult , Blood Coagulation , Hematocrit , Humans , Reference Values , Thrombelastography
4.
J. bras. econ. saúde (Impr.) ; 12(3): 173-188, Dezembro/2020.
Article in English | LILACS, ECOS | ID: biblio-1141294

ABSTRACT

Objective: The transfusion of blood components and blood products in cardiac surgery patients can be guided by protocols based on standard laboratory tests and/or clinical decisions (Standardof-Care, SOC) or viscoelastic haemostatic assays (VHA). The aim of this study is to evaluate the cost-effectiveness and budget impact of VHAs compared to SOC. Methods: A decision tree model was built in TreeAge Pro® 2009. Costs and benefits were taken from the medical literature. The costeffectiveness was evaluated in a base-case scenario and a worst-case scenario, considering low costs of adverse events. The budget impact was evaluated from data taken from Datasus. Cost data were measured in 2019 USD and outcomes were measured in QALYs. Results: VHAs were considered dominant in the base-case scenario and very cost-effective in the worst-case scenario (ICER = $ 1,083.21 USD/QALY). The budget impact analysis varied from a cost-saving result in the base-case scenario to a reasonable increase in cost in the worst-case scenario. Since the total market share of the technology is unlikely, a reasonable estimative for the base-case scenario and the worst-case scenario are about -$275 million USD and $132 million USD, respectively. Conclusion: We conclude that the VHAs are cost-effective and should be recommended for the use in the perioperative period of cardiac surgeries, especially for patients with a high risk of hemorrhage or coagulation problems.


Objetivo: A transfusão de sangue, hemocomponentes e produtos sanguíneos em pacientes submetidos a cirurgia cardíaca pode ser guiada por protocolos baseados em testes laboratoriais padrão e/ou decisão clínica (Standard-of-Care, SOC) ou testes viscoelásticos (TVEs). O objetivo deste estudo é avaliar o custo-efetividade e o impacto orçamentário dos TVEs em comparação com o SOC. Métodos: Um modelo de árvore de decisão foi construído em TreeAge Pro® 2009. Os parâmetros de custos e benefícios foram obtidos da literatura médica. A relação custo-efetividade foi avaliada em um cenário-base e no pior cenário, considerando baixos custos de eventos adversos. O impacto orçamentário foi avaliado a partir de dados extraídos do Datasus. Os custos foram avaliados em USD 2019 e os desfechos em AVAQs. Resultados: Os TVEs foram considerados dominantes no cenário-base e muito custo-efetivos no pior cenário avaliado (RCEI = 1.083,21 USD/QALY). A análise de impacto orçamentário variou de um resultado de economia de custos no cenário-base a um aumento razoável no custo no pior cenário. Como a hipótese de que a tecnologia será adotada para toda a demanda do mercado é improvável, estimativas razoáveis para o cenário-base e o pior cenário são de aproximadamente -275 milhões de USD e 132 milhões de USD, respectivamente. Conclusão: Concluímos que os VHAs são econômicos e devem ser recomendados para uso no período perioperatório de cirurgias cardíacas, principalmente para pacientes com alto risco de problemas de hemorragia ou coagulação.


Subject(s)
Technology Assessment, Biomedical , Thoracic Surgery , Thrombelastography , Blood Coagulation , Cost-Effectiveness Evaluation
5.
Rev. bras. ter. intensiva ; 32(3): 474-478, jul.-set. 2020. graf
Article in English, Portuguese | LILACS | ID: biblio-1138507

ABSTRACT

RESUMO Este relato de caso detalha um caso grave de febre amarela complicada por insuficiência hepática e coagulação intravascular disseminada. A tromboelastometria foi capaz de identificar os distúrbios da coagulação e orientar o tratamento hemostático. Relatamos o caso de um homem com 23 anos de idade admitido na unidade de terapia intensiva com quadro com início abrupto de febre e dor muscular generalizada associados a insuficiência hepática e coagulação intravascular disseminada. Os resultados dos exames laboratoriais convencionais revelaram trombocitopenia, enquanto a tromboelastometria sugeriu coagulopatia com discreta hipofibrinogenemia, consumo de fatores de coagulação e, consequentemente, aumento do risco de sangramento. Diferentemente dos exames laboratoriais convencionais, a tromboelastometria identificou o distúrbio de coagulação específico e, assim, orientou o tratamento hemostático. Administraram-se concentrados de fibrinogênio e vitamina K, não sendo necessária a transfusão de qualquer componente do sangue, mesmo na presença de trombocitopenia. A tromboelastometria permitiu a identificação precoce da coagulopatia e ajudou a orientar a terapêutica hemostática. A administração de fármacos hemostáticos, incluindo concentrados de fibrinogênio e vitamina K, melhorou os parâmetros tromboelastométricos, com correção do transtorno da coagulação. Não se realizou transfusão de hemocomponentes, e não ocorreu qualquer sangramento.


Abstract This case report a severe case of yellow fever complicated by liver failure and disseminated intravascular coagulation. Thromboelastometry was capable of identifying clotting disorders and guiding hemostatic therapy. We report the case of a 23-year-old male admitted to the Intensive Care Unit with sudden onset of fever, generalized muscle pain associated with liver failure, and disseminated intravascular coagulation. The results of conventional laboratory tests showed thrombocytopenia, whereas thromboelastometry suggested coagulopathy with slight hypofibrinogenemia, clotting factor consumption, and, consequently, an increased risk of bleeding. Unlike conventional laboratory tests, thromboelastometry identified the specific coagulation disorder and thereby guided hemostatic therapy. Both fibrinogen concentrates and vitamin K were administered, and no blood component transfusion was required, even in the presence of thrombocytopenia. Administration of hemostatic drugs, including fibrinogen concentrate and vitamin K, improved thromboelastometric parameters, correcting the complex coagulation disorder. Blood component transfusion was not performed, and there was no bleeding.


Subject(s)
Humans , Male , Young Adult , Yellow Fever/complications , Blood Coagulation Disorders/diagnosis , Liver Failure/complications , Disseminated Intravascular Coagulation/complications , Thrombelastography/methods , Blood Coagulation Disorders/etiology , Blood Coagulation Disorders/therapy , Hemostatics/administration & dosage , Liver Failure/virology
6.
Pesqui. vet. bras ; 40(2): 113-120, Feb. 2020. tab, ilus
Article in English | LILACS, VETINDEX | ID: biblio-1098439

ABSTRACT

Patients with chronic kidney disease (CKD) have paradoxical hemostatic potential because they have bleeding episodes but are also prone to thrombosis. Few studies have evaluated blood viscoelastic properties in dogs with kidney disease; on the other hand, hypercoagulability has been observed in these patients. It is also emphasized that the platelet function and its participation in this process have not yet been fully understood. The objective of this study was to evaluate and compare the Thrombin Generation Test (TGT) and also viscoelastic properties of the blood measured by thromboelastometry (TEM) in dogs with proteinuria in CKD. Twenty healthy dogs (Control Group) and 19 dogs with CKD in stage III or IV, classified according to International Renal Interest Society - IRIS, were selected, and the reference test of urine protein:creatinine ratio (UPCR) should be greater than one (CKD group). Blood samples for TEM, thrombin generation, Prothrombin Time (PT), activated Partial Thromboplastin Time (aPTT), and fibrinogen concentration was collected at a single time for both groups after inclusion criteria being confirmed. Statistical analysis was performed according to the distribution of variables at 5% significance level. Differences were observed between healthy dogs and those with proteinuria in CKD noted in TEM. The TGT was unable to differentiate between sick and healthy groups. However, when the nephropathy was stratified, increases in TTP and peak thrombin concentration by TGT were observed in females and dogs over 30 days of diagnosis of CKD. Both tests signaled a discrete state of hypercoagulability. In fact, TEM is more sensitive to detect hypercoagulability in dogs with CKD. However, the TGT has potential clinical application by allowing long-term sample storage.(AU)


Os pacientes com doença renal crônica (DRC) apresentam um potencial hemostático paradoxal, pois apresentam episódios de sangramento, mas também são propensos à trombose. Poucos estudos avaliaram as propriedades viscoelásticas sanguíneas em cães com doenças renais, entretanto, a hipercoagulabilidade já foi observada nestes pacientes. Ressalta-se ainda que a função plaquetária e sua participação neste processo ainda não foram totalmente esclarecidas. O objetivo foi avaliar e comparar o teste de geração de trombina (TGT) e as propriedades viscoelásticas sanguíneas medidas pela tromboelastometria (TEM) em cães com DRC proteinúrica. Foram selecionados 20 cães saudáveis (grupo controle) e 19 cães com DRC em estágios III ou IV classificados segundo o IRIS e a relação proteína/creatinina urinária maior que um (grupo DRC). As amostras de sangue para a realização da tromboelastometria (TEM), geração de trombina, tempo de protrombina (TP), tempo de tromboplastina parcial ativada (TTPA) e concentração de fibrinogênio foram colhidas em momento único para ambos os grupos após os critérios de inclusão confirmados. A análise estatística foi realizada de acordo com a distribuição das variáveis, ao nível de 5% de significância. Foi observada diferença entre os cães saudáveis e os com DRC proteinúrica observados na TEM. O teste de geração de trombina não foi capaz de diferenciar os grupos doente e saudável. Entretanto, quando os nefropatas foram analisados de forma estratificada, foram observados aumentos do ETP e da concentração máxima de trombina (peak) pelo TGT em fêmeas e em cães com mais de 30 dias de diagnóstico da DRC. Ambos os testes sinalizando para um discreto estado de hipercoagulabiliade. A tromboelastometria é mais sensível para detectar a hipercoagulabilidade em cães com DRC. Entretanto, o teste de geração de trombina tem melhor aplicabilidade por permitir o armazenamento da amostra em longo prazo.(AU)


Subject(s)
Animals , Dogs , Thrombosis/prevention & control , Thrombin , Renal Insufficiency, Chronic/blood , Renal Insufficiency, Chronic/veterinary , Hemorrhage/prevention & control , Hemorrhage/veterinary , Hemostasis , Proteinuria/veterinary , Thrombelastography/veterinary
7.
Article in Chinese | WPRIM | ID: wpr-828947

ABSTRACT

OBJECTIVE@#To assess the changes in the coagulation profiles of patients with chronic kidney disease (CKD) using thromboelastography (TEG) and identify the risk factors of hypercoagulation in CKD patients.@*METHODS@#A total of 128 patients with CKD admitted in Hunan Provincial People's Hospital between August, 2018 and May, 2019 were recruited. The results of conventional coagulation test and TEG were compared between patients with CKD and 21 healthy control adults. The patients with CKD were divided into hypercoagulation group with a maximum amplitude (MA) > 68 mm (=66) and non-hypercoagulation group (MA≤68 mm, =62). The laboratory indicators were compared between the groups, and the factors affecting the hypercoagulable state in patients with CKD were analyzed.@*RESULTS@#The levels of fibrinogen and D-Dimer increased significantly in patients with CKD at different stages as compared with the control subjects ( < 0.05). In the patients with CKD, the reaction time and K time decreased while MA, α-angle and coagulation index increased significantly in patients in stage 3-4 and those in stage 5 either with or without hemodialysis compared with the control group ( < 0.05). The estimated glomerular filtration rate (eGFR), percentage of patients with diabetes mellitus, history of stroke, percentage of neutrophils, neutrophil-lymphocyte ratio, red blood cell count, hemoglobin levels, platelet count, serum creatinine, serum cystatin-C, serum albumin, and lipoprotein (a) all differed significantly between hypercoagulation group and non-hypercoagulation group ( < 0.05). The eGFR, platelet count and hemoglobin levels were identified as independent factors affecting hypercoagulability in patients with CKD ( < 0.05).@*CONCLUSIONS@#s The hypercoagulable state of patients with CKD worsens gradually with the disease progression, and eGFR, platelet count and hemoglobin levels are all risk factors for the hypercoagulable state in patients with CKD.


Subject(s)
Blood Coagulation , Humans , Renal Insufficiency, Chronic , Risk Factors , Thrombelastography , Thrombophilia
8.
Rev. chil. pediatr ; 90(6): 617-623, dic. 2019. tab, graf
Article in Spanish | LILACS | ID: biblio-1058192

ABSTRACT

INTRODUCCIÓN: Los exámenes habituales de coagulación evalúan distintos elementos de la hemostasia en forma par cial, y no traducen las interacciones celulares, lo que es especialmente sensible en pacientes críticos. Las técnicas viscoelásticas, como el tromboelastograma (TEG) muestran el proceso de coagulación completo, y están siendo evaluadas como exámenes de la coagulación global. OBJETIVO: determinar la correlación de los exámenes habituales de coagulación con los valores del TEG, en niños atendidos en una unidad de cuidados intensivos (UCI). PACIENTES Y MÉTODO: Se revisaron 238 TEG de pacientes <18 años, con evidencia de alteración de coagulación clínica y/o de laboratorio, hospitalizados en UCI. Se correlacionaron los valores de los parámetros del TEG con cada uno de los valores de los exámenes habituales de coagulación. Los exámenes se obtuvieron según protocolo, utilizando una muestra de sangre de 4,5 ml para TEG con equipo TEG® 5000 Thrombelastograph Hemostasis Sys tem, mediante un transductor electromagnético que permite la medición de la resistencia durante la formación y lisis del coágulo. El recuento de plaquetas se obtuvo utilizando método automatizado o microscopía con contraste de fase; el fibrinógeno, tiempo de protrombina y de tromboplastina parcial activada por métodos nefelométricos. RESULTADOS: 201 TEGs correspondientes a 59 pacientes. Se evidenció una correlación moderada a baja en todos los parámetros medidos. No se encontró co rrelación entre porcentaje de lisis del coágulo, ni firmeza del coágulo. CONCLUSIONES: Existe una baja correlación entre la información entregada por TEG y los exámenes de coagulación habituales, esto sugiere que el TEG aporta información diferente acerca del estado de coagulación de los pacientes críticos evaluados.


INTRODUCTION: Usual coagulation tests partially evaluate different elements of hemostasis, and do not translate cell interactions, which is an especially sensitive issue in critically ill patients. Viscoelastic measurement techniques, such as thromboelastogram (TEG) show the complete coagulation pro cess and are being evaluated as global coagulation tests. OBJECTIVE: To determine the correlation of the usual coagulation tests with the TEG values, in children treated in an intensive care unit (ICU). PATIENTS AND METHOD: We reviewed 238 TEGs of patients under 18 years of age, with evidence of clinical and/or laboratory coagulation alterations, who were hospitalized in the ICU. The TEG para meter values were correlated with each of the usual coagulation test values. The tests were obtained according to the protocol, using a 4.5 ml blood sample for TEG with TEG® 5000 Thrombelastograph Hemostasis System, through an electromagnetic transducer that allows the measurement of resis tance during the clot formation and lysis. Platelet count was obtained using an automated method or phase-contrast microscopy, and fibrinogen levels, prothrombin time, and partial thromboplastin time activated by nephelometric methods. RESULTS: 201 TEGs corresponding to 59 patients were re viewed. A moderate to low correlation was observed in all the measured parameters. No correlation was found between the percentages of clot lysis or clot firmness. CONCLUSIONS: There is a low corre lation between the information provided by TEG and the usual coagulation tests. This suggests that the TEG provides different information about the coagulation status of the evaluated critical patients.


Subject(s)
Humans , Male , Female , Infant , Child, Preschool , Child , Adolescent , Thrombelastography/methods , Critical Illness , Platelet Count , Reaction Time , Time Factors , Blood Coagulation , Blood Coagulation Tests , Intensive Care Units, Pediatric , Retrospective Studies
9.
Rev. bras. anestesiol ; 69(4): 383-389, July-Aug. 2019. tab, graf
Article in English | LILACS | ID: biblio-1042009

ABSTRACT

Abstract Background and objectives Modern crystalloid and colloid solutions are balanced solutions which are increasingly used in perioperative period. However, studies investigating their negative effect on whole blood coagulation are missing, and vivid debate is going on about which solution has the minimal coagulopathy effect. The aim of our study was to assess the effect of modern fluid solutions on whole blood coagulation using rotational thromboelastometry. Methods Blood samples were obtained from 30 patients during knee arthroscopy before and after administration of 500 mL of crystalloid, Hydroxyethyl Starch and gelatin according to the randomization. Rotational thromboelastometry (Extem, Intem and Fibtem tests) was used to assess negative effect of fluid solutions on whole blood coagulation. Results In Extem test, the initiation phase of fibrin clot formation represented by CT parameter was not influenced by any fluid solution (p > 0.05). The speed of clot formation represented by CFT and α angle was impaired by Hydroxyethyl Starch and gelatin but not by crystalloids (p < 0.05). The strength of formatted coagulum represented by MCF parameter was impaired both in Extem and Fibtem test by HES and in Fibtem also by crystalloids (p < 0.05). Intem test was not negatively influenced by any crystalloid or colloid solution in any parameter (p > 0.05). Conclusion Extem test appears to be sensitive to coagulopathy effect of modern colloids and crystalloids. Hydroxyethyl starch has the most obvious negative effect on clot formation followed by gelatin and finally by crystalloids. Intem test seems to be insensitive to adverse effect of modern colloids and crystalloids.


Resumo Justificativa e objetivos Os cristaloides e coloides modernos são soluções balanceadas e cada vez mais utilizadas no período perioperatório. No entanto, não há estudos que avaliem seu efeito negativo na coagulação do sangue total e o intenso debate sobre a solução que cause um efeito mínimo na coagulopatia permanece. O objetivo de nosso estudo foi avaliar o efeito das soluções líquidas modernas na coagulação do sangue total com o uso da tromboelastometria rotacional. Métodos De acordo com a randomização, amostras de sangue foram colhidas de 30 pacientes durante a artroscopia de joelho, antes e após a administração de 500 mL de cristaloides, hidroxietilamido e gelatina. A tromboelastometria rotacional (testes Extem, Intem e Fibtem) foi utilizada para avaliar o efeito negativo das soluções líquidas na coagulação do sangue total. Resultados No teste Extem, a fase de iniciação da formação de coágulos de fibrina representada pelo parâmetro CT não foi influenciada por qualquer solução líquida (p > 0,05). A velocidade da formação de coágulos representada pelo CFT e pelo ângulo α foi prejudicada pelo hidroxietilamido e pela gelatina, mas não pelos cristaloides (p < 0,05). A força do coágulo formatado representado pelo parâmetro MCF foi prejudicada tanto no teste Extem quanto no teste Fibtem pelo HES e no teste Fibtem também pelos cristaloides (p < 0,05). O teste Intem não foi influenciado negativamente por nenhuma solução cristaloide ou coloide em nenhum parâmetro (p > 0,05). Conclusão O teste Extem parece ser sensível ao efeito de coagulopatia dos coloides e cristaloides modernos. O hidroxietilamido apresentou o efeito negativo mais óbvio na formação do coágulo, seguido pela gelatina e finalmente pelos cristaloides. O teste Intem parece ser insensível ao efeito adverso dos coloides e cristaloides modernos.


Subject(s)
Humans , Male , Female , Adult , Thrombelastography/methods , Crystalloid Solutions/administration & dosage , Gelatin/administration & dosage , Arthroscopy/methods , Blood Coagulation/drug effects , Blood Coagulation Tests , Hydroxyethyl Starch Derivatives/administration & dosage , Plasma Substitutes/administration & dosage , Colloids/administration & dosage , Knee Joint/surgery , Middle Aged
10.
Braz. j. med. biol. res ; 52(4): e8006, 2019. tab, graf
Article in English | LILACS | ID: biblio-1001515

ABSTRACT

The aim of the study was to evaluate the diagnostic accuracy of thromboelastometry for assessing rivaroxaban concentrations. The accuracy of thromboelastometry was compared with the high-performance liquid chromatography tandem mass spectrometry (HPLC-MS/MS) method, which is the gold standard for drug plasma monitoring (the reference standard). Forty-six clinically stable patients were treated with 10, 15, or 20 mg of rivaroxaban once daily (OD group) or 15 mg twice a day (BID group) (no particular indication for treatment). Patient samples were collected 2 h after the use of the medication (peak) and 2 h before the next dose (trough). The rivaroxaban plasma concentrations were determined via HPLC-MS/MS, and thromboelastometry was performed using a ROTEM® delta analyzer. There were significant prolongations in clotting time (CT) for the 10, 15, and 20 mg of rivaroxaban treatments in the OD groups. In the 15 mg BID group, the responses at the peak and trough times were similar. At the peak times, there was a positive correlation between the plasma concentration of rivaroxaban and CT (Spearman correlation rho=0.788, P<0.001) and clot formation time (rho=0.784, P<0.001), and a negative correlation for alpha angle (rho=−0.771, P<0.001), amplitude after 5 min (rho=−0.763, P<0.001), and amplitude after 10 min (rho=−0.680, P<0.001). The CT presented higher specificity and sensitivity using the cut-off determined by the receiver characteristics curve. ROTEM has potential as screening tool to measure possible bleeding risk associated with rivaroxaban plasma levels.


Subject(s)
Humans , Male , Female , Adult , Middle Aged , Aged , Aged, 80 and over , Drug Monitoring/methods , Factor Xa Inhibitors/blood , Rivaroxaban/blood , Hemorrhage/prevention & control , Thrombelastography , Blood Coagulation Tests , Chromatography, High Pressure Liquid , Tandem Mass Spectrometry , Factor Xa Inhibitors/administration & dosage , Rivaroxaban/administration & dosage , Data Accuracy
11.
Article in English | WPRIM | ID: wpr-785373

ABSTRACT

During pregnancy, the procoagulant activity increases (manifested by elevation in factor VII, factor VIII, factor X, and fibrinogen levels), while the anticoagulant activity decreases (characterized by reduction in fibrinolysis and protein S activity), resulting in hypercoagulation. Standard coagulation tests, such as prothrombin time or activated partial thromboplastin time, are still used despite the lack of evidence supporting its accuracy in evaluating the coagulation status of pregnant women. Thromboelastography and rotational thromboelastometry, which are used to assess the function of platelets, soluble coagulation factors, fibrinogen, and fibrinolysis, can replace standard coagulation tests. Platelet count and function and the effect of anticoagulant treatment should be assessed to determine the risk of hematoma associated with regional anesthesia. Moreover, anesthesiologists should monitor patients for postpartum hemorrhage (PPH), and attention should be paid when performing rapid coagulation tests, transfusions, and prohemostatic pharmacotherapy. Transfusion of a high ratio of plasma and platelets to red blood cells (RBCs) showed high hemostasis success and low bleeding-related mortality rates in patients with severe trauma. However, the effects of high ratios of plasma and platelets and the ratio of plasma to RBCs and platelets to RBCs in the treatment of massive PPH were not established. Intravenous tranexamic acid should be administered immediately after the onset of postpartum bleeding. Pre-emptive treatment with fibrinogen for PPH is not effective in reducing bleeding. If fibrinogen levels of less than 2 g/L are identified, 2–4 g of fibrinogen or 5–10 ml/kg cryoprecipitate should be administered.


Subject(s)
Anesthesia, Conduction , Blood Coagulation Factors , Blood Transfusion , Drug Therapy , Erythrocytes , Factor VII , Factor VIII , Factor X , Female , Fibrinogen , Fibrinolysis , Hematoma , Hemorrhage , Hemostasis , Humans , Mortality , Partial Thromboplastin Time , Plasma , Platelet Count , Postpartum Hemorrhage , Postpartum Period , Pregnancy , Pregnant Women , Protein S , Prothrombin Time , Thrombelastography , Tranexamic Acid
12.
Article in Chinese | WPRIM | ID: wpr-771873

ABSTRACT

OBJECTIVE@#To investigate the efficacy of disease control, survival time and safely in treatment of newly diagnosed multiple mycloma patients with different dose of tenalidomide regimens.@*METHODS@#The clinical data of 116 patients with multiple myeloma from June 2011 to June 2015 were collected and analyzed retrospectively. According to doses of used lenalidomide based on dexamethasone plus lenalidomide regimen 116 patients were divided into 2 groups: conventional dose group (58 cases) and low dose group (58 cases). The ORR, PFS rate and OS rate during followed-up for 3 years, KPS score, RNS score and immunophenotypic index before and after treatment and drug toxicity incidence were compared between 2 groups.@*RESULTS@#The ORR for 2 treatment courses of low dose group was significantly lower than that in conventienal dose group (P<0.05). The ORR for 4 and 6 treatment courses was not significantly different between 2 groups (P>0.05). The PFS rate and OS rate during followed-up for 3 years was no significantly different between 2 groups (P>0.05). The KPS score and RNS score after treatment of low dose group were significantly better than those in conventional dose group and before treatment (P<0.05). The levels of immunophenotypic index after treatment of both groups were significantly better than those before treatment (P<0.05). The incidence of III-IV grade hematological toxicity, pulmonary infection and herpes were not significantly different between 2 groups (P>0.05). The incidence of peripheral neuropathy and gastrointestinal reactions in the low dose group were significantly lower than that in conventional dose group (P<0.05).@*CONCLUSION@#Conventional and low doses of lenalidomide possess the same control effects and survival time for treatment of newly dingnosed patients with multiple myeloma; Despite, the initiation of effects from the low dose lenalidomide is relatively slower, it contributes to raise the overall quality of life and reduce the risk of drug toxicity.


Subject(s)
Antineoplastic Combined Chemotherapy Protocols , Blood Coagulation , Child , Dexamethasone , Humans , Multiple Myeloma , IgA Vasculitis , Quality of Life , Retrospective Studies , Thalidomide , Thrombelastography , Treatment Outcome
13.
Article in Chinese | WPRIM | ID: wpr-771868

ABSTRACT

OBJECTIVE@#To evaluate the coagulation function of children with Henoch-Schönlein purpura (HSP) by thromboelastography (TEG) and conventional coagulation tests (CCTs), and to explore the correlation and consistency of the 2 test methods.@*METHODS@#A total of 468 children with HSP were selected from January 2017 to December 2017 in Beijing Children's Hospital, Capital Medical University. The TEG and CCTs data were analyzed to evaluate coagulation function of children with HSP, meanwhile, the coagulation results were analysed the superiority of the 2 test methods was compared by Pearson correlation and Kappa consistency analysis.@*RESULTS@#There were no clinically significant abnormalities practically in HSP children by TEG and CCTs analysis, except for D-dimer level was elevated (t=9.15, P<0.001). There were no significant changes for coagulation data from, sex comparison of HSP children (P>0.05 all), but the coagulation reaction time (R), blood clot formation time (K), α-Angle, CI value, fibrinogen, D-dimer and anti-thrombin III in HSP children with different age groups showed difference (P<0.05 all), and the blood in children aged 0-2 years old tended to be hypercoagulable. The TEG indexes demonstrated no significant difference in coagulation function of children with HSP each other (P>0.05). However, CCTs data showed that the blood in children with severe kidney involvement were hypercoagulable. Comparision results of the correlation and consistency of TEG and CCTs in detecting coagulation function of HSP children showed that R was weakly correlated with prothrombin time (PT), International Normalized Ratio (INR) and activated partial thromboplastin time (APTT). There were weak correlation between K, α-Angle and Fib (0.1<|r|<0.4 all). There was no obvious consistency between them each other (kappa<0.4 all).@*CONCLUSION@#The overall changes in coagulation function in children with HSP are not obvious, but the hyperfibrinolysis in hypercoagulable state may exists. Furthermore, younger age and severe kidney involvement may cause hypercoagulation in HSP children. The weakly correlation and consistency of TEG and CCTs in detecting coagulation function of HSP children are furtherly confirmation, and the 2 test methods may be irreplaceable.


Subject(s)
Blood Coagulation , Blood Coagulation Tests , Child, Preschool , Humans , Infant , Infant, Newborn , IgA Vasculitis , Retrospective Studies , Thrombelastography
14.
Journal of Experimental Hematology ; (6): 1622-1626, 2019.
Article in Chinese | WPRIM | ID: wpr-775674

ABSTRACT

OBJECTIVE@#To analyze and compare the correlation of platelet aggregation rate measured by platelet analyzer, platelet aggregometer and thromboelastography.@*METHODS@#The performance of platelet analyzer in platelet count and platelet aggregation function was evaluated. The platelet aggregation rate of 55 patients with type 2 diabetes mellitus (T2DM) before and after taking aspirin alone (32 cases) and clopidogrel alone (23 cases) was measured by thromboelastography, platelet aggregometer and platelet analyzer respectively, and the analytical results were compared. The correlation between the results measured by different instruments and equipment were further analyzed and the data were included in the statistical analysis.@*RESULTS@#The precision of platelet analyzer in day and in batch was 1/3 lower than the total error (7%). The contamination rate was 0.30%. The slope of regression equation was 1.02 and R was 0.99 in the linear range of 4.15×10/L to 1379.95×10/L. The coincidence rate of platelet count and platelet reference method was 85%, which met the requirements of industry standards. The platelet aggregation rates of patients with T2DM after clopidogrel or aspirin by using thromboelastography, platelet aggregometer and platelet analyzer respectively was significantly lower than those whom before clopidogrel administration (P<0.01).@*CONCLUSION@#Platelet analyzer can provide reliable, objective and accurate information for clinical detection of platelet count and aggregation function, which is meet the requirements of industry standards, and its results are similar to those of platelet aggregometer and thromboelastography.


Subject(s)
Diabetes Mellitus, Type 2 , Humans , Platelet Aggregation , Platelet Aggregation Inhibitors , Platelet Function Tests , Thrombelastography
15.
Article in English | WPRIM | ID: wpr-759554

ABSTRACT

Rotational thromboelastometry (ROTEM) is a point-of-care viscoelastic method and enables to assess viscoelastic profiles of whole blood in various clinical settings. ROTEM-guided bleeding management has become an essential part of patient blood management (PBM) which is an important concept in improving patient safety. Here, ROTEM testing and hemostatic interventions should be linked by evidence-based, setting-specific algorithms adapted to the specific patient population of the hospitals and the local availability of hemostatic interventions. Accordingly, ROTEM-guided algorithms implement the concept of personalized or precision medicine in perioperative bleeding management (‘theranostic’ approach). ROTEM-guided PBM has been shown to be effective in reducing bleeding, transfusion requirements, complication rates, and health care costs. Accordingly, several randomized-controlled trials, meta-analyses, and health technology assessments provided evidence that using ROTEM-guided algorithms in bleeding patients resulted in improved patient's safety and outcomes including perioperative morbidity and mortality. However, the implementation of ROTEM in the PBM concept requires adequate technical and interpretation training, education and logistics, as well as interdisciplinary communication and collaboration.


Subject(s)
Cooperative Behavior , Education , Health Care Costs , Hemorrhage , Humans , Interdisciplinary Communication , Methods , Mortality , Organization and Administration , Patient Safety , Point-of-Care Systems , Precision Medicine , Technology Assessment, Biomedical , Thrombelastography
16.
Article in English | WPRIM | ID: wpr-759517

ABSTRACT

BACKGROUND: We investigated the effect of irrigation fluid on coagulation according to the hemodilution level using rotational thromboelastometry (ROTEM). METHODS: Venous blood was taken from 12 healthy volunteers and divided into four specimen tubes that were diluted to various levels (0%, 10%, 20%, and 40%) using an irrigation fluid composed of 2.7% sorbitol and 0.54% mannitol. RESULTS: Significant prolongation of clotting time was observed in the 40% diluted sample using both INTEM (P = 0.009) and EXTEM (P = 0.001) assays. However, the clot formation time was prolonged significantly in the 10%, 20%, and 40% diluted samples using both INTEM (P < 0.001) and EXTEM (P = 0.002, P < 0.001, and P < 0.001, respectively) assays. A significant decrease of α-angle of INTEM and EXTEM were observed in the 10% (P < 0.001), 20% (P < 0.001 and P = 0.001, respectively), and 40% (P < 0.001) groups compared with the 0% dilution group. The maximum clot firmness (MCF) of INTEM decreased significantly in the 20% (P < 0.001) and 40% (P < 0.001) diluted samples. In the MCF of EXTEM and FIBTEM assays, 10% (P = 0.009 and P = 0.015, respectively), 20% (P = 0.001), and 40% (P < 0.001) samples showed a significant decrease compared with the 0% sample. Nevertheless, most of the ROTEM values were within the reference range, except the 40% sample. CONCLUSIONS: Blood became hypocoagulable when it was diluted in vitro with a fluid composed of 2.7% sorbitol and 0.54% mannitol.


Subject(s)
Blood Coagulation , Healthy Volunteers , Hemodilution , In Vitro Techniques , Mannitol , Reference Values , Sorbitol , Thrombelastography
17.
Rev. bras. anestesiol ; 68(6): 645-649, Nov.-Dec. 2018. graf
Article in English | LILACS | ID: biblio-977409

ABSTRACT

Abstract Introduction: Advanced hepatic disease may - in addition to the widely recognized hemorrhagic complications - occur with thrombotic events. We describe the case of a cirrhotic patient taking warfarin and whose coagulation management during liver transplantation was guided by thromboelastometry (ROTEM®). Case report: A 56 year-old male patient diagnosed with alcohol cirrhosis using warfarin (2.5 mg.day−1) for partial portal vein thrombosis with the International Normalized Ratio (INR) of 2.14. At the beginning of surgery, the ROTEM® parameters were all normal. In the anhepatic phase, EXTEM and INTEM remained normal, but FIBTEM showed reduction of amplitude after 10 min and maximum clot firmness. Finally, in the neohepatic phase, there was a slight alteration in the hypocoagulability of most of the parameters of the EXTEM, INTEM and FIBTEM, besides a notable correction of the Coagulation Time (CT) in HEPTEM compared to the CT of the INTEM. Therefore, the patient did not receive any transfusion of blood products during surgery and in the postoperative period, being discharged on the 8th postoperative day. Discussion: Coagulation deficit resulting from cirrhosis distorts INR as a parameter of anticoagulation adequacy and as a determinant of the need for blood transfusion. Thus, thromboelastometry can provide important information for patient management.


Resumo Introdução: A doença hepática avançada pode, além das complicações hemorrágicas amplamente reconhecidas, ocorrer com eventos trombóticos. Descrevemos o caso de um paciente cirrótico em uso de varfarina, cujo manejo da coagulação durante o transplante de fígado foi guiado por tromboelastometria (ROTEM®). Relato de caso: Paciente do sexo masculino, 56 anos, diagnosticado com cirrose alcoólica, recebendo varfarina (2,5 mg.dia−1) para trombose parcial da veia porta, com razão normalizada internacional (INR) de 2,14. No início da cirurgia, os parâmetros ROTEM® estavam todos normais. Na fase não hepática, EXTEM e INTEM permaneceram normais, mas FIBTEM mostrou redução da amplitude após 10 min e firmeza máxima do coágulo. Por fim, na fase neo-hepática houve uma ligeira alteração da hipocoagulabilidade na maioria dos parâmetros de EXTEM, INTEM e FIBTEM, além de uma correção notável do tempo de coagulação (CT) de HEPTEM em comparação com o CT de INTEM. Portanto, o paciente não recebeu transfusão de hemoderivados durante a cirurgia e no período pós-operatório, obteve alta no oitavo dia de pós-operatório. Discussão: O déficit de coagulação resultante da cirrose distorce o INR como um parâmetro da adequação da anticoagulação e como um determinante da necessidade de transfusão de sangue. Portanto, a tromboelastometria pode fornecer informações importantes para o manejo do paciente.


Subject(s)
Humans , Male , Thrombelastography , Warfarin/therapeutic use , Blood Coagulation , Monitoring, Intraoperative/methods , Liver Transplantation , Anticoagulants/therapeutic use , Venous Thrombosis/etiology , Venous Thrombosis/prevention & control , Venous Thrombosis/blood , Liver Cirrhosis/surgery , Liver Cirrhosis/complications , Liver Cirrhosis/blood , Middle Aged
18.
Rev. bras. ter. intensiva ; 30(3): 394-397, jul.-set. 2018. tab, graf
Article in Portuguese | LILACS | ID: biblio-977974

ABSTRACT

RESUMO A transfusão de concentrado de plaquetas é prática comum para prevenção de sangramento espontâneo ou decorrente de procedimentos invasivos; sabe-se que a transfusão de componentes alogênicos do sangue se associa a aumento da mortalidade e piora do desfecho clínico. A força do coágulo é avaliada por meio da tromboelastometria rotacional e determinada pela interação entre plaquetas e fibrinogênio. O efeito compensatório do incremento na concentração sérica de fibrinogênio na força do coágulo, em pacientes com trombocitopenia, tem sido demonstrado em diferentes contextos clínicos, incluindo sepse. Relatamos o caso de uma paciente com trombocitopenia grave, cujo resultado da tromboelastometria rotacional demonstrou efeito compensatório na força do coágulo determinada pelos níveis plasmáticos aumentados de fibrinogênio como reagente de fase aguda em pacientes sépticos. Relatamos o caso de uma paciente de 62 anos com diagnóstico de aplasia de medula óssea admitida a uma unidade de terapia intensiva com choque séptico e trombocitopenia grave. Nas primeiras 24 horas na unidade de terapia intensiva, ela apresentou quadro clínico de insuficiência respiratória aguda e choque. Foi necessário utilizar ventilação mecânica invasiva e fármaco vasoativo. A radiografia de tórax mostrou padrão de lesão pulmonar bilateral. Desta forma, foi solicitada broncoscopia com lavagem broncoalveolar para investigação diagnóstica. Conduziu-se uma tromboelastometria rotacional, e seu resultado mostrou perfil de coagulação normal. Apesar da trombocitopenia grave (1.000/mm3), os níveis de fibrinogênio aumentaram (1.050mg/dL) devido ao choque séptico. A broncoscopia foi realizada sem que subsequentemente ocorresse sangramento ativo. Este caso relata o uso da tromboelastometria como ferramenta diagnóstica em distúrbios da coagulação de pacientes graves, permitindo prevenir o uso desnecessário de transfusões profiláticas de concentrado de plaquetas.


ABSTRACT Platelet transfusion is a common practice to prevent spontaneous bleeding or bleeding due to invasive procedures. Transfusion of allogeneic blood components is associated with increased mortality and a worse clinical outcome. The clot strength is assessed by thromboelastometry and determined by the interaction between platelets and fibrinogen. The compensatory effect of high levels of fibrinogen on clot strength in patients with thrombocytopenia has been demonstrated in different clinical settings including sepsis. We report the case of a patient with severe thrombocytopenia whose thromboelastometry showed clot strength that was compensated for by the increase in plasma fibrinogen levels as an acute phase reactant of septic patients. Here, we report a case of a 62-year-old female diagnosed with bone marrow aplasia admitted in the intensive care unit with septic shock and severe thrombocytopenia. During the first 24 hours in the intensive care unit, she presented acute respiratory insufficiency and circulatory shock. The use of invasive mechanical ventilation and norepinephrine was required. Her chest X-ray showed bilateral lung injury. Thus, bronchoscopy with bronchoalveolar lavage was requested. Thromboelastometry was performed and resulted in a normal coagulable profile. Despite severe thrombocytopenia (1,000/mm3), fibrinogen levels were increased (1,050mg/dL) due to septic shock. Bronchoscopy was performed without any active or further bleeding. Here, we report the use of thromboelastometry in the diagnosis of coagulation disorders, preventing unnecessary prophylactic platelet transfusion.


Subject(s)
Humans , Female , Shock, Septic/complications , Thrombelastography/methods , Thrombocytopenia/physiopathology , Fibrinogen/metabolism , Thrombocytopenia/etiology , Blood Coagulation Disorders/diagnosis , Blood Coagulation Disorders/etiology , Bronchoscopy/methods , Bone Marrow Cells/pathology , Intensive Care Units , Middle Aged
19.
Rev. méd. Chile ; 146(3): 277-281, mar. 2018. tab, graf
Article in Spanish | LILACS | ID: biblio-961391

ABSTRACT

Background: Compared to standard coagulation essays (SCE), such as international normalized ratio (INR), prothrombin activated partial thromboplastin time (aPTT), or platelet count, thromboelastograhy (TEG) offers precise and real-time information about hemostasis. TEG tests both platelet function and coagulation by assaying several parameters of clot formation dynamically in whole blood. Aim: To evaluate hemostasis in cirrhotic patients undergoing liver transplantation and determine the positive and negative predictive values of SCE for alterations of TEG. Material and Methods: Preoperative SCE and TEG were prospectively analyzed in 25 patients. Results were categorized as normal, laboratory alteration or clinical alteration. SCE results were compared with TEG parameters to determine positive (PPV) and negative predictive values (NPV). Results: Hemostasis was abnormal and laboratory abnormalities were observed in all patients. One patient had clinical signs of excessive bleeding. SCE were abnormal in all patients and TEG was normal in nine patients. The most common alteration in TEG was hypocoagulability, in some cases associated with hypercoagulability and hyperfibrinolysis. Two patients had solely hypercoagulability. PPV of INR, aPTT, platelet count and fibrinogenemia were 0, 0, 0.5 and 0.17 respectively. NPV of the same tests were 1, 1, 0.34 and 1 respectively. Conclusions: Hypocoagulability was the most common laboratory alteration, however, clinical signs of coagulopathy were rarely present. SCE had a poor predictive value to diagnose o discard hemostatic abnormalities.


Subject(s)
Humans , Male , Female , Middle Aged , Thrombelastography , Blood Coagulation Tests , Liver Transplantation , Preoperative Period , Prospective Studies
20.
Article in English | WPRIM | ID: wpr-717876

ABSTRACT

The coagulation profile of patients with end-stage liver disease (ESLD) is different from that of healthy individuals. Because hemostasis is rebalanced in chronic liver disease, prophylactic transfusion of blood products may be not necessary for these patients even if they show severe coagulation dysfunction in conventional coagulation results. A 44-year-old man with hepatocellular carcinoma, cholangiocarcinoma and liver cirrhosis was scheduled for extra-hepatic mass excision under general anesthesia. His preoperative tests showed severe thrombocytopenia 19 × 10⁹/L. The patient underwent extrahepatic mass excision surgery under general anesthesia without transfusion of blood products. The post-operative course was uneventful without requiring any further hemostatic therapy. In this case report, we focus on the concept of rebalanced hemostasis in ESLD, and coagulation management based on rotational thromboelastometry.


Subject(s)
Adult , Anesthesia, General , Blood Coagulation , Blood Platelets , Carcinoma, Hepatocellular , Cholangiocarcinoma , Hemostasis , Humans , Liver Cirrhosis , Liver Diseases , Liver , Platelet Count , Thrombelastography , Thrombocytopenia
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