ABSTRACT
Thromboelastography (TEG) and rotational thromboelastometry (ROTEM) are point-of-care viscoelastic tests of whole blood that provide real-time analyses of coagulation. TEG and ROTEM are often used to guide blood product administration in the trauma and surgical settings. These tests are increasingly being explored for their use in other disease states encountered in critically ill patients and in the management of antithrombotic medications. As the medication experts, pharmacists should be familiar with how to interpret and apply viscoelastic tests to disease state and medication management. The purpose of this narrative review is to provide a primer for pharmacists on viscoelastic tests and their interpretation and to explore non-trauma indications for viscoelastic testing in critical care. Literature evaluating the use of TEG and ROTEM for patients with acute and chronic liver disease, ischemic and hemorrhagic stroke, myocardial infarction, cardiac arrest, coronavirus disease 2019, and extracorporeal membrane oxygenation are described. Current applications of viscoelastic tests by pharmacists and potential future roles of critical care pharmacists in expanding the use of viscoelastic tests are summarized.Copyright © 2023 The Authors. JACCP: Journal of the American College of Clinical Pharmacy published by Wiley Periodicals LLC on behalf of Pharmacotherapy Publications, Inc.
ABSTRACT
Objective: Hypercoagulation and high incidence of thrombosis during COVID-19 is well established. However, there is a lack of data, how it changes over time. The main purpose of our study was to access different parts of hemostasis in few months after acute disease. Material and methods. Patients discharged from our hospital were invited for follow up examination in 2,3-3,8 (group 1 - 55 pts) or 4,6-5,7 months (group 2 - 45 pts) after admission. Control group (37 healthy adults) had been collected before pandemic started. Standard coagulation tests, aggregometry, thrombodynamics and fibrinolysis results were compared between groups. Result(s): D-dimer was significantly higher, and was APPT was significantly lower in group 2 compared to group 1, while fibrinogen, prothrombin levels didn't differ. Platelet aggregation induced by ASA, ADP, TRAP, spontaneous aggregation didn't differ significantly between groups. Thrombodynamics revealed hypocoagulation in both group 1 and group 2 compared to control: V, mum/min 27,3 (Interquartile range (IQR) 26,3;29,4) and 28,3 (IQR 26,5;30,1) vs. 32,6 (IQR 30,4;35,9) respectively;all p < 0,001. Clot size and density in both group 1 and group 2 were significantly lower than in control group. Fibrinolysis appeared to be enhanced in x2 compared to control and group 1. Lysis progression, %/min was higher: 3,5 (2,5;4,8) vs. 2,4 (1,6;3,5) and 2,6 (2,2;3,4) respectively, all p < 0,05. Lysis onset time in both group 1 and group 2 was significantly shorter compared to control. Conclusion(s): We revealed normalization of parameters of clot formation process in 2-6 months after COVID-19, while fibrinolysis remained still enhanced. Further study is required to investigate the clinical significance of these changes.Copyright © Creative Cardiology 2021.
ABSTRACT
Objective: Studies have shown that high mortality rates associated with abnormal coagulation response, bleeding and coagulation disorders in COVID-19 patients. In our study, it was aimed to investigate the effect of the use of favipiravir on coagulation tests such as INR, PTT and Aptt. Materials-Methods: 50 patients who had a positive RT-PCR in nasal and throat swabs result and were diagnosed with COVID-19 using favipiravir and 50 non-users favipiravir COVID-19 patients were included. INR, PT, Aptt data were evaluated for all patients. Result(s): Results of patients using favipiravir;INR 1.3+/-0.2, PT(s) 16.4+/-3.4, Aptt(s) 40.7+/-10.1, while the results of patients who did not use favipiravir were INR 1,2+/-0.2, PT(s) 14.6+/-2.5, Aptt(s) was found 38.4+/-7.8. While PT and INR were found to be significantly higher in patients using favipiravir (p<0.05), the elevation in Aptt values was not significant. Conclusion(s): As a result, it was observed that favipiravir prolongs the clotting time. In the light of these RESULTS, it is recommended to consider this in anticoagulant therapy used for treatment.
ABSTRACT
Background and Aim: The new type of Severe Acute Respiratory Syndrome Coronavirus 2 (Coronavirus 2019-COVID-19) infection is the largest pandemic in the last decade. Acute respiratory distress syndrome is the complication with the highest mortality rate of this infection and there is no adequate treatment with proven efficacy to reduce mortality. This multi-center, retrospective study aimed to determine the effect of high-dose vitamin C on survival and other endpoints in invasively ventilated ARDS patients. Method(s): This multi-center, observational retrospective cohort study was performed at five ICU centers between March 2020 and July 2020. Patients with ARDS due to COVID-19 who required IMV were included. High-dose vitamin C group was defined as patients who were treated with vitamin C over 200 mg/kg for four days. Patients who were not given vitamin C treatment were defined as the control group by using propensity score match analysis, as well. The groups were compared about the effects of high-dose vitamin C treatment on ICU mortality. Result(s): A total of 86 patients with a mean age of 67.85 +/- 10.38 were included in the study. 72.1% of the patients were male. Forty-two (49%) patients were in the high dose vitamin C group, and 44 (51%) were in the control group. The mean PaO2/FiO2 at the time of admission to the ICU was 128.27+/-58.69 mmHg (133.63+/-56.51 mmHg in the control group, 122.36+/-61.18 mmHg in the study group, p=0.389). The mortality rate of high dose vitamin C group was lower than the control group (73.8% vs. 90.9%, p = 0.037,respectively). Conclusion(s): As an adjunctive therapy in invasively ventilated patients with COVID-19-associated ARDS, high doses of vitamin C may reduce mortality and development of organ damage. Prospective, randomized controlled studies with larger numbers of patients are needed to confirm these findings.Copyright © 2023, Society of Turkish Intensivists. All rights reserved.
ABSTRACT
COVID-19 is represented by a large number of different phenotypes, ranging from asymptomatic infection to the development of severe multiple organ dysfunction syndrome. The mechanisms of development of multiple organ dysfunction syndrome are multifactorial, they frequently include hypercoagulable states and Background thrombus formation. Such mechanisms are diagnosed as thrombotic complications that cause blood clots in veins, pulmonary arteries, and coronary arteries. An observational study revealed that the incidence of venous and arterial thrombosis is as high as 31% in patients with COVID-19 pneumonia. However, large studies regarding this topic have not yet been conducted. To compile and analyze our own observations concerning the clinical course of Aim patients with thrombosis in COVID-19. The study included 5 male patients with arterial and venous thrombosis and Methods COVID-19. The experience in the management of 5 patients with COVID-19 and arterial and venous thrombosis was analyzed. All patients exhibited dynamic changes in their blood coagulation tests. The patients with negative COVID-19 test results on Results admission, and changes in the coagulogram indices found on the day of recurrence of thrombosis were of the most interest. All patients received standard treatment and were discharged upon showing improvement and negative COVID-19 test results. Compiling data on the clinical course of patients with COVID-19 and different Conclusion types of thrombosis allowed us to develop treatment strategy for these groups of patients.Copyright © 2021 Russian Academy of Sciences. All right reserved.
ABSTRACT
Background: With a prevalence of 1-3 cases per million, acquired haemophilia A (AHA) is a rare autoimmune bleeding disorder caused by the presence of neutralizing antibodies against factor VIII. Even though diagnosis of this bleeding disorder is rarely established among children and adolescents, AHA may lead to severe, life-threatening hemorrhage in this age group, and therefore it requires special caution. Case report: 19 year old primigravida with confirmed SARS-CoV-2 infection was admitted to hospital due to prolonged vaginal bleeding six weeks postpartum. All gynaecological causes of uterine bleeding were excluded, Foley catheter was placed, but the bleeding still persisted. Coagulation tests revealed isolated deranged aPTT values. Further haematology evaluation demonstrated factor VIII deficiency, presence of factor VIII inhibiting factors, and the diagnosis of AHA was proposed. The anti-inhibitor coagulant complex drug was introduced and patient has responded positively to the treatment. Conclusion(s): Due to disturbance of immune system, pregnancy and postpartum period represent predilection time for AHA development. Furthermore, viral infection in pregnancy, such as COVID-19, might be considered as an additional risk factor for AHA development and several reported cases of AHA after COVID-19 infection support this hypothesis. Even though AHA is a rare disease, due to its high mortality rate of more than 20%, it should be considered in all cases of unusual bleeding of unknown cause in all age groups. Publication of this case report is approved by Institutional Review Board.Copyright © 2023
ABSTRACT
Introduction: In critically ill patients with AKI, unacceptably high mortality rates reaching up to 50-80% in all dialyzed ICU patients are seen despite the availability of intensive renal support. At present there is no specific or targeted therapy for AKI. Pathophysiology of AKI is multifactorial. Systemic inflammation, mediated in part by cytokines, might be contributing majorly to the development of AKI. This mandates a multipronged approach to the treatment of AKI. There are hardly any studies on the use of ulinastatin in AKI. Our premise regarding the use of molecule in AKI was based on the fact that this molecule acts at multiple levels in the sepsis and can act to stop the cascade and thereby stop the "storm." Methods: We studied a total of 200 patients with AKI who needed ICU care in our hospital in the period between June 2017 - Jan 2020. Out of these, 100 patients received Injection ulinastatin 3 doses a day for 5 days, against a similar number of control patients. We included those patients with AKI who had SOFA scores more than 8. None of the patients had COVID 19 infection. We compared the same number of patients who had received ulinastatin with controls. Injection ulinastatin 1,50,000IU was given three times a day for 5 days. All the patients included had received dialytic therapy. We recorded the age of the patients, it varied from 11-94 years (mean age 52 years), > 60 % (120) of the patients being in the age group of 26-40 years. The ratio of males to females 1.8:1 (M: F 129:71). The etiologies were as follows: Malaria - complicated - P vivax, P falciparum (n= 76) 38% Enteric fever (n= 40) 20% UTI (n=30) 15% Post-partum (n=20) 10% Dengue (n = 14) 7% Acute gastroenteritis/diarrheal diseases (n= 12) 6% Pancreatitis (n= 6) 3% Obstructive uropathy (n= 3) 1.5% 33 % (n= 66) patients had diabetes as a co morbid condition. The renal function tests of all the patients along with liver function tests, sepsis parameters like d-dimer, serum procalcitonin levels, CRP-hs levels, coagulation tests, complete blood counts, and arterial blood gas analysis were done We recorded the length of stay, need and duration of renal replacement therapy, time to stoppage of renal replacement therapy, need for mechanical ventilation, mortality and post AKI recovery and progression to CKD. Result(s): The patients who received ulinastatin had a shorter stay in the ICU (p <0.01 vs control group);also, the time to stoppage of renal replacement therapy was shorter (p < 0.05). The recovery of renal function was seen in 84% (n=168). The progression to CKD was seen in 11% (n=22) of patients. The average number of sittings of dialysis needed were 11 (range3-20), lesser number of dialysis were needed in the ulinastatin group. The overall mortality was 36 %(n=72).The average follow up period post discharge has been 141 days (21 - 240 days) Conclusion(s): There definitely seem to be advantages in using ulinastatin and results look promising. But there are limitations to this study - this was a retrospective analysis hence not all the patients received ulinastatin. Moreover, the drug is expensive. This study was done in a semi urban set up where causes for AKI are predominantly infective. A larger prospective double-blind study will be needed to consider ulinastatin as a routine option for treating AKI. Till then preventing AKI should be the aim for us. No conflict of interestCopyright © 2023
ABSTRACT
Introduction: Acquired hemophilia A (AHA) is a rare autoimmune disease due to anti-factor VIII antibodies. It may be associated with infections and malignancies. The association with Covid vaccine is extremely rare. Immunosuppressive therapy with steroids, cytotoxic agents, is the traditionalmainstay for antibodies eradication. Rituximab standard doses have been used with success. There are few reports on low-dose Rituximab for AHA.We present a case of AHA post Covid-19 vaccination successfully treated with low dose of Rituximab. Method(s): case report Results: A non hemophilic 69-year-old male with no medical history consulted for multiple ecchymosis that spontaneously occurred with no context of trauma. Two months previously he received a second dose of CoronaVac-Sinovac vaccine. Coagulation tests revealed an isolated and prolonged aPTT (100 sec/30s;ratio=3.33) not corrected with normal plasma. The coagulation factors assay revealed an isolated decrease of factor VIII to 1% with a titer of 121 Bethesda units/ml confirming the diagnosis of AHA. Hepatitis B and C and HIV tests were negative. A full body-computed tomography scan was normal. Treatment with Prednisolone 1 mg/kg/d was started with tranexamic acid. Bypassing therapy was not considered because of the absence of life-threatening bleeding. Seventeen days after corticosteroid initiation, a worsening of the ecchymosis was noted with the non-improvement of the aPTT. A low-dose rituximab (100 mg/week) was added for 4 weeks. After 3 doses of Rituximab a complete clinical response was achieved. Factor VIII inhibitor was completely eradicated. Corticosteroid was discontinued. At 3-month follow-up the patient remains in remission without further treatment Discussion/Conclusion:More than 50 cases of AHA following COVID-19 vaccine have been reported. To our knowledge only 2 cases of AHA were successfully treated with low dose of rituximab. Low-dose Rituximab appears to be effective for Factor VIII inhibitor eradication in AHA with a lower cost.
ABSTRACT
Introduction: Thrombotic thrombocytopenic purpura (TTP) is a rare thrombotic microangiopathy characterized by severe thrombocytopenia, microangiopathic hemolytic anemia, and organ ischemia ascribable to platelet-rich microthrombi. TTP is related to a severe deficiency in ADAMTS13, the specific von Willebrand factor-cleaving metalloprotease. The aim of our study is to analyze the clinical characteristics, treatment and outcome of patients with TTP. Method(s): We retrospectively analyzed 15 patients with TTP treated Farhat Hached hospital, Sousse, Tunisia, from2004 to 2021. Result(s): Among the 15 patients, there were 7 males and 8 females, with a median age of 45,5 (30~72) years. Two of them had evolutive cancer and 1 had covid-19 vaccination 3 months earlier. Twelve patients had neurological presentations (80%), 4 had mucocutaneous bleeding and 2 had fever. Biology showed thrombopenia, mechanical hemolytic anemia in all patients and renal failure in 2 patients. No abnormalities in coagulation tests were detected. The ADAMTS13 activity was performed in only 3 patients (Due to test unavailability) showing a level <=10% in all 3 patients. All patients were treated with plasma exchange/ plasma infusion + glucocorticoid, combined with rituximab in 2 cases. Ten patients showed complete remission, 1 relapsed within the first year, 2 died and 2 others were lost to follow-up. Discussion/Conclusion: Most TTP patients presented with the triad of microangiopathic anemia, thrombocytopenia, and neurologic abnormalities and improved with plasma therapy.
ABSTRACT
The coronavirus infection (COVID-19), an acute viral disease with predominant affection of the upper respiratory tract, is a challenge for modern medicine. Considering the fact that in the patho-genesis of coronavirus pneumonia there is violation of the im-mune response (hyper-response, cytokine storm) the drugs that locally regulate it may be promising in the pneumonia treatment. Biological activity of exosomes is widely investigated in the world. Small extracellular vesicles of mesenchymal cells have the following effects: anti-apoptotic, proliferation stimulation, anti-inflammatory and immunomodulatory. Objective(s): to evaluate the safety and efficacy of the method of inhalation administration of small extracellular vesicles in bilateral pneumonia caused by a new SARS-CoV-2 coronavirus infection. To study these effects an interventional, prospective, random-ized, double-blind, placebo-controlled study has been conducted to evaluate the safety and efficacy of inhaled small extracellular vesicles administration to the patients with bilateral pneumonia caused by the new coronavirus infection SARS-CoV-2. Altogether 36 patients with confirmed new coronavirus infection COVID-19, complicated by bilateral pneumonia of moderate severity (12 patients each in study groups 1 and 2, depending on the type of given small extracellular vesicles, and the control group) participated in the study. Small extracellular vesicles were inhaled twice a day in the dose of 2-10x1010 particles. The efficacy and safety of the method were assessed judging by the patients' general state, as-sessment of the disease severity, general and biochemical blood tests, coagulogram, saturation, CT scan of the lungs before and after 10 days of treatment. The observation period was 30 days after hospitalization. During the study the safety of the method was proved, all the patients recovered. Reliable differences of the blood CRP index, which normalized by day 10 of treatment in groups 1 and 2, but remained elevated in the control group. No significant differences were found in other assessed parameters.Copyright © 2022, Human Stem Cell Institute. All rights reserved.
ABSTRACT
Objectives: To investigate the effects of vaccination on age, mortality, and healthcare workers among patients followed in the COVID-19 Intensive Care Unit. Method(s): We examined age, gender, occupation, demographic characteristics, comorbid diseases, hemogram, biochemistry parameters, coagulation tests, morbidity-mortality characteristics of 548 patients in Bozyaka Training and Research Hospital COVID-19 intensive care unit admitted between March and October 2021. In addition, the vaccination status of the patients and the type of vaccination were recorded via the Ministry of Health Vaccine Tracking System (VTS). Within the vaccine follow-up system, patients who received at least 2 doses of vaccine 4 weeks prior to study were considered vaccinated. Result(s): The data of 548 patients in the COVID-19 intensive care unit between March 2021 and October 2021 were analyzed. The mortality rate was 50.7% (n = 278). It was determined that 428 (78.1%) of the patients followed in the COVID-19 intensive care unit were not vaccinated. In terms of age distribution, the number of patients under the age of 65 was 357 (65.1%), while the number of patients aged 65 and over was 191 (34.9%). When mortality rates were compared based on vaccination status, the mortality rate in the unvaccinated group was found to be statistically significantly higher than in the vaccinated group (p < 0.05). Mortality rate in the vaccinated group was 12.5% whereas it was 61.4% in the unvaccinated group. Conclusion(s): Vaccination to protect against SARS-CoV-2 infection reduces intensive care unit admission and reduces mortality rates. Being unvaccinated increases hospitalization and mortality in intensive care units in addition to carrying risks for all age groups. Copyright © 2022 by Prusa Medical Publishing.
ABSTRACT
Background: Recent evidence has suggested the presence of unique coagulation abnormalities in patients with COVID-19. Clot waveform analysis (CWA) has not been adequately described as a tool for the evaluation of coagulation. Aim(s): To comparatively assess the changes in clot waveform analysis (CWA) parameters between COVID-19 patients upon hospital admission and healthy individuals. Method(s): In this retrospective observational study, we evaluated 227 CoVID-19 patients upon their hospital admission, prior to the initiation of anticoagulation therapy relative to 84 healthy individuals. Coagulation tests and CWA were performed on BCS XP System (SIEMENS). The CWA parameters of PT, aPTT and Fifrinogen (FIB) were the change in Absorbance (dmA) and the time difference between the starting time of the reaction (mixing of reagent and sample) until a specific absorbance change (absorbance threshold). All statistical analyses were performed using SPSS27. Variables were tested with Student's t tests or Mann-Whitney U tests for differences in distributions of dmA and dsec of PT, aPTT and FIB between two groups. P values < 0.05 were considered statistically significant. Result(s): A statistically significant increase in the dmA values of PT, aPTT and FIB was detected in CoVID-19 patients compared with the healthy individuals (p < 0.001) (fig.1). A statistically significant decrease in CoVID-19 patients was found only for the dsec values of FIB (p < 0.001) (fig.2). Conclusion(s): CWA variables upon admission in COVID-19 patients may be used for the evaluation of their inflammatory response or/ and hypercoagulopathy. Our results may help to identify patients at a high risk of thromboembolism. (Figure Presented).
ABSTRACT
Background: The activation of coagulation is one of the most severe complications of CoVID-19. The automatic optical end-point coagulation analyzers have the ability to present the clot reaction curve of the PT, APTT and Fibrinogen(FIB) which is referred as a clot waveform analysis (CWA). Aim(s): To investigate the ability of CWA parameters for the prognosis of the length of hospital stay of CoVID-19 patients. Method(s): Coagulation tests and CWA on BCSXP System (SIEMENS) were performed in 268 CoVID-19 patients upon hospital admission and prior to the initiation of anticoagulation therapy. The measured CWA parameters of PT, aPTT and FIB were the change in Absorbance(dmA) and the time difference from the starting time of the reaction (mixing of reagent and sample) until a specific absorbance change (absorbance threshold). The patients were divided into 3 groups depending on the duration of hospitalization: A: < 5 days (n = 42), B:6-10 days (n = 81), C:>10days (n = 145). Variables were tested with Student's t-test or Mann-WhitneyU test for differences in distributions of dmA and dsec among three groups. Pearson's correlation coefficient was used for comparison among the above parameters of 268 patients and their days of hospitalization. P values < 0.05 were considered statistically significant. All statistical analyses were performed using SPSS27. Result(s): A gradual increase in the values of dmA was detected from A to C group. Statistical significance was present in aPTT and PT among all groups but in FIB only between B and C. From the comparison of dsec, statistical significant decreased values were found only in FIB between A and C (p = 0.027) and B and C (p = 0.002). The comparison between CoVID-19 patients and duration of hospitalization revealed statistical significant correlation of dmA in PT, aPTT (p < 0.001) and in FIB (p = 0.01). Conclusion(s): CWA variables upon admission in COVID-19 patients, may be utilized for the prognosis of the duration of hospitalization.
ABSTRACT
Background: Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV- 2) is associated with a prothrombotic phenotype with an increased risk for thrombosis. Aim(s): To investigate whether COVID-19 is associated with changes in coagulation parameters upon presentation at the emergency department and whether these changes are associated with the development of thrombotic complications in patients with SARS-CoV- 2 infection. Method(s): A single centre, cross-sectional cohort study: The MArkers in COVID-19 And Relations to Outcomes in the Netherlands (MACARON) study was conducted. All patients suspected of SARS-CoV- 2 infection referred to the emergency department of the Meander Medical Center between March-May 2020 were included. 519 patients (26% PCR positive, median age 66 (range 19-97 years), 52.2% male) were included from whom an oro-and nasopharyngeal swab was obtained for detection of SARS-CoV- 2 by polymerase chain reaction (PCR). Blood samples for laboratory analysis were obtained from all patients. Thrombosis was defined as a clinical diagnosis of venous thromboembolism or atherothrombotic event based upon radiology and laboratory results. Result(s): SARS-CoV- 2 PCR positive patients had increased fibrinogen levels (5.41 g/L vs. 4.21 g/L, p < 0.001) and decreased levels of protein C (85.1% vs. 96.1%, p < 0.001) and alpha2-macroglobulin (4.41 muM vs. 5.11 muM, p < 0.001) compared to the PCR negative patients. In addition, we found more acquired activated protein C resistance in PCR positive patients. Furthermore, we found that elevated levels of factor VIII (208% vs. 162%, p = 0.028) and von Willebrand Factor (208% vs. 186%, p = 0.038) and decreased ADAMTS-13 levels (597 ng/ml vs. 691 ng/ml, p < 0.001) were associated with increased occurrence of thrombosis in PCR positive patients (thrombosis vs. non-thrombosis). Conclusion(s): We found that PCR positive patients had a more pronounced prothrombotic phenotype with endothelial activation upon hospital admission showing that coagulation tests may be considered useful to discriminate severe cases of COVID-19 at risk for thrombosis.
ABSTRACT
Background: Reports of thrombosis post COVID-19 mRNA vaccination have sparked concerns about safety. Aim(s): We prospectively evaluated blood samples of 18 participants who had received 2 doses of the BNT162b2 mRNA vaccine to determine if vaccination results in endothelial activation or hypercoagulability. Method(s): 18 participants who received the BNT162b2 vaccine were enrolled. Participants completed a questionnaire on their cardiovascular and thrombotic risk factors. Blood samples were collected at three time points: Pre-vaccination (day of vaccination), a median of 17 (IQR 16-18) days after the first dose and a median of 9 (IQR 7.5-14.5) days after the second dose of BNT162b2 vaccine. Endothelial markers included ICAM-1, VCAM-1 and P-selectin. Coagulation tests included PT and aPTT with clot waveform analysis, von Willebrand factor levels, Factor VIII and D-dimer levels. Statistical tests of association between endothelial and coagulation parameters were performed with repeated measures ANOVA and Mauchly's test of sphericity. Result(s): The median age of the participants was 35 years (IQR 31 -44), and 14 (78%) were female. 15 did not have any cardiovascular risk factors. There was a statistically significant increase in median ICAM levels post first (66.1ng/ml) and second dose of vaccination (69.5ng/ml)(p = 0.04), although this remained within the normal limit of ICAM levels. A statistically significant decrease in median PT (p = 0.005) and aPTT (p = 0.03) was observed post vaccination, with a corresponding statistically significant increase in aPTT clot waveform analysis (CWA) for maximum acceleration (max2)(p = 0.03) and maximum deceleration (max2)(p = 0.04) post first and second dose of vaccination. However, all evaluated endothelial and coagulation parameters remain within the reference ranges (Table 1). Conclusion(s): Our findings provide reassuring preliminary data that BNT162b2 vaccination does not result in endothelial activation or hypercoagulability. Mild variations in endothelial markers and coagulation parameters, though statistically significant, remain within the reference ranges and may be related to an inflammatory immune response to vaccination. (Table Presented).
ABSTRACT
Background: There is universal concern about the inappropriate use of fresh frozen plasma (FFP). Earlier investigations have indicated that FFP may be associated with high rates of inappropriate transfusion, with some studies indicating rates of up to 50% non-compliance with established guidelines. The current British Committee for Standards in Haematology (BCSH) guidelines on the use of FFP aim to reinforce the message regarding avoidance of its inappropriate use. Aims: Audit the use of appropiate FFP in the context of the COVID pandemia. Methods: Retrospective analysis of requests for plasma transfusion in adults, in our institution, between January/2020 and January/2022, This audit was undertaken to determine current use of FFP and to see if any improvements in the use of this component in relation to recommended guidance. May be we use more FFP due to covid situation. The data was obtained by consulting the Integrated System of Blood Banks. Results: During the study period, 98 units of FFP were used for 'acute' episodes including management of acute COVID complications. Only 67% of these transfusion episodes were deemed appropriate, based on the BSH criteria. This also means that 13 units of FFP may have been wasted. FFP is used by both medical and surgical specialties with general surgery, general medicine and neurosurgery being the main users. During the study period, 98 units of FFP were used for 'acute' episodes including management of acute COVID complications. Only 67% of these transfusion episodes were deemed appropriate, based on the BSH criteria. This also means that 13 units of FFP may have been wasted. FFP is used by both medical and surgical specialties with general surgery, general medicine and neurosurgery being the main users. 159 requests for plasma were registered in the analyzed period. In most cases (98), the reason was hemorrhage due to multiple factor deficiencies, including liver disease, trauma, lung disease or a massive transfusion. Prophylactic/therapeutic replacement of congenital factor XI deficiency, associated with bleeding episodes, was indicated in 2 situations. In 1 case, the indication was treatment of HUS and 2 cases of HELLP syndrome. In 7 cases, there was an overlapping of indications. In 7 cases, plasma was administered in unforeseen situations, such as for the correction of laboratory abnormalities without clinical manifestations (4 cases) or for prophylaxis of invasive techniques without abnormal coagulation tests (2 cases). Summary/Conclusion: The proportion of inappropriate requests is similar between surgical and non-surgical specialties and also when broken down into individual departments, the number of inappropriate requests consistently outnumbers appropriate requests across all departments. FFP continues to be frequently used in the absence of bleeding and / or evidence of abnormal coagulation, thus highlights the need for concerted efforts in the education of clinicians who prescribe FFP. In the analysis of the indications for plasma prescription, it is concluded that in 17 % cases the indication was not complete adequately or justifable. 7% of cases given FFP had no record of post-transfusion coagulation data. Following this work, dissemination coupled with education was undertaken. The use of FFP for Warfarin reversal has correctly indicated (> 95%). it may suggest that an education programmes directed at specific aspects of practice do influence clinical behaviour over needs to be addressed.
ABSTRACT
Since late 2021, we have observed a significant increase in the proportion of children infected with SARS-CoV-2. The course of the disease in children is usually sparsely symptomatic or asymptomatic. However, the predominance of new virus variants makes children more likely to become symptomatically ill and require hospitalisation. This paper aims to update recommendations for managing a child with COVID-19 in out- and inpatient settings. Current options for prevention and antiviral treatment are discussed, noting the limited availability of therapy for children. In most children with COVID-19, the basis for treatment remains symptomatic and supportive therapy and measures to reduce SARS-CoV-2 infection spread.
ABSTRACT
Background: Infections, drugs, surgical procedures, blood transfusions, solid and hematological cancers, and autoimmune disorders are associated with the risk of developing acquired FV inhibitors. Case report presentation: A 66-year-old Caucasian woman presented to the Emergency Department because of recurrent episodes of bowel bleeding from 2 week, and bleeding from the sites of venous sampling. Coagulation tests showed that the platelet count was normal: prolonged prothrombin time (PT): 45.5 seconds, international normalized ratio: 4.03, and activated partial thromboplastin time (aPTT): 165 seconds, aPTT ratio: 5.4. Coagulation factor II (FII), factor X (FX), factor VIII (FVIII), and fibrinogen were normal. The FV activity was 0.2% (range of normality 60-120%). The PT, aPTT, and one-stage coagulation factors assays were performed using an ACL TOP 550 coagulometer, and factor V was determined using a onestage PT-based assay, and factor V-deficient substrate plasma. Anticardiolipin antibodies were negative. Mixing test of patient's plasma with normal pooled plasma revealed the existence of an FV inhibitor, with an activity level of 4.0 Bethesda unit/mL. Three weeks before, the patient had been treated for coronavirus disease 2019 (COVID- 19) at home, with steroids (dexamethasone 6 mg daily for 5 days), enoxaparin 4,000 IU daily, and oxygen. Conclusions: The Authors presented a case report with acquired factor V inhibitor after SARS-CoV2 disease.
ABSTRACT
Introduction: Management of coagulation remains the foremost challenge during extracorporeal life support (ECLS). Thromboelastography (TEG) and other viscoelastic clotting tests have shown utility for assessing coagulation status in trauma and ECLS patients and have also been utilized in COVID 19 patients. However, with few exceptions, these methods are performed in a laboratory setting, not at the bedside, and rely on cumbersome, non-portable equipment. The Viscoelastic Coagulation Monitor (VCM;Entegrion;Durham, NC) is a portable device/test developed for use at the bedside and outside hospitals to assess clot formation and lysis using a small sample of whole blood. Blood coagulation is activated by contact with the glass surface on the cartridge, and measurements are derived pertaining to clot formation, stability, and lysis - similar to metrics obtained by the TEG 5000 (Haemonetics;Boston, MA). In a recent study, the relationship of VCM results and heparin dose administered in 36 COVID-19 patients was investigated;however, use of VCM for ECLS with application of heparinase has not been reported. We investigated efficacy of the VCM for coagulation monitoring during 72 hours of continuous ECLS in swine and hypothesized that the VCM with heparinase correlates with TEG heparinase. Methods: Female Yorkshire swine (n=3, 53.4±1.6kg) were anesthetized, mechanically ventilated, and systemically heparinized. Blood samples were collected at baseline, post ECLS, 6, 24, 48, and 72-hours post ECLS initiation. For the VCM, 350μL of whole blood was added to a 0.05 IU heparinase vial, mixed, and then added to a VCM cartridge. For TEG, 340μL of citrated whole blood was added to 20μL 0.2 M CaCl2, and samples were activated with a kaolin reagent. Heparinase cups (Haemonetics;Boston, MA) were used for testing. Spearman correlation was performed to compare standard VCM metrics (clotting time [CT], clot formation time [CFT], alpha, maximum clot firmness [MCF], clot retraction/fibrinolysis [LI30]) to the respective TEG metrics (reaction time [R], clot formation time [K], alpha, maximum amplitude [MA], clot retraction/fibrinolysis [LY30]), and also to other conventional coagulation measurements such as prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen (FIB), and platelet count (PLT) for each timepoint. A p-value of 0.05 was used for significance. Results: All VCM metrics significantly correlated with the respective TEG measurements (see Table 1). Both VCM and TEG show the same positive and negative correlation relationships for clot formation time, clot kinetics, and clot retraction with conventional coagulation tests (see Table 2). Additionally, clotting time and maximum clot firmness did not show moderate or significant correlation with conventional tests. Prothrombin time did not correlate with any values. Conclusion: The VCM is comparable to TEG in assessing coagulation status in heparinized swine and can be used during austere care with ECLS application. In the next round of experiments, we will validate the VCM in clinically-relevant trauma with and without ECLS.
ABSTRACT
Background-aim: Critically ill patients with COVID-19 pneumonia suffered both high thrombotic and bleeding risk. The effect of SARS-CoV-2 on coagulation and fibrinolysis is not well known. Methods: Retrospective cohort study including 84 patients, during 16 months, divided into two groups: patients with severe SARS-Cov-2 pneumonia (group 1, N=42) and patients with severe non-COVID-19 pneumonia (group 2, N=42). We evaluated coagulation standard parameters (hemoglobin, platelet count and conventional laboratory coagulation tests) in group 1 vs group 2 and coagulation standard parameters on day of admission (T0) and 10 (T10) days after admission to ICU and coagulation function using rotational thromboelastometry (ROTEM) in patients with severe SARS-Cov-2 pneumonia. Results: 84 patients were enrolled into the study. Similar results in conventional laboratory coagulation tests were detected in group 1 and group 2: prothrombin time (15.14s vs 14.76s, p=0.212), international normalized ratio (1.21 vs 1.19, p=0.112), activated partial thromboplastin time (32.17s vs 25.52s, p=0.06), fibrinogen level (6.15 mg/dl vs 3.39 mg/dl, p=0.208), hemoglobin (11.81 g/dl vs 11.20 g/dl, p=0.139) and platelet count (208.98x103/ul vs 288.74 x103/ul, p=0.123). However, a statistically significant difference was observed in the D-dimer count (2442.11 ng/ml vs 370 ng/ml, p=0.03). In addition, statistically significant increase in D-dimer count during Intensive Care Unit (ICU) stay (T0=2442.11 ng/ml vs T10=8564.39 ng/ml, p=0.000) in group 1 were detected. Finally, blood thromboelastometry profiles were consistent with hypercoagulability characterized by higher clot strength (MCF or maximum clot firmness close to upper limit in FIBTEM test, MCF median value= 25.9 mm). Clotting time presented normal results in INTEM (163.41 s) and EXTEM (68.74 s). No sign of secondary hyperfibrinolysis were found during the study period. In six patients a deep vein thrombosis and in six patients a thromboembolic event. Eighteen patients (43%) died during hospitalization due to coagulopathy produced by SARS-Cov-2 pneumonia. Conclusions: The results observed in our study support hypercoagulability in a severe inflammatory state, rather than a Consumption Coagulopathy (DIC) state. More studies are needed to better understanding of coagulopathy produced in patients with severe COVID-19 pneumonia.