Thromboelastography in elective total hip arthroplasty

BACKGROUND Hypercoagulability plays an important role in predisposing patients to venous thromboembolism(VTE)after total hip arthroplasty(THA).We used thromboelastography(TEG)to examine the coagulation status of patients undergoing THA.AIM To examine coagulation as measured by TEG in patients undergoing THA who received standard VTE chemoprophylaxis with enoxaparin.METHODS After ethical approval,we performed a retrospective analysis of data collected in patients undergoing primary elective THA.We analyzed TEG data on samples performed before skin incision,intraoperatively and for 5 d postoperatively.Conventional coagulation tests were performed preoperatively and on postoperative day 5.RESULTS Twenty patients undergoing general anesthesia and 32 patients undergoing spinal anesthesia(SA)were included.TEG demonstrated a progressively hypercoagulable state postoperatively,characterized by elevated maximum amplitude.TEG also demonstrated transient intraoperative hypercoagulability in patients receiving SA.In contrast,conventional coagulation tests were normal in all patients,pre-and postoperatively,except for an increase in plasma fibrinogen day 5 postoperatively.CONCLUSION Despite VTE prophylaxis,patients following total hip replacement remain in a hypercoagulable state as measured by both TEG and conventional tests.This group may benefit from more optimal anticoagulation and/or additional perioperative hemostatic monitoring,via TEG or otherwise.

Haemostatic management for aortic valve replacement in a patient with advanced liver disease

Redo-sternotomy and aortic valve replacement in patients with advanced liver disease is rare and associated with a prohibitive morbidity and mortality. Refractory coagulopathy is common and a consequence of intense activation of the coagulation system that can be triggered by contact of blood with the cardiopulmonary bypass circuitry, bypass-induced fibrinolysis, plate-let activation and dysfunction, haemodilution, surgical trauma, hepatic decompensation and hypothermia. Management can be further complicated by right heart dysfunction, porto-pulmonary hypertension, poor myocardial protection, and hepato-renal syndrome. Complex interactions between coagulation/fibrinolysis and systemic inflammatory response syndrome reactions like "post-perfusion-syndrome" also compound haemostatic failure. Given the limited information available for the specific management and prevention of cardiopulmonary bypass-induced haemostatic failure, this report serves to guide the anaesthesia and medical management of future cases of a similar kind. We discuss our multimodal management of haemostatic failure using pharmacological strategies, thromboelastography, continuous cerebral and liver oximetry, and continuous cardiac output monitoring.