Use of thrombin inhibitors ex vivo allows critical care clinical chemistry and hematology testing on common specimens

Simulation of repetitive diagnostic blood loss and onset of iatrogenic anemia in critical care patients with a mathematical model

Anemia is prevalent among critical care patients and is attributed to pathologic and iatrogenic processes and bleeding. The extent that diagnostic blood loss contributes to anemia among adult critical care patients is controversial and multi-factorial. The aim of this study is to describe an erythrokinetic model that integrates rates of phlebotomy, erythropoiesis and red cell senescence with patient characteristics to predict the onset of iatrogenic anemia in an objective manner. Using sex-specific parameters, the model predicts that adults with (average body weight and average blood volume), initial hemoglobin concentration at mid-reference interval, active erythropoiesis and losing 53 mL of blood per day by phlebotomy would require 40-70 days to reach 70 g/L of hemoglobin. To mimic critical care patients with low initial hemoglobin and suppressed erythropoiesis, the influence of daily blood loss and total blood volume was predicted. Simultaneous lack of erythropoiesis, initial hemoglobin concentrations at the lower limit of the reference interval (110 g/L), low body weight and increased phlebotomy accelerated onset of ~70 g/L hemoglobin transfusion threshold to 9-14 days. This computer simulation depicts the extent that adult critical care patients with anemia risk factors could benefit from conservative test ordering practices and subsequent reduced diagnostic phlebotomy.

The role of ethylenediamine tetraacetic acid (EDTA) as in vitro anticoagulant for diagnostic purposes

Anticoagulants are used to prevent clot formation both in vitro and in vivo. In the specific field of in vitro diagnostics, anticoagulants are commonly added to collection tubes either to maintain blood in the fluid state for hematological testing or to obtain suitable plasma for coagulation and clinical chemistry analyses. Unfortunately, no universal anticoagulant that could be used for evaluation of several laboratory parameters in a sample from a single test tube is available so far. Ethylenediamine tetraacetic acid (EDTA) is a polyprotic acid containing four carboxylic acid groups and two amine groups with lone-pair electrons that chelate calcium and several other metal ions. Calcium is necessary for a wide range of enzyme reactions of the coagulation cascade and its removal irreversibly prevents blood clotting within the collection tube. Historically, EDTA has been recommended as the anticoagulant of choice for hematological testing because it allows the best preservation of cellular components and morphology of blood cells. The remarkable expansion in laboratory test volume and complexity over recent decades has amplified the potential spectrum of applications for this anticoagulant, which can be used to stabilize blood for a variety of traditional and innovative tests. Specific data on the behavior of EDTA as an anticoagulant in hematology, including possible pitfalls, are presented. The use of EDTA for measuring cytokines, protein and peptides, and cardiac markers is described, with an outline of the protection of labile molecules provided by this anticoagulant. The use of EDTA in proteomics and in general clinical chemistry is also described in comparison with other anticoagulants and with serum samples. Finally, the possible uses of alternative anticoagulants instead of EDTA and the potential use of a universal anticoagulant are illustrated.

Pharmacology of argatroban

Argatroban, a synthetic peptidomimetic antithrombin agent, is the first clinical anticoagulant solely to target thrombin. For some time, this drug has been used in Japan for the management of thromboembolic disorders. Recently, it has been approved in Japan for use in thrombotic and ischaemic stroke. Despite a large number of preclinical studies on the pharmacology of this agent, clinical trials in Europe and North America were only initiated in 1996. Argatroban produces anticoagulant effects comparable to therapeutic heparinisation at concentrations of approximately 1 microg/ml. At concentrations of 5-10 microg/ml, this agent produces adequate anticoagulation for inteventional cardiovascular procedures and prolongs the activated clotting time (ACT) to 400-600 s. The predictable anticoagulant effect of this agent is relatively short lasting, and may not warrant pharmacologic neutralisation in the majority of patients. However, patients with hepatic dysfunction may need some means of neutralisation. Unlike heparin, this drug produces its anticoagulant effects by direct inhibition of thrombin and thrombin-mediated processes. This agent is not influenced by endogenous factors such as platelet factor 4 and other proteins which bind heparin. Argatroban's use does not lead to the formation of antiplatelet antibodies. Thus, this drug is useful in the management of heparin induced thrombocytopenic (HIT) patients. Although argatroban was initially developed for the management of deep vein thrombosis (DVT), based on its pharmacologic properties, it can be developed for safer anticoagulation in such indications as acute coronary syndromes, as an adjunct to thrombolytics, thrombotic and ischaemic stroke and inflammatory diseases resulting in thrombotic complications.

The use of hirudin as universal anticoagulant in haematology, clinical chemistry and blood grouping

Undesirable interactions between anticoagulants and diagnostic test kit procedures so far have prevented the development of a single uniform blood sampling tube. Contrary to K2-EDTA, heparin and other anticoagulants, hirudin only minimally alters blood cells and dissolved blood constituents, thus qualifying as a universal anticoagulant for diagnostic purposes. Automated complete blood counts, automated analyses of clinical chemistry analytes and immunohaematology were performed from hirudinised and routinely processed blood obtained from healthy volunteers (n=35) and hospitalised patients (n=45). Hirudin (400 ATU/ml blood) sufficiently anticoagulated blood for diagnostic purposes. The measurements of automated complete blood counts obtained from K2-EDTA-anticoagulated and hirudinised blood correlated significantly as did the measurements of 24 clinical chemistry analytes from hirudinised plasma and serum. Regression analysis revealed that the results of complete blood counts and clinical chemistry tests were predictable from the respective measurements from hirudinised blood (p=0.001). Immunohaematological tests and cross-matching from hirudinised and native blood of the same donors gave identical results. Single clotting factors, but not global coagulation analytes, could be measured from hirudinised blood. Therefore, a universal hirudin-containing blood sampling tube could be designed for automated analysis of haematological, serological and clinical chemistry analytes.

Evaluation of argatroban and DUP 714 as anticoagulants for blood gas, electrolyte and ionized calcium analyses

The objective of this study was to determine if the thrombin inhibitors Argatroban and DUP 714 could anticoagulate whole blood without influencing the analyses of blood gases, electrolytes, ionized calcium or CO-oximetry. The anticoagulant potency of DUP 714 (0.5-68 micromol/l) and Argatroban (1.5-390 micromol/l) was evaluated using the activated partial thromboplastin time (APTT), prothrombin time (PT) and whole blood clot time (WBCT). APTT and the PT were measured using a Behring Fibrintimer. APTT was found to be more sensitive to prolongation by both of the thrombin inhibitors than were the PT or WBCT assays. DUP 714 was found to a more potent anticoagulant than Argatroban. DUP 714 anticoagulated specimens (>2.2 micromol/l) did not clot for at least 2 days, whereas Argatroban preserved specimens (390 micromol/l) clotted within 5.5 h of collection. No statistically significant changes in the measurement of pH, PCO2, PO2, Na, K, ionized calcium, oxyhaemoglobin, deoxyhaemoglobin, methaemoglobin or carboxyhaemoglobin (measured using a Corning 288 Blood Gas/Electrolyte Analyzer and a Coming 270 CO-oximeter) were detected in DUP 714 (34 micromol/l) or Argatroban (390 micromol/l) anticoagulated whole blood specimens. In conclusion, DUP 714 and Argatroban are suitable anticoagulants for preserving blood prior to blood gas and electrolyte analyses.

Evaluation of the thrombin inhibitor D-phenylalanyl-L-prolyl-L-arginine chloromethylketone (PPACK) with the factor Xa inhibitor 1,5-dansyl-L-glutamyl-L-glycyl-L-arginine chloromethylketone (GGACK) as anticoagulants for critical care clinical chemistry specimens

The objective of this study was to determine whether a thrombin inhibitor (PPACK) and a factor Xa inhibitor (GGACK) either alone or in combination can anticoagulate whole blood without biasing the analysis of several critical care analytes. Whole blood clot time was used to assess anticoagulant efficacy. The analytical biases mediated by the anticoagulants on glucose, urea, creatinine, electrolytes, amylase, lactate dehydrogenase, creatine kinase, ionized calcium and pH were assessed. The protease inhibitor mixture (100 micrommol/l PPACK + 500 micromol/l GGACK) was more a potent anticoagulant than the individual agents at the same concentrations. Both PPACK and GGACK, alone and in combination, reduced the activity of creatine kinase and amylase by 3-10% while the remaining critical care analytes were less affected. In conclusion, PPACK and GGACK mixtures can effectively anticoagulate whole blood, but the mixtures exert pre-analytical influences that limit the analytical versatility of these novel plasma-matrices.