Point-of-care coagulation testing and transfusion algorithms.

Patients with cardiovascular disease have an array of haemostasis disorders that predispose to the development of thrombotic and embolic disease states. These patients are often maintained on anti-thrombotic medication to prevent adverse cardiovascular events. Patients undergoing cardiac surgery also have haemostatic disorders that include their intrinsic disease state, adjunctive medication, and the coagulation disturbances induced by cardiopulmonary bypass. The following review introduces the monitors that are available for monitoring perioperative coagulation, with an emphasis on cardiovascular surgery. Heparin monitors, platelet function monitors for use in transfusion algorithms, and monitoring anti-platelet drugs will be discussed.

[1]  B. Spiess,et al.  Thromboelastography as an indicator of post-cardiopulmonary bypass coagulopathies , 2004, Journal of Clinical Monitoring.

[2]  G. Nuttall,et al.  Efficacy of a Simple Intraoperative Transfusion Algorithm for Nonerythrocyte Component Utilization after Cardiopulmonary Bypass , 2001, Anesthesiology.

[3]  P. Moerloose,et al.  Point of care and central laboratory determinations of the aPTT are not interchangeable in surgical intensive care patients , 2001, Canadian journal of anaesthesia = Journal canadien d'anesthesie.

[4]  R. McCarthy,et al.  Evaluation of coagulation during cardiopulmonary bypass with a heparinase-modified thromboelastographic assay. , 1994, Journal of cardiothoracic and vascular anesthesia.

[5]  R. Davidson,et al.  Description of an In Vitro Platelet Function Analyzer-PFA-100™ , 1995, Seminars in Thrombosis & Hemostasis.

[6]  A. Hanke,et al.  Perioperative Coagulation Management and Control of Platelet Transfusion by Point-of-Care Platelet Function Analysis , 2007, Transfusion Medicine and Hemotherapy.

[7]  D. Royston,et al.  Reduced haemostatic factor transfusion using heparinase-modified thrombelastography during cardiopulmonary bypass. , 2001, British journal of anaesthesia.

[8]  D. Graham Detailed diagnoses and procedures for patients discharged from short-stay hospitals. , 1988, Vital and health statistics. Series 13, Data from the National Health Survey.

[9]  J. T. ten Berg,et al.  The use of the VerifyNow system to monitor antiplatelet therapy: A review of the current evidence , 2008, Platelets.

[10]  J. Albes,et al.  Cost reduction of perioperative coagulation management in cardiac surgery: value of "bedside" thrombelastography (ROTEM). , 2007, European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery.

[11]  P. Berguson,et al.  Blood transfusion requirements in coronary artery surgery with and without the activated clotting time (ACT) technique , 1985, Klinische Wochenschrift.

[12]  B. Spiess,et al.  Transfusion of Blood Products Affects Outcome in Cardiac Surgery , 2004, Seminars in cardiothoracic and vascular anesthesia.

[13]  R. Carroll,et al.  Comparison of modified Thrombelastograph and Plateletworks whole blood assays to optical platelet aggregation for monitoring reversal of clopidogrel inhibition in elective surgery patients. , 2005, The Journal of laboratory and clinical medicine.

[14]  C. Hofer,et al.  Coagulation Monitoring: Current Techniques and Clinical Use of Viscoelastic Point-of-Care Coagulation Devices , 2008, Anesthesia and analgesia.

[15]  R. Kekomäki,et al.  On‐site coagulation monitoring does not affect hemostatic outcome after cardiac surgery , 2001, Acta anaesthesiologica Scandinavica.

[16]  M. Laato,et al.  Use of activated clotting time to monitor anticoagulation during cardiac surgery. , 1984, Scandinavian journal of thoracic and cardiovascular surgery.

[17]  A. Civelek,et al.  Thromboelastography‐Based Transfusion Algorithm Reduces Blood Product Use after Elective CABG: A Prospective Randomized Study , 2009, Journal of cardiac surgery.

[18]  R. Hetzer,et al.  Evaluation of post-cardiopulmonary bypass coagulation disorders by differential diagnosis with a multichannel modified thromboelastogram: a pilot investigation. , 2001, The journal of extra-corporeal technology.

[19]  M. Kuro,et al.  Evaluation of Platelet Function by Sonoclot Analysis Compared with Other Hemostatic Variables in Cardiac Surgery , 1998, Anesthesia and analgesia.

[20]  D. Jobes,et al.  Increased accuracy and precision of heparin and protamine dosing reduces blood loss and transfusion in patients undergoing primary cardiac operations. , 1995, The Journal of thoracic and cardiovascular surgery.

[21]  M. Abdelnoor,et al.  Assessment of heparin anticoagulation: comparison of two commercially available methods. , 1999, The Annals of thoracic surgery.

[22]  G. Janvier,et al.  Reproductibilité et interchangeabilité du Thromboélastographe®, Sonoclot® et du temps de coagulation activé (Hémochron®), en chirurgie cardiaque , 2001 .

[23]  I. Yada,et al.  Alterations in coagulation and fibrinolysis associated with cardiopulmonary bypass during open heart surgery. , 1989, Journal of cardiothoracic anesthesia.

[24]  W. Hauck,et al.  Changes in blood coagulation during and following cardiopulmonary bypass: lack of correlation with clinical bleeding. , 1996, American journal of clinical pathology.

[25]  B. Spiess,et al.  Changes in transfusion therapy and reexploration rate after institution of a blood management program in cardiac surgical patients. , 1995, Journal of cardiothoracic and vascular anesthesia.

[26]  M. Lordkipanidzé,et al.  Assessment of VerifyNow P2Y12 Assay Accuracy in Evaluating Clopidogrel-Induced Platelet Inhibition , 2008, Therapeutic drug monitoring.

[27]  C. Cerletti,et al.  Platelet function, antiplatelet therapy and clinical outcomes: to test or not to test? , 2007, Journal of thrombosis and haemostasis : JTH.

[28]  Fun-Gee Chen,et al.  Prediction of excessive bleeding after coronary artery bypass graft surgery: the influence of timing and heparinase on thromboelastography. , 2002, Journal of cardiothoracic and vascular anesthesia.

[29]  G. Despotis,et al.  Optimal Management of Bleeding Complications After Cardiac Surgery , 2001 .

[30]  C. Eby,et al.  Risks associated with bleeding and transfusion: rationale for the optimal management of bleeding after cardiac surgery , 2007 .

[31]  K. Maquelin,et al.  Disappearance of glycoprotein Ib from the platelet surface in pericardial blood during cardiopulmonary bypass. , 1998, The Journal of thoracic and cardiovascular surgery.

[32]  W. Dietrich,et al.  The Predictive Value of Modified Computerized Thromboelastography and Platelet Function Analysis for Postoperative Blood Loss in Routine Cardiac Surgery , 2003, Anesthesia and analgesia.

[33]  P. Kolh,et al.  Guideline on antiplatelet and anticoagulation management in cardiac surgery. , 2008, European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery.

[34]  M. DePerio,et al.  Thromboelastography-guided transfusion algorithm reduces transfusions in complex cardiac surgery. , 1999, Anesthesia and analgesia.

[35]  F. Spinale,et al.  Identification of patients at risk for excessive blood loss during coronary artery bypass surgery: thromboelastography versus coagulation screen. , 1993, Anesthesia and analgesia.

[36]  A. Brill,et al.  Using Cone and Plate(let) Analyzer to Predict Bleeding in Cardiac Surgery , 2006, Asian cardiovascular & thoracic annals.

[37]  L. Goodnough,et al.  The Variability of Transfusion Practice in Coronary Artery Bypass Surgery , 1991 .

[38]  L. Shore-lesserson,et al.  Coagulation monitoring. , 2006, Anesthesiology clinics.

[39]  S. Bélisle,et al.  [Reproducibility and interchangeability of the Thromboelastograph, Sonoclot and Hemochron activated coagulation time in cardiac surgery]. , 2001, Canadian journal of anaesthesia = Journal canadien d'anesthesie.

[40]  D. Birnbaum,et al.  Are In-Vitro Platelet Function Tests Useful in Predicting Blood Loss Following Open Heart Surgery? , 1998, The Thoracic and cardiovascular surgeon.

[41]  G. Gravlee,et al.  Heparin management protocol for cardiopulmonary bypass influences postoperative heparin rebound but not bleeding. , 1992, Anesthesiology.

[42]  L. Goodnough,et al.  The variability of transfusion practice in coronary artery bypass surgery. Transfusion Medicine Academic Award Group. , 1991, JAMA.

[43]  M. Steiner,et al.  Transfusion algorithms and how they apply to blood conservation: the high-risk cardiac surgical patient. , 2007, Hematology/oncology clinics of North America.

[44]  A. Schwartz,et al.  Monitoring heparin anticoagulation and its neutralization. , 1981, The Annals of thoracic surgery.

[45]  Paul B. Watkins,et al.  Atorvastatin Reduces the Ability of Clopidogrel to Inhibit Platelet Aggregation: A New Drug–Drug Interaction , 2003, Circulation.

[46]  J. Hirsh Drug therapy : heparin , 1991 .

[47]  R. Pokras Detailed diagnoses and procedures for patients discharged from short-stay hospitals. United States, 1985. , 1987, Vital and health statistics. Series 13, Data from the National Health Survey.

[48]  E. Spitznagel,et al.  Prospective evaluation and clinical utility of on-site monitoring of coagulation in patients undergoing cardiac operation. , 1994, The Journal of thoracic and cardiovascular surgery.

[49]  O. Pradier,et al.  Does the platelet function analyser (PFA-100) predict blood loss after cardiopulmonary bypass? , 2003, British Journal of Anaesthesia.

[50]  I. Björk,et al.  Mechanism of the anticoagulant action of heparin , 1982, Molecular and Cellular Biochemistry.

[51]  Justin T. Newcomer,et al.  Evaluation of Dose-Related Effects of Aspirin on Platelet Function: Results From the Aspirin-Induced Platelet Effect (ASPECT) Study , 2007, Circulation.

[52]  D. Ekouevi,et al.  Platelet function point-of-care tests in post-bypass cardiac surgery: are they relevant? , 2002, British journal of anaesthesia.

[53]  H. Hartert,et al.  The physical and biological constants of thrombelastography , 1962 .

[54]  N. Neerchal,et al.  Evaluation of Dose-Related Effects of Aspirin on Platelet Function: Results From the Aspirin-Induced Platelet Effect (ASPECT) Study , 2007 .

[55]  A. Lefemine,et al.  Activated clotting time for control of anticoagulation during surgery. , 1985, The American surgeon.

[56]  J. Essell,et al.  Comparison of thromboelastography to bleeding time and standard coagulation tests in patients after cardiopulmonary bypass. , 1993, Journal of cardiothoracic and vascular anesthesia.

[57]  J. Roth,et al.  Use of activated coagulation time to monitor heparin during cardiac surgery. , 1979, The Annals of thoracic surgery.

[58]  B. Spiess,et al.  Comparison of Viscoelastic Measures of Coagulation after Cardiopulmonary Bypass , 1989, Anesthesia and analgesia.

[59]  L. Goodnough,et al.  Monitoring of hemostasis in cardiac surgical patients: impact of point-of-care testing on blood loss and transfusion outcomes. , 1997, Clinical chemistry.

[60]  R. Carroll,et al.  A novel modification of the Thrombelastograph assay, isolating platelet function, correlates with optical platelet aggregation. , 2004, The Journal of laboratory and clinical medicine.

[61]  C. Samama,et al.  Near‐patient testing of haemostasis in the operating theatre: an approach to appropriate use of blood in surgery , 2003, Vox sanguinis.

[62]  B. Akl,et al.  Clinical experience with the activated clotting time for the control of heparin and protamine therapy during cardiopulmonary bypass. , 1980, The Journal of thoracic and cardiovascular surgery.

[63]  G. Chatellier,et al.  A Study of Platelet Functions with a New Analyzer Using High Shear Stress (PFA100™) in Patients Undergoing Coronary Artery Bypass Graft , 2000, Thrombosis and Haemostasis.

[64]  L. Harker,et al.  Bleeding complications associated with cardiopulmonary bypass. , 1990, Blood.

[65]  J. Ostrowsky,et al.  Plateletworks™ Platelet Function Test Compared to the Thromboelastograph™ for Prediction of Postoperative Outcomes , 2004, The Journal of ExtraCorporeal Technology.

[66]  S. Body,et al.  Platelet transfusions during coronary artery bypass graft surgery are associated with serious adverse outcomes , 2004, Transfusion.

[67]  A. Gori,et al.  Different methodologies for evaluating the effect of clopidogrel on platelet function in high‐risk coronary artery disease patients , 2007, Journal of thrombosis and haemostasis : JTH.

[68]  A. Greinacher,et al.  Antigen Generation in Heparin-Associated Thrombocytopenia: The Nonimmunologic Type and the Immunologic Type Are Closely Linked in Their Pathogenesis , 1995, Seminars in thrombosis and hemostasis.

[69]  J H Lewis,et al.  Intraoperative Changes in Blood Coagulation and Thrombelastographic Monitoring in Liver Transplantation , 1985, Anesthesia and analgesia.

[70]  C. Kaufmann,et al.  Usefulness of thrombelastography in assessment of trauma patient coagulation. , 1997, The Journal of trauma.

[71]  K. Rådegran,et al.  Use of the activated coagulation time in cardiac surgery. Effects on heparin-protamine dosages and bleeding. , 1981, Scandinavian journal of thoracic and cardiovascular surgery.

[72]  J. Caprini,et al.  Comparison of Thrombelastography with Common Coagulation Tests , 1981, Thrombosis and Haemostasis.

[73]  M. Avidan,et al.  Comparison of structured use of routine laboratory tests or near-patient assessment with clinical judgement in the management of bleeding after cardiac surgery. , 2004, British journal of anaesthesia.

[74]  N. Savion,et al.  Impact – The Cone and Plate(let) Analyzer: Testing Platelet Function and Anti-Platelet Drug Response , 2006, Pathophysiology of Haemostasis and Thrombosis.

[75]  A. Gori,et al.  Comparison of different methods to evaluate the effect of aspirin on platelet function in high-risk patients with ischemic heart disease receiving dual antiplatelet treatment. , 2007, American journal of clinical pathology.

[76]  C. Greenberg,et al.  Reversible shear-mediated platelet dysfunction during cardiac surgery as assessed by the PFA-100® platelet function analyzer , 2001, Blood coagulation & fibrinolysis : an international journal in haemostasis and thrombosis.

[77]  J. Mathew,et al.  Modulation of platelet surface adhesion receptors during cardiopulmonary bypass. , 1991, Anesthesiology.

[78]  Sibu P Saha,et al.  Perioperative blood transfusion and blood conservation in cardiac surgery: the Society of Thoracic Surgeons and The Society of Cardiovascular Anesthesiologists clinical practice guideline. , 2007, The Annals of thoracic surgery.

[79]  R. Scharpf,et al.  Utility of Whole Blood Hemostatometry Using the Clot Signature Analyzer® for Assessment of Hemostasis in Cardiac Surgery , 2002, Anesthesiology.

[80]  Comparison of thrombelastography with common coagulation tests. , 1981 .

[81]  B. Pasche,et al.  The platelet function defect of cardiopulmonary bypass. , 1993, Blood.

[82]  H. Stormorken,et al.  The value of activated coagulation time in monitoring heparin therapy during extracorporeal circulation. , 1984, Scandinavian journal of thoracic and cardiovascular surgery.

[83]  K. Kanter,et al.  Predicting and Treating Coagulopathies After Cardiopulmonary Bypass in Children , 1997, Anesthesia and analgesia.