Skip to main content

Advertisement

SpringerLink
Log in

Perioperative coagulation assessment of patients undergoing major elective orthopedic surgery

  • IM - ORIGINAL
  • Published:
Internal and Emergency Medicine Aims and scope Submit manuscript

Abstract

Traditional coagulative parameters are of limited use in identifying perioperative coagulopathy occurring in patients undergoing major elective orthopedic surgery (MEOS). The aim of our study was to evaluate the coagulation changes in patients undergoing MEOS and to facilitate an early detection of perioperative coagulopathy in patients experiencing major intraoperative bleeding. We enrolled 40 consecutive patients (M/F 10/30, age range 34–90 years) who underwent MEOS at the Orthopedic Unit of the Padua University Hospital, Italy, between January 2014 and January 2015. Blood samples were obtained at the following time points: T0-pre: 30 min before surgery; T0-post: 30 min after the end of the procedure; T1: morning of the first postoperative day; T2: 7 ± 2 days after surgery. Patients who experienced an intraoperative blood loss ≥250 mL/h were considered as cases. Routine coagulative parameters, thromboelastometry and thrombin generation (TG) profiles were evaluated. At baseline, a significantly lower platelet count and FIBTEM MCF/AUC were observed in patents with excessive bleeding (p < 0.05 and 0.02/0.01, respectively). At T0-post and T1 intervals, cases showed hypocoagulation characterized by a significantly low platelet count (p = 0.001), prolonged CFT INTEM/EXTEM, reduction of alpha-angle and MaxV INTEM/EXTEM, MCF and AUC INTEM/EXTEM/FIBTEM (p < 0.05 in all comparisons). The only TG parameter standing out between study groups was time to peak at T0-pre. A low platelet count and fibrinogen activity were associated with significant intraoperative bleeding in patients undergoing MEOS. Thromboelastometry performed by ROTEM® identifies patients with coagulopathy.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Oberweis BS, Nukala S, Rosenberg A, Guo Y, Stuchin S, Radford MJ, Berger JS et al (2013) Thrombotic and bleeding complications after orthopedic surgery. Am Heart J 165:427–433

    Article  PubMed  PubMed Central  Google Scholar 

  2. Mansour J, Graf K, Lafferty P (2012) Bleeding disorders in orthopedic surgery. Orthopedics 35:1053–1062

    Article  PubMed  Google Scholar 

  3. Bjørnarå BT, Gudmundsen TE, Dahl OE (2006) Frequency and timing of clinical venous thromboembolism after major joint surgery. J Bone Joint Surg Br 88:386–391

    Article  PubMed  Google Scholar 

  4. Falck-Ytter Y, Francis CW, Johanson NA, Curley C, Ola E, Dahl OE, Schulman S, Ortel TL, Pauker SG, Colwell CW (2012) Prevention of VTE in orthopedic surgery patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 141:e278S–e325S

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  5. Vera-Llonch M, Hagiwara M, Oster G (2006) Clinical and economic consequences of bleeding following major orthopedic surgery. Thromb Res 117:569–577

    Article  CAS  PubMed  Google Scholar 

  6. Lison S, Weiss G, Spannagl M, Heindl B (2011) Postoperative changes in procoagulant factors after major surgery. Blood Coagul Fibrinolysis 22:190–196

    Article  CAS  PubMed  Google Scholar 

  7. Jakoi A, Kumar N, Vaccaro A, Radcliff K (2014) Perioperative coagulopathy monitoring. Musculoskelet Surg 98:1–8

    Article  CAS  PubMed  Google Scholar 

  8. Dickinson KJ, Troxler M, Homer-Vanniasinkam S (2008) The surgical application of point-of-care haemostasis and platelet function testing. Br J Surg 95:1317–1330

    Article  CAS  PubMed  Google Scholar 

  9. Wilson D, Cooke EA, McNally MA, Wilson HK, Yeates A, Mollan RA (2001) Changes in coagulability as measured by thrombelastography following surgery for proximal femoral fracture. Injury 32:765–770

    Article  CAS  PubMed  Google Scholar 

  10. Horlocker TT, Nuttall GA, Dekutoski MB, Bryant SC (2001) The accuracy of coagulation tests during spinal fusion and instrumentation. Anesth Analg 93:33–38

    Article  CAS  PubMed  Google Scholar 

  11. Mittermayr M, Streif W, Haas T, Fries D, Velik-Salchner C, Klingler A, Oswald E, Bach C, Schnapka-Koepf M, Innerhofer P (2007) Hemostatic changes after crystalloid or colloid fluid administration during major orthopedic surgery: the role of fibrinogen administration. Anesth Analg 105:905–917

    Article  CAS  PubMed  Google Scholar 

  12. Okamura K, Nakagawa I, Hidaka S, Okada Y, Kubo T, Kato T (2007) Perioperative changes of blood coagulability evaluated by thromboelastography (TEG) in patients undergoing total knee and total hip arthroplasty. Masui 56:645–649

    PubMed  Google Scholar 

  13. Topçu I, Civi M, Oztürk T, Keleş GT, Coban S, Yentür EA, Okçu G (2012) Evaluation of hemostatic changes using thromboelastography after crystalloid or colloid fluid administration during major orthopedic surgery. Braz J Med Biol Res 45:869–874

    PubMed  PubMed Central  Google Scholar 

  14. Oberweis BS, Cuff G, Rosenberg A, Pardo L, Nardi MA, Guo Y, Dweck E, Marshall M, Steiger D, Stuchin S, Berge JS (2014) Platelet aggregation and coagulation factors in orthopedic surgery. J Thromb Thrombolysis 38:430–438

    Article  CAS  PubMed  Google Scholar 

  15. Oswald E, Velik-Salchner C, Innerhofer P, Tauber H, Auckenthaler T, Ulmer H, Streif W (2015) Results of rotational thromboelastometry, coagulation activation markers and thrombin generation assays in orthopedic patients dring thromboprophylaxis with rivaroxaban and enoxaparin: a prospective cohort study. Blood Coagul Fibrinolysis 26:136–144

    Article  CAS  PubMed  Google Scholar 

  16. Kozek-Langenecker SA, Afshari A, Albaladejo P, Santullano CA, De Robertis E, Filipescu DC, Fries D, Görlinger K, Haas T, Imberger G, Jacob M, Lancé M, Llau J, Mallett S, Meier J, Rahe-Meyer N, Samama CM, Smith A, Solomon C, Van der Linden P, Wikkelsø AJ, Wouters P, Wyffels P (2013) Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol 30:270–382

    Article  PubMed  Google Scholar 

  17. Spiezia L, Radu C, Marchioro P, Bertini D, Rossetto V, Castelli M, Pagnan A, Sørensen B, Simioni P (2008) Peculiar whole blood rotation thromboelastometry (Rotem) profile in 40 sideropenic anaemia patients. Thromb Haemost 100:1106–1110

    CAS  PubMed  Google Scholar 

  18. Sørensen B, Johansen P, Christiansen K, Woelke M, Ingerslev J (2003) Whole blood coagulation thromboelastographic profiles employing minimal tissue factor activation. J Thromb Haemost 1:551–558

    Article  PubMed  Google Scholar 

  19. Hemker HC, Giesen P, Al Dieri R, Regnault V, de Smedt E, Wagenvoord R, Lecompte T, Béguin S (2003) Calibrated automated thrombin generation measurement in clotting plasma. Pathophysiol Haemost Thromb 33:4–15

    Article  CAS  PubMed  Google Scholar 

  20. Dahl OE, Molnar I, Rø JS, Vinje A (1988) Global tests on coagulation and fibrinolysis in systemic and pulmonary circulation accompanying hip arthroplasty with acrylic cement. Thromb Res 50:865–873

    Article  CAS  PubMed  Google Scholar 

  21. Grassetto A, Fullin G, Cerri G, Simioni P, Spiezia L, Maggiolo C (2014) Management of severe bleeding in a ruptured extrauterine pregnancy: a theragnostic approach. Blood Coagul Fibrinolysis 25:176–179

    Article  PubMed  Google Scholar 

  22. Weber CF, Görlinger K, Meininger D, Herrmann E, Bingold T, Moritz A, Cohn LH, Zacharowski K (2012) Point-of-care testing: a prospective, randomized clinical trial of efficacy in coagulopathic cardiac surgery patients. Anesthesiology 117:531–547

    Article  PubMed  Google Scholar 

  23. Wang SC, Shieh JF, Chang KY, Chu YC, Liu CS, Loong CC, Chan KH, Mandell S, Tsou MY (2010) Thromboelastography-guided transfusion decreases intraoperative blood transfusion during orthotopic liver transplantation: randomized clinical trial. Transplant Proc 42:2590–2593

    Article  PubMed  Google Scholar 

  24. Schulman S, Angerås U, Bergqvist D, Eriksson B, Lassen MR, Fisher W, Subcommittee on Control of Anticoagulation of the Scientific and Standardization Committee of the International Society on Thrombosis and Haemostasis (2010) Definition of major bleeding in clinical investigations of antihemostatic medicinal products in surgical patients. J Thromb Haemost 8:202–204

    Article  CAS  PubMed  Google Scholar 

  25. Niemi TT, Soujaranta-Ylinen RT, Kukkonen SI, Kuitunen AH (2006) Gelatin and hydroxyethyl starch, but not albumin, impair hemostasis after cardiac surgery. Anesth Analg 102:998–1006

    Article  CAS  PubMed  Google Scholar 

  26. De Jonge E, Levi M (2001) Effects of different plasma substitutes on blood coagulation: a comparative review. Crit Care Med 29:1261–1267

    Article  PubMed  Google Scholar 

Download references

Author information

Author notes

    Authors and Affiliations

    1. Thrombotic and Hemorrhagic Unit, Department of Medicine, University of Padova, Via Ospedale Civile 105, 35100, Padua, Italy

      Luca Spiezia, Elena Campello, Sara Maggiolo, Sabrina Gavasso & Paolo Simioni

    2. Anesthesiology and Intensive Care Unit, Department of Medicine, University of Padova, Padua, Italy

      Francesco Vasques & Astrid Behr

    3. Department of Orthopedics, University of Padova, Padua, Italy

      Antonio Berizzi

    4. HaemaCon Ltd, Bromley, England, UK

      Barry Woodhams

    5. Department of Surgery, Oulu University Hospital, Oulu, Finland

      Fausto Biancari

    Authors
    1. Luca Spiezia
      View author publications

      You can also search for this author in PubMed Google Scholar

    2. Francesco Vasques
      View author publications

      You can also search for this author in PubMed Google Scholar

    3. Astrid Behr
      View author publications

      You can also search for this author in PubMed Google Scholar

    4. Elena Campello
      View author publications

      You can also search for this author in PubMed Google Scholar

    5. Sara Maggiolo
      View author publications

      You can also search for this author in PubMed Google Scholar

    6. Antonio Berizzi
      View author publications

      You can also search for this author in PubMed Google Scholar

    7. Sabrina Gavasso
      View author publications

      You can also search for this author in PubMed Google Scholar

    8. Barry Woodhams
      View author publications

      You can also search for this author in PubMed Google Scholar

    9. Fausto Biancari
      View author publications

      You can also search for this author in PubMed Google Scholar

    10. Paolo Simioni
      View author publications

      You can also search for this author in PubMed Google Scholar

    Corresponding author

    Correspondence to Paolo Simioni.

    Ethics declarations

    Conflict of interest

    Luca Spiezia, Francesco Vasques, Astrid Behr, Elena Campello, Sara Maggiolo, Antonio Berizzi, Sabrina Gavasso, Fausto Biancari and Paolo Simioni have no conflict of interest. Barry Woodhams (BW) acts as a consultant, via HaemaCon, for Diagnostica Stago.

    Statement of human and animal rights

    All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the author.

    Informed consent

    Informed consent was obtained from all individual participants included in the study.

    Additional information

    L. Spiezia and F. Vasques equally contributed to this paper.

    Rights and permissions

    Reprints and permissions

    About this article

    Check for updates. Verify currency and authenticity via CrossMark

    Cite this article

    Spiezia, L., Vasques, F., Behr, A. et al. Perioperative coagulation assessment of patients undergoing major elective orthopedic surgery. Intern Emerg Med 11, 793–801 (2016). https://doi.org/10.1007/s11739-016-1414-x

    Download citation

    • Received:

    • Accepted:

    • Published:

    • Issue Date:

    • DOI: https://doi.org/10.1007/s11739-016-1414-x

    Keywords

    Search

    Navigation