Assessment of Hyperfibrinolysis in Liver Transplantation Surgery as Measured by Rotational Thromboelastometry

Hyperfibrinolysis is a significant concern during liver transplantation surgeries. Rotational thromboelastometry (ROTEM) is a point of care device that is capable of intraoperatively measuring the clotting properties of whole blood samples, including the rate of fibrinolysis. The aim of this study was to use ROTEM to determine if improved surgical techniques have lowered rates of hyperfibrinolysis during liver transplantations. Blood samples were taken from 284 patients during liver transplantations that took place over five years from 2014-2019. The blood samples were drawn at various time points during the preanhepatic phase, anhepatic phase, and neohepatic phase of the surgery. Hyperfibrinolysis was defined using an accepted ROTEM definition of a maximum lysis value (ML) greater than 15%. Preliminary results show that 14% of patients experienced hyperfibrinolysis at some point during the surgery, which is similar to rates that previous studies have reported (p-values are currently unknown, as mentioned above). Preoperative MELD score, preoperative INR, and intraoperative clot strength do not appear to be related to hyperfibrinolysis. Both increased age, and non-alcohol related liver diseases (hemochromatosis, hepatocellular carcinoma, Hepatitis C etc.) as the reason for transplantation show higher rates of hyperfibrinolysis. The study suggests that hyperfibrinolysis remains a serious concern in liver transplantation surgeries, despite improvements in surgical technique. In addition, the study also suggests that non-alcohol related liver diseases and increased age are significant risk factors for hyperfibrinolysis that deserve special hematological attention

Real-time baseline coagulation profiles using ROTEM in patients undergoing liver transplantation

Real-time monitoring of blood coagulation during invasive surgeries is an important component of ensuring patient safety and effective treatment. Rotational thromboelastometry (ROTEM) is a viscoelastic monitoring system of hemostasis in blood that allows for ongoing measurement of global markers of coagulation. This study compares coagulation in a population of hepatocellular carcinoma liver-transplant patients (HCC) with a transplant population of other etiologies (non-HCC). A database of ROTEM measurements acquired peri-operatively during liver transplantation was compiled from over 400 Jefferson patients. A baseline profile was developed comprised of ROTEM measurements of clot initiation/stability that can be used as a methodological standard. Analysis was conducted to compare clot formation time in the HCC and non-HCC groups, and MELD (Model for End-Stage Liver Disease) score was used to assess association between liver coagulopathy diagnostic measures and ROTEM measurements. Preliminary analysis shows a trend towards ROTEM clotting time and MELD scores indicating less coagulopathy in the HCC population than the non-HCC group, though levels of variance were high. This could be explained by the focal nature of HCC lesions compared to other liver pathologies that are widespread throughout the parenchyma. Population-wide ROTEM clotting times had weak correlation with MELD scores to lend support to ROTEM measurement validity in assessing coagulopathy. Results indicate high variability in ROTEM coagulation measures for liver transplant patients regardless of hepatocellular carcinoma status, with some evidence at the group-level of HCC status being associated with less coagulopathy. Findings from this study can inform practice of hemostatic treatment in future transplantation procedures

A 36-Year-Old Woman with Acute Liver Failure Following Acetaminophen Overdose, Raised INR of 8.7, and Normal Blood Viscosity Measured by Rotational Thromboelastometry (ROTEM)

BACKGROUND Fulminant hepatic failure (FHF) is commonly associated with elevated prothrombin time (PT) and international normalized ratio (INR). There is a commensurate decline in pro- and anti-hemostatic factors, and hemostatic function is rebalanced, not reflected in INR. This report presents the case of a 36-year-old woman with FHF following acetaminophen overdose, an increased INR above 8.7, and normal blood viscosity measured by rotational thromboelastometry (ROTEM). CASE REPORT A 36-year-old woman presented with FHF following an acetaminophen overdose. On arrival, she was lethargic but arousable and followed commands. Her King\u27s College Criteria for acetaminophen toxicity was 2 and her MELD score was 36. Her INR was unmeasurably high (\u3e8.7). To evaluate whole-blood coagulation, a ROTEM analysis was performed. All parameters (CT, CFT, alpha-angle, A10, MCF) of the NATEM were within reference range. Despite the normal ROTEM, spontaneous bleeding was a concern. The patient received 5 units of cryoprecipitate and 9 units of FFP prior to a central venous line placement. She was started on molecular adsorbent recirculating system and continuous veno-venous hemodialysis, but died on day 7. CONCLUSIONS Patients with FHF can have normal whole-blood coagulation based on ROTEM even if INR levels are unmeasurably high. Viscoelastic tests such as ROTEM, which assesses whole-blood coagulation properties, are preferrable for coagulation monitoring in these patients. Blood product transfusion to correct coagulation abnormality, like FFP and cryoprecipitate, may be used based on the result of viscoelastic testing over conventional coagulation testing

Assessment of reporting quality of conference abstracts in sports injury prevention according to CONSORT and STROBE criteria and their subsequent publication rate as full papers

<p>Abstract</p> <p>Background</p> <p>The preliminary results of a study are usually presented as an abstract in conference meetings. The reporting quality of those abstracts and the relationship between their study designs and full paper publication rate is unknown. We hypothesized that randomized controlled trials are more likely to be published as full papers than observational studies.</p> <p>Methods</p> <p>154 oral abstracts presented at the World Congress of Sports Injury Prevention 2005 Oslo and the corresponding full paper publication were identified and analysed. The main outcome measures were frequency of publication, time to publication, impact factor, CONSORT (for Consolidated Standards of Reporting Trials) score, STROBE (for Strengthening the Reporting of Observational Studies in Epidemiology) score, and minor and major inconsistencies between the abstract and the full paper publication.</p> <p>Results</p> <p>Overall, 76 of the 154 (49%) presented abstracts were published as full papers in a peer-reviewed journal with an impact factor of 1.946 ± 0.812. No significant difference existed between the impact factor for randomized controlled trials (2.122 ± 1.015) and observational studies (1.913 ± 0.765, p = 0.469). The full papers for the randomized controlled trials were published after an average (SD) of 17 months (± 13 months); for observational studies, the average (SD) was 12 months (± 14 months) (p = 0.323). A trend was observed in this study that a higher percentage of randomized controlled trial abstracts were published as full papers (71% vs. 47%, p = 0.078) than observational trials. The reporting quality of abstracts, published as full papers, significantly increased compared to conference abstracts both in randomized control studies (CONSORT: 5.7 ± 0.7 to 7.2 ± 1.3; p = 0.018, CI -2.7 to -0.32) and in observational studies (STROBE: 8.2 ± 1.3 to 8.6 ± 1.4; p = 0.007, CI -0.63 to -0.10). All of the published abstracts had at least one minor inconsistency (title, authors, research center, outcome presentation, conclusion), while 65% had at least major inconsistencies (study objective, hypothesis, study design, primary outcome measures, sample size, statistical analysis, results, SD/CI). Comparing the results of conference and full paper; results changed in 90% vs. 68% (randomized, controlled studies versus observational studies); data were added (full paper reported more result data) in 60% vs. 30%, and deleted (full paper reported fewer result data) in 40% vs. 30%.</p> <p>Conclusions</p> <p>No significant differences with respect to type of study (randomized controlled versus observational), impact factor, and time to publication existed for the likelihood that a World Congress of Sports Injury conference abstract could be published as a full paper.</p

Emergent airway management outside of the operating room - a retrospective review of patient characteristics, complications and ICU stay.

BACKGROUND: Emergent airway management outside of the operating room is a high-risk procedure. Limited data exists about the indication and physiologic state of the patient at the time of intubation, the location in which it occurs, or patient outcomes afterward. METHODS: We retrospectively collected data on all emergent airway management interventions performed outside of the operating room over a 6-month period. Documentation included intubation performance, and intubation related complications and mortality. Additional information including demographics, ASA-classification, comorbidities, hospital-stay, ICU-stay, and 30-day in-hospital mortality was obtained. RESULTS: 336 intubations were performed in 275 patients during the six-month period. The majority of intubations (n = 196, 58%) occurred in an ICU setting, and the rest 140 (42%) occurred on a normal floor or in a remote location. The mean admission ASA status was 3.6 ± 0.5, age 60 ± 16 years, and BMI 30 ± 9 kg/m2. Chest X-rays performed immediately after intubation showed main stem intubation in 3.3% (n = 9). Two immediate (within 20 min after intubation) intubation related cardiac arrest/mortality events were identified. The 30-day in-hospital mortality was 31.6% (n = 87), the overall in-hospital mortality was 37.1% (n = 102), the mean hospital stay was 22 ± 20 days, and the mean ICU-stay was 14 days (13.9 ± 0.9, CI 12.1-15.8) with a 7.3% ICU-readmission rate. CONCLUSION: Patients requiring emergent airway management are a high-risk patient population with multiple comorbidities and high ASA scores on admission. Only a small number of intubation-related complications were reported but ICU length of stay was high

Randomized Controlled Trial of Enhanced Recovery After Surgery Protocols in Live Kidney Donors: ERASKT Study

BACKGROUND: Enhanced recovery after surgery (ERAS) pathways represent a comprehensive approach to optimizing perioperative management and reducing hospital stay and cost. In living donor kidney transplantation, key impediments to postoperative discharge include pain, and opioid associated complications such as nausea, vomiting, and the return of gastrointestinal function. METHODS: In this randomized controlled trial, living kidney transplantation donors were assigned to either the ERAS or control group. The ERAS group patients received 15 preoperative, 17 intraoperative, 19 postoperative element intervention. The control group received standard care. The ERAS group received a multimodal opioid sparing pain management including an intraoperative transverse abdominis plane block. Our primary outcome measure was postoperative opioid consumption. The secondary outcome measures were postoperative pain scores, first oral intake, and hospital length of stay. RESULTS: There were no significant differences in demographics between the 2 groups. The ERAS group had a statistically significant reduction in total postoperative opioid consumption calculated in intravenous morphine equivalents (24.2 ± 20.2 versus 71 ± 39.5 mg, CONCLUSIONS: The ERAS group experienced superior postoperative analgesia and a shorter length of hospital stay compared with controls

Quality of reporting according to the CONSORT, STROBE and Timmer instrument at the American Burn Association (ABA) annual meetings 2000 and 2008

<p>Abstract</p> <p>Background</p> <p>The quality of oral and poster conference presentations differ. We hypothesized that the quality of reporting is better in oral abstracts than in poster abstracts at the American Burn Association (ABA) conference meeting.</p> <p>Methods</p> <p>All 511 abstracts (2000: N = 259, 2008: N = 252) from the ABA annual meetings in year 2000 and 2008 were screened. RCT's and obervational studies were analyzed by two independent examiners regarding study design and quality of reporting for randomized-controlled trials (RCT) by CONSORT criteria, observational studies by the STROBE criteria and additionally the Timmer instrument.</p> <p>Results</p> <p>Overall, 13 RCT's in 2000 and 9 in 2008, 77 observational studies in 2000 and 98 in 2008 were identified. Of the presented abstracts, 5% (oral; 7%(n = 9) vs. poster; 3%(n = 4)) in 2000 and 4% ((oral; 5%(n = 7) vs. poster; 2%(n = 2)) in 2008 were randomized controlled trials. The amount of observational studies as well as experimental studies accepted for presentation was not significantly different between oral and poster in both years. Reporting quality of RCT was for oral vs. poster abstracts in 2000 (CONSORT; 7.2 ± 0.8 vs. 7 ± 0, p = 0.615, CI -0.72 to 1.16, Timmer; 7.8 ± 0.7 vs. 7.5 ± 0.6,) and 2008 (CONSORT; 7.2 ± 1.4 vs. 6.5 ± 1, Timmer; 9.7 ± 1.1 vs. 9.5 ± 0.7). While in 2000, oral and poster abstracts of observational studies were not significantly different for reporting quality according to STROBE (STROBE; 8.3 ± 1.7 vs. 8.9 ± 1.6, p = 0.977, CI -37.3 to 36.3, Timmer; 8.6 ± 1.5 vs. 8.5 ± 1.4, p = 0.712, CI -0.44 to 0.64), in 2008 oral observational abstracts were significantly better than posters (STROBE score; 9.4 ± 1.9 vs. 8.5 ± 2, p = 0.005, CI 0.28 to 1.54, Timmer; 9.4 ± 1.4 vs. 8.6 ± 1.7, p = 0.013, CI 0.32 to 1.28).</p> <p>Conclusions</p> <p>Poster abstract reporting quality at the American Burn Association annual meetings in 2000 and 2008 is not necessarily inferior to oral abstracts as far as study design and reporting quality of clinical trials are concerned. The primary hypothesis has to be rejected. However, endorsement for the comprehensive use of the CONSORT and STROBE criteria might further increase the quality of reporting ABA conference abstracts in the future.</p

Severe Congenital Factor VII Deficiency with Normal Perioperative Coagulation Profile Based on ROTEM Analysis in a Hepatectomy.

BACKGROUND Factor VII (FVII) deficiency is the most common autosomal-recessive bleeding disorder. FVII activity level (FVII: C) of 10-20% is often used as the threshold for administering activated recombinant FVII (rFVIIa) for patients undergoing major surgery. However, rFVIIa is expensive and carries the risk of a thromboembolic event, and thus should only be administered when truly indicated. CASE REPORT A 22-year-old woman with 8% FVII: C underwent a hepatectomy. Although there were no clinical signs of bleeding, peri-operative administration of rFVIIa was recommended by the hematologist (first dose at surgical incision, then 4 h later, then every 12 h until 48 h postoperatively). Intraoperatively, serials of ROTEM analysis were performed to evaluate the effect of rFVIIa administration. No significant effect of rFVIIa was seen on NATEM. Surgery was unremarkable, without any significant blood loss. The patient developed radial artery thrombosis 24 h postoperatively, the arterial line was removed, and rFVIIa was discontinued (PT: 14.6, FVII: C 36%). On POD 3, INR was elevated (3.15, FVII: C 3%). To correct INR, the patient was transfused 8 units of FFP, despite any signs of clinical bleeding. However, INR and FVII: C did not correct and the patient was discharged on POD 7 in a stable condition. CONCLUSIONS Even with FVII: C of 8%, the ROTEM analysis revealed a normal coagulation status. The administration of rFVIIa did not improve the already normal baseline coagulation profile, but rather potentially led to an accelerated coagulation or hypercoagulable state and may have led to the radial artery thrombosis. We endorse the use of viscoelastic testing for hemostasis assessment and factor replacement in congenital FVII deficiency