Evaluation of Coagulation Function in Hip Replacement Arthroplasty Using Thromboelastography / 대한마취과학회지

BACKGROUND: Hip replacement arthroplasty is highly traumatic and may be associated with serious perioperative cardiorespiratory and vascular complications. Bone traumatization induces activation of the hemostatic system. A method of assessment of hemostatic function with whole blood is thromboelastography (TEG), which is a sensitive indicator of platelet interreaction with protein coagulation cascade. The authors investigated the effect of bone cement on blood coagulation during hip arthroplasty by TEG. METHODS: Sixty patients scheduled for hip replacement arthroplasty were randomly allocated to either a noncemented group (n = 35) or cemented group (n = 25). All the patients were operated on under general anesthesia. Collected 0.36 ml blood samples were measured by TEG from 210 seconds to 270 seconds after sampling. TEG parameters were measured at preoperation, before and after bone cement insertion (before and after reaming in the noncemented group), at postoperative 6, 24 hours in both groups. RESULTS: There were no significant changes of r, k, alpha angle, MA and Ly60 irrespective of the use of bone cement. Also, in the cemented group, there were no significant changes in TEG measurements between before and after bone cement insertion. However, there were increase in MA and alpha angle at postoperative 6 hours compared with preoperation irrespective of the use of bone cement. CONCLUSIONS: This study reveals that there are no differences between fixation with and without bone cement in the activation of the cascade systems by hip replacement arthroplasty.

The Effect of Epidural Anesthesia on Coagulation Following Vascular Surgery in Patients with Arteriosclerosis Obliterance / 대한마취과학회지

BACKGROUND: The purpose of this study was to examine the relationship of epidural anesthesia with coagulation status and surgery outcome following lower extremity revascularization. METHODS: Twenty patients with arteriosclerosis obliterance (ASO) scheduled for lower extremity vascular reconstruction were randomized to receive either general anesthesia or combined general-epidural anesthesia. An additional 20 randomly selected patients without atherosclerotic vascular disease undergoing lower abdominal or lower extremity surgery served as controls for coagulation status. In the group with general anesthesia, anesthesia was induced by administration of pentothal sodium and succinylcholine and maintained with N2O-O2, isoflurane and vecuronium. In the group with combined anesthesia, epidural anesthesia was performed at the level of L2-3 or L3-4 epidural space using 2% lidocaine, followed by general anesthesia same as general group. Postoperative pain control was followed by on-demand oral or intravenous narcotics in the general group and followed by epidural 0.125% bupivacaine and morphine in the combined group. The coagulation status was monitored using thrombelastography (TEG) and standard coagulation tests. RESULTS: The ASO patients were hypercoagulable compared to the control patients before operation and on the first postoperative day. The hypercoagulability was attenuated postoperatively in the combined group. In the ASO-general group, postoperative MA, alpha and TEG index were 69.5 +/- 6.1 mm, 53.3 +/- 7.5 degree and 1.18 1.29 respectively, but in the ASO-combined anesthesia group, they were 58.0 +/- 6.2 mm, 38.0 +/- 4.0 degree and - 0.38 +/- 1.20 respectively (P < 0.05). The rates of postoperative complications did not significantly differ between the two groups. CONCLUSIONS: In patients with arteriosclerosis obliterance undergoing arterial reconstructive surgery, thrombelastographic evidence of increased platelet-fibrinogen interaction is associated with early postoperative thrombotic events, and epidural anesthesia is associated with beneficial effects on coagulation status.

Clinical Experience of Coagulation Management in Multiple Myeloma Patient with Thrombocytopenia Using Thromboelastography: A case report / 대한마취과학회지

Multiple myeloma is malignant proliferation of plasma cells whose pathologic condition is produced by bone marrow invasion as well as excessive production of immunoglobulin. Its invasion into bone marrow causes severe pancytopenia. Therefore these patients are susceptible to thrombocytopenia and have bleeding tendency, especially during surgery. We experienced an anesthetic management of meningioma operation in a patient with multiple myeloma who showed severe thrombocytopenia and excessive abonormal immunoglobulin.

Clinical Experience of Coagulation Management in Multiple Myeloma Patient with Thrombocytopenia Using Thromboelastography: A case report / 대한마취과학회지

Multiple myeloma is malignant proliferation of plasma cells whose pathologic condition is produced by bone marrow invasion as well as excessive production of immunoglobulin. Its invasion into bone marrow causes severe pancytopenia. Therefore these patients are susceptible to thrombocytopenia and have bleeding tendency, especially during surgery. We experienced an anesthetic management of meningioma operation in a patient with multiple myeloma who showed severe thrombocytopenia and excessive abonormal immunoglobulin.

Coagulation Management with Thromboelastography in Patient with Coagulopathy: A case report / 대한마취과학회지

A fifty five-year-old man who had been decrease in levels of coagulation factors V, VIII, X and XI was monitored by thromboelastography(TEG) to evaluate the effectiveness of blood component replacement therapy during operation of chest wall reconstruction. Cryoprecipitate(9 units) was infused in the preoperative day because the clot formation rate was slow( : 27.5 ). During the operation cryoprecipitate(9 units), fresh frozen plasma(9 units), whole blood(2 units) and packed red blood cells(6 units) were transfused for blood loss of 4000 ml and abnormal findings on TEG. The operation site was not abnormal bleeding tendency. So TEG patterns were normal toward the end of operation. As a result, TEG is effective to monitor hemostasis and guide for transfusion therapy of coagulation abnormalities associated with intraoperative blood loss.

Augmentin-Induced Coagulation Abnormalities as Measured by Thromboelastography / 대한마취과학회지

BACKGROUND: Antibiotics are used prophylactically in surgery to prevent postoperative infection. However, antibiotics administered in large doses can cause a bleeding diathesis as a result of platelet dysfunction. We wondered whether these antibiotics might impair platelet function by interfering with the initial step of platelet activation: the binding of agonists to their specific receptors on the platelet surface. METHODS: In 30 patients (male 18, women 12) undergoing primary elective knee arthroscopic surgery, the whole blood coagulation system was prospectively evaluated before, and 10 and 40 minutes after administration of 1 g of augmentin. All patients who had abnormal preoperative coagulation profiles or who received anticoagulant or antiplatelet, antibiotics therapy within 7 days prior to surgery were precluded. RESULTS: At 10 minutes after augmentin administration 25 of 30 patients had a significant impairment in all phases of whole blood coagulation as monitored by thromboelastography. In contrast, three of 30 patients had a significantly decreased coagulation time. Two of 30 patients had no significant changes of TEG variables. TEG variables were restored toward baseline in fourty minutes after augmentin administration. CONCLUSIONS: Augmentin can cause a significant but transient change in the viscoelastic properties of blood. Coagulation parameters of the TEG should be measured prior to augmentin administration to prevent and prospect a bleeding diathesis as a result of platelet dysfunction.

In Vitro Aprotinin Enhanced Anticoagulation Synergistically to Heparinized Blood on Thromboelastography / 대한마취과학회지

BACKGROUND: Aprotinin is a potent, nonspecific broad serine protease inhibitor. It's inhibitory effects on intrinsic pathway of coagulation cascade can augment anticoagulation by heparin. This study designed to demonstrate augmented anticoagulation of aprotinin to heparin contaminated blood on thromboelastography(TEG). METHODS: This study designed into two phases for 21 healthy volunteers undergoing elective opeation. The first phase study, it was for looking at TEG differences between blood treated with aprotinin 200 KIU and blood treated with heparin 0.05 unit and 0.1 unit per blood 1 ml. The second phase study was for looking at anticoagulation of aprotinin added by heparin 0.05 unit and 0.1 unit per blood 1 ml and their reversal added by optimal dose of protamine sulfate. RESULTS: The aprotinin treated blood showed only a prolonged reaction time. Blood treated with incremental dose of heparin showed longer reaction time and smaller alpha angle than TEGs of native blood. Aprotinin added to the heparin contaminated blood showed much longer reaction time and much less alpha angle when compared with TEGs of aprotinin or heparin treated blood. Depressed TEG pattern by the heparin and aprotinin mixture reversed back to the TEGs of blood treated with aprotinin when optimal dose of protamine added. CONCLUSIONS: Those results suggest that aprotinin administered in open cardiac surgery can augment the remained anticoagulation effect due to heparin even after first dose fo protamine after weaning of cardiopulmonary bypass. This is of clinically improtance to distinguish heparin related coagulopathy from heparin non related coagulopathy by thromboelastography.

Intraoperative Normovolemic Hemodilution in Patients Undergonig Posterolateral Spinal Fusion: Safety and Efficacy / 대한마취과학회지

BACKGROUND: The implementation of intraoperative normovolemic hemodilution is a strategy used in an attempt to diminish the need for or obviate allogeneic transfusion and to avert the potential complications. The goal of this study was to evaluate the safety and efficacy of moderate intraoperative normovolemic hemodilution. METHODS: Fifteen patients scheduled for posterolateral spinal fusion underwent intraoperative normovolemic hemodilution with 10% pentastarch to a target hematocrit level of 25% (hemodilution group). All units of blood procured by hemodilution and additional allogeneic blood was transfused in the perioperative period to maintain the hematocrit level of>25%. We investigated the effect of hemodilution on whole blood coagulation as measured by the thromboelastography and, evaluated its efficacy of decreasing the need for allogeneic blood transfusion as compared to the nonhemodilution group, retrospectively. RESULTS: Hemodilution with pentastarch caused a decrease in response and coagulation time (p<0.01) but did not influence on the alpha angle and maximum amplitude on thromboelstogram. Amount of transfusion of allogeneic blood was 4.1 1.7 units for the hemodilution group and 5.0 1.5 units for the nonhemodilution group. Net red blood cell volume ""saved"" from hemodilution was about 120 ml. CONCLUSION: Moderate intraoperative normovolemic hemodilution with pentastarch does not affect the coagulability of whole blood. But its efficacy of decreasing the need for allogeneic blood transfusion is minimal.

Intraoperative Coagulation Management by TEG in a Patient with Aplastic Anemia: A case report / 대한마취과학회지

This case was an acquired aplastic anemia patient who required a major operation for excision of a mediastinal mass. The authors previewed that the coagulation abnormalities would be developed due to major operation. Thus we decided to monitoring the coagulation function using the thromboelastography during the perioperative period and checked the complete blood count, concommitantly. The total blood volume lost during operation was 1800 ml, so we gave him a transfusion of 10 U's of platelet concentrate, 10 U's of pheretic platelet rich plasma and 5 U's of whole blood. The thromboelastography was a good guide that helped us to avoid excessive treatment of the coagulation abnormalities. We concluded that the thromboelastograhy was a reliable and effective monitoring system at the intraoperative coagulation management.