BACKGROUND It is widely accepted that Point‐of Care Test (PoCT) devices are useful in the detection of coagulopathies in situations of massive bleeding such as major cardiac surgery. These devices contribute to the reduction of blood transfusion. However, their implementation remains limited in Japan because of their cost and lack of health insurance support. STUDY DESIGN AND METHODS Conventional coagulation tests and thromboelastography (TEG)/Sonoclot values were measured in 50 consecutive cardiac surgery cases. Clinical background information such as operative procedures was obtained from electronic medical records, and the theoretical perioperative total blood loss was calculated by measuring the hemoglobin content and total red blood cell transfusion volume. The correlation between perioperative total blood loss and the measured laboratory values or clinical parameters was evaluated by a multivariate linear regression analysis. The risk factors of the total amount of platelet transfusion and postoperative drain bleeding volume were similarly evaluated. RESULTS No significant association between the estimated perioperative total blood loss (eTBL) and the laboratory measurements including conventional coagulation tests, TEG and Sonoclot was observed. On the other hand, postoperative drain bleeding volume was significantly associated with postoperative Sonoclot CR (p = 0.039) as well as preoperative use of oral anticoagulants and cell saver treated blood volume. Platelet transfusion amount was significantly associated with post‐CBP PF and time to peak value of Sonoclot (p = 0.014 and 0.001, respectively). CONCLUSION Sonoclot measurements may be useful to estimate the risks of postoperative bleeding and platelet transfusion in cardiac surgeries in Japan.

Background: Fluid resuscitation, which is critical to counter acute hemorrhagic shock, requires prompt and accurate intravascular volume estimation for optimal fluid administration. This study aimed to evaluate whether cardiac variation of internal jugular vein (IJV), evaluated by ultrasonography, could detect hypovolemic status and predict response to fluid resuscitation. Methods: Patients undergoing autologous blood transfusion for elective surgery who were prospectively enrolled at the study blood donation center between August 2014 and January 2015. Vertical B-mode ultrasonography movies of IJV were recorded at five timepoints during blood donation: before donation, during donation, end of donation, end of fluid replacement, and after hemostasis. Cardiac variation of the IJV area and circumference were objectively measured using an automated extraction program together with blood pressure and heart rate. Results: A total of 140 patients were screened, and data from 104 patients were included in the final analyses. Among the variables analyzed, only collapse index area and collapse index circumference could detect both intravascular volume loss and response to fluid administration. Conclusions: Cardiac variation of IJV may be a reliable indicator of intravascular volume loss and response to fluid administration in hemorrhagic shock.

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A trace amount of thrombin cleaves factor VIII (FVIII) into an active form (FVIIIa), which catalyzes FIXa-mediated activation of FX on the activated platelet surface. FVIII rapidly binds to von Willebrand factor (VWF) after secretion and becomes highly concentrated via VWF-platelet interaction at a site of endothelial inflammation or injury. Circulating levels of FVIII and VWF are influenced by age, blood type (nontype O > type O), and metabolic syndromes. In the latter, hypercoagulability is associated with chronic inflammation (known as thrombo-inflammation). In acute stress including trauma, releasable pools of FVIII/VWF are secreted from the Weibel-Palade bodies in the endothelium and then augment local platelet accumulation, thrombin generation, and leukocyte recruitment. Early systemic increases of FVIII/VWF (>200% of normal) levels in trauma result in a lower sensitivity of contact-activated clotting time (activated partial thromboplastin time [aPTT] or viscoelastic coagulation test [VCT]). However, in severely injured patients, multiple serine proteases (FXa plasmin and activated protein C [APC]) are locally activated and may be systemically released. Severity of traumatic injury correlates with prolonged aPTT and elevated activation markers of FXa, plasmin, and APC, culminating in a poor prognosis. In a subset of acute trauma patients, cryoprecipitate that contains fibrinogen, FVIII/VWF, and FXIII is theoretically advantageous over purified fibrinogen concentrate to promote stable clot formation, but comparative efficacy data are lacking. In chronic inflammation or subacute phase of trauma, elevated FVIII/VWF contributes to the pathogenesis of venous thrombosis by enhancing not only thrombin generation but also augmenting inflammatory functions.

In Reply Dr Phillips correctly points out that we did not include leg length inequality as a biomechanical risk factor for hip and knee osteoarthritis in our review. 1 We regret the omission. Indeed, analyses conducted with data from the Multicenter Osteoarthritis Study, Osteoarthritis Initiative, and Johnston County Osteoarthritis Project showed that leg length inequality of 1 cm or greater was associated with a higher incidence of knee and hip osteoarthritis in the shorter limb, adjusting for age, sex, and body mass index. [2][3][4] When a threshold of 2 cm or greater was used to define leg length inequality, the risks of knee and hip osteoarthritis were even higher. For example, in 1 study, the odds of incident symptomatic knee osteoarthritis in the shorter leg of people with leg length inequality of 1 cm or greater were 1.7fold higher than in those without leg length inequality. 2 In this study, the odds ratio doubled to 4.1 for leg length inequality of 2 cm or greater.Phillips speculates that use of an orthotic insert for the shorter limb may reduce the risk of knee or hip osteoarthritis. This hypothesis has been examined in small clinical studies, mostly for low back pain. 5 Currently, there is insufficient evidence to recommend routine use of orthotic inserts for prevention or treatment of knee or hip osteoarthritis in persons with leg length inequality. We also note that because altered joint tissue metabolism can be driven by biomechanical factors, it is unlikely that leg length inequality would cause osteoarthritis only by simple "wear and tear," as suggested by Phillips.

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Background. Fluid resuscitation is crucial to counter acute haemorrhagic shock and requires prompt and accurate intravascular volume estimation for optimal fluid administration. This study aimed to evaluate whether cardiac variation of the internal jugular vein (IJV), measured by ultrasound, could detect hypovolemic status and predict response to fluid resuscitation. Methods. Autologous blood transfusion patients for their own elective surgeries were prospectively enrolled at our blood donation centre from August 2014 to January 2015., and movies of vertical B-mode ultrasonography of the IJV were recorded at five points during blood donation, namely, before donation, during donation, end of donation, end of fluid replacement and after hemostasis. Cardiac variation in IJV area and circumference were objectively measured using an automated extraction programme, along with blood pressure and heart rate. Results. We screened 140patients and data from 104 were eventually evaluated. Among the variables analysed, only collapse index area (CIa) and collapse index circumference (CIc) could detect both intravascular volume loss and response to fluid administration Conclusions. The cardiac variation of IJV may be a reliable indicator of intravascular volume loss and response to fluid administration in haemorrhagic shock.