1
|
Heubner L, Oertel R, Tiebel O, Mehlig-Warnecke N, Beyer-Westendorf J, Mirus M, Roessler M, Renner B, Spieth PM. Monitoring of Argatroban in Critically Ill Patients: A Prospective Study Comparing Activated Partial Thromboplastin Time, Point-of-Care Viscoelastic Testing with Ecarin Clotting Time and Diluted Thrombin Time to Mass Spectrometry. Anesthesiology 2024; 140:261-271. [PMID: 37787760 DOI: 10.1097/aln.0000000000004787] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
BACKGROUND The direct thrombin inhibitor argatroban is indicated for the treatment of heparin-induced thrombocytopenia II, but it is also used off-label to treat critically ill patients presenting with heparin resistance, severe antithrombin deficiency, or hypercoagulability. Direct drug monitoring is not routinely available, and argatroban dosing is mainly based on global coagulation assays such as activated partial thromboplastin time (PTT) or diluted thrombin time (TT), both of which have limitations in patients with hypercoagulability. METHODS Blood samples were obtained from critically ill patients treated with argatroban. Activated PTT and diluted TT were measured with a STA R Max3 analyzer (STAGO Deutschland GmbH, Germany) using an argatroban-calibrated kit. Ecarin clotting time was measured using a point-of-care viscoelastic test device. Liquid chromatography with tandem mass spectrometry was performed using a reversed-phase column, a solvent gradient, and an API4000 mass spectrometer with electrospray. Correlation was described using Pearson correlation coefficient r and Bayesian multilevel regression to estimate relationships between outcomes and covariates. RESULTS From June 2021 to March 2022, 205 blood samples from 22 patients were analyzed, allowing for 195 activated PTT-liquid chromatography with tandem mass spectrometry comparisons, 153 ecarin clotting time-liquid chromatography with tandem mass spectrometry comparison, and 105 diluted TT-liquid chromatography with tandem mass spectrometry comparisons. Compared to liquid chromatography with tandem mass spectrometry, performance of argatroban quantification was best for diluted TT (r = 0.91), followed by ecarin clotting time (r = 0.58) and activated PTT (r = 0.48). Regression analysis revealed that patients with sepsis were more prone to argatroban overdosing (coefficient, 4.194; 95% credible interval, 2.220 to 6.792). CONCLUSIONS Although activated PTT monitoring of argatroban is the most commonly used test, in critically ill patients, diluted TT provides more precise measurements. Alternately, point-of-care viscoelastic ecarin clotting time also provides guidance for argatroban dosing to identify overdosing if available. The data also suggested that patients with sepsis are at greater risk for argatroban overdosing. EDITOR’S PERSPECTIVE
Collapse
Affiliation(s)
- Lars Heubner
- Department of Anesthesiology and Intensive Care Medicine, University Hospital "Carl Gustav Carus," Technische Universität Dresden, Dresden, Germany
| | - Reinhard Oertel
- Institute of Clinical Pharmacology, Faculty of Medicine, University Hospital "Carl Gustav Carus," Technische Universität Dresden, Dresden, Germany
| | - Oliver Tiebel
- Institute of Clinical Chemistry, University Hospital "Carl Gustav Carus," Technische Universität Dresden, Dresden, Germany
| | - Nicole Mehlig-Warnecke
- Department of Anesthesiology and Intensive Care Medicine, University Hospital "Carl Gustav Carus," Technische Universität Dresden, Dresden, Germany
| | - Jan Beyer-Westendorf
- Division of Hematology and Hemostasis, Department of Medicine I Thrombosis Research, University Hospital "Carl Gustav Carus," Technische Universität Dresden, Dresden, Germany
| | - Martin Mirus
- Department of Anesthesiology and Intensive Care Medicine, University Hospital "Carl Gustav Carus", Technische Universität Dresden, Dresden, Germany
| | - Martin Roessler
- BARMER Institut für Gesundheitssystemforschung, Berlin, Germany
| | - Bertold Renner
- Institute of Clinical Pharmacology, Faculty of Medicine, University Hospital "Carl Gustav Carus," Technische Universität Dresden, Dresden, Germany
| | - Peter Markus Spieth
- Department of Anesthesiology and Intensive Care Medicine, University Hospital "Carl Gustav Carus," Technische Universität Dresden, Dresden, Germany
| |
Collapse
|
2
|
Heubner L, Vicent O, Beyer-Westendorf J, Spieth PM. Bleeding management in patients with direct oral anticoagulants. Minerva Anestesiol 2023; 89:707-715. [PMID: 37079285 DOI: 10.23736/s0375-9393.23.17230-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Abstract
Bleeding events in patients under direct oral anticoagulation (DOAC) can be life-threating but are commonly not related to drug overdose. However, a relevant DOAC plasma concentration impairs the hemostasis and should therefore be ruled out immediately after hospital admission. The effect of DOAC is typically not visible in standard coagulation tests such as activated partial thrombin time or thromboplastin time. Specific anti-Xa or anti-IIa assays allow a specific drug monitoring, but they are too time-consuming in critical bleeding events and typically not available 24 h/7 d in routine care. Recent advantages in point-of-care (POC) testing might improve patient care by early exclusion of relevant DOAC levels, but sufficient validation is still lacking. POC urine analysis help to exclude DOAC in emergency patients, but does not provide a quantitative information about plasma concentration. POC viscoelastic testing (VET) can determine the DOAC effect on clotting time and helps further to reveal other concomitant bleeding disorders in emergency, e.g., factor deficiency or hyperfibrinolysis. If a relevant plasma concentration of the DOAC is assumed or was proven by either laboratory assays or POC testing, restoration of factor IIa or factor IIa activity is key for effective hemostasis. Limited evidence suggests that specific reversals for DOAC, e.g., idarucizumab for dabigatran and andexanet alfa for apixaban or rivaroxaban, might be superior to increasing thrombin generation by administration of prothrombin complex concentrates. To determinate, if DOAC reversal is indicated or not, time from last intake, anti-Xa/dTT values or results from POC tests can be considered. This experts' opinion provides a feasible decision algorithm for clinical practice.
Collapse
Affiliation(s)
- Lars Heubner
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden (TU Dresden), Dresden, Germany -
| | - Oliver Vicent
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden (TU Dresden), Dresden, Germany
| | - Jan Beyer-Westendorf
- Unit of Thrombosis Research, Division of Hematology and Hemostasis, Department of Medicine I, University Hospital Carl Gustav Carus, Technische Universität Dresden (TU Dresden), Dresden, Germany
| | - Peter M Spieth
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden (TU Dresden), Dresden, Germany
| |
Collapse
|
3
|
Beyer-Westendorf J, Köhler C. Direct Oral Anticoagulants: Laboratory Challenges and Antidotes. Hamostaseologie 2023; 43:37-43. [PMID: 36807818 DOI: 10.1055/a-1987-3559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
The use of direct oral anticoagulants (DOACs) is increasing in patients needing treatment of venous thromboembolism (VTE) and stroke prevention in atrial fibrillation (SPAF). This is due to the net clinical benefit in comparison to vitamin K antagonists (VKAs). The rise in DOAC use is accompanied by a remarkable reduction in heparin and VKA prescriptions. However, this rapid change in anticoagulation patterns brought new challenges to patients, prescribers, laboratories, and emergency physicians. Patients have new liberties concerning nutritional habits and comedication and no longer need frequent monitoring or dose adjustments. Still, they have to comprehend that DOACs are potent anticoagulants that may cause or contribute to bleeding. Challenges for the prescriber include decision pathways for choosing the right anticoagulant and dosage for a specific patient and to change bridging practice in case of invasive procedures. Laboratory personnel are challenged by DOAC due to limited 24/7 availability of specific DOAC quantification tests and by the impact of DOAC on routine coagulation assays and thrombophilia tests. Challenges for the emergency physician result from the increasing age of DOAC anticoagulated patients, the difficulties to establish last intake of DOAC type and dosage, to interpret coagulation test results in emergency situations, and to make decisions for or against DOAC reversal strategies in acute bleeding or urgent surgery. In conclusion, although DOACs make long-term anticoagulation safer and more convenient for patients, DOACs pose challenge to all healthcare providers involved in anticoagulation decisions. The key to correct patient management and optimal outcome therefore lies in education.
Collapse
Affiliation(s)
- Jan Beyer-Westendorf
- Department of Medicine I, Universitätsklinikum "Carl Gustav Carus," Dresden, Germany
| | - Christina Köhler
- Department of Medicine I, Universitätsklinikum "Carl Gustav Carus," Dresden, Germany
| |
Collapse
|
4
|
Schröder TA, Leonhardt H, Haim D, Bräuer C, Papadopoulos KK, Vicent O, Güldner A, Mirus M, Schmidt J, Held HC, Tiebel O, Birkner T, Beyer-Westendorf J, Lauer G, Spieth PM, Koch T, Heubner L. Enhancing Anticoagulation Monitoring and Therapy in Patients Undergoing Microvascular Reconstruction in Maxillofacial Surgery: A Prospective Observational Trial. J Pers Med 2022; 12:jpm12081229. [PMID: 36013177 PMCID: PMC9410460 DOI: 10.3390/jpm12081229] [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: 06/13/2022] [Revised: 07/22/2022] [Accepted: 07/25/2022] [Indexed: 11/16/2022] Open
Abstract
Background: In reconstructive surgery, loss of a microvascular free flap due to perfusion disorders, especially thrombosis, is a serious complication. In recent years, viscoelastic testing (VET) has become increasingly important in point-of-care (POC) anticoagulation monitoring. This paper describes a protocol for enhanced anticoagulation monitoring during maxillofacial flap surgery. Objective: The aim of the study will be to evaluate, in a controlled setting, the predictive value of POC devices for the type of flap perfusion disorders due to thrombosis or bleeding. VET, Platelet monitoring (PM) and standard laboratory tests (SLT) are comparatively examined. Methods/Design: This study is an investigator-initiated prospective trial in 100 patients undergoing maxillofacial surgery. Patients who undergo reconstructive surgery using microvascular-free flaps will be consecutively enrolled in the study. All patients provide blood samples for VET, PM and SLT at defined time points. The primary outcome is defined as free flap loss during the hospital stay. Statistical analyses will be performed using t-tests, including the Bonferroni adjustment for multiple comparisons. Discussion: This study will help clarify whether VET can improve individualized patient care in reconstruction surgery. A better understanding of coagulation in relation to flap perfusion disorders may allow real-time adaption of antithrombotic strategies and potentially prevent flap complications.
Collapse
Affiliation(s)
- Tom A. Schröder
- Department of Oral and Maxillofacial Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany; (T.A.S.); (H.L.); (D.H.); (C.B.); (K.K.P.); (G.L.)
| | - Henry Leonhardt
- Department of Oral and Maxillofacial Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany; (T.A.S.); (H.L.); (D.H.); (C.B.); (K.K.P.); (G.L.)
| | - Dominik Haim
- Department of Oral and Maxillofacial Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany; (T.A.S.); (H.L.); (D.H.); (C.B.); (K.K.P.); (G.L.)
| | - Christian Bräuer
- Department of Oral and Maxillofacial Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany; (T.A.S.); (H.L.); (D.H.); (C.B.); (K.K.P.); (G.L.)
| | - Kiriaki K. Papadopoulos
- Department of Oral and Maxillofacial Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany; (T.A.S.); (H.L.); (D.H.); (C.B.); (K.K.P.); (G.L.)
| | - Oliver Vicent
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany; (O.V.); (A.G.); (M.M.); (J.S.); (P.M.S.); (T.K.)
| | - Andreas Güldner
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany; (O.V.); (A.G.); (M.M.); (J.S.); (P.M.S.); (T.K.)
| | - Martin Mirus
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany; (O.V.); (A.G.); (M.M.); (J.S.); (P.M.S.); (T.K.)
| | - Jürgen Schmidt
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany; (O.V.); (A.G.); (M.M.); (J.S.); (P.M.S.); (T.K.)
| | - Hanns C. Held
- Department of General, Thoracic and Vascular Surgery, Carl Gustav Carus Faculty of Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany;
| | - Oliver Tiebel
- Institute of Clinical Chemistry, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany;
| | - Thomas Birkner
- Center for Evidence-Based Healthcare (ZEGV), Carl Gustav Carus Faculty of Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany;
| | - Jan Beyer-Westendorf
- Division of Hematology and Hemostasis, Department of Medicine I, Thrombosis Research University Hospital “Carl Gustav Carus”, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany;
| | - Günter Lauer
- Department of Oral and Maxillofacial Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany; (T.A.S.); (H.L.); (D.H.); (C.B.); (K.K.P.); (G.L.)
| | - Peter M. Spieth
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany; (O.V.); (A.G.); (M.M.); (J.S.); (P.M.S.); (T.K.)
| | - Thea Koch
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany; (O.V.); (A.G.); (M.M.); (J.S.); (P.M.S.); (T.K.)
| | - Lars Heubner
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany; (O.V.); (A.G.); (M.M.); (J.S.); (P.M.S.); (T.K.)
- Correspondence: ; Tel.: +49-351-45811660
| |
Collapse
|