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Hellemans A, Devriendt N, Duchateau L, Devreese KMJ, De Somer F, Bosmans T, Mampaey G, Smets P. Evaluation of the use of a heparin dose-response test in dogs to determine the optimal heparin dose during intravascular procedures and assessment of the in vitro heparin response in healthy dogs. Vet Med Sci 2024; 10:e1326. [PMID: 37987511 PMCID: PMC10951632 DOI: 10.1002/vms3.1326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 10/05/2023] [Accepted: 11/07/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND No guidelines for administering and monitoring anticoagulants intraprocedurally are currently available in dogs, despite the prevalence of procedures necessitating systemic anticoagulation with heparin. OBJECTIVES To evaluate an activated clotting time (ACT)-based heparin dose-response (HDR) test to predict the individual required heparin dose in dogs during intravascular procedures, and to investigate both the in vitro heparin - ACT and in vitro heparin - factor anti-Xa activity (anti-Xa) relationships in dogs. METHODS Blood was collected from eight healthy beagles undergoing a cardiac procedure and utilised to establish baseline ACT and for in vitro evaluation. Subsequently, 100 IU/kg heparin was administered intravenously (IV) and ACT was remeasured (HDR test). The required heparin dose for an ACT target response ≥300 s was calculated for each individual and ACT was remeasured after administration of this dose. For in vitro testing, a serial heparin blood dilution (0-0.5-1-2-4 international unit (IU)/mL) was prepared and ACT and anti-Xa were determined using whole blood and frozen plasma, respectively. RESULTS The HDR test overestimated the required heparin dose in 3/7 dogs. In vitro, ACT and anti-Xa increased significantly with increasing blood heparin concentration. Heparin - ACT was nonlinear in 4/8 dogs at heparin concentrations >2 IU/mL, whereas heparin - anti-Xa remained linear throughout the tested range. CONCLUSIONS The HDR test poorly estimated the required heparin dose in dogs. This is most likely attributed to a nonlinear heparin - ACT relationship, as observed in vitro. Anti-Xa is a promising alternative for ACT; however, unavailability as a point-of-care test and lack of in vivo target values restrict its current use.
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Affiliation(s)
- A. Hellemans
- Faculty of Veterinary MedicineSmall Animal DepartmentGhent UniversityMerelbekeBelgium
| | - N. Devriendt
- Faculty of Veterinary MedicineSmall Animal DepartmentGhent UniversityMerelbekeBelgium
| | - L. Duchateau
- Faculty of Veterinary MedicineBiometrics Research CenterGhent UniversityMerelbekeBelgium
| | - K. M. J. Devreese
- Coagulation LaboratoryFaculty of MedicineDepartment of Diagnostic SciencesGhent University HospitalGhent UniversityGhentBelgium
| | - F. De Somer
- Faculty of Medical SciencesDepartment of Cardiac SurgeryGhent UniversityGhentBelgium
- Experimental Research Laboratory of Cardiac Surgery and Circulatory PhysiologyFaculty of Medical SciencesGhent UniversityGhentBelgium
| | - T. Bosmans
- Faculty of Veterinary MedicineSmall Animal DepartmentGhent UniversityMerelbekeBelgium
| | - G. Mampaey
- Faculty of Veterinary MedicineSmall Animal DepartmentGhent UniversityMerelbekeBelgium
| | - P. Smets
- Faculty of Veterinary MedicineSmall Animal DepartmentGhent UniversityMerelbekeBelgium
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Singh G, Vinson KA, Jones K, Gunsolus B, Keever J, Keel BA. Long-term alliance for pathology equipment and technology acquisition: a paradigm shift for improved quality and efficiency. Lab Med 2024; 55:117-126. [PMID: 37506389 DOI: 10.1093/labmed/lmad071] [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] [Indexed: 07/30/2023] Open
Abstract
OBJECTIVE Personnel costs are the largest single budget item in the clinical laboratory, other major expenses being equipment, analyzers, blood and blood components, and cost of day-to-day consumables. This report describes our experience with developing a long-term relationship with a single major vendor as a paradigm shift from the traditional multiple vendors, multiple contracts, and recurrent extended negotiations. Our objective was to develop a long-term approach for replacement of effete equipment and upgrades to operations in a pathology and laboratory medicine department in collaboration with vendors providing equipment and services. METHODS Major vendors were invited to visit the department to analyze the workload and workflow and suggest integrated solutions to meet the goals of the department. Multiple iterations of the proposals were evaluated, and a recommendation made to the medical center leadership. The vendor, the medical center, and the department jointly developed a 15-year partnership plan to improve the operations of pathology services. The agreement encompasses a range of management and performance criteria for both sides. The salient items discussed were laboratory staffing, turnaround time, workload change, test insourcing, reference laboratory costs, and scholarly productivity and teaching. RESULTS The agreement reduced laboratory staffing by 21%, eliminated stat tests by reducing the turnaround time for routine tests to less than 45 minutes for 90% of tests, with an increase of 9.1% in the number of tests, Cost avoidance in salary and reference laboratory costs was $3,424,136/year against an expected target of $2 million in total savings, despite not including cost avoidance from promoting appropriate use of laboratory testing for inpatients and increase in revenue from increase in ambulatory testing. Vizient score in laboratory utilization improved from the 94th to 76th percentile. Scholarly output increased by more than 100%. CONCLUSION This model of a long-term alliance with a chosen vendor led to improvements in quality and efficiency.
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Affiliation(s)
- Gurmukh Singh
- Shepeard Chair in Clinical Pathology, Department of Pathology, Augusta University, Augusta, GA, US
| | | | - Kari Jones
- Alliance, AU Medical Center, Augusta University, Augusta, GA, US
| | - Brandy Gunsolus
- Medical College of Georgia at, Augusta University, Augusta, GA, US
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Hellemans A, Devriendt N, De Somer F, Marynissen S, Daminet S, Paepe D, Smets P. Reference interval, longitudinal variability and reliability of activated clotting time in healthy dogs using a point-of-care analyser. Vet Med Sci 2023. [PMID: 37139641 DOI: 10.1002/vms3.1148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 02/19/2023] [Accepted: 04/11/2023] [Indexed: 05/05/2023] Open
Abstract
BACKGROUND Activated clotting times (ACTs) are used to screen for coagulopathies and monitor heparin therapy. OBJECTIVES To determine a reference interval (RI) for ACT in dogs using a point-of-care analyser, to quantify intra-subject within- and between-day variability, to quantify analyser reliability and inter-analyser agreement and to study the influence of a delay in measurement. METHODS Forty-two healthy dogs were included. Measurements were performed on fresh venous blood using the i-STAT 1 analyser. The RI was determined using the Robust method. Intra-subject within-day variability and between-day variability were quantified between baseline and 2 h (n = 8) or 48 h (n = 10) later. Analyser reliability and inter-analyser agreement were studied by duplicate measurements (n = 8) on identical analysers. The influence of measurement delay was studied before and after a delay of one analytical run (n = 6). RESULTS Mean, lower and upper reference limits for ACT were 92.9 ± 9.1, 74.4 and 111.2 s, respectively. Coefficients of variation of intra-subject within- and between-day variability were 8.1% and 10.4%, respectively, resulting in a significant between-day measurement difference. Analyser reliability assessed by the intraclass correlation coefficient and coefficient of variation were 0.87% and 3.3%, respectively. Significantly lower ACT values were observed after a measurement delay compared to direct analysis. CONCLUSIONS Our study provides an RI for ACT in healthy dogs using the i-STAT 1 and suggests low intra-subject within- and between-day variability. Analyser reliability and inter-analyser agreement were good; however, analysis delay and between-day differences could significantly influence ACT results.
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Affiliation(s)
- Arnaut Hellemans
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - Nausikaa Devriendt
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - Filip De Somer
- Department of Cardiac Surgery, Faculty of Medical Sciences, Ghent University, Ghent, Belgium
- Experimental Research Laboratory of Cardiac Surgery and Circulatory Physiology, Faculty of Medical Sciences, Ghent University, Ghent, Belgium
| | - Sofie Marynissen
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - Sylvie Daminet
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - Dominique Paepe
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - Pascale Smets
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
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Li H, Bartoszko J, Serrick C, Rao V, Karkouti K. Titrated versus conventional anticoagulation management for thrombin generation in cardiac surgery: a randomized controlled trial. Can J Anaesth 2022; 69:1117-1128. [PMID: 35799088 DOI: 10.1007/s12630-022-02278-1] [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: 06/20/2021] [Revised: 02/17/2022] [Accepted: 02/23/2022] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Optimal heparin titration during cardiopulmonary bypass (CPB) may reduce coagulation system activation and preserve hemostatic function post-CPB. Our objective was to assess if the Heparin Management System (HMS) Plus improves heparin titration, thereby leading to higher thrombin generation post-CPB compared with activated clotting time (ACT)-guided management. METHODS We conducted a randomized controlled trial of 100 patients undergoing cardiac surgery with CPB at a single center. A total of 50 patients were randomized to conventional ACT-guided management, and 50 to the HMS Plus system. The primary outcome was change in thrombin generation post-CPB compared with baseline, as assessed by calibrated automated thrombography. Secondary outcomes included intraoperative blood loss, chest drain output up to 72 hr, and transfusions. In an exploratory analysis, we compared the quintile of patients with the highest average heparin concentration on CPB (≥ 4.0 mg⋅kg-1) with the rest of the cohort. RESULTS A total of 100 patients were included in an intent-to-treat analysis. We observed no difference in post-CPB thrombin generation or secondary outcomes. However, patients in the HMS Plus group had higher average heparin concentrations while on CPB than patients in the conventional management group did (mean difference, -0.21; 95% confidence interval, -0.42 to -0.01). The quintile of patients with the highest average heparin concentration (4.0 mg⋅kg-1) had higher thrombin generation post-CPB than the rest of the cohort did. CONCLUSIONS The HMS Plus system did not show significant benefits in thrombin generation, bleeding outcomes, or transfusion in patients undergoing cardiac surgery with CPB. Higher average heparin concentrations on CPB were associated with higher post-CPB thrombin generation. STUDY REGISTRATION www. CLINICALTRIALS gov (NCT03347201); first submitted 12 October 2017.
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Affiliation(s)
- Han Li
- Perfusion Services, University Health Network, Toronto, ON, Canada
| | - Justyna Bartoszko
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Cyril Serrick
- Perfusion Services, University Health Network, Toronto, ON, Canada
| | - Vivek Rao
- Cardiovascular Surgery, University Health Network and University of Toronto, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Keyvan Karkouti
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
- Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, ON, Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
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5
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Abstract
From preoperative medications to intraoperative needs to postoperative thromboprophylaxis, anticoagulants are encountered throughout the perioperative period. This review focuses on coagulation testing clinicians utilize to monitor the effects of these medications.
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Singh G, Bollag R, Kolhe R, McMullen A, Savage NM. Engaging Pathology Residents in Scholarly Activities. J Appl Lab Med 2021; 6:567-569. [PMID: 33674882 DOI: 10.1093/jalm/jfaa094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 05/11/2020] [Indexed: 11/14/2022]
Affiliation(s)
- Gurmukh Singh
- Medical College of Georgia at Augusta University, GA
| | - Roni Bollag
- Medical College of Georgia at Augusta University, GA
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Anticoagulation Monitoring During Extracorporeal Membrane Oxygenation: Continuing Progress. Crit Care Med 2020; 48:1920-1921. [PMID: 33255117 DOI: 10.1097/ccm.0000000000004635] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Singh G, Bollag RJ, Savage NM. Engaging Pathology Residents in Clinical Chemistry: The Essential Ingredient Is a Committed Teacher. J Appl Lab Med 2020; 6:522-531. [PMID: 33674880 DOI: 10.1093/jalm/jfaa140] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 07/28/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Pathology residents are thought to show a lack of interest in clinical chemistry, therefore potentially graduating from training programs unprepared to function as laboratory directors and clinical consultants. METHODS A structured program of tutorials based primarily on Henry's textbook, supplemented by recent review articles; a question bank of about 600 questions to emphasize key concepts; requirement for performing and presenting quality improvement projects; participation in on-site CAP inspections; review of reference laboratory test requests; and involving residents in scholarly activity have resulted in sustained, transferable, and significant improvements in engagement, knowledge, competence, and examination scores. RESULTS The primary parameter for measuring change in resident competence and engagement were improvements in resident in-service examination (RISE) scores, publications in peer-reviewed journals, and receipt of awards. The revised program produced significant improvement in RISE scores in clinical chemistry, over and above the improvements in the general residency program. The residents were authors on 12 publications in peer-reviewed PubMed listed journals in the 5-year period since revision in the clinical chemistry curriculum compared to no publications in clinical chemistry in the 5-year period before the new curriculum. Over the past 2 years, 6 of the 11 publications by graduating residents were in clinical chemistry, and 6 of 7 awards for research were garnered by residents engaged in clinical chemistry investigations. All of the residents passed their clinical pathology boards on first attempt since the change compared to 2 failures in the prior 5-year period. CONCLUSIONS The structured program described here is important as a template that could be adopted by any pathology training program. The question bank developed by this program is a valuable and transferable aid. However, success of such a program is dependent on the commitment of a knowledgeable, dedicated, and passionate teacher.
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Affiliation(s)
- Gurmukh Singh
- Department of Pathology, Medical College of Georgia at Augusta University, Augusta, GA
| | - Roni J Bollag
- Department of Pathology, Medical College of Georgia at Augusta University, Augusta, GA
| | - Natasha M Savage
- Department of Pathology, Medical College of Georgia at Augusta University, Augusta, GA
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Savage NM, Bollag R, Singh G. Inclusion and Diversity in Pathology Residency Training. J Appl Lab Med 2020; 6:304-306. [PMID: 33156913 DOI: 10.1093/jalm/jfaa170] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 08/31/2020] [Indexed: 11/13/2022]
Affiliation(s)
- Natasha M Savage
- Departments of Pathology.,Hematology and Hematopathology.,Pathology Residency Training Program
| | - Roni Bollag
- Departments of Pathology.,Department of Pathology, Transfusion Medicine Fellowship
| | - Gurmukh Singh
- Departments of Pathology.,Department of Clinical Pathology, Medical College of Georgia at Augusta University, Augusta, GA
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Bolliger D, Maurer M, Tanaka KA. Toward Optimal Anticoagulation Monitoring During Cardiopulmonary Bypass: It Is Still A Tough "ACT". J Cardiothorac Vasc Anesth 2020; 34:2928-2930. [PMID: 32741612 DOI: 10.1053/j.jvca.2020.07.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 07/06/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Daniel Bolliger
- Department for Anesthesia, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Markus Maurer
- Department for Anesthesia, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Kenichi A Tanaka
- Department of Anesthesiology, University of Maryland Medical Center, Baltimore, Maryland
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11
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Falter F, MacDonald S, Matthews C, Kemna E, Cañameres J, Besser M. Evaluation of Point-of-Care ACT Coagulometers and Anti-Xa Activity During Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2020; 34:2921-2927. [PMID: 32620484 DOI: 10.1053/j.jvca.2020.06.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 06/06/2020] [Accepted: 06/08/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The activated clotting time (ACT) is used worldwide to confirm safe heparin anticoagulation for cardiopulmonary bypass. For the present study, the performances of 2 commonly used ACT devices were compared with each other and with anti-Xa levels throughout the surgical procedure in order to understand whether they can be used interchangeably. DESIGN Prospective study. SETTING Tertiary care center. PARTICIPANTS The study comprised 33 elective adult cardiac surgical patients. INTERVENTIONS Blood samples were taken at standard times throughout the surgery (after induction, after heparin bolus, 4 samples at 30-minute intervals during cardiopulmonary bypass, after protamine), and ACTs and anti-Xa levels were analyzed. Data were compared using receiver operating characteristics and LOESS regression. MEASUREMENTS AND MAIN RESULTS The correlation between anti-Xa levels and the Hemochron ACT (Instrumentation Laboratory, Bedford, MA) was acceptable (r = 0.82, 95% confidence interval [CI] 0.757-0.868; p < 0.0001), as was the correlation between anti-Xa levels and the i-STAT (Abbott Point of Care, Abbott Park, IL) (r = 0.81, 95% CI 0.738-0.858; p < 0.0001). The correlation between the 2 ACT methods was poorer (r = 0.77, 95% CI 0.707-0.828; p < 0.0001) than their correlation to anti-Xa levels. When compared with anti-Xa levels, the sensitivity and specificity were mediocre for both devices, although the i-STAT performed better than the Hemochron ACT. The Hemochron ACT read higher values than the i-STAT ACT throughout the course of the surgery. CONCLUSION The correlation between the Hemochron ACT and i-STAT ACT is moderate, and they have different sensitivity and specificity when compared with anti-Xa levels. This suggests that ACT devices should not be used interchangeably, but cut-off values for safe anticoagulation during cardiopulmonary bypass should be determined for each type of device, particularly when switching supplier.
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Affiliation(s)
- Florian Falter
- Department of Anesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK.
| | - Stephen MacDonald
- Division of Clinical Haematology and Blood Transfusion, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Claire Matthews
- Division of Clinical Haematology and Blood Transfusion, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Evelien Kemna
- Medlon, Medisch Laboratorium Oost-Nederland, Enschede, The Netherlands
| | - José Cañameres
- Department of Clinical Perfusion, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Martin Besser
- Division of Clinical Haematology and Blood Transfusion, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Mazzeffi MA, Patel PA, Bolliger D, Erdoes G, Tanaka K. The Year in Coagulation: Selected Highlights From 2019. J Cardiothorac Vasc Anesth 2020; 34:1745-1754. [DOI: 10.1053/j.jvca.2020.01.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 01/27/2020] [Indexed: 12/26/2022]
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13
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Nair AB, Parker RI. Hemostatic Testing in Critically Ill Infants and Children. Front Pediatr 2020; 8:606643. [PMID: 33490001 PMCID: PMC7820389 DOI: 10.3389/fped.2020.606643] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 12/10/2020] [Indexed: 12/12/2022] Open
Abstract
Children with critical illness frequently manifest imbalances in hemostasis with risk of consequent bleeding or pathologic thrombosis. Traditionally, plasma-based tests measuring clot formation by time to fibrin clot generation have been the "gold standard" in hemostasis testing. However, these tests are not sensitive to abnormalities in fibrinolysis or in conditions of enhanced clot formation that may lead to thrombosis. Additionally, they do not measure the critical roles played by platelets and endothelial cells. An added factor in the evaluation of these plasma-based tests is that in infants and young children plasma levels of many procoagulant and anticoagulant proteins are lower than in older children and adults resulting in prolonged clot generation times in spite of maintaining a normal hemostatic "balance." Consequently, newer assays directly measuring thrombin generation in plasma and others assessing the stages hemostasis including clot initiation, propagation, and fibrinolysis in whole blood by viscoelastic methods are now available and may allow for a global measurement of the hemostatic system. In this manuscript, we will review the processes by which clots are formed and by which hemostasis is regulated, and the rationale and limitations for the more commonly utilized tests. We will also discuss selected newer tests available for the assessment of hemostasis, their "pros" and "cons," and how they compare to the traditional tests of coagulation in the assessment and management of critically ill children.
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Affiliation(s)
- Alison B Nair
- Pediatric Critical Care Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Robert I Parker
- Pediatric Hematology/Oncology, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, United States
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