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Davidson S. Interpretation of coagulation laboratory tests for patients on ECMO. Int J Lab Hematol 2024; 46:606-612. [PMID: 38747332 DOI: 10.1111/ijlh.14308] [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: 01/19/2024] [Accepted: 05/01/2024] [Indexed: 07/04/2024]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a type of circulatory life support for patients with severe lung failure. The use of ECMO has increased worldwide since the pandemic of H1N1 in 2009 and more recently SARS-CoV-2 in 2020 both of which caused severe respiratory failure. ECMO patients experience both increased risk of bleeding and thrombosis. This is due to the pathological insult that damages the lungs, the ECMO circuit, coagulopathy, inflammation and anticoagulation. ECMO presents unique demands on the coagulation laboratory both in tests required to manage the patients and result interpretation. This is a personal opinion of 20 years ECMO experience as a clinical scientist and a short current review of the literature. It will focus on the laboratory coagulation tests used to manage ECMO patients, including different anticoagulants used, testing frequency and interpretation of the results.
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Affiliation(s)
- Simon Davidson
- Division of Medicine, Faculty of Medical Sciences, University College London, London, UK
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2
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Lanoiselée J, Mourer J, Jungling M, Molliex S, Thellier L, Tabareau J, Jeanpierre E, Robin E, Susen S, Tavernier B, Vincentelli A, Ollier E, Moussa MD. Heparin Dosing Regimen Optimization in Veno-Arterial Extracorporeal Membrane Oxygenation: A Pharmacokinetic Analysis. Pharmaceutics 2024; 16:770. [PMID: 38931891 PMCID: PMC11207075 DOI: 10.3390/pharmaceutics16060770] [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: 04/19/2024] [Revised: 05/24/2024] [Accepted: 05/31/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND Unfractionated heparin is administered in patients undergoing veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Anticoagulation monitoring is recommended, with an anti-activated factor X (anti-Xa) targeting 0.3 to 0.7 IU/mL. Owing to heparin's heterogeneous pharmacokinetic properties, anti-Xa is unpredictable, generating a challenge in anticoagulation practices. The aim of this study was to build a pharmacokinetic model of heparin accounting for potential confounders, and derive an optimized dosing regimen for a given anti-Xa target. METHODS Adult patients undergoing VA-ECMO were included between January 2020 and June 2021. Anticoagulation was managed with an initial 100 IU/kg heparin loading dose followed by a continuous infusion targeting 0.2 to 0.7 IU/mL anti-Xa. The data were split into model development and model validation cohorts. Statistical analysis was performed using a nonlinear mixed effects modeling population approach. Model-based simulations were performed to develop an optimized dosing regimen targeting the desired anti-Xa. RESULTS A total of 74 patients were included, with 1703 anti-Xa observations. A single-compartment model best fitted the data. Interpatient variability for distribution volume was best explained by body weight, C-reactive protein and ECMO indication (post-cardiotomy shock or medical cardiogenic shock), and interpatient variability for elimination clearance was best explained by serum creatinine and C-reactive protein. Simulations using the optimized regimen according to these covariates showed accurate anti-Xa target attainment. CONCLUSION In adult patients on VA-ECMO, heparin's effect increased with serum creatinine and medical indication, whereas it decreased with body weight and systemic inflammation. We propose an optimized dosing regimen accounting for key covariates, capable of accurately predicting a given anti-Xa target.
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Affiliation(s)
- Julien Lanoiselée
- Department of Anesthesiology and Intensive Care Medicine, Saint-Etienne University Hospital, F-42055 Saint-Etienne, France
- INSERM U1059, Dysfonction Vasculaire et Hémostase, F-42055 Saint-Etienne, France
| | - Jérémy Mourer
- Department of Anesthesiology and Intensive Care Medicine, CHU Lille, F-59000 Lille, France
| | - Marie Jungling
- Department of Cardiac Surgery, CHU Lille, F-59000 Lille, France
| | - Serge Molliex
- Department of Anesthesiology and Intensive Care Medicine, Saint-Etienne University Hospital, F-42055 Saint-Etienne, France
- INSERM U1059, Dysfonction Vasculaire et Hémostase, F-42055 Saint-Etienne, France
| | - Lise Thellier
- Department of Anesthesiology and Intensive Care Medicine, CHU Lille, F-59000 Lille, France
| | - Julien Tabareau
- Department of Anesthesiology and Intensive Care Medicine, CHU Lille, F-59000 Lille, France
| | - Emmanuelle Jeanpierre
- Inserm, CHU Lille, Institut Pasteur de Lille, U1011-EGID, University of Lille, F-59000 Lille, France
| | - Emmanuel Robin
- Department of Anesthesiology and Intensive Care Medicine, CHU Lille, F-59000 Lille, France
| | - Sophie Susen
- Inserm, CHU Lille, Institut Pasteur de Lille, U1011-EGID, University of Lille, F-59000 Lille, France
| | - Benoit Tavernier
- Department of Anesthesiology and Intensive Care Medicine, CHU Lille, F-59000 Lille, France
- ULR 2694-METRICS, Évaluation des Technologies de Santé et des Pratiques Médicales, University of Lille, F-59000 Lille, France
| | - André Vincentelli
- Department of Cardiac Surgery, CHU Lille, F-59000 Lille, France
- Inserm, CHU Lille, Institut Pasteur de Lille, U1011-EGID, University of Lille, F-59000 Lille, France
| | - Edouard Ollier
- INSERM U1059, Dysfonction Vasculaire et Hémostase, F-42055 Saint-Etienne, France
- Unité de Recherche Clinique Innovation et Pharmacologie, Saint-Etienne University Hospital, F-42270 Saint-Etienne, France
| | - Mouhamed Djahoum Moussa
- Department of Anesthesiology and Intensive Care Medicine, CHU Lille, F-59000 Lille, France
- ULR 2694-METRICS, Évaluation des Technologies de Santé et des Pratiques Médicales, University of Lille, F-59000 Lille, France
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Wang Y, Xu X, Zhu W. Anticoagulant therapy in orthopedic surgery - a review on anticoagulant agents, risk factors, monitoring, and current challenges. J Orthop Surg (Hong Kong) 2024; 32:10225536241233473. [PMID: 38411153 DOI: 10.1177/10225536241233473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024] Open
Abstract
Orthopedic surgeries are associated with high-risk of thromboembolism which occurs in 40% to 60% of orthopedic patients in the absence of thromboprophylaxis. Conventionally heparin anticoagulants were used for thromboprophylaxis and currently direct oral anticoagulants (DOACs) are widely used due to their minimal complexity. Anticoagulant use carries bleeding risk and requires optimal laboratory monitoring through conventional thrombin-based assays, anti-Xa assay, anti-IIa assay and contemporary ecarin chromogenic assay (ECA) and rotational thromboelastometry. Monitoring requires multiple hospital visits and hence, the development of point-of-care assays is gaining momentum. Also, a thorough risk assessment model (RAM) is necessary for successful anticoagulant therapy since it enables personalized approach for better thromboprophylaxis outcomes. Despite welcoming changes, lack of guideline consensus, population-based thromboprophylaxis, deficiencies in risk stratification and non-adherence are still a concern. Stronger clinical and process support system with uniform guidelines approaches and patient-specific RAM can aid in the successful implementation of anticoagulant therapy.
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Affiliation(s)
- Yiqun Wang
- Department of Orthopedics, Shanghai Songjiang District Central Hospital, Shanghai, China
| | - Xiaobin Xu
- Department of Orthopedics, Shanghai Songjiang District Central Hospital, Shanghai, China
| | - Wei Zhu
- Department of Orthopedics, Shanghai Songjiang District Central Hospital, Shanghai, China
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Lasne D, Toussaint-Hacquard M, Delassasseigne C, Bauters A, Flaujac C, Savard P, Mouton C, De Maistre E, Stepanian A, Eschwège V, Delrue M, Georges JL, Gros A, Mansour A, Leroy G, Jouffroy R, Mattei M, Beurton A, Pontis A, Neuwirth M, Nedelec-Gac F, Lecompte T, Curis E, Siguret V, Gouin-Thibault I. Factors Influencing Anti-Xa Assays: A Multicenter Prospective Study in Critically Ill and Noncritically Ill Patients Receiving Unfractionated Heparin. Thromb Haemost 2023; 123:1105-1115. [PMID: 37321244 DOI: 10.1055/s-0043-1770096] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
BACKGROUND The presence of dextran sulfate (DS) in reagents and the type of blood collection tube (citrate/citrated-theophylline-adenosine-dipyridamole [CTAD]) can lead to discrepancies between unfractionated heparin (UFH) anti-Xa levels. OBJECTIVES To evaluate the extent of the effect (1) of different reagents containing or not containing DS and (2) of the blood collection tubes, on UFH anti-Xa levels, in various clinical situations (NCT04700670). METHODS We prospectively included patients from eight centers: group (G)1, cardiopulmonary bypass (CPB) after heparin neutralization (n = 39); G2, cardiothoracic intensive care unit (ICU) after CPB (n = 35); G3, medical ICU (n = 53); G4, other medical inpatients (n = 38). Blood was collected into citrated and CTAD tubes. Chromogenic anti-Xa assays were centrally performed, using seven reagent/analyzer combinations including two without DS. The association between anti-Xa levels and covariates was tested using a linear mixed-effects model. RESULTS We analyzed 4,546 anti-Xa values from 165 patients. Median anti-Xa levels were systematically higher with reagents containing DS, whatever the patient group, with the greatest effect observed in G1 (0.32 vs. 0.05 IU/mL). Anti-Xa levels were slightly higher in CTAD than in citrate samples, irrespective of the assay. The model showed: (1) a significant dextran-patient group interaction (p < 0.0001), the effect of DS on anti-Xa levels varying from 30.9% in G4 to 296% in G1, and (2) a significant effect of CTAD, varying between patient groups (p = 0.0302). CONCLUSION The variability of anti-Xa levels with a great overestimation of the values, using a reagent containing DS, can lead to different treatment decisions, especially after heparin neutralization by protamine. Clinical consequences of these differences remain to be demonstrated.
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Affiliation(s)
- Dominique Lasne
- AP-HP, Laboratoire d'hématologie générale, Hôpital Necker, INSERM, Univ. Paris-Saclay, Le Kremlin-Bicêtre, France
| | | | | | - Anne Bauters
- CHU Lille, Institut d'Hématologie-Transfusion, Lille, France
| | - Claire Flaujac
- Laboratoire de Biologie Médicale (Secteur Hémostase), Centre Hospitalier de Versailles, André Mignot, Le Chesnay, France
| | | | - Christine Mouton
- Laboratoire Hématologie, Hôpital Haut-Lévêque, CHU Bordeaux, France
| | | | - Alain Stepanian
- AP-HP, Service d'Hématologie Biologique, Hôpital Lariboisière, Paris Cité University, Paris, France
| | | | - Maxime Delrue
- AP-HP, Service d'Hématologie Biologique, Hôpital Lariboisière, Paris Cité University, Paris, France
| | - Jean-Louis Georges
- Service de réanimation medico-chirurgicale, Centre Hospitalier de Versailles, André Mignot, Le Chesnay, France
| | - Antoine Gros
- Service de réanimation medico-chirurgicale, Centre Hospitalier de Versailles, André Mignot, Le Chesnay, France
| | - Alexandre Mansour
- Department of Anesthesia and Critical Care, Pontchaillou, University Hospital of Rennes; Univ Rennes, CHU Rennes, Inserm, IRSET, Rennes, France
| | | | - Romain Jouffroy
- AP-HP, Service de réanimation adulte, Hôpital Necker, Paris, France
| | - Matthieu Mattei
- Unité d'Anesthésie et Réanimation Cardiaque & Réanimation Médicale Brabois, CHRU Nancy, Nancy, France
| | - Antoine Beurton
- Department of Cardiovascular Anaesthesia and Critical care, Surgical Medical Center Magellan, Haut-Lévêque Hospital, Pessac, France
| | - Adeline Pontis
- Hématologie Biologique, Hôpital Pontchaillou, University Hospital of Rennes, Univ. Rennes, CHU Rennes, Inserm, IRSET, Rennes, France
| | - Marie Neuwirth
- AP-HP, Service d'Hématologie Biologique, Hôpital Lariboisière, Paris Cité University, Paris, France
| | - Fabienne Nedelec-Gac
- Hématologie Biologique, Hôpital Pontchaillou, University Hospital of Rennes, Univ. Rennes, CHU Rennes, Inserm, IRSET, Rennes, France
| | - Thomas Lecompte
- Department of Pharmacy, Faculté de médecine, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), Université de Lorraine & Université de Namur, Namur, Belgium
- Hématologie Biologique, Hôpital Pontchaillou University Hospital of Rennes, Rennes, France
| | - Emmanuel Curis
- UR 7537 BioSTM, faculté de pharmacie de Paris, université Paris Cité, Paris, France
- Service d'Hématologie Biologique, Hôpital Lariboisière, AP-HP, Paris, France
| | - Virginie Siguret
- AP-HP, Service d'Hématologie Biologique, Hôpital Lariboisière, Paris Cité University, Paris, France
| | - Isabelle Gouin-Thibault
- Hématologie Biologique, Hôpital Pontchaillou, University Hospital of Rennes, Univ. Rennes, CHU Rennes, Inserm, IRSET, Rennes, France
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Hardy M, Cabo J, Deliège A, Douxfils J, Gouin-Thibault I, Lecompte T, Mullier F. Reassessment of dextran sulfate in anti-Xa assay for unfractionated heparin laboratory monitoring. Res Pract Thromb Haemost 2023; 7:102257. [PMID: 38193053 PMCID: PMC10772882 DOI: 10.1016/j.rpth.2023.102257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 09/20/2023] [Accepted: 10/18/2023] [Indexed: 01/10/2024] Open
Abstract
Background Anti-Xa assays are used for unfractionated heparin (UFH) monitoring. Dextran sulfate (DS) is used in some assays to overcome the artifactual preanalytical release of platelet factor 4. However, the practical implications of this test modification have not been studied extensively. Objectives To investigate the impact of the presence of DS in the anti-Xa assay for UFH laboratory monitoring. Methods We studied factor Xa inhibition, using an assay without DS (Stago Liquid Anti-Xa), in normal pool plasma spiked with various concentrations of UFH (up to 1 IU/mL) in the presence of increasing concentrations of DS (up to 2560 μg/mL). We also investigated the effect of DS on FXa inhibition measured after the addition of UFH and heparin antagonists (protamine and Polybrene; Sigma Aldrich). Eventually, we compared the anti-Xa levels measured using the assay without DS to those measured with an assay containing DS (BIOPHEN Heparin LRT, Hyphen BioMed). Results DS per se had a detectable anti-Xa effect. FXa inhibition in UFH-spiked plasma linearly increased with increasing concentrations of added DS, with a plateau at approximately 160 μg/mL DS, at which the apparent anti-Xa level had almost doubled. In the presence of heparin antagonists, the addition of DS increased anti-Xa levels, corresponding to the dissociation of the UFH-antagonists complexes in vitro. With the anti-Xa assay containing DS, UFH inhibition was not detected. Conclusion In the presence of high concentrations of DS, FXa inhibition was much higher than that predicted from added UFH amounts, presumably related to the greater availability of UFH for interaction with antithrombin. While the relevance of measuring this "masked" heparin has not been demonstrated, the presence of DS renders the result inaccurate in the presence of protamine or Polybrene.
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Affiliation(s)
- Michael Hardy
- CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Hematology Laboratory, Yvoir, Belgium
- CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Department of Anesthesiology, Yvoir, Belgium
- Université catholique de Louvain, Institut de Recherche Expérimentale et Clinique, Pôle Mont, Yvoir, Belgium
| | - Julien Cabo
- CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Hematology Laboratory, Yvoir, Belgium
| | - Antoine Deliège
- CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Hematology Laboratory, Yvoir, Belgium
| | - Jonathan Douxfils
- University of Namur, Department of Pharmacy, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Namur, Belgium
- QUALIblood s.a., Namur, Belgium
| | | | - Thomas Lecompte
- University of Namur, Department of Pharmacy, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Namur, Belgium
- CHU of Rennes, Department of Laboratory Hematology, IRSET-INSERM-1085, Rennes, France
- University of Lorraine, CHRU of Nancy, Nancy, France
| | - François Mullier
- CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Hematology Laboratory, Yvoir, Belgium
- Université catholique de Louvain, Institut de Recherche Expérimentale et Clinique, Pôle Mont, Yvoir, Belgium
- University of Namur, Department of Pharmacy, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Namur, Belgium
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Šoltés J, Skribuckij M, Říha H, Lipš M, Michálek P, Balík M, Pořízka M. Update on Anticoagulation Strategies in Patients with ECMO-A Narrative Review. J Clin Med 2023; 12:6067. [PMID: 37763010 PMCID: PMC10532142 DOI: 10.3390/jcm12186067] [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: 08/08/2023] [Revised: 09/14/2023] [Accepted: 09/18/2023] [Indexed: 09/29/2023] Open
Abstract
The use of extracorporeal membrane oxygenation (ECMO) has recently increased exponentially. ECMO has become the preferred mode of organ support in refractory respiratory or circulatory failure. The fragile balance of haemostasis physiology is massively altered by the patient's critical condition and specifically the aetiology of the underlying disease. Furthermore, an application of ECMO conveys another disturbance of haemostasis due to blood-circuit interaction and the presence of an oxygenator. The purpose of this review is to summarise current knowledge on the anticoagulation management in patients undergoing ECMO therapy. The unfractionated heparin modality with monitoring of activated partial thromboplastin tests is considered to be a gold standard for anticoagulation in this specific subgroup of intensive care patients. However, alternative modalities with other agents are comprehensively discussed. Furthermore, other ways of monitoring can represent the actual state of coagulation in a more complex fashion, such as thromboelastometric/graphic methods, and might become more frequent. In conclusion, the coagulation system of patients with ECMO is altered by multiple variables, and there is a significant lack of evidence in this area. Therefore, a highly individualised approach is the best solution today.
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Affiliation(s)
- Ján Šoltés
- Department of Anaesthesiology and Intensive Care Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, 12808 Prague, Czech Republic; (J.Š.); (H.Ř.); (M.L.); (P.M.); (M.B.)
- Emergency Service of Central Bohemia, Vančurova 1544, 27201 Kladno, Czech Republic
| | - Michal Skribuckij
- Department of Anaesthesia, Golden Jubilee University National Hospital, Clydebank G81 4DY, UK;
| | - Hynek Říha
- Department of Anaesthesiology and Intensive Care Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, 12808 Prague, Czech Republic; (J.Š.); (H.Ř.); (M.L.); (P.M.); (M.B.)
- Department of Anaesthesiology and Intensive Care Medicine, Institute for Clinical and Experimental Medicine, 14021 Prague, Czech Republic
| | - Michal Lipš
- Department of Anaesthesiology and Intensive Care Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, 12808 Prague, Czech Republic; (J.Š.); (H.Ř.); (M.L.); (P.M.); (M.B.)
| | - Pavel Michálek
- Department of Anaesthesiology and Intensive Care Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, 12808 Prague, Czech Republic; (J.Š.); (H.Ř.); (M.L.); (P.M.); (M.B.)
- Department of Anaesthesia, Antrim Area Hospital, Antrim BT41 2RL, UK
| | - Martin Balík
- Department of Anaesthesiology and Intensive Care Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, 12808 Prague, Czech Republic; (J.Š.); (H.Ř.); (M.L.); (P.M.); (M.B.)
| | - Michal Pořízka
- Department of Anaesthesiology and Intensive Care Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, 12808 Prague, Czech Republic; (J.Š.); (H.Ř.); (M.L.); (P.M.); (M.B.)
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7
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Schultinge L, Hulshof AM, van Neerven D, Mulder MMG, Sels JWEM, Hulsewe HPMG, Kuiper GJAJM, Olie RH, Ten Cate H, van der Horst ICC, van Bussel BCT, Henskens YMC. Applications of rotational thromboelastometry in heparin monitoring in critical COVID-19 disease: Observations in the Maastricht Intensive Care COVID cohort. THROMBOSIS UPDATE 2023; 12:100140. [PMID: 38620129 PMCID: PMC10245457 DOI: 10.1016/j.tru.2023.100140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 05/16/2023] [Accepted: 06/06/2023] [Indexed: 04/17/2024] Open
Abstract
Background Critically ill COVID-19 patients are at risk for venous thromboembolism (VTE). Therefore, they receive thromboprophylaxis and, when appropriate, therapeutic unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH). To monitor heparins in COVID-19 disease, whole-blood rotational thromboelastometry (ROTEM) may be a promising alternative to the aPTT and anti-Xa assays. Objective To evaluate the ROTEM INTEM/HEPTEM ratios in mechanically ventilated COVID-19 patients treated with UFH and therapeutic LMWH. Material and methods A subcohort of mechanically ventilated COVID-19 patients of the prospective Maastricht Intensive Care Covid (MaastrICCht) cohort was studied. Anti-Xa, aPTT, and ROTEM measurements following treatment with UFH or therapeutic dose of LMWH (nadroparin) were evaluated using uni- and multivariable linear regression analysis and receiver operating characteristics. Results A total of 98 patients were included, of which 82 were treated with UFH and 16 with therapeutic LMWH. ROTEM-measured INTEM/HEPTEM CT ratio was higher in patients using UFH (1.4 [1.3-1.4]) compared to patients treated with LMWH (1.0 [1.0-1.1], p < 0.001). Both the aPTT and anti-Xa were associated with the CT ratio. However, the β-regression coefficient (95%CI) was significantly higher in patients on UFH (0.31 (0.001-0.62)) compared to therapeutic LMWH (0.09 (0.05-0.13)) for comparison with the anti-Xa assay. Furthermore, ROC analysis demonstrated an area under the curve for detecting UFH of 0.936(0.849-1.00), 0.851(0.702-1.000), and 0.645(0.465-0.826) for the CT ratio, aPTT, and anti-Xa, respectively. Conclusion The ROTEM INTEM/HEPTEM CT ratio appears a promising tool to guide anticoagulant therapy in ICU patients with COVID-19 disease, but associations with clinical endpoints are currently lacking.
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Affiliation(s)
- Lejan Schultinge
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, the Netherlands
- Department of Intensive Care Medicine, Laurentius Hospital Roermond, the Netherlands
| | - Anne-Marije Hulshof
- Central Diagnostic Laboratory, Maastricht University Medical Centre+, Maastricht, the Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht University+, Maastricht, the Netherlands
| | - Danihel van Neerven
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, the Netherlands
- Department of Anaesthesiology and Pain Treatment Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Mark M G Mulder
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, the Netherlands
- Department of Anaesthesiology and Pain Treatment Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Jan-Willem E M Sels
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, the Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht University+, Maastricht, the Netherlands
| | - Hendrina P M G Hulsewe
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Gerardus J A J M Kuiper
- Department of Anaesthesiology and Pain Treatment Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Renske H Olie
- Cardiovascular Research Institute Maastricht, Maastricht University+, Maastricht, the Netherlands
- Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, the Netherlands
- Thrombosis Expert Centre Maastricht, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Hugo Ten Cate
- Cardiovascular Research Institute Maastricht, Maastricht University+, Maastricht, the Netherlands
- Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, the Netherlands
- Thrombosis Expert Centre Maastricht, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, the Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht University+, Maastricht, the Netherlands
| | - Bas C T van Bussel
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, the Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht University+, Maastricht, the Netherlands
- Care and Public Health Research Institute, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Yvonne M C Henskens
- Central Diagnostic Laboratory, Maastricht University Medical Centre+, Maastricht, the Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht University+, Maastricht, the Netherlands
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8
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Shao L, Yu H, Song J, Liu S, Li G. Pyrene-Based Self-Assembling Peptide for Ratiometric Detection of Heparin. Chembiochem 2023; 24:e202200652. [PMID: 36592168 DOI: 10.1002/cbic.202200652] [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: 11/10/2022] [Revised: 12/18/2022] [Accepted: 01/02/2023] [Indexed: 01/03/2023]
Abstract
Heparin is a commonly used anticoagulant in clinical practice; however, excessive heparin can cause serious adverse reactions. Convenient and accurate detection of heparin levels is thus very important. In this research, a pyrene-based self-assembling fluorescent peptide PyFFRRR was designed for simple, selective, and efficient heparin detection. The guanidine groups in the arginine residues of PyFFRRR bind tightly with heparin, which is highly sulfated, through electrostatic interactions. Charge neutralization facilitated the self-assembly of PyFFRRR, resulting in its spectral response changing from deep blue monomer fluorescence to green excimer fluorescence. PyFFRRR exhibited excellent sensitivity and selectivity for ratiometric detection of heparin. The binding mechanism was investigated by using spectral and simulation tools, and structural observation. Finally, PyFFRRR was employed in human serum samples for ratiometric detection of heparin.
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Affiliation(s)
- Liang Shao
- Department of Biophysics, School of Basic Medical Sciences, Health Science Centre, Xi'an Jiaotong University, Shaanxi, 710061, P. R. China
| | - Hongwen Yu
- Department of Biophysics, School of Basic Medical Sciences, Health Science Centre, Xi'an Jiaotong University, Shaanxi, 710061, P. R. China.,Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Shaanxi, 710061, P. R. China
| | - Jiaqi Song
- Department of Biophysics, School of Basic Medical Sciences, Health Science Centre, Xi'an Jiaotong University, Shaanxi, 710061, P. R. China
| | - Shichang Liu
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Shaanxi, 710061, P. R. China
| | - Guanying Li
- Department of Biophysics, School of Basic Medical Sciences, Health Science Centre, Xi'an Jiaotong University, Shaanxi, 710061, P. R. China
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9
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Yin ZJ, Huang YJ, Chen QL. Risk factor analysis and a new prediction model of venous thromboembolism after pancreaticoduodenectomy. BMC Surg 2023; 23:25. [PMID: 36709302 PMCID: PMC9883972 DOI: 10.1186/s12893-023-01916-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 01/16/2023] [Indexed: 01/30/2023] Open
Abstract
AIM The present study aimed to identify risk factors for venous thromboembolism (VTE) after pancreaticoduodenectomy (PD) and to develop and internally validate a predictive model for the risk of venous thrombosis. METHODS We retrospectively collected data from 352 patients who visited our hospital to undergo PD from January 2018 to March 2022. The number of patients recruited was divided in an 8:2 ratio by using the random split method, with 80% of the patients serving as the training set and 20% as the validation set. The least absolute shrinkage and selection operator (Lasso) regression model was used to optimize feature selection for the VTE risk model. Multivariate logistic regression analysis was used to construct a prediction model by incorporating the features selected in the Lasso model. C-index, receiver operating characteristic curve, calibration plot, and decision curve were used to assess the accuracy of the model, to calibrate the model, and to determine the clinical usefulness of the model. Finally, we evaluated the prediction model for internal validation. RESULTS The predictors included in the prediction nomogram were sex, age, gastrointestinal symptoms, hypertension, diabetes, operative method, intraoperative bleeding, blood transfusion, neutrophil count, prothrombin time (PT), activated partial thromboplastin time (APTT), aspartate aminotransferase (AST)/alanine aminotransferase (ALT) ratio (AST/ALT), and total bilirubin (TBIL). The model showed good discrimination with a C-index of 0.827, had good consistency based on the calibration curve, and had an area under the ROC curve value of 0.822 (P < 0.001, 95%confidence interval:0.761-0.882). A high C-index value of 0.894 was reached in internal validation. Decision curve analysis showed that the VTE nomogram was clinically useful when intervention was decided at the VTE possibility threshold of 10%. CONCLUSION The novel model developed in this study is highly targeted and enables personalized assessment of VTE occurrence in patients who undergo PD. The predictors are easily accessible and facilitate the assessment of patients by clinical practitioners.
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Affiliation(s)
- Zhi-Jie Yin
- grid.412631.3Digestive and Vascular Center, Department of Pancreatic Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054 People’s Republic of China
| | - Ying-Jie Huang
- grid.412631.3Digestive and Vascular Center, Department of Pancreatic Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054 People’s Republic of China
| | - Qi-Long Chen
- grid.412631.3Digestive and Vascular Center, Department of Pancreatic Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054 People’s Republic of China
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10
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Bunch CM, Berquist M, Ansari A, McCoy ML, Langford JH, Brenner TJ, Aboukhaled M, Thomas SJ, Peck E, Patel S, Cancel E, Al-Fadhl MD, Zackariya N, Thomas AV, Aversa JG, Greene RB, Seder CW, Speybroeck J, Miller JB, Kwaan HC, Walsh MM. The Choice between Plasma-Based Common Coagulation Tests and Cell-Based Viscoelastic Tests in Monitoring Hemostatic Competence: Not an either-or Proposition. Semin Thromb Hemost 2022; 48:769-784. [PMID: 36174601 DOI: 10.1055/s-0042-1756302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
There has been a significant interest in the last decade in the use of viscoelastic tests (VETs) to determine the hemostatic competence of bleeding patients. Previously, common coagulation tests (CCTs) such as the prothrombin time (PT) and partial thromboplastin time (PTT) were used to assist in the guidance of blood component and hemostatic adjunctive therapy for these patients. However, the experience of decades of VET use in liver failure with transplantation, cardiac surgery, and trauma has now spread to obstetrical hemorrhage and congenital and acquired coagulopathies. Since CCTs measure only 5 to 10% of the lifespan of a clot, these assays have been found to be of limited use for acute surgical and medical conditions, whereby rapid results are required. However, there are medical indications for the PT/PTT that cannot be supplanted by VETs. Therefore, the choice of whether to use a CCT or a VET to guide blood component therapy or hemostatic adjunctive therapy may often require consideration of both methodologies. In this review, we provide examples of the relative indications for CCTs and VETs in monitoring hemostatic competence of bleeding patients.
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Affiliation(s)
- Connor M Bunch
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Margaret Berquist
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Aida Ansari
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Max L McCoy
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Jack H Langford
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Toby J Brenner
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Michael Aboukhaled
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Samuel J Thomas
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Ethan Peck
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Shivani Patel
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Emily Cancel
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Mahmoud D Al-Fadhl
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Nuha Zackariya
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Anthony V Thomas
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - John G Aversa
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Ryan B Greene
- Department of Interventional Radiology, St. Joseph Regional Medical Center, Mishawaka, Indiana
| | - Christopher W Seder
- Department of Cardiovascular and Thoracic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Jacob Speybroeck
- Department of Orthopedic Surgery, Case Western Medical Center, Cleveland, Ohio
| | - Joseph B Miller
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Hau C Kwaan
- Division of Hematology and Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mark M Walsh
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana.,Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
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11
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Filip C, Covali R, Socolov D, Carauleanu A, Tanasa IA, Scripcariu IS, Ciuhodaru M, Butureanu T, Pavaleanu I, Akad M, Boiculese LV, Socolov R. The postpartum uterine ultrasonographic scale in assessment of uterine involution after cesarean section in treated thrombophilia pregnant patients at term. J Clin Lab Anal 2022; 36:e24645. [PMID: 36082463 PMCID: PMC9459266 DOI: 10.1002/jcla.24645] [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: 04/01/2022] [Revised: 06/22/2022] [Accepted: 07/27/2022] [Indexed: 11/06/2022] Open
Abstract
Background Pregnancy is a prothrombotic condition which can be abnormally exaggerated in women with thrombophilia. Methods In a prospective study, patients who delivered at term, by cesarean section, between 1 October 2017 and 1 December 2021, who already had a diagnosis of thrombophilia before coming to our hospital, were included in the study group (n = 80). A similar number of nonthrombophilia patients (n = 80) without any history of thrombotic events, age‐ and para‐matched with the study group, were included in the control group. The postpartum uterine ultrasonographic scale (PUUS) values, in the first 24–48 h, were correlated with the patients' data. Results The P‐LCR (platelet large cell ratio), was significantly higher in the treated thrombophilia group (p = 0.042). There was no correlation between PUUS and complete blood count values, coagulation factors, maternal characteristics, or fetal outcomes, except for postpartum neutrophils (p = 0.047) and postpartum platelet count (p = 0.046). Conclusions Postpartum uterine involution was not significantly different, after cesarean section, between treated thrombophilia patients and nonthrombophilia patients. Involution correlated only with postpartum neutrophils and postpartum platelet count.
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Affiliation(s)
- Catalina Filip
- Department of Vascular Surgery, Faculty of Medicine Grigore T. Popa University of Medicine and Pharmacy Iasi Romania
| | - Roxana Covali
- Department of Radiology, Biomedical Engineering Faculty, Grigore T. Popa University of Medicine and Pharmacy Iasi Elena Doamna Obstetrics and Gynecology University Hospital Iasi Romania
| | - Demetra Socolov
- Department of Obstetrics and Gynecology, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy Iasi Cuza Voda Obstetrics and Gynecology University Hospital Iasi Romania
| | - Alexandru Carauleanu
- Department of Obstetrics and Gynecology, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy Iasi Cuza Voda Obstetrics and Gynecology University Hospital Iasi Romania
| | - Ingrid Andrada Tanasa
- Department of Obstetrics and Gynecology, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy Iasi Cuza Voda Obstetrics and Gynecology University Hospital Iasi Romania
| | - Ioana Sadyie Scripcariu
- Department of Obstetrics and Gynecology, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy Iasi Cuza Voda Obstetrics and Gynecology University Hospital Iasi Romania
| | - Madalina Ciuhodaru
- Department of Obstetrics and Gynecology, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy Iasi Elena Doamna Obstetrics and Gynecology University Hospital Iasi Romania
| | - Tudor Butureanu
- Department of Obstetrics and Gynecology, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy Iasi Elena Doamna Obstetrics and Gynecology University Hospital Iasi Romania
| | - Ioana Pavaleanu
- Department of Obstetrics and Gynecology, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy Iasi Elena Doamna Obstetrics and Gynecology University Hospital Iasi Romania
| | - Mona Akad
- Department of Obstetrics and Gynecology, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy Iasi Elena Doamna Obstetrics and Gynecology University Hospital Iasi Romania
| | | | - Razvan Socolov
- Department of Obstetrics and Gynecology, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy Iasi Elena Doamna Obstetrics and Gynecology University Hospital Iasi Romania
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12
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Boie SD, Engelhardt LJ, Coenen N, Giesa N, Rubarth K, Menk M, Balzer F. A recurrent neural network model predicts activated partial thromboplastin time after treatment with heparin: a retrospective study (Preprint). JMIR Med Inform 2022; 10:e39187. [PMID: 36227653 PMCID: PMC9614623 DOI: 10.2196/39187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/17/2022] [Accepted: 08/11/2022] [Indexed: 11/28/2022] Open
Abstract
Background Anticoagulation therapy with heparin is a frequent treatment in intensive care units and is monitored by activated partial thromboplastin clotting time (aPTT). It has been demonstrated that reaching an established anticoagulation target within 24 hours is associated with favorable outcomes. However, patients respond to heparin differently and reaching the anticoagulation target can be challenging. Machine learning algorithms may potentially support clinicians with improved dosing recommendations. Objective This study evaluates a range of machine learning algorithms on their capability of predicting the patients’ response to heparin treatment. In this analysis, we apply, for the first time, a model that considers time series. Methods We extracted patient demographics, laboratory values, dialysis and extracorporeal membrane oxygenation treatments, and scores from the hospital information system. We predicted the numerical values of aPTT laboratory values 24 hours after continuous heparin infusion and evaluated 7 different machine learning models. The best-performing model was compared to recently published models on a classification task. We considered all data before and within the first 12 hours of continuous heparin infusion as features and predicted the aPTT value after 24 hours. Results The distribution of aPTT in our cohort of 5926 hospital admissions was highly skewed. Most patients showed aPTT values below 75 s, while some outliers showed much higher aPTT values. A recurrent neural network that consumes a time series of features showed the highest performance on the test set. Conclusions A recurrent neural network that uses time series of features instead of only static and aggregated features showed the highest performance in predicting aPTT after heparin treatment.
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Affiliation(s)
- Sebastian Daniel Boie
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Medical Informatics, Berlin, Germany
| | - Lilian Jo Engelhardt
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Medical Informatics, Berlin, Germany
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Berlin, Germany
| | - Nicolas Coenen
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Berlin, Germany
| | - Niklas Giesa
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Medical Informatics, Berlin, Germany
| | - Kerstin Rubarth
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Medical Informatics, Berlin, Germany
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Biometry and Clinical Epidemiology, Berlin, Germany
| | - Mario Menk
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Medical Informatics, Berlin, Germany
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Berlin, Germany
| | - Felix Balzer
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Medical Informatics, Berlin, Germany
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13
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Roberts TR, Garren MRS, Wilson SN, Handa H, Batchinsky AI. Development and In Vitro Whole Blood Hemocompatibility Screening of Endothelium-Mimetic Multifunctional Coatings. ACS APPLIED BIO MATERIALS 2022; 5:2212-2223. [PMID: 35404571 DOI: 10.1021/acsabm.2c00073] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Multifunctional antithrombotic surface modifications for blood-contacting medical devices have emerged as a solution for foreign surface-mediated coagulation disturbance. Herein, we have developed and evaluated an endothelium-inspired strategy to reduce the thrombogenicity of medical plastics by imparting nitric oxide (NO) elution and heparin immobilization on the material surface. This dual-action approach (NO+Hep) was applied to polyethylene terephthalate (PET) blood incubation vials and compared to isolated modifications. Vials were characterized to evaluate NO surface flux as well as heparin density and activity. Hemocompatibility was assessed in vitro using whole blood from human donors. Compared to unmodified surfaces, blood incubated in the NO+Hep vials exhibited reduced platelet aggregation (15% decrease AUC, p = 0.040) and prolonged plasma clotting times (aPTT = 147% increase, p < 0.0001, prothrombin time = 5% increase, p = 0.0002). Prolongation of thromboelastography reaction time and elevated antifactor Xa levels in blood from NO+Hep versus PET vials suggests some heparin leaching from the vial surface, confirmed by post-blood incubation heparin density assessment. Results suggest NO+Hep surface modification is a promising approach for blood-contacting plastics; however, careful tuning of NO flux and heparin stabilization are essential and require assessment using human blood as performed here.
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Affiliation(s)
- Teryn R Roberts
- Autonomous Reanimation and Evacuation Research Program, The Geneva Foundation, 2509 Kennedy Circle Bldg 125, San Antonio, Texas 78235, United States
| | - Mark R S Garren
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, Athens, Georgia 30602, United States
| | - Sarah N Wilson
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, Athens, Georgia 30602, United States
| | - Hitesh Handa
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, Athens, Georgia 30602, United States.,Department of Pharmaceutical and Biomedical Sciences, College of Pharmacy, University of Georgia, Athens, Georgia 30602, United States
| | - Andriy I Batchinsky
- Autonomous Reanimation and Evacuation Research Program, The Geneva Foundation, 2509 Kennedy Circle Bldg 125, San Antonio, Texas 78235, United States
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14
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Swan D, Carrier M, Lisman T, Thachil J. Heparin - Messias or Verschlimmbesserung? J Thromb Haemost 2021; 19:2373-2382. [PMID: 34272818 PMCID: PMC9906358 DOI: 10.1111/jth.15464] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/02/2021] [Accepted: 07/14/2021] [Indexed: 12/11/2022]
Abstract
A heightened risk of thrombosis noted early on with the severe acute respiratory syndrome coronavirus 2 infection led to the widespread use of heparin anticoagulation in the coronavirus disease 2019 (COVID-19) pandemic. However, reports soon started appearing in the literature where an apparent failure of heparin to prevent thrombotic events was observed in hospitalized patients with this viral infection. In this review, we explore the likely mechanisms for heparin failure with particular relevance to COVID-19. We also explore the role of anti-Xa assays and global hemostatic tests in this context. The current controversy of dosing heparin in this disease is detailed with some possible mechanistic reasons for anticoagulant failure. We hope that lessons learnt from the use of heparin in COVID-19 could assist us in the appropriate use of this anticoagulant in the future.
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Affiliation(s)
- Dawn Swan
- Department of Haematology, St James' Hospital, Dublin, Ireland
| | - Marc Carrier
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Ton Lisman
- Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jecko Thachil
- Department of Haematology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
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15
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Toulon P, Smahi M, De Pooter N. APTT therapeutic range for monitoring unfractionated heparin therapy. Significant impact of the anti-Xa reagent used for correlation: Response from original authors Toulon et al. J Thromb Haemost 2021; 19:2090-2091. [PMID: 34327830 DOI: 10.1111/jth.15350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 04/23/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Pierre Toulon
- Hematology Department, Université Côte d'Azur, CHU Nice, Nice, France
| | - Motalib Smahi
- Hematology Department, Simone Veil Hospital, Eaubonne, France
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16
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What Do We Know about Thromboprophylaxis and Its Monitoring in Critically Ill Patients? Biomedicines 2021; 9:biomedicines9080864. [PMID: 34440068 PMCID: PMC8389559 DOI: 10.3390/biomedicines9080864] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/16/2021] [Accepted: 07/16/2021] [Indexed: 01/19/2023] Open
Abstract
Venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism, is an important complication in patients hospitalized in intensive care units (ICU). Thromboprophylaxis is mainly performed with Low Molecular Weight Heparin (LMWH) and, in some specific patients, with Unfractionated Heparin (UFH). These intensive units are an environment where individual patient variability is extreme and where traditional antithrombotic protocols are frequently ineffective. This was known for a long time, but the hospitalization of many patients with COVID-19 inflammatory storms suddenly highlighted this knowledge. It is therefore reasonable to propose variable antithrombotic prevention protocols based initially on a series of individual criteria (weight, BMI, and thrombotic risks). Secondly, they should be adjusted by the monitoring of anticoagulant activity, preferably by measuring the anti-Xa activity. However, we still face unresolved questions, such as once- or twice-daily LMWH injections, monitoring at the peak and/or trough, and poorly defined therapeutic targets. Equally surprisingly, we observed a lack of standardization of the anti-Xa activity kits.
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17
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Amiral J, Amiral C, Dunois C. Optimization of Heparin Monitoring with Anti-FXa Assays and the Impact of Dextran Sulfate for Measuring All Drug Activity. Biomedicines 2021; 9:700. [PMID: 34205548 PMCID: PMC8235539 DOI: 10.3390/biomedicines9060700] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 06/08/2021] [Accepted: 06/16/2021] [Indexed: 11/22/2022] Open
Abstract
Heparins, unfractionated or low molecular weight, are permanently in the spotlight of both clinical indications and laboratory monitoring. An accurate drug dosage is necessary for an efficient and safe therapy. The one-stage kinetic anti-FXa assays are the most widely and universally used with full automation for large series, without needing exogenous antithrombin. The WHO International Standards are available for UFH and LMWH, but external quality assessment surveys still report a high inter-assay variability. This heterogeneity results from the following: assay formulation, designed without or with dextran sulfate to measure all heparin in blood circulation; calibrators for testing UFH or LMWH with the same curve; and automation parameters. In this study, various factors which impact heparin measurements are reviewed, and we share our experience to optimize assays for testing all heparin anticoagulant activities in plasma. Evidence is provided on the usefulness of low molecular weight dextran sulfate to completely mobilize all of the drug present in blood circulation. Other key factors concern the adjustment of assay conditions to obtain fully superimposable calibration curves for UFH and LMWH, calibrators' formulations, and automation parameters. In this study, we illustrate the performances of different anti-FXa assays used for testing heparin on UFH or LMWH treated patients' plasmas and obtained using citrate or CTAD anticoagulants. Comparable results are obtained only when the CTAD anticoagulant is used. Using citrate as an anticoagulant, UFH is underestimated in the absence of dextran sulfate. Heparin calibrators, adjustment of automation parameters, and data treatment contribute to other smaller differences.
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Affiliation(s)
| | - Cédric Amiral
- HYPHEN BioMed, 95000 Neuville sur Oise, France; (C.A.); (C.D.)
| | - Claire Dunois
- HYPHEN BioMed, 95000 Neuville sur Oise, France; (C.A.); (C.D.)
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18
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McRae HL, Militello L, Refaai MA. Updates in Anticoagulation Therapy Monitoring. Biomedicines 2021; 9:262. [PMID: 33800804 PMCID: PMC8001784 DOI: 10.3390/biomedicines9030262] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 02/27/2021] [Accepted: 03/03/2021] [Indexed: 11/29/2022] Open
Abstract
In the past six decades, heparin and warfarin were the primary anticoagulants prescribed for treatment and prophylaxis of venous thromboembolism worldwide. This has been accompanied by extensive clinical knowledge regarding dosing, monitoring, and reversal of these anticoagulants, and the resources required to do so have largely been readily available at small and large centers alike. However, with the advent of newer oral and parenteral anticoagulants such as low molecular weight heparins, factor Xa inhibitors, and direct thrombin inhibitors in recent years, new corresponding practice guidelines have also emerged. A notable shift in the need for monitoring and reversal agents has evolved as well. While this has perhaps streamlined the process for physicians and is often desirable for patients, it has also left a knowledge and resource gap in clinical scenarios for which urgent reversal and monitoring is necessary. An overview of the currently available anticoagulants with a focus on the guidelines and available tests for anticoagulant monitoring will be discussed in this article.
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Affiliation(s)
| | | | - Majed A. Refaai
- Department of Pathology and Laboratory Medicine, Transfusion Medicine Division, Hemostasis and Thrombosis Unit, University of Rochester Medical Center, Rochester, NY 14642, USA; (H.L.M.); (L.M.)
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