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Mair A, Sahli SD, Studt JD, Braun J, Lunkiewicz J, Spahn DR, Kaserer A. Impact of elevated direct factor Xa inhibitor plasma levels on perioperative blood loss in patients undergoing urgent surgery. Transfusion 2024. [PMID: 39319425 DOI: 10.1111/trf.18021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 09/06/2024] [Accepted: 09/07/2024] [Indexed: 09/26/2024]
Abstract
INTRODUCTION Data on the perioperative bleeding risk associated with elevated plasma levels of direct factor Xa inhibitors (FXa inhibitors) are limited. This study examines perioperative red blood cell (RBC) loss in patients undergoing urgent surgery with a residual FXa inhibitor level exceeding 100 mcg/L and without preoperative FXa inhibitor reversal. METHODS This retrospective analysis includes data from 32 patients who underwent urgent noncardiac surgery between 2018 and 2022. This study aims to analyze perioperative RBC loss in patients undergoing urgent surgery with a residual FXa inhibitor level exceeding 100 mcg/L and without preoperative FXa inhibitor antidote-based reversal or unspecific treatment with 4-factor prothrombin complex concentrate (PCC). All patients were managed using a watch-and-wait strategy. RESULTS The last determination of FXa inhibitor plasma concentration prior to surgery showed a median of 245 mcg/L (IQR 144-345), with a median time interval of 3.8 h (IQR 2.4-7.2) before incision. Median RBC loss during surgery was 49 mL (IQR 0-253), 189 mL (IQR 104-217) until POD1 and 254 mL (IQR 58-265) until POD3. Only one patient required intraoperative treatment with 4-factor-PCC and none required reversal with andexanet alfa. Linear regression models found no significant influence of FXa inhibitor plasma levels on intraoperative RBC loss. Rivaroxaban was associated with higher RBC loss until postoperative Day 1 compared with apixaban. No thromboembolic events were observed. CONCLUSION Despite markedly elevated plasma concentrations of residual direct FXa inhibitors, perioperative RBC loss was limited in patients undergoing urgent noncardiac surgery. The intraoperative watch-and-wait strategy with selective intraoperative FXa inhibitor reversal or treatment only when required appears to be an appropriate approach.
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Affiliation(s)
- Alexander Mair
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Sebastian D Sahli
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Jan-Dirk Studt
- Department of Medical Oncology and Hematology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Julia Braun
- Departments of Biostatistics and Epidemiology, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Justyna Lunkiewicz
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Donat R Spahn
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Alexander Kaserer
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
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Crochemore T, Görlinger K, Lance MD. Early Goal-Directed Hemostatic Therapy for Severe Acute Bleeding Management in the Intensive Care Unit: A Narrative Review. Anesth Analg 2024; 138:499-513. [PMID: 37977195 PMCID: PMC10852045 DOI: 10.1213/ane.0000000000006756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2023] [Indexed: 11/19/2023]
Abstract
This is a narrative review of the published evidence for bleeding management in critically ill patients in different clinical settings in the intensive care unit (ICU). We aimed to describe "The Ten Steps" approach to early goal-directed hemostatic therapy (EGDHT) using point-of-care testing (POCT), coagulation factor concentrates, and hemostatic drugs, according to the individual needs of each patient. We searched National Library of Medicine, MEDLINE for publications relevant to management of critical ill bleeding patients in different settings in the ICU. Bibliographies of included articles were also searched to identify additional relevant studies. English-language systematic reviews, meta-analyses, randomized trials, observational studies, and case reports were reviewed. Data related to study methodology, patient population, bleeding management strategy, and clinical outcomes were qualitatively evaluated. According to systematic reviews and meta-analyses, EGDHT guided by viscoelastic testing (VET) has been associated with a reduction in transfusion utilization, improved morbidity and outcome in patients with active bleeding. Furthermore, literature data showed an increased risk of severe adverse events and poor clinical outcomes with inappropriate prophylactic uses of blood components to correct altered conventional coagulation tests (CCTs). Finally, prospective, randomized, controlled trials point to the role of goal-directed fibrinogen substitution to reduce bleeding and the amount of red blood cell (RBC) transfusion with the potential to decrease mortality. In conclusion, severe acute bleeding management in the ICU is still a major challenge for intensive care physicians. The organized and sequential approach to the bleeding patient, guided by POCT allows for rapid and effective bleeding control, through the rational use of blood components and hemostatic drugs, since VET can identify specific coagulation disorders in real time, guiding hemostatic therapy with coagulation factor concentrates and hemostatic drugs with individual goals.
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Affiliation(s)
- Tomaz Crochemore
- From the Department of Critical Care, Hospital Vila Nova Star, São Paulo, Brazil
- Department of Critical Care, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Werfen LATAM, São Paulo, Brazil
| | - Klaus Görlinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, Essen, Germany
- TEM Innovations GmbH/Werfen PBM, Munich, Germany
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Kaserer A, Schöchl H, Spahn DR. Navigating Critical Waters: The Importance of a Systematic Coagulation Algorithm in the Intensive Care Unit. Anesth Analg 2024; 138:496-498. [PMID: 38364241 DOI: 10.1213/ane.0000000000006865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Affiliation(s)
- Alexander Kaserer
- From the Institute of Anesthesiology, University of Zurich and University Hospital of Zurich, Zurich, Switzerland
| | - Herbert Schöchl
- Ludwig Boltzmann Institute for Traumatology, Vienna and Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Donat R Spahn
- Formerly, Institute of Anesthesiology, University of Zurich and University Hospital of Zurich, Zurich, Switzerland
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Gasciauskaite G, Castellucci C, Malorgio A, Budowski AD, Schweiger G, Kolbe M, Fries D, Grande B, Nöthiger CB, Spahn DR, Roche TR, Tscholl DW, Akbas S. User Perceptions of Visual Clot in a High-Fidelity Simulation Study: Mixed Qualitative-Quantitative Study. JMIR Hum Factors 2024; 11:e47991. [PMID: 38206666 PMCID: PMC10811569 DOI: 10.2196/47991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 10/17/2023] [Accepted: 11/27/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Viscoelastic hemostatic assays, such as rotational thromboelastometry (ROTEM) or thromboelastography, enable prompt diagnosis and accelerate targeted treatment. However, the complex interpretation of the results remains challenging. Visual Clot-a situation awareness-based visualization technology-was developed to assist clinicians in interpreting viscoelastic tests. OBJECTIVE Following a previous high-fidelity simulation study, we analyzed users' perceptions of the technology, to identify its strengths and limitations from clinicians' perspectives. METHODS This is a mixed qualitative-quantitative study consisting of interviews and a survey. After solving coagulation scenarios using Visual Clot in high-fidelity simulations, we interviewed anesthesia personnel about the perceived advantages and disadvantages of the new tool. We used a template approach to identify dominant themes in interview responses. From these themes, we defined 5 statements, which were then rated on Likert scales in a questionnaire. RESULTS We interviewed 77 participants and 23 completed the survey. We identified 9 frequently mentioned topics by analyzing the interview responses. The most common themes were "positive design features," "intuitive and easy to learn," and "lack of a quantitative component." In the survey, 21 respondents agreed that Visual Clot is easy to learn and 16 respondents stated that a combination of Visual Clot and ROTEM would help them manage complex hemostatic situations. CONCLUSIONS A group of anesthesia care providers found Visual Clot well-designed, intuitive, and easy to learn. Participants highlighted its usefulness in emergencies, especially for clinicians inexperienced in coagulation management. However, the lack of quantitative information is an area for improvement.
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Affiliation(s)
- Greta Gasciauskaite
- Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland
| | - Clara Castellucci
- Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland
| | - Amos Malorgio
- Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland
| | | | - Giovanna Schweiger
- Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland
| | - Michaela Kolbe
- Simulation Centre, University Hospital Zurich, Zurich, Switzerland
| | - Daniel Fries
- Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland
| | - Bastian Grande
- Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland
| | | | - Donat R Spahn
- Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland
| | - Tadzio R Roche
- Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland
| | - David W Tscholl
- Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland
| | - Samira Akbas
- Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland
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Roggan CLM, Akbas S, Arvanitakis M, Mannil L, Spahn DR, Plock JA, Kaserer A. Changes in coagulation and temperature management in burn patients - A survey of burn centers in Switzerland, Austria and Germany. Burns 2023; 49:1566-1573. [PMID: 36914441 DOI: 10.1016/j.burns.2023.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 01/13/2023] [Accepted: 02/19/2023] [Indexed: 03/04/2023]
Abstract
BACKGROUND Severely burned patients suffer from both coagulopathy and hypothermia, with a lack of international consensus and appropriate treatment guidelines. This study examines recent developments and trends in coagulation and temperature management in European burn centers. METHODS A survey was sent to burn centers in Switzerland, Austria and Germany in 2016 and again in 2021. The analysis was performed using descriptive statistics, with categorical data reported in absolute numbers (n) and percentages (%) and numerical data reported as mean and standard deviation. RESULTS The rate of completed questionnaires was 84 % (16 of 19 questionnaires) in 2016 and 91 % (21 of 22 questionnaires) in 2021. The number of global coagulation tests performed has decreased over the observation period in favor of single factor determination and bed-side point-of-care coagulation tests. This has also led to increased administration of single factor concentrates in therapy. Although many centers had a defined treatment protocol for hypothermia in 2016, coverage increased such that in 2021 all centers surveyed had such a protocol. The body temperature was measured more consistently in 2021; thus, hypothermia was more actively sought, detected and treated. CONCLUSION A point-of-care guided, factor-based coagulation management and the maintenance of normothermia have gained importance in the care of burn patients in recent years.
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Affiliation(s)
- Celine L M Roggan
- Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland
| | - Samira Akbas
- Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland
| | - Michael Arvanitakis
- University Hospital Zurich, University of Zurich, Zurich, Switzerland; Department of Plastic Surgery and Hand Surgery, Burn Center, University of Zurich, Zurich, Switzerland
| | - Lijo Mannil
- University Hospital Zurich, University of Zurich, Zurich, Switzerland; Department of Plastic Surgery and Hand Surgery, Burn Center, University of Zurich, Zurich, Switzerland
| | - Donat R Spahn
- Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland
| | - Jan A Plock
- University Hospital Zurich, University of Zurich, Zurich, Switzerland; Department of Plastic Surgery and Hand Surgery, Burn Center, University of Zurich, Zurich, Switzerland; Department of Plastic Surgery and Hand Surgery; Cantonal Hospital Aarau; Aarau, Switzerland
| | - Alexander Kaserer
- Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland.
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Spahn DR, Kaserer A. Management of severe peri-operative bleeding: A call for action by the ESAIC. Eur J Anaesthesiol 2023; 40:223-225. [PMID: 36855940 DOI: 10.1097/eja.0000000000001804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Affiliation(s)
- Donat R Spahn
- From the Institute of Anesthesiology, University of Zurich and University Hospital of Zurich, Zurich, Switzerland (DRS, AK)
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Gasciauskaite G, Malorgio A, Castellucci C, Budowski A, Schweiger G, Kolbe M, Grande B, Noethiger CB, Spahn DR, Roche TR, Tscholl DW, Akbas S. User Perceptions of ROTEM-Guided Haemostatic Resuscitation: A Mixed Qualitative-Quantitative Study. Bioengineering (Basel) 2023; 10:bioengineering10030386. [PMID: 36978777 PMCID: PMC10044818 DOI: 10.3390/bioengineering10030386] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 03/17/2023] [Accepted: 03/20/2023] [Indexed: 03/30/2023] Open
Abstract
Viscoelastic point-of-care haemostatic resuscitation methods, such as ROTEM or TEG, are crucial in deciding on time-efficient personalised coagulation interventions. International transfusion guidelines emphasise increased patient safety and reduced treatment costs. We analysed care providers' perceptions of ROTEM to identify perceived strengths and areas for improvement. We conducted a single-centre, mixed qualitative-quantitative study consisting of interviews followed by an online survey. Using a template approach, we first identified themes in the responses given by care providers about ROTEM. Later, the participants rated six statements based on the identified themes on five-point Likert scales in an online questionnaire. Seventy-seven participants were interviewed, and 52 completed the online survey. By analysing user perceptions, we identified ten themes. The most common positive theme was "high accuracy". The most common negative theme was "need for training". In the online survey, 94% of participants agreed that monitoring the real-time ROTEM temograms helps to initiate targeted treatment more quickly and 81% agreed that recurrent ROTEM training would be beneficial. Anaesthesia care providers found ROTEM to be accurate and quickly available to support decision-making in dynamic and complex haemostatic situations. However, clinicians identified that interpreting ROTEM is a complex and cognitively demanding task that requires significant training needs.
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Affiliation(s)
- Greta Gasciauskaite
- Institute of Anaesthesiology, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland
| | - Amos Malorgio
- Institute of Anaesthesiology, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland
| | - Clara Castellucci
- Institute of Anaesthesiology, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland
| | - Alexandra Budowski
- Institute of Anaesthesiology, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland
| | - Giovanna Schweiger
- Institute of Anaesthesiology, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland
| | - Michaela Kolbe
- Simulation Center, University Hospital Zurich, Gloriastrasse 19, 8091 Zurich, Switzerland
| | - Bastian Grande
- Institute of Anaesthesiology, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland
| | - Christoph B Noethiger
- Institute of Anaesthesiology, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland
| | - Donat R Spahn
- Institute of Anaesthesiology, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland
| | - Tadzio R Roche
- Institute of Anaesthesiology, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland
| | - David W Tscholl
- Institute of Anaesthesiology, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland
| | - Samira Akbas
- Institute of Anaesthesiology, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland
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