Features of Blood Clotting on Thromboelastography in Hospitalized Patients With Cirrhosis

Shamseddeen, Hani; Patidar, Kavish R.; Ghabril, Marwan; Desai, Archita P.; Nephew, Lauren; Kuehl, Sandra; Chalasani, Naga; Orman, Eric S.

doi:10.1016/j.amjmed.2020.04.029

Cited by 14 publications

(22 citation statements)

References 50 publications

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“…These findings suggest that elective endoscopic interventions (particularly polypectomy) in this population may not be appropriate for hospitalized patients and may best be deferred to the outpatient setting. These data confirming the increased risk in the setting of infection are consistent with other work showing impaired hemostasis in liver disease resulting from increased circulating endogenous heparinoids ( 39 – 41 ). This increased risk remains substantial despite appropriate antibiotic therapy and suggests that elective endoscopic procedures should wait until infection has been eradicated whenever possible.…”

Section: Discussionsupporting

confidence: 92%

Bleeding After Elective Interventional Endoscopic Procedures in a Large Cohort of Patients With Cirrhosis

Kundumadam

Phatharacharukul

Reinhart

et al. 2020

Clin Transl Gastroenterol

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INTRODUCTION: Elective therapeutic endoscopy is an important component of care of cirrhotic patients, but there are concerns regarding the risk of bleeding. This study examined the incidence, risk factors, and outcomes of bleeding after endoscopic variceal ligation (EVL), colonoscopic polypectomy, and endoscopic retrograde cholangiopancreatography with sphincterotomy in cirrhotic patients. METHODS: A cohort study of patients with cirrhosis who underwent the above procedures at a single center between 2012 and 2014 was performed. Patients with active bleeding at the time of procedure were excluded. Patients were followed for 30 days to assess for postprocedural bleeding and for 90 days for mortality. RESULTS: A total of 1,324 procedures were performed in 857 patients (886 upper endoscopies, 358 colonoscopies, and 80 endoscopic retrograde cholangiopancreatograpies). After EVL, bleeding occurred in 2.8%; after polypectomy, bleeding occurred in 2.0%; and after sphincterotomy, bleeding occurred in 3.8%. Independent predictors of bleeding after EVL and polypectomy included younger age and lower hemoglobin. For EVL, bleeding was also associated with infection and model for end-stage liver disease-Na. International normalized ratio was associated with bleeding in univariate analysis only, and platelet count was not associated with bleeding in any procedure. Bleeding after EVL was associated with 29% 90-day mortality, and bleeding after polypectomy was associated with 14% mortality. Of the 3 patients with postsphincterotomy bleeding, none were outliers regarding their baseline characteristics. DISCUSSION: In patients with cirrhosis, bleeding occurs infrequently after elective therapeutic endoscopy and is associated with younger age, lower hemoglobin, and high mortality. Consideration of these risk factors may guide appropriate timing and preprocedural management to optimize outcomes.

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Section: Discussionsupporting

confidence: 92%

Bleeding After Elective Interventional Endoscopic Procedures in a Large Cohort of Patients With Cirrhosis

Kundumadam

Phatharacharukul

Reinhart

et al. 2020

Clin Transl Gastroenterol

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“…(20) In patients with cirrhosis who undergo invasive procedures, the use of TEG has been recently associated with a significant reduction of blood product requirements (21)(22)(23)(24)(25) ; however, the utility of TEG to estimate the risk of procedure-related bleeding remains unclear. (26)(27)(28) In patients with decompensated cirrhosis, it is unclear whether alterations in lab tests assessing hemostasis are truly associated with increased risk of bleeding or simply reflect the underlying severity of liver dysfunction. (9) Similarly, it is also unknown whether the correction of such hemostatic alterations directly mitigates the risk of procedure-related bleeding.…”

Section: Reduced Clot Stability By Thromboelastography As a Potentialmentioning

confidence: 99%

“…In patients with cirrhosis who undergo invasive procedures, the use of TEG has been recently associated with a significant reduction of blood product requirements ( 21‐25 ) ; however, the utility of TEG to estimate the risk of procedure‐related bleeding remains unclear. ( 26‐28 )…”

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confidence: 99%

Reduced Clot Stability by Thromboelastography as a Potential Indicator of Procedure-Related Bleeding in Decompensated Cirrhosis

Zanetto

Rinder

Senzolo

et al. 2021

Hepatology Communications

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In patients with decompensated cirrhosis, procedure-related bleeding is a potentially lethal complication. Routine coagulation tests such as international normalized ratio and platelet count do not predict bleeding risk. We investigated whether thromboelastography (TEG) can identify patients with cirrhosis who are at risk of procedure-related bleeding. As a part of a prospective study on hemostasis in decompensated cirrhosis, patients had TEG performed on admission and were followed prospectively during hospitalization for the development of procedure-related bleeding. Eighty patients with cirrhosis were included. Among the 72 who had procedures performed, 7 had procedure-related bleeding, which was major in three cases (two following paracentesis and one following thoracentesis). Conventional coagulation tests were comparable between bleeding and nonbleeding patients, whereas TEG parameters of k-time (4.5 minutes vs. 2.2 minutes; P = 0.02), α-angle (34° vs. 59°; P = 0.003), and maximum amplitude (37 mm vs. 50 mm; P = 0.004) were significantly different (all indicative of hypocoagulability). TEG maximum amplitude (MA), a marker of overall clot stability, accurately discriminated between patients who had major, life-threatening bleeding (all with MA < 30 mm) and those who had mild or no bleeding (all with MA > 30 mm), whereas a platelet count < 50 × 109/L could not discriminate between bleeding (minor or major) and nonbleeding patients. Conclusion: In a prospective cohort of hospitalized patients with decompensated cirrhosis, TEG parameters associated with hypocoagulability appeared to predict procedure-related bleeding, particularly a TEG MA < 30 mm. If results are validated in a larger cohort, this could be a threshold to identify patients with decompensated cirrhosis at higher risk for procedure-related bleeding, in whom to consider preprocedural prophylaxis.

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“…Some biomarkers, such as D-Dimer and brinogen (Fib) have been proved promising in PJI diagnosis [10][11][12][13] and determining the timing of reimplantation [10,14]. Thromboelastography (TEG) is a routine test of coagulation that assesses the whole process of the clotting along time in the body [15], TEG provides a full-scale evaluation of clot formation, elasticity, and duration with measures describing various coagulation elements [16]. K-value (clotting time) re ects the rate of blood clot formation and is an indicator of brinogen function [17], Angle (α-angle) represents the clot growth rate, MA (maximum amplitude) means the maximum clot amplitude [18], A30 (amplitude at 30 min) measures clot strength at 30 minutes after MA [19], and TPI (thrombodynamic potential index) was derived from MA and K value [20].…”

Section: Introductionmentioning

confidence: 99%

“…K-value (clotting time) re ects the rate of blood clot formation and is an indicator of brinogen function [17], Angle (α-angle) represents the clot growth rate, MA (maximum amplitude) means the maximum clot amplitude [18], A30 (amplitude at 30 min) measures clot strength at 30 minutes after MA [19], and TPI (thrombodynamic potential index) was derived from MA and K value [20]. TEG yields information about all phases of coagulation and provides further information over standard coagulation tests [16,21]. Plentiful literature has proved that TEG is useful in evaluating coagulation status, predicting bleeding in patients with severe sepsis, monitoring hemostasis during cardiac surgery and liver transplant procedures, etc.…”

Section: Introductionmentioning

confidence: 99%

Thromboelastography Performs Well for the Diagnosis of Periprosthetic Joint Infection.

Yuan

Wang

2021

Preprint

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Background: Coagulation-related biomarkers are drawing new attention in diagnosing periprosthetic joint infection (PJI). Thromboelastography (TEG) analysis provides a comprehensive assessment of coagulation and therefore could be a promising test for PJI. This study aims to assess the value of TEG in diagnosing PJI and to determine the clinical significance of TEG in analyzing reimplantation timing for the second-stage revision.Methods: From October 2017 to September 2020, 62 patients who underwent revision arthroplasty were prospectively included, PJI was defined by 2011 Musculoskeletal Infection Society (MSIS) criteria. Twenty-three patients were diagnosed with PJI (Group A) and the other 39 patients were included as aseptic loosen (Group B). Seventeen patients in Group A finished two-stage revision in our center. C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), D-dimer and TEG parameters (K (clotting time), Angle (α-angle), MA (maximum amplitude), A30 (amplitude at 30 min), TPI (thrombodynamic potential index)) were measured preoperatively in all included patients. Receiver operating characteristic curves were applied to evaluate the diagnostic value of these biomarkers.Results: ESR (AUC 0.953, sensitivity 81.82, specificity 94.87) performed best in PJI diagnosis, followed by MA (AUC 0.895, sensitivity 82.61, specificity 97.44) and CRP (AUC 0.893, sensitivity 82.61, specificity 94.74). When these biomarkers combined in pairs, the diagnosis value improved compared with any individual biomarker. The overall success rate of the two-stage revision was 100%. ESR and MA showed valuable in determining the time of reimplantation, with their values all decreased below cut-off values before reimplantation.Conclusion: TEG could be a promising test in assisting PJI diagnosis, and a useful tool in judging the proper timing of reimplantation.

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Features of Blood Clotting on Thromboelastography in Hospitalized Patients With Cirrhosis

Cited by 14 publications

References 50 publications

Bleeding After Elective Interventional Endoscopic Procedures in a Large Cohort of Patients With Cirrhosis

Bleeding After Elective Interventional Endoscopic Procedures in a Large Cohort of Patients With Cirrhosis

Reduced Clot Stability by Thromboelastography as a Potential Indicator of Procedure-Related Bleeding in Decompensated Cirrhosis

Thromboelastography Performs Well for the Diagnosis of Periprosthetic Joint Infection.

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