1
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Sahli SD, Castellucci C, Roche TR, Rössler J, Spahn DR, Kaserer A. The impact of direct oral anticoagulants on viscoelastic testing - A systematic review. Front Cardiovasc Med 2022; 9:991675. [PMID: 36419490 PMCID: PMC9676657 DOI: 10.3389/fcvm.2022.991675] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 10/03/2022] [Indexed: 09/12/2023] Open
Abstract
BACKGROUND In case of bleeding patients and in acute care, the assessment of residual direct oral anticoagulant (DOAC) activity is essential for evaluating the potential impact on hemostasis, especially when a timely decision on urgent surgery or intervention is required. Viscoelastic tests are crucial in a modern goal-directed coagulation management to assess patients' coagulation status. However, the role of viscoelastic test to detect and quantify residual DOAC plasma levels is controversially discussed. The aim of this review was to systematically summarize the evidence of viscoelastic tests for the assessment of residual DOAC activity. METHOD PubMed, Embase, Scopus, and the Cochrane Library were searched for original articles investigating the effect of rivaroxaban, apixaban, edoxaban, or dabigatran plasma levels on different viscoelastic tests of the adult population from database inception to December 31, 2021. RESULTS We included 53 studies from which 31 assessed rivaroxaban, 22 apixaban, six edoxaban, and 29 dabigatran. The performance of viscoelastic tests varied across DOACs and assays. DOAC specific assays are more sensitive than unspecific assays. The plasma concentration of rivaroxaban and dabigatran correlates strongly with the ROTEM EXTEM, ClotPro RVV-test or ECA-test clotting time (CT) and TEG 6s anti-factor Xa (AFXa) or direct thrombin inhibitor (DTI) channel reaction time (R). Results of clotting time (CT) and reaction time (R) within the normal range do not reliable exclude relevant residual DOAC plasma levels limiting the clinical utility of viscoelastic assays in this context. CONCLUSION Viscoelastic test assays can provide fast and essential point-of-care information regarding DOAC activity, especially DOAC specific assays. The identification and quantification of residual DOAC plasma concentration with DOAC unspecific viscoelastic assays are not sensitive enough, compared to recommended anti-Xa activity laboratory measurements. SYSTEMATIC REVIEW REGISTRATION [https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=320629], identifier [CRD42022320629].
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Affiliation(s)
- Sebastian D. Sahli
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Clara Castellucci
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Tadzio R. Roche
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Julian Rössler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States
| | - 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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2
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Niemann M, Otto E, Eder C, Youssef Y, Kaufner L, Märdian S. Coagulopathy management of multiple injured patients - a comprehensive literature review of the European guideline 2019. EFORT Open Rev 2022; 7:710-726. [PMID: 36287131 PMCID: PMC9619392 DOI: 10.1530/eor-22-0054] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
The European guideline on the management of trauma-induced major bleeding and coagulopathy summarises the most relevant recommendations for trauma coagulopathy management. The management of trauma-induced major bleeding should interdisciplinary follow algorithms which distinguish between life-threatening and non-life-threatening bleeding. Point-of-care viscoelastic methods (VEM) assist target-controlled haemostatic treatment. Neither conventional coagulation assays nor VEM should delay treatment in life-threatening trauma-induced bleeding. Adjustments may be rational due to local circumstances, including the availability of blood products, pharmaceuticals, and employees.
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Affiliation(s)
- Marcel Niemann
- Charité – Universitätsmedizin Berlin, Center for Musculoskeletal Surgery, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany,Julius Wolff Institute for Biomechanics and Musculoskeletal Regeneration, Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany,Correspondence should be addressed to M Niemann;
| | - Ellen Otto
- Charité – Universitätsmedizin Berlin, Center for Musculoskeletal Surgery, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany,Julius Wolff Institute for Biomechanics and Musculoskeletal Regeneration, Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Christian Eder
- Charité – Universitätsmedizin Berlin, Center for Musculoskeletal Surgery, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Yasmin Youssef
- Department of Orthopaedics, Trauma Surgery and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Lutz Kaufner
- Charité – Universitätsmedizin Berlin, Department of Anesthesiology and Intensive Care Medicine, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Sven Märdian
- Charité – Universitätsmedizin Berlin, Center for Musculoskeletal Surgery, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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3
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Chen F, Zhang L, Bai X, Wang X, Geng Z. Clinical Application of Thromboelastography in Acute Ischemic Stroke. Clin Appl Thromb Hemost 2022; 28:10760296221131801. [PMID: 36285384 PMCID: PMC9608017 DOI: 10.1177/10760296221131801] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Acute ischemic stroke (AIS), characterized by high morbidity and mortality, has imposed a considerable burden on society. Despite rapid development in the treatment of AIS, there is still a high risk of recurrence. Furthermore, there is a time delay in waiting for the results of conventional coagulation tests in candidate patients for intravenous thrombolysis therapy. Heterogeneous responses to antiplatelet, intravascular thrombolysis, and endovascular therapies also worsen the situation. Thromboelastography (TEG), as a global and portable detection method for hemostasis, facilitates clinicians in disease monitoring, treatment evaluation, and prognosis prediction in AIS. In this narrative review, we provided a comprehensive summary of the clinical application of TEG in ischemic stroke and gave insights to further studies.
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Affiliation(s)
- Feng Chen
- Department of Neurology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Liren Zhang
- Department of Neurology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaolin Bai
- Department of Neurology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiuzhe Wang
- Department of Neurology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China,Zhi Geng, 600 Yishan Road, Xuhui District, Shanghai, 200233 China.
Xiuzhe Wang, 600 Yishan Road, Xuhui District, Shanghai, 200233 China
| | - Zhi Geng
- Department of Neurology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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4
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Mamczak CN, Speybroeck J, Stillson JE, Dynako J, Piscoya A, Peck EE, Aboukhaled M, Cancel E, McDonald M, Garcia D, Lovejoy J, Lubin S, Stanton R, Kutcher ME. Viscoelastic Hemostatic Assays for Orthopedic Trauma and Elective Procedures. J Clin Med 2022; 11:jcm11144029. [PMID: 35887803 PMCID: PMC9323142 DOI: 10.3390/jcm11144029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/07/2022] [Accepted: 07/07/2022] [Indexed: 02/04/2023] Open
Abstract
The application of viscoelastic hemostatic assays (VHAs) (e.g., thromboelastography (TEG) and rotational thromboelastometry (ROTEM)) in orthopedics is in its relative infancy when compared with other surgical fields. Fortunately, several recent studies describe the emerging use of VHAs to quickly and reliably analyze the real-time coagulation and fibrinolytic status in both orthopedic trauma and elective orthopedic surgery. Trauma-induced coagulopathy—a spectrum of abnormal coagulation phenotypes including clotting factor depletion, inadequate thrombin generation, platelet dysfunction, and dysregulated fibrinolysis—remains a potentially fatal complication in severely injured and/or hemorrhaging patients whose timely diagnosis and management are aided by the use of VHAs. Furthermore, VHAs are an invaluable compliment to common coagulation tests by facilitating the detection of hypercoagulable states commonly associated with orthopedic injury and postoperative status. The use of VHAs to identify hypercoagulability allows for an accurate venous thromboembolism (VTE) risk assessment and monitoring of VTE prophylaxis. Until now, the data have been insufficient to permit an individualized approach with regard to dosing and duration for VTE thromboprophylaxis. By incorporating VHAs into routine practice, orthopedic surgeons will be better equipped to diagnose and treat the complete spectrum of coagulation abnormalities faced by orthopedic patients. This work serves as an educational primer and up-to-date review of the current literature on the use of VHAs in orthopedic surgery.
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Affiliation(s)
- Christiaan N. Mamczak
- Department of Orthopaedic Trauma, Florida Orthopaedic Institute, St. Petersburg, FL 33701, USA;
| | - Jacob Speybroeck
- Department of Orthopaedic Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA;
| | - John E. Stillson
- Department of Family Medicine, John Peter Smith Hospital, Fort Worth, TX 76104, USA
- Correspondence:
| | - Joseph Dynako
- Department of Orthopaedic Surgery, University of Mississippi Medical Center, Jackson, MS 39216, USA;
| | - Andres Piscoya
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA;
| | - Ethan E. Peck
- Department of Emergency Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (E.E.P.); (M.A.); (E.C.); (D.G.)
| | - Michael Aboukhaled
- Department of Emergency Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (E.E.P.); (M.A.); (E.C.); (D.G.)
| | - Emily Cancel
- Department of Emergency Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (E.E.P.); (M.A.); (E.C.); (D.G.)
| | - Michael McDonald
- Department of Graduate Medical Education, Naval Medical Readiness and Training Command, Portsmouth, VA 23708, USA;
| | - Diego Garcia
- Department of Emergency Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (E.E.P.); (M.A.); (E.C.); (D.G.)
| | - John Lovejoy
- Department of Orthopaedic Surgery, University of Florida Health Jacksonville, Jacksonville, FL 32209, USA;
| | - Stephanie Lubin
- Department of Orthopaedic Surgery, Hôpital Sacré Coeur, Milot 1230, Haiti;
| | - Robert Stanton
- Department of Pediatric Orthopaedics, Nemours Children’s Health-Florida, Orlando, FL 32827, USA;
| | - Matthew E. Kutcher
- Departments of Surgery and Emergency Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA;
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5
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Wei YH, Miao ZX, Guo XJ. Thromboelastography in guiding preventive platelet transfusion in patients with haematologic diseases. Int J Lab Hematol 2022; 44:945-951. [PMID: 35748054 DOI: 10.1111/ijlh.13917] [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: 04/01/2022] [Accepted: 05/31/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE This study analysed the relationships between the main thromboelastography (TEG) parameters, the platelet (PLT) count and clinical bleeding in patients with blood diseases. We explored the threshold of the relevant parameters in the pathological condition of bleeding, aiming to scientifically guide clinical prophylactic PLT transfusion. METHODS In total, 268 patients with clear diagnoses of blood diseases and thrombocytopenia were enrolled and divided into five groups, A, B, C, D and E, corresponding to PLT counts of 0-10 × 109 /L, 11-20 × 109 /L, 21-30 × 109 /L, 31-50 × 109 /L and 51-100 × 109 /L, respectively. TEG and routine blood testing were performed simultaneously, the main TEG parameters and the PLT count were analysed, and the thresholds of the main TEG parameters in each group when the patient had bleeding were obtained. RESULTS The maximum amplitude (MA) in groups A, B and C increased gradually, with a significant difference between each pair of these groups (P < 0.05). In groups A, B, C, D and E, the corresponding MA at the time of bleeding was 43.5 mm, 39.6 mm, 38.0 mm, 35.2 mm and 50.5 mm, respectively, with statistically significant differences (P < 0.05). CONCLUSIONS The MA can be used as a reference indicator for preventive PLT transfusion to a certain extent. When the PLT count is within different ranges, the MA threshold for preventive PLT transfusion also differs. It is recommended that different PLT counts be correlated with different MA thresholds to guide clinical prophylactic PLT transfusion.
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Affiliation(s)
- Yan-Hui Wei
- Department of Haematology, Puyang Oilfield General Hospital Affiliated with Xinxiang Medical University, Puyang, China.,School of Medicine, Southeast University, Nanjing, China
| | - Zhao-Xu Miao
- Department of Haematology, Puyang Oilfield General Hospital Affiliated with Xinxiang Medical University, Puyang, China
| | - Xue-Jun Guo
- Department of Haematology, Puyang Oilfield General Hospital Affiliated with Xinxiang Medical University, Puyang, China
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6
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Brill JB, Brenner M, Duchesne J, Roberts D, Ferrada P, Horer T, Kauvar D, Khan M, Kirkpatrick A, Ordonez C, Perreira B, Priouzram A, Cotton BA. The Role of TEG and ROTEM in Damage Control Resuscitation. Shock 2021; 56:52-61. [PMID: 33769424 PMCID: PMC8601668 DOI: 10.1097/shk.0000000000001686] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 12/05/2019] [Accepted: 10/20/2020] [Indexed: 11/26/2022]
Abstract
ABSTRACT Trauma-induced coagulopathy is associated with very high mortality, and hemorrhage remains the leading preventable cause of death after injury. Directed methods to combat coagulopathy and attain hemostasis are needed. The available literature regarding viscoelastic testing, including thrombelastography (TEG) and rotational thromboelastometry (ROTEM), was reviewed to provide clinically relevant guidance for emergency resuscitation. These tests predict massive transfusion and developing coagulopathy earlier than conventional coagulation testing, within 15 min using rapid testing. They can guide resuscitation after trauma, as well. TEG and ROTEM direct early transfusion of fresh frozen plasma when clinical gestalt has not activated a massive transfusion protocol. Reaction time and clotting time via these tests can also detect clinically significant levels of direct oral anticoagulants. Slowed clot kinetics suggest the need for transfusion of fibrinogen via concentrates or cryoprecipitate. Lowered clot strength can be corrected with platelets and fibrinogen. Finally, viscoelastic tests identify fibrinolysis, a finding associated with significantly increased mortality yet one that no conventional coagulation test can reliably detect. Using these parameters, guided resuscitation begins within minutes of a patient's arrival. A growing body of evidence suggests this approach may improve survival while reducing volumes of blood products transfused.
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Affiliation(s)
- Jason B. Brill
- Department of Surgery, University of Texas Health Science Center, Houston, Texas
| | - Megan Brenner
- Department of Surgery, University of California Riverside, Riverside, California
| | - Juan Duchesne
- Division Chief Acute Care Surgery, Department of Surgery Tulane, New Orleans, Louisiana
| | - Derek Roberts
- Division Chief Acute Care Surgery, Department of Surgery Tulane, New Orleans, Louisiana
| | - Paula Ferrada
- VCU Surgery Trauma, Critical Care and Emergency Surgery, Richmond, Virginia
| | - Tal Horer
- Department of Cardiothoracic and Vascular Surgery, Faculty of Life Science Örebro University Hospital and University, Örebro, Sweden
| | - David Kauvar
- Vascular Surgery Service, San Antonio Military Medical Center, San Antonio, Texas
| | - Mansoor Khan
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, UK
| | - Andrew Kirkpatrick
- Regional Trauma Services Foothills Medical Centre, Calgary, Alberta, Canada
- Departments of Surgery, Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
- Canadian Forces Health Services, Calgary, Alberta, Canada
| | - Carlos Ordonez
- Fundación Valle del Lili, Division of Trauma and Acute Care Surgery, Department of Surgery. Universidad del Valle, Valle, Colombia
| | - Bruno Perreira
- Department of Surgery and Surgical Critical Care, University of Campinas, Campinas, Brazil
| | - Artai Priouzram
- Department of Cardiothoracic and Vascular Surgery, Linköping University Hospital, Linköping, Sweden
| | - Bryan A. Cotton
- Department of Surgery, University of Texas Health Science Center, Houston, Texas
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7
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Topical Issues in Diagnosis of Coagulopathies and Prevention of Thromboembolic Complications of Atrial Fibrillation in Patients with Liver Cirrhosis. Fam Med 2021. [DOI: 10.30841/2307-5112.5-6.2020.225448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Nowadays the comorbid pathology of liver cirrhosis and atrial fibrillation has been widely discussed and reported in the literature in the light of recent findings from the study of the effectiveness and safety of anticoagulants in this category of patients. The review is devoted to summarizing the existing data on the comorbid course of these diseases from the point of view of the impact of bleeding and thrombosis on the quality of life and mortality of patients and the possibility of using new methods of diagnosis and prevention of these complications.
The purpose of the review is to focus the attention of physicians and researches on the relevance and prevalence of comorbid course of liver cirrhosis and atrial fibrillation, their complications, and discuss the benefits and possibilities of applying global methods of hemostasis assessment and anticoagulants in clinical practice.
This article examines the main pathophysiological aspects of «rebalanced hemostasis» theory in liver coagulopathies, its effect on the onset of bleeding and thrombotic events, and considering the clinical benefit of the use of anticoagulants. The disadvantages of traditional coagulation assessment tests compared to the benefits of thromboelastometry (ROTEM) and thromboelastography (TEG), general fulfilling principles and evaluation of their indicators are discussed. Existing research findings on the safety and efficacy of warfarin and direct oral anticoagulants in patients with liver cirrhosis and atrial fibrillation compared with no treatment are highlighted.
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8
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Oberladstätter D, Voelckel W, Schlimp C, Zipperle J, Ziegler B, Grottke O, Schöchl H. A prospective observational study of the rapid detection of clinically-relevant plasma direct oral anticoagulant levels following acute traumatic injury. Anaesthesia 2020; 76:373-380. [PMID: 32946123 DOI: 10.1111/anae.15254] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2020] [Indexed: 12/15/2022]
Abstract
In urgent clinical situations, such as trauma, urgent surgery or before thrombolysis, rapid quantification of direct oral anticoagulant plasma drug levels is warranted. Using the ClotPro® analyser, we assessed two novel viscoelastic tests for detection of clinically-relevant plasma drug levels in trauma patients. The ecarin clotting time was used to assess the plasma concentration of dabigatran and Russell´s viper venom clotting time to determine the plasma concentration of direct factor Xa inhibitors. In parallel, plasma concentrations were analysed using plasma-based chromogenic assays. A total of 203 simultaneous measurements were performed. Strong to very strong linear correlations were detected between ecarin clotting time and plasma concentration of dabigatran (r = 0.9693), and between Russell´s viper venom clotting time and plasma concentrations of apixaban (r = 0.7391), edoxaban (r = 0.9251) and rivaroxaban (r = 0.8792), all p < 0.001. An ecarin clotting time ≥ 189 seconds provided 100% sensitivity and 90% specificity for detecting plasma dabigatran concentrations ≥ 50 ng.ml-1 . Corresponding Russell´s viper venom clotting time cut-off values were ≥ 136 seconds for apixaban (80% sensitivity, 88% specificity), ≥ 168 seconds for edoxaban (100% sensitivity, 100% specificity) and ≥ 177 seconds for rivaroxaban (90% sensitivity, 100% specificity). Detection of drug levels ≥ 100 ng.ml-1 was also investigated: for dabigatran, an ecarin clotting time ≥ 315 seconds yielded 92% sensitivity and 100% specificity; while Russell´s viper venom clotting time cut-offs of 191, 188 and 196 seconds were calculated for apixaban (67% sensitivity, 88% specificity), edoxaban (100% sensitivity, 75% specificity) and rivaroxaban (100% sensitivity, 91% specificity), respectively. We have demonstrated strong positive correlations between plasma drug levels and clotting time values in the specific ClotPro assays. Cut-off values for detecting clinically-relevant drug levels showed high levels of sensitivity and specificity.
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Affiliation(s)
- D Oberladstätter
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University Salzburg, Salzburg, Austria.,Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria
| | - W Voelckel
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University Salzburg, Salzburg, Austria
| | - C Schlimp
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University Salzburg, Salzburg, Austria.,Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria
| | - J Zipperle
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria
| | - B Ziegler
- Department of Anaesthesiology and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - O Grottke
- Department of Anaesthesiology, University Hospital of the RWTH Aachen, Aachen, Germany
| | - H Schöchl
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University Salzburg, Salzburg, Austria.,Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria
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9
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In vitro effects of a kaolin-coated hemostatic dressing on anticoagulated blood. J Trauma Acute Care Surg 2019; 85:485-490. [PMID: 29851903 DOI: 10.1097/ta.0000000000001999] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The use of kaolin-coated dressings has become common and have efficacy in normal patients, but their increased use will inevitably include use on bleeding patients taking anticoagulants. We hypothesize that kaolin coating material (KCM) will improve clotting regardless of anticoagulation medication. METHODS A prospective study was performed on blood from patients who were on a vitamin K antagonist (VKA), unfractionated heparin (UH), an antiplatelet (AP) agent, a Xa inhibitor (Xa), or a direct thrombin inhibitor (DTI). None were on more than one type of anticoagulation medication. Viscoelastic testing was performed with and without KCM. All p values were adjusted for multiple comparisons. RESULTS The addition of KCM significantly decreased the time for initial clot formation (CT) in all groups. The mean CT for controls was decreased from 692 to 190.8 s (p < 0.0001). KCM decreased the initial clot formation time by about 1.5 times in those on DTI (p = 0.043) and 2.5 times in those taking AP medication (p < 0.001). The most profound effect was seen in those on UH (no KCM 1,602 s vs. KCM 440 s; p < 0.001), VKA (no KCM 1,152 s vs. 232 s; p < 0.01), and Xa (no KCM 1,342 s vs. 287 s; p < 0.001). Analysis of other clot formation parameters revealed that KCM significantly improved the clot formation kinetics (CFT) only in patients taking Xa (p = 0.03). KCM improved maximum clot strength in patients on Xa inhibitors (p = 0.05). Patients on UH had a larger effect size with an increase in clot strength from 24.35 mm to 43.35 mm whereas those on Xa had an increase of 38.7 mm to 49.85 mm. CONCLUSION In this in vitro analysis, the addition of KCM to the blood of patients taking any of these anticoagulation medications significantly improved the time to initial clot formation, indicating that kaolin-based hemostatic dressings will be effective in initiating clot formation in patients on anticoagulants. LEVEL OF EVIDENCE Therapeutic, level IV.
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10
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Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ, Komadina R, Maegele M, Nardi G, Riddez L, Samama CM, Vincent JL, Rossaint R. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care 2019; 23:98. [PMID: 30917843 PMCID: PMC6436241 DOI: 10.1186/s13054-019-2347-3] [Citation(s) in RCA: 696] [Impact Index Per Article: 139.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 02/06/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. RESULTS Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group's belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms. CONCLUSIONS A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient.
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Affiliation(s)
- Donat R. Spahn
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - Bertil Bouillon
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Vladimir Cerny
- Department of Anaesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Socialni pece 3316/12A, CZ-40113 Usti nad Labem, Czech Republic
- Centre for Research and Development, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic, Sokolska 581, CZ-50005 Hradec Kralove, Czech Republic
- Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine in Hradec Kralove, Charles University, Simkova 870, CZ-50003 Hradec Kralove, Czech Republic
- Department of Anaesthesia, Pain Management and Perioperative Medicine, QE II Health Sciences Centre, Dalhousie University, Halifax, 10 West Victoria, 1276 South Park St, Halifax, NS B3H 2Y9 Canada
| | - Jacques Duranteau
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, University of Paris XI, Faculté de Médecine Paris-Sud, 78 rue du Général Leclerc, F-94275 Le Kremlin-Bicêtre Cedex, France
| | - Daniela Filipescu
- Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, RO-022328 Bucharest, Romania
| | - Beverley J. Hunt
- King’s College and Departments of Haematology and Pathology, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Radko Komadina
- Department of Traumatology, General and Teaching Hospital Celje, Medical Faculty Ljubljana University, SI-3000 Celje, Slovenia
| | - Marc Maegele
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Giuseppe Nardi
- Department of Anaesthesia and ICU, AUSL della Romagna, Infermi Hospital Rimini, Viale Settembrini, 2, I-47924 Rimini, Italy
| | - Louis Riddez
- Department of Surgery and Trauma, Karolinska University Hospital, S-171 76 Solna, Sweden
| | - Charles-Marc Samama
- Hotel-Dieu University Hospital, 1, place du Parvis de Notre-Dame, F-75181 Paris Cedex 04, France
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070 Brussels, Belgium
| | - Rolf Rossaint
- Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, D-52074 Aachen, Germany
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11
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Wang J, Zhu HL, Shi ZJ, Zhang Y. The Application of Thromboelastography in Understanding and Management of Ecchymosis After Total Knee Arthroplasty. J Arthroplasty 2018; 33:3754-3758. [PMID: 30219266 DOI: 10.1016/j.arth.2018.08.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 08/05/2018] [Accepted: 08/21/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Ecchymosis is a common complication after total knee arthroplasty (TKA). However, only a few studies have been conducted to determine the coagulation status of these patients. Using thromboelastography (TEG), a new technique recording the viscoelastic changes of a whole-blood sample, this study was performed to understand the ecchymosis-related coagulation status and its risk factors. METHODS Seventy-five patients receiving unilateral TKA were recruited in this observational study. Oral rivaroxaban was applied as prophylaxis treatment after surgery. TEG was performed 1 day before surgery and 4 days after surgery. Total blood loss and hidden blood loss were recorded and calculated. Univariate and multivariate analyses were conducted to determine risk factors. RESULTS Twenty-five patients (33.3%) developed ecchymosis within 2-3 days after TKA. Compared with the baseline before TKA, the α-angle (P = .032) and calculated coagulation index (CI; P = .012) were increased in non-ecchymosis group, whereas in the ecchymosis group, there was no significant difference regarding any variable of postoperative TEG evaluation. The ecchymosis group exhibited more hidden blood loss (P = .007) and total blood loss (P = .011). Value change of CI (OR = 0.666, 95% confidence interval = [0.496, 0.895], P = .007) and hidden blood loss (OR = 1.008, 95% confidence interval = [1.002, 1.013], P = .004) were recognized as the independent risk factors for postoperative ecchymosis. CONCLUSION In TEG evaluation, the value change of CI and hidden blood loss are independent risk factors of ecchymosis. In view of the relative hypocoagulation status, it is reasonable to stop anticoagulation therapy in patients with excessive ecchymosis. Personalized anticoagulation therapy may be helpful for managing ecchymosis after TKA.
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Affiliation(s)
- Jian Wang
- Department of Orthopaedic Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Hai-Lun Zhu
- Orthopaedic Center, Shenzhen Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Zhan-Jun Shi
- Department of Orthopaedic Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Yang Zhang
- Department of Orthopaedic Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
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12
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Taune V, Skeppholm M, Ågren A, Gryfelt G, Malmström RE, Wikman A, Van Ryn J, Wallén H. Rapid determination of anticoagulating effects of dabigatran in whole blood with rotational thromboelastometry and a thrombin-based trigger. J Thromb Haemost 2018; 16:2462-2470. [PMID: 30288934 DOI: 10.1111/jth.14308] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Indexed: 01/16/2023]
Abstract
Essentials A rapid test to detect thrombin inhibition by dabigatran would be valuable in acute situations. A thrombin-based trigger was applied in whole blood using rotation thromboelastometry. Effects of dabigatran were assessed in vitro and in samples from patients on dabigatran. The test produced data rapidly and was sensitive to dabigatran concentrations from 20 to 500 ng mL-1 . SUMMARY: Background Rapid determination of the anticoagulant effect of dabigatran is essential in emergency situations. Objective To study a viscoelastic test (rotational thromboelastometry [ROTEM]) for rapid determination of dabigatran effects in whole blood samples. Method ROTEM measurements were performed with comparison of two triggers (thrombin-based versus the commercial tissue factor-based trigger Ex-tem) in samples from 10 healthy donors spiked with dabigatran (20-500 ng mL-1 ) and in samples from 35 patients receiving dabigatran treatment; 10 healthy subjects served as controls. Clotting time (CT) and the difference in CT without versus with addition of the dabigatran antidote idarucizumab (CTdiff ) were measured. Addition of idarucizumab reveals the contribution of dabigatran to ROTEM measurements and its potential reversibility. Results In vitro studies showed that thrombin CT and thrombin CTdiff were more sensitive than Ex-tem CT and Ex-tem CTdiff in detecting dabigatran in whole blood samples. In patient samples, when thrombin CT and thrombin CTdiff were used, it was possible to detect dabigatran with a cut-off of dabigatran at 20 ng mL-1 , whereas, when Ex-tem CT and Ex-tem CTdiff were used, the method was less sensitive. Data from patient samples were obtained within 15 min of blood sampling. Conclusions ROTEM CT with a thrombin-based trigger is more sensitive to dabigatran effects than Ex-tem CT, and detects anticoagulant effects of drug concentrations in the low-very low therapeutic range. Analysis with idarucizumab (CTdiff ) reveals dabigatran-specific effects. As data are rapidly obtained, this method could, with further development and validation of its performance, be suitable for detecting clinically significant dabigatran effects in emergency situations.
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Affiliation(s)
- V Taune
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - M Skeppholm
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - A Ågren
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - G Gryfelt
- Department of Laboratory Medicine, Division of Clinical Immunology and Transfusion Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - R E Malmström
- Department of Medicine Solna, Karolinska Institutet & Clinical Pharmacology, Karolinska University Hospital, Stockholm, Sweden
| | - A Wikman
- Department of Laboratory Medicine, Division of Clinical Immunology and Transfusion Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - J Van Ryn
- Department of Medicine, Boehringer Ingelheim International GmbH, Biberach an der Riss, Germany
| | - H Wallén
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
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13
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Williams DM, Hodge A, Catino J, DiMaggio C, Marshall G, Ayoung-Chee P, Frangos S, Bukur M. Correlation of thromboelastography with conventional coagulation testing in elderly trauma patients on pre-existing blood thinning medications. Am J Surg 2018. [DOI: 10.1016/j.amjsurg.2018.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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14
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Kobayashi LM, Brito A, Barmparas G, Bosarge P, Brown CV, Bukur M, Carrick MM, Catalano RD, Holly-Nicolas J, Inaba K, Kaminski S, Klein AL, Kopelman T, Ley EJ, Martinez EM, Moore FO, Murry J, Nirula R, Paul D, Quick J, Rivera O, Schreiber M, Coimbra R. Laboratory measures of coagulation among trauma patients on NOAs: results of the AAST-MIT. Trauma Surg Acute Care Open 2018; 3:e000231. [PMID: 30402564 PMCID: PMC6203140 DOI: 10.1136/tsaco-2018-000231] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 09/11/2018] [Accepted: 09/15/2018] [Indexed: 12/22/2022] Open
Abstract
Background Warfarin is associated with poor outcomes after trauma, an effect correlated with elevations in the international normalized ratio (INR). In contrast, the novel oral anticoagulants (NOAs) have no validated laboratory measure to quantify coagulopathy. We sought to determine if use of NOAs was associated with elevated activated partial thromboplastin time (aPTT) or INR levels among trauma patients or increased clotting times on thromboelastography (TEG). Methods This was a post-hoc analysis of a prospective observational study across 16 trauma centers. Patients on dabigatran, rivaroxaban, or apixaban were included. Laboratory data were collected at admission and after reversal. Admission labs were compared between medication groups. Traditional measures of coagulopathy were compared with TEG results using Spearman's rank coefficient for correlation. Labs before and after reversal were also analyzed between medication groups. Results 182 patients were enrolled between June 2013 and July 2015: 50 on dabigatran, 123 on rivaroxaban, and 34 apixaban. INR values were mildly elevated among patients on dabigatran (median 1.3, IQR 1.1-1.4) and rivaroxaban (median 1.3, IQR 1.1-1.6) compared with apixaban (median 1.1, IQR 1.0-1.2). Patients on dabigatran had slightly higher than normal aPTT values (median 35, IQR 29.8-46.3), whereas those on rivaroxaban and apixaban did not. Fifty patients had TEG results. The median values for R, alpha, MA and lysis were normal for all groups. Prothrombin time (PT) and aPTT had a high correlation in all groups (dabigatran p=0.0005, rivaroxaban p<0.0001, and apixaban p<0.0001). aPTT correlated with the R value on TEG in patients on dabigatran (p=0.0094) and rivaroxaban (p=0.0028) but not apixaban (p=0.2532). Reversal occurred in 14%, 25%, and 18% of dabigatran, rivaroxaban, and apixaban patients, respectively. Both traditional measures of coagulopathy and TEG remained within normal limits after reversal. Discussion Neither traditional measures of coagulation nor TEG were able to detect coagulopathy in patients on NOAs. Level of evidence Level IV.
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Affiliation(s)
- Leslie M Kobayashi
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California San Diego, San Diego, California, USA
| | - Alexandra Brito
- Department of Surgery, University of California San Diego, San Diego, California, USA
| | - Galinos Barmparas
- Department of Surgery, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Patrick Bosarge
- Division of Acute Care Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Carlos V Brown
- Dell Medical School, University of Texas at Austin, Austin, Texas, USA
| | - Marko Bukur
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Surgical Intensive Care Unit Bellevue Hospital Center, New York, USA
| | - Matthew M Carrick
- University of North Texas Health Science Center, Fort Worth, Texas, USA
| | | | - Jan Holly-Nicolas
- Department of Surgery, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Kenji Inaba
- Division of Trauma & Critical Care, University of Southern California, Los Angeles, California, USA
| | - Stephen Kaminski
- Department of General Surgery and Surgical Critical Care, Santa Barbara Cottage Hospital, Santa Barbara, California, USA
| | - Amanda L Klein
- Department of Surgery, Dell Medical School, University of Texas at Austin, Austin, Texas, USA
| | - Tammy Kopelman
- Division of Burns, Trauma, and Surgical Critical Care, University of Arizona Medical School-Phoenix Campus, Phoenix, Arizona, USA
| | - Eric J Ley
- Department of General Surgery, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Ericca M Martinez
- Chandler Regional Medical Center, Grand Canyon University, Phoenix, Arizona, USA
| | - Forrest O Moore
- Department of General Surgery, Trauma and Surgical Critical Care, Chandler Regional Medical Center, University of Arizona College of Medicine, Chandler, Arizona, USA
| | - Jason Murry
- Department of General Surgery Trauma Services, East Texas Medical Center, Tyler, Texas, USA
| | - Raminder Nirula
- Department of General Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Douglas Paul
- Division of Trauma, Critical Care and Acute Care Surgery, Kettering Medical Center, Kettering, Ohio, USA
| | - Jacob Quick
- Division of Acute Care Surgery, University of Missouri, Columbia, Missouri, USA
| | - Omar Rivera
- Division of Trauma and Critical Care, University of Southern California, Los Angeles, California, USA
| | - Martin Schreiber
- Division of Trauma, Critical Care & Acute Care Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Raul Coimbra
- Department of General Surgery, Riverside University Health System Medical Center, Loma Linda University School of Medicine, Moreno Valley, California, USA
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Rivaroxaban and dabigatran did not affect clotting profiles in plasma reconstituted with varying levels of autologous platelets to the same degree as heparin when evaluated using thromboelastography. Blood Coagul Fibrinolysis 2018; 29:521-527. [DOI: 10.1097/mbc.0000000000000751] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Korpallová B, Samoš M, Bolek T, Škorňová I, Kovář F, Kubisz P, Staško J, Mokáň M. Role of Thromboelastography and Rotational Thromboelastometry in the Management of Cardiovascular Diseases. Clin Appl Thromb Hemost 2018; 24:1199-1207. [PMID: 30041546 PMCID: PMC6714776 DOI: 10.1177/1076029618790092] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
The monitoring of coagulation by viscoelastometric methods—thromboelastography and rotational thromboelastometry—may detect the contributions of cellular and plasma components of hemostasis. These methods might overcome some of the serious limitations of conventional laboratory tests. Viscoelastic testing can be repeatedly performed during and after surgery and thus provides a dynamic picture of the coagulation process during these periods. Several experiences with the use of these methods in cardiovascular surgery have been reported, but there is perspective for more frequent use of these assays in the assessment of platelet response to antiplatelet therapy and in the assessment of coagulation in patients on long-term dabigatran therapy. This article reviews the current role and future perspectives of thromboelastography and thromboelastometry in the management of cardiovascular diseases.
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Affiliation(s)
- Barbora Korpallová
- 1 Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Matej Samoš
- 1 Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Tomáš Bolek
- 1 Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Ingrid Škorňová
- 2 Department of Hematology and Blood Transfusion, National Centre of Hemostasis and Thrombosis, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - František Kovář
- 1 Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Peter Kubisz
- 2 Department of Hematology and Blood Transfusion, National Centre of Hemostasis and Thrombosis, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Ján Staško
- 2 Department of Hematology and Blood Transfusion, National Centre of Hemostasis and Thrombosis, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Marián Mokáň
- 1 Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
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17
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Comuth WJ, Henriksen LØ, van de Kerkhof D, Husted SE, Kristensen SD, de Maat MPM, Münster AMB. Comprehensive characteristics of the anticoagulant activity of dabigatran in relation to its plasma concentration. Thromb Res 2018; 164:32-39. [PMID: 29475179 DOI: 10.1016/j.thromres.2018.02.141] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 02/08/2018] [Accepted: 02/16/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND Issues with laboratory measurement of dabigatran include: 1. Do coagulation assays reflect dabigatran plasma concentrations? 2. Do samples from patients treated with dabigatran have the same coagulability as dabigatran-spiked samples from healthy volunteers? 3. What is the long-term stability of dabigatran after storage at -80 °C? This study aims to evaluate these questions. MATERIALS AND METHODS Ecarin chromogenic assay (ECA), a laboratory-developed diluted thrombin time (LD-dTT), prothrombin time (PT) and activated partial thromboplastin time (APTT) and ROTEM® were used to measure dabigatran anticoagulant activity and liquid chromatography-tandem mass spectrometry (LC-MS/MS) to measure dabigatran plasma concentrations. ROTEM® (EXTEM, INTEM, FIBTEM) was performed in whole blood and the other assays in platelet poor plasma (PPP), both in samples spiked with dabigatran (0, 25, 50, 100, 250, 500 and 1000 ng/mL) from healthy donors and in ex vivo samples from patients treated with dabigatran etexilate. Citrated PPP samples were frozen and stored at -80 °C, 1, 3, 6 and 12 months until analysis. RESULTS EXTEM and FIBTEM clotting time (CT), ECA and LD-dTT correlate well with dabigatran plasma concentrations. With the exception of few ROTEM® parameters, there were no differences between spiked and patient samples. Samples were stable for at least 12 months at -80 °C. CONCLUSIONS EXTEM and FIBTEM CT, ECA and LD-dTT are suitable for measuring the effect of dabigatran in treated patients. In general, results from spiked plasma samples are similar to those of patient samples. Storage of dabigatran plasma samples for up to 12 months does not influence measured levels.
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Affiliation(s)
- Willemijn J Comuth
- Department of Clinical Biochemistry, Hospital Unit West, Herning, Holstebro, Denmark; Department of Cardiology, Hospital Unit West, Herning, Denmark; Faculty of Health, Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - Linda Ø Henriksen
- Department of Clinical Biochemistry, Hospital Unit West, Herning, Holstebro, Denmark
| | - Daan van de Kerkhof
- Department of Clinical Biochemistry, Catharina Hospital, Eindhoven, The Netherlands
| | - Steen E Husted
- Department of Cardiology, Hospital Unit West, Herning, Denmark; Faculty of Health, Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Steen D Kristensen
- Faculty of Health, Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Moniek P M de Maat
- Department of Haematology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Anna-Marie B Münster
- Department of Clinical Biochemistry, Hospital of South West Denmark, Esbjerg, Denmark; Unit for Thrombosis Research, Esbjerg, Denmark
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18
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Solbeck S, Jensen AS, Maschmann C, Stensballe J, Ostrowski SR, Johansson PI. The anticoagulant effect of therapeutic levels of dabigatran in atrial fibrillation evaluated by thrombelastography (TEG ®), Hemoclot Thrombin Inhibitor (HTI) assay and Ecarin Clotting Time (ECT). Scandinavian Journal of Clinical and Laboratory Investigation 2018; 78:25-30. [PMID: 29304563 DOI: 10.1080/00365513.2017.1408138] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Monitoring the effect of dabigatran (Pradaxa®) is challenging. The aim of this study was to evaluate if thrombelastography reaction time (TEG® R) could detect the anticoagulant effect of dabigatran showing a correlation between TEG® R, Hemoclot Thrombin Inhibitor (HTI) assay and Ecarin Clotting Time (ECT) in patients with non-valvular atrial fibrillation (NVAF). Blood samples from 35 AF patients receiving either 110 mg (n 19) or 150 mg (n 16) dabigatran twice daily were analyzed with TEG®, HTI and ECT 2-3 h after dabigatran intake. All patients had prolonged TEG® R. The patients receiving dabigatran 110 mg ×2 had a TEG® R mean 14.2 min (range 9.1-25), a mean dabigatran concentration measured by HTI of 268.5 ng/mL (range 54-837 ng/mL) and by ECT of 355.7 ng/mL (range 40-1020 ng/mL). The corresponding numbers for patients receiving dabigatran 150 mg ×2 were TEG® R mean of 12.5 min (range 9.2-23.2 min), mean dabigatran concentration of 179.2 ng/mL by HTI (range 26-687 ng/mL) and by ECT 225.1 ng/mL (range 42-1020 ng/mL). The two dosage groups had comparable anticoagulation demonstrated by equally prolonged TEG® R (p = .909), HTI (p = .707) and ECT (p = .567). No difference in creatinine levels in the two dosage groups was observed (p = .204) though patients with dabigatran concentration >400 ng/mL had significantly higher creatinine levels (p = .001). Large individual variation of the anticoagulant response was observed. Some patients had TEG® R values up to three times upper normal limit with immediate risk of bleeding. Our data indicate that TEG® R reflected dabigatran levels in NVAF patients and that TEG® R correlated to HTI and ECT.
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Affiliation(s)
- Sacha Solbeck
- a Section for Transfusion Medicine, Capital Region Blood Bank , Rigshospitalet, Copenhagen University Hospital , Copenhagen , Denmark
| | | | - Christian Maschmann
- c Emergency Department & Department of Anesthesia and Intensive Care , Copenhagen University Hospital Bispebjerg , Copenhagen , Denmark
| | - Jakob Stensballe
- a Section for Transfusion Medicine, Capital Region Blood Bank , Rigshospitalet, Copenhagen University Hospital , Copenhagen , Denmark.,d Department of Anaesthesiology, Centre of Head and Orthopaedics , Copenhagen University Hospital, Rigshospitalet , Copenhagen , Denmark
| | - Sisse Rye Ostrowski
- a Section for Transfusion Medicine, Capital Region Blood Bank , Rigshospitalet, Copenhagen University Hospital , Copenhagen , Denmark
| | - Pär I Johansson
- a Section for Transfusion Medicine, Capital Region Blood Bank , Rigshospitalet, Copenhagen University Hospital , Copenhagen , Denmark.,e Department of Surgery , University of Texas Health Medical School , Houston , TX , USA
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Ten Cate H, Henskens YM, Lancé MD. Practical guidance on the use of laboratory testing in the management of bleeding in patients receiving direct oral anticoagulants. Vasc Health Risk Manag 2017; 13:457-467. [PMID: 29263674 PMCID: PMC5732550 DOI: 10.2147/vhrm.s126265] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Direct oral anticoagulants (DOACs) have demonstrated a favorable benefit–risk profile in several thromboembolic disorders and are increasingly used in routine clinical practice. A number of real-world studies on DOACs are ongoing, and data published so far have shown broadly similar outcomes to those demonstrated in the respective phase III trials. Despite their beneficial attributes, bleeding risk (as with any other anticoagulants) is often a concern for physicians when prescribing DOACs, particularly in elderly patients, those with significant comorbidities, and other high-risk patient populations. Although the absence of routine coagulation monitoring is an advantage of the DOACs, measuring their anticoagulant effect and/or plasma drug levels may be helpful in certain clinical scenarios to help patient management and improve outcomes. In this paper, practical guidance and recommendations are provided for clinical situations in which the test results may aid clinical decision-making, including patients with life-threatening bleeding events, patients without bleeding but with test results indicating a risk of bleeding, for those patients with a suspected thromboembolism while receiving a DOAC, or prior to patients undergoing elective or urgent surgical procedures. Finally, appropriate monitoring of the DOACs could be of substantial benefit to patients, and there is a high potential for development in this area in the future.
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Affiliation(s)
- Hugo Ten Cate
- Department of Internal Medicine, Cardiovascular Research Institute
| | | | - Marcus D Lancé
- Department of Anaesthesiology, Maastricht University Medical Centre, Maastricht, the Netherlands
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Eikelboom JW, Kozek-Langenecker S, Exadaktylos A, Batorova A, Boda Z, Christory F, Gornik I, Kėkštas G, Kher A, Komadina R, Koval O, Mitic G, Novikova T, Pazvanska E, Ratobilska S, Sütt J, Winder A, Zateyshchikov D. Emergency care of patients receiving non-vitamin K antagonist oral anticoagulants. Br J Anaesth 2017; 120:645-656. [PMID: 29576106 DOI: 10.1016/j.bja.2017.11.082] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 09/06/2017] [Accepted: 09/15/2017] [Indexed: 01/19/2023] Open
Abstract
Non-vitamin K antagonist oral anticoagulants (NOACs), which inhibit thrombin (dabigatran) and factor Xa (rivaroxaban, apixaban, edoxaban) have been introduced in several clinical indications. Although NOACs have a favourable benefit-risk profile and can be used without routine laboratory monitoring, they are associated-as any anticoagulant-with a risk of bleeding. In addition, treatment may need to be interrupted in patients who need surgery or other procedures. The objective of this article, developed by a multidisciplinary panel of experts in thrombosis and haemostasis, is to provide an update on the management of NOAC-treated patients who experience a bleeding episode or require an urgent procedure. Recent advances in the development of targeted reversal agents are expected to help streamline the management of NOAC-treated patients in whom rapid reversal of anticoagulation is required.
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Affiliation(s)
- J W Eikelboom
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada.
| | - S Kozek-Langenecker
- Department of Anaesthesia and Intensive Care, Evangelical Hospital Vienna, Vienna, Austria
| | - A Exadaktylos
- Department of Emergency Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - A Batorova
- Department of Haematology and Transfusion Medicine, Faculty of Medicine of Comenius University, and University Hospital, Bratislava, Slovakia
| | - Z Boda
- Department of Internal Medicine, Thrombosis and Haemostasis Centre, University of Debrecen, Debrecen, Hungary
| | - F Christory
- Medical Education Global Solutions, Paris, France
| | - I Gornik
- Intensive Care Unit, Department of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia; University of Zagreb School of Medicine, Zagreb, Croatia
| | - G Kėkštas
- Department of Anaesthesiology and Intensive Care, Vilnius University Hospital Santariškių Klinikos, Vilnius, Lithuania
| | - A Kher
- Laboratory of Biological Hematology, Hôtel-Dieu University Hospital, Paris, France
| | - R Komadina
- Department of Traumatology, General and Teaching Hospital Celje, Celje, Slovenia
| | - O Koval
- Department of Hospital Therapy No. 2, Dnipropetrovsk State Medical Academy, Dnipropetrovsk, Ukraine
| | - G Mitic
- Thrombosis and Haemostasis Unit, Centre of Laboratory Medicine, Clinical Centre of Vojvodina, and Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - T Novikova
- Department of Cardiology, Northwestern Medical University I. I. Mechnikov, and Vascular Centre, Pokrovskaya City Hospital, Saint Petersburg, Russian Federation
| | - E Pazvanska
- Department Anaesthesia and Intensive Care, 4th City Hospital, Sofia, Bulgaria
| | - S Ratobilska
- Intensive Care Unit, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - J Sütt
- Anaesthesiology and Intensive Care Clinic, Tartu University Hospital, Tartu, Estonia
| | - A Winder
- Department of Hematology, Thrombosis and Hemostasis Unit, Wolfson Medical Center, Holon, Israel
| | - D Zateyshchikov
- Primary Vascular Department, City Clinical Hospital No. 51, Moscow, Russia
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21
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Comuth WJ, Haase AM, Henriksen LØ, Malczynski J, van de Kerkhof D, Münster AMB. Cholestatic liver injury as a side-effect of dabigatran and the use of coagulation tests in dabigatran intoxication and after reversal by idarucizumab in bleeding and sepsis. Scandinavian Journal of Clinical and Laboratory Investigation 2017; 78:1-5. [PMID: 29148292 DOI: 10.1080/00365513.2017.1402127] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Idarucizumab, an antidote specific for dabigatran, became available recently. Dabigatran is not associated with increased risk of hepatotoxicity in comparison with warfarin, but it is seen as a rare side-effect. Cases of cholestatic liver injury due to dabigatran have not been reported previously. We present a case of severe gastro-intestinal bleeding with underlying dabigatran intoxication in a patient with renal failure and the effect of reversal of dabigatran using idaruzicumab on coagulation assays. International normalized ratio (INR) and activated partial thromboplastin time (APTT) results were elevated in a setting of sepsis, possibly due to liver failure. INR and APTT can be elevated if sepsis is complicated by disseminated intravascular coagulation (DIC) or liver failure, making it challenging to determine dabigatrans contribution to their prolongation. A rebound effect after administration of idarucizumab and slow elimination of dabigatran due to reduced kidney function could be detected using the Hemoclot® diluted thrombin time (dTT) in this situation, in contrast to with non-dilutional assays. Before admission, cholestatic liver injury started shortly after initiation of dabigatran etexilate therapy. As no other cause was found, this liver injury was likely to be drug-induced. Bleeding cessated promptly after administration of idarucizumab in dabigatran intoxication. In conclusion, the anticoagulant effect of dabigatran can be measured by Hemoclot® dTT in sepsis and cholestatic liver injury was seen as a possible rare side-effect of dabigatran treatment.
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Affiliation(s)
- Willemijn J Comuth
- a Department of Clinical Biochemistry , Hospital Unit West, Herning and Holstebro , Denmark.,b Department of Cardiology , Hospital Unit West , Herning , Denmark.,c Faculty of Health , Institute of Clinical Medicine, Aarhus University , Aarhus , Denmark
| | - Anne-Mette Haase
- d Department of Medicine , Hospital Unit West , Herning , Denmark
| | - Linda Ø Henriksen
- a Department of Clinical Biochemistry , Hospital Unit West, Herning and Holstebro , Denmark
| | - Jerzy Malczynski
- b Department of Cardiology , Hospital Unit West , Herning , Denmark
| | - Daan van de Kerkhof
- e Department of Clinical Biochemistry , Catharina Hospital , Eindhoven , the Netherlands
| | - Anna-Marie B Münster
- f Unit for Thrombosis Research , University of Southern Denmark , Esbjerg , Denmark.,g Department of Clinical Biochemistry , Hospital of South West Denmark , Esbjerg , Denmark
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22
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Kvint S, Schuster J, Kumar MA. Neurosurgical applications of viscoelastic hemostatic assays. Neurosurg Focus 2017; 43:E9. [DOI: 10.3171/2017.8.focus17447] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Patients taking antithrombotic agents are very common in neurosurgical practice. The perioperative management of these patients can be extremely challenging especially as newer agents, with poorly defined laboratory monitoring and reversal strategies, become more prevalent. This is especially true with emergent cases in which rapid reversal of anticoagulation is required and the patient’s exact medical history is not available. With an aging patient population and the associated increase in diseases such as atrial fibrillation, it is expected that the use of these agents will continue to rise in coming years. Furthermore, thromboembolic complications such as deep venous thrombosis, pulmonary embolism, and myocardial infarction are common complications of major surgery. These trends, in conjunction with a growing understanding of the hemostatic process and its contribution to the pathophysiology of disease, stress the importance of the complete evaluation of a patient’s hemostatic profile in guiding management decisions. Viscoelastic hemostatic assays (VHAs), such as thromboelastography and rotational thromboelastometry, are global assessments of coagulation that account for the cellular and plasma components of coagulation. This FDA-approved technology has been available for decades and has been widely used in cardiac surgery and liver transplantation. Although VHAs were cumbersome in the past, advances in software and design have made them more accurate, reliable, and accessible to the neurosurgeon. VHAs have demonstrated utility in guiding intraoperative blood product transfusion, identifying coagulopathy in trauma, and managing postoperative thromboprophylaxis. The first half of this review aims to evaluate and assess VHAs, while the latter half seeks to appraise the evidence supporting their use in neurosurgical populations.
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Affiliation(s)
| | | | - Monisha A. Kumar
- Departments of 1Neurosurgery and
- 2Neurology, University of Pennsylvania, Philadelphia, Pennsylvania
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23
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Taune V, Wallén H, Ågren A, Gryfelt G, Sjövik C, Wintler AM, Malmström RE, Wikman A, Skeppholm M. Whole blood coagulation assays ROTEM and T-TAS to monitor dabigatran treatment. Thromb Res 2017; 153:76-82. [DOI: 10.1016/j.thromres.2017.03.018] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 02/22/2017] [Accepted: 03/15/2017] [Indexed: 01/19/2023]
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24
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Körber MK, Langer E, Köhr M, Wernecke KD, Korte W, von Heymann C. In vitro and ex vivo Measurement of Prophylactic Dabigatran Concentrations with a New Ecarin-Based Thromboelastometry Test. Transfus Med Hemother 2017; 44:100-105. [PMID: 28503126 DOI: 10.1159/000470622] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 03/16/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND An increasing number of oral anticoagulants has been approved, including dabigatran etexilate (DE). DE is a direct thrombin inhibitor that requires no routine monitoring, but, if necessary (e.g. urgent surgery etc.), the diluted thrombin time measured with Hemoclot® has shown reliable results. So far, no point-of-care (PoC) assay is available to measure DE effects. The EcaTEM assay uses ecarin to initiate the coagulation cascade at the step of thrombin generation and measures the clotting time (CT) by thromboelastometry. METHODS This study investigated the correlation of the EcaTEM with standard laboratory assays in dabigatran-treated patients. Ten patients undergoing total hip or knee arthroplasty were included in the study. DE for thromboprophylaxis was started 4 h after surgery. Blood samples were taken before surgery as well as 2, 6 and 12 h after ingestion on the 3rd postoperative day. Dabigatran concentration (Hemoclot), activated partial thromboplastin time, thrombin time and CT EcaTEM were measured. RESULTS Only CT EcaTEM and Hemoclot showed a correlation > 0.75 for all measurements. CONCLUSION CT EcaTEM appears a valid PoC method parameter to detect thrombin inhibition and thus the presence of dabigatran beside diluted thrombin time at different concentration levels. This may represent an opportunity to identify the presence of dabigatran, e.g., in emergency situations.
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Affiliation(s)
- Mareike Kristina Körber
- Department of Anesthesiology and Intensive Care Medicine, Charité -Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Elisabeth Langer
- Labor Berlin - Charite Vivantes GmbH Berlin, Berlin, Germany.,Institute for Laboratory Medicine, Clinical Chemistry and Pathobiochemistry, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Martin Köhr
- Department of Anesthesiology and Intensive Care Medicine, Charité -Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | | | - Wolfgang Korte
- Center for Laboratory Medicine; and Hemostasis and Hemophilia Center St. Gallen, Switzerland
| | - Christian von Heymann
- Department of Anesthesiology and Intensive Care Medicine, Charité -Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany.,Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Netzwerk für Gesundheit GmbH, Klinikum im Friedrichshain, Berlin, Germany
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25
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Ho KM, Pavey W. Applying the Cell-Based Coagulation Model in the Management of Critical Bleeding. Anaesth Intensive Care 2017; 45:166-176. [DOI: 10.1177/0310057x1704500206] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
The cell-based coagulation model was proposed 15 years ago, yet has not been applied commonly in the management of critical bleeding. Nevertheless, this alternative model may better explain the physiological basis of current coagulation management during critical bleeding. In this article we describe the limitations of the traditional coagulation protein cascade and standard coagulation tests, and explain the potential advantages of applying the cell-based model in current coagulation management strategies. The cell-based coagulation model builds on the traditional coagulation model and explains many recent clinical observations and research findings related to critical bleeding unexplained by the traditional model, including the encouraging results of using empirical 1:1:1 fresh frozen plasma:platelets:red blood cells transfusion strategy, and the use of viscoelastic and platelet function tests in patients with critical bleeding. From a practical perspective, applying the cell-based coagulation model also explains why new direct oral anticoagulants are effective systemic anticoagulants even without affecting activated partial thromboplastin time or the International Normalized Ratio in a dose-related fashion. The cell-based coagulation model represents the most cohesive scientific framework on which we can understand and manage coagulation during critical bleeding.
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Affiliation(s)
- K. M. Ho
- Intensive Care Specialist, Department of Intensive Care, Royal Perth Hospital, Clinical Associate Professor, School of Population Health, University of Western Australia, Adjunct Associate Professor, School of Veterinary & Life Sciences, Murdoch University, Perth, Western Australia
| | - W. Pavey
- Consultant Cardiac Anaesthetist, Department of Anaesthesia, Fiona Stanley Hospital and Adjunct Lecturer, School of Veterinary & Life Sciences, Murdoch University, Perth, Western Australia
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26
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Nonvitamin K antagonist oral anticoagulant activity: challenges in measurement and reversal. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:273. [PMID: 27659071 PMCID: PMC5034528 DOI: 10.1186/s13054-016-1422-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background Four nonvitamin K antagonist oral anticoagulants (NOACs) are approved for the prevention of stroke in patients with nonvalvular atrial fibrillation and for the treatment of venous thromboembolism. These include the direct thrombin inhibitor dabigatran and the direct factor Xa inhibitors rivaroxaban, apixaban, and edoxaban. Bleeding is a complication for all anticoagulants and concerns regarding bleeding risk and the suitability of effective reversal strategies may be a barrier to their prescription. Despite the reduced risk of bleeding compared with vitamin K antagonists, questions persist regarding the management of bleeding related to NOAC use. Main text To date, although a number of assays are responsive to NOACs, no single routine laboratory test has been identified to accurately measure the clinical anticoagulation state of patients on NOACs or established as a reliable predictor of bleeding risk. In addition, the establishment of a reliable human bleeding model to test novel inhibitors of the coagulation cascade has proved challenging. Although routine monitoring of anticoagulant levels is not necessary in patients taking NOACs, anticoagulant reversal and a means of measuring reversal may be required for patients who present with bleeding or require urgent surgery. Prothrombin complex concentrates are pooled plasma products containing varying amounts of inactive vitamin K-dependent clotting factors in addition to vitamin K-dependent proteins and can replenish factors in the intrinsic and extrinsic coagulation cascade, reversing an anticoagulant effect. Only one agent, idarucizumab, has been approved for rapid reversal of dabigatran-induced anticoagulation and one more agent, andexanet alfa, has been submitted for approval to reverse the anticoagulatory effects of direct and indirect factor Xa inhibitors. Conclusions This review discusses the laboratory tests available for assessing anticoagulation, human models of bleeding, and the use of current strategies—including prothrombin complex concentrates for reversal of anticoagulation by NOACs—to manage bleeding in patients.
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