A Ashworth

A Espinosa

DB Bischof

DM Monroe

DR Spahn

KR Brandy

P Whiting

R Rossaint

English

Mitsutaka Edanaga

Tomoe Hoshi

Ryu Azumaguchi

Michiaki Yamakage

Crossref

CASE REPORT Open AccessA case of hemothorax due to traumaticbleeding managed effectively bySonoclot®-guided blood transfusionMitsutaka Edanaga1*, Tomoe Hoshi2, Ryu Azumaguchi1 and Michiaki Yamakage1AbstractA 71-year-old woman was transported to our hospital due to traumatic bleeding, and an operation wasimmediately performed for achieving hemostasis. We decided to perform Sonoclot®-guided blood transfusion.When Sonoclot signatures had returned normal values, further bleeding did not occur. We experienced the firstcase of traumatic bleeding managed effectively by using Sonoclot. We suggest that a Sonoclot analyzer may beuseful for the management of severe coagulopathy due to traumatic bleeding like ROTEM and TEG.Keywords: Traumatic bleeding, Conventional blood coagulation test, Sonoclot® analyzerBackgroundAppropriate management and treatment of fluid andblood transfusion resuscitation for a case of massivebleeding is difficult. The amount and type of transfusionmust usually be considered to estimate the degree ofsurgical site bleeding. Sonoclot® analyzer is a device forpoint-of-care monitoring of blood coagulation [1]. It canmainly show three signatures [2]: activated coagulationtime (SonACT), degree of fibrin formation (clot rate(CR)), and ability of the clot retraction (platelet function(PF)), all of which can be measured within about 20 min[3]. We could manage effectively for a case of hemotho-rax due to traumatic bleeding by using Sonoclot.Case presentationA 71-year-old woman (weight, 86 kg; height, 158 cm;blood type, type A) was transported to another hospitalfor hemodynamic unstability due to trauma. She wassuspected of having right hemothorax at that time. Thus,she was immediately transported to the Department ofEmergency Medicine, Advanced Critical Care and Emer-gency Center Care Unit in Sapporo Medical UniversityHospital. Although she had severe hypotension (about40 mmHg) during the transportation by ambulance, bloodpressure at admission to our hospital was 74/45 mmHg,heart rate was 86 bpm, arterial saturation by oxygen inhal-ation (10 L/min mask) was 95 %, and Glasgow ComaScale was 12. She was intubated and central venouscatheterization was performed. She was then immediatelyadmitted to operating room. Laboratory data before ad-mission to the operating room showed severe coagulationdisorders as follows (Table 1): hemoglobin was 15.9 g/dL,platelet count was 26,000/μL, international normalizedratio of prothrombin time (PT-INR) was 1.6, activatedpartial thromboplastin time (APTT) was 59.3 s, and fi-brinogen was 65 mg/dL. Blood pressure at admission tooperating room was 66/36 mmHg, heart rate was 77 bpm,arterial saturation was 100 %, and body temperature was36.0°. During the operation, the amount of bleeding after2 h exceeded 7000 mL. Thus, we considered the necessityfor point-of-care monitoring of blood coagulation for ap-propriate transfusion. We decided to perform Sonoclot-guided transfusion. The first data (Table 2) were obtainedat 2 h after starting the operation. The first data were asfollows (point 1): SonACT was 581 s, CR was 1.5, and PFwas 0.5. Thus, we continued to perform massive transfu-sion. The amounts of red blood cells (RBC), fresh frozenproducts (FFP), and platelets at that time were 28, 28, and20 units, respectively. Although the degree of bleedinggradually decreased, the amount of bleeding reached9000 mL. The second Sonoclot signature (point 2) showedthat SonACT was 258 s, CR was 6.5, and PF was 0.5.* Correspondence: edanaka@sapmed.ac.jp1Department of Anesthesiology, Sapporo Medical University School ofMedicine, South 1, West 16, Chuo-ku, Sapporo, Hokkaido 060-8543, JapanFull list of author information is available at the end of the article© 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made.Edanaga et al. JA Clinical Reports  (2016) 2:16 DOI 10.1186/s40981-016-0042-9Thus, we mainly performed transfusion of FFP and plate-lets. We measured the Sonoclot signature again (point 3)since bleeding from the surgical site had almost stopped.SonACT was 193 s, CR was 11.3 (normal range), and PFwas 3.2 (normal range). We therefore did not performadditional transfusion. The bleeding was diminished, andthe operation was soon finished. Total bleeding was9680 mL, and total amounts of RBC, FFP, and plateletstransfused were 36, 46, and 40 units, respectively. Thecell-salvaged blood was also transfused 2750 mL. Labora-tory data after the operation were as follows: hemoglobinwas 6.7 g/dL, platelet count was 74,000/μL, PT-INR was1.31, APTT was 52.5 s, and fibrinogen was 136 mg/dL.Blood pressure at operation finished was 116/59 mmHg,heart rate was 77 bpm, arterial saturation was 100 %, andbody temperature was 35.6°. She was transported to theAdvanced Critical Care and Emergency Center Care Unit,but further bleeding did not occur and she graduallyrecovered.DiscussionWe experienced a typical case of hemorrhagic shock dueto traumatic bleeding, and the first clinical case of trau-matic patient managed effectively by using Sonoclot. Ap-propriate management and treatment of fluid and bloodtransfusion resuscitation for a case of massive bleedingas in our case is difficult. In the circumstances, severecoagulopathy inevitably occur. The amount and type ofblood must be considered for estimating the degree ofsurgical site bleeding. However, we also think that a usefuland appropriate parameter or guideline to support theclinical decision for blood transfusion in a case of massivehemorrhage is necessary. For example, arterial blood gasanalysis can be performed quickly. But arterial blood gasanalysis is useful as a guide for RBC transfusion. Also,conventional blood coagulation tests for PT-INR, APTT,and fibrinogen usually take much time for the indicationof FFP or platelet transfusion.European guidelines for the management of bleedingfollowing major trauma were published in 2007 [4].According to the guidelines, point-of care monitoringof blood coagulation such as thrombelastometry mightbe useful for more accurate targeting of therapy [5].However, there are no guidelines for the treatment oftraumatic bleeding in Japan. Thus, we have to manageand treat massive bleeding based on our own clinicaldecision. Although it was thought that the viscoelasticdevice as ROTEM and TEG was useful for trauma pa-tients [6], no data on clinical effectiveness of Sonoclotfor traumatic bleeding was reported. Sonoclot analyzeris always disposed in our operating room. And wefound that Sonoclot was useful as a guide for bloodtransfusion during cardiac surgery and massive bleedingin a clinical situation and in our clinical study (not yetpublished). Thus, we thought that a Sonoclot analyzer isvery useful for management of coagulopathy and used aSonoclot analyzer in our case. The main benefits of thisdevice are as follows. Firstly, when we use the analyzer, wecan evaluate not only blood clotting function as the degreeof fibrin gel formation but also platelet function as clot re-traction. Secondly, data can be obtained from the Sonoclotanalyzer after only 15 to 20 min. Thirdly, Sonoclotanalyzer can perform measurements using whole blood.While, the disadvantage of Sonoclot compared to ROTEMis that we cannot evaluate the exact cause for severe coag-ulopathy, for example, intrinsic factor, extrinsic factor, orfibrinogen. Therefore, when we would like to check anexact cause for it, we should consider using not onlySonoclot but also other device like ROTEM.By the way, measurements of PT-INR and APTT areperformed using blood contained no platelet. Plateletand coagulation factor are greatly related to the intra-cellular collect blood coagulation system [7]. Therefore,we think that the values of PT-INR and APTT are notan appropriate signature for blood coagulation. In theEuropean guideline mentioned above [5], it was reportedthat PT-INR and APTT alone should not be used to guidehemostatic therapy. In fact, conventional blood coagulationtests after the operation showed some coagulopathy. Thefinal SonACT and postoperative APTT were slightly pro-longed. According to the past report [8], the cell-salvagedtransfusion may cause coagulopathy. The cell-salvagedblood was transfused 2750 ml during the operation.Table 1 Change in data obtained by conventional tests during the operationPT-INRnormal <1.16APTTnormal <37 sFibrinogennormal >200 mg/dLPlatelet countnormal >15 × 104/μLBefore operation 1.6 59.3 65 2.6 × 104After operation 1.31 52.5 136 7.4 × 104Although conventional blood coagulation tests before the operation showed severe coagulation disorders, there were slightly improvements after operationTable 2 Changes in three signatures of Sonoclot® analyzerduring the operationSonACTnormal 100–155 sClot rate (CR)normal 9–35Platelet function (PF)normal >1.5Point 1 581 1.5 0.5Point 2 258 6.5 0.5Point 3 193 11.3 3.2Although all signatures of the Sonoclot analyzer, which is a point-of-caremonitor of clotting factor and platelet function, showed severe coagulopathy(points 1 and 2), CR and PF, but not SonACT, were in normal ranges after thebleeding had stopped (point 3)Edanaga et al. JA Clinical Reports  (2016) 2:16 Page 2 of 3Although we should consider the amount of cell-salvagedblood, CR and PF of Sonoclot signature was normal andpostoperative further bleeding did not occur. Therefore,our results indicate that the value of Sonoclot may be reli-able rather than PT-INR and APTT.ConclusionsWe experienced the first case of traumatic bleedingmanaged effectively by using Sonoclot. Although thefurther data is necessary, we suggest that the Sonoclotanalyzer may be useful for the management of severecoagulopathy due to not only traumatic bleeding butalso massive bleeding of emergent situation.Authors’ contributionsME managed the case and wrote the manuscript. TH and RA supported themanagement. MY helped to draft the manuscript. All authors read andapproved the final manuscript.Competing interestsThe authors declare that they have no competing interests.Ethics approval and consent to participateThis is an anonymous case report. Although written informed consent wasobtained from the patient for publication of this case report, the ethicalcommittee in our hospital suggested that there is no need for obtainingethical committee approval.Author details1Department of Anesthesiology, Sapporo Medical University School ofMedicine, South 1, West 16, Chuo-ku, Sapporo, Hokkaido 060-8543, Japan.2Department of Anesthesia, Japanese Red Cross Kitami Hospital, Kitami, Japan.Received: 11 June 2016 Accepted: 29 July 2016References1. Brandy KR, Meyer RM, Luo X, et al. Evaluation of the coagulation profileamong oral and vaginal combined hormonal contraceptive users usingsonoclot coagulation analyzer. Clin Appl Thromb Hemost. 2012;18:576–81.2. Bischof DB, Ganter MT, Shore-Lesserson L, et al. Viscoelastic blood coagulationmeasurement with sonoclot predicts postoperative bleeding in cardiac surgeryafter heparin reversal. J Cardiothorac Vasc Anesth. 2015;29:715–22.3. Espinosa A, Stenseth R, Videm V, et al. Comparison of three point-of-caretesting devices to detect hemostatic changes in adult elective cardiacsurgery: a prospective observational study. BMC Anesthesiol. 2014;14:80.4. Spahn DR, Cerny V, Coats TJ, et al. Management of bleeding followingmajor trauma: a European guideline. Crit Care. 2007;11:R17.5. Rossaint R, Bouillon B, Cerny V, et al. Management of bleeding followingmajor trauma: an updated European guideline. Crit Care. 2010;14:R52.6. Whiting P, Al M, Westwood M, et al. Viscoelastic point-of-care testing toassist with the diagnosis, management and monitoring of haemostasis: asystematic review and cost-effectiveness analysis. Health Technol Assess.2015;19:1–228.7. Monroe DM, Hoffman M. What does it take to make the perfect clot?Arterioscler Thromb Vasc Biol. 2006;26:41–8.8. Ashworth A, Klein AA. Cell salvage as part of a blood conservation strategyin anaesthesia. Br J Anaesth. 2010;105:401–16.Submit your manuscript to a journal and beneﬁ t from:7 Convenient online submission7 Rigorous peer review7 Immediate publication on acceptance7 Open access: articles freely available online7 High visibility within the ﬁ eld7 Retaining the copyright to your article    Submit your next manuscript at 7 springeropen.comEdanaga et al. JA Clinical Reports  (2016) 2:16 Page 3 of 3

JA Clinical Reports

A case of hemothorax due to traumatic bleeding managed effectively by Sonoclot®-guided blood transfusion

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A case of hemothorax due to traumatic bleeding managed effectively by Sonoclot®-guided blood transfusion

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