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Rim G, Hyun K, Cho DG, Lim Z, Lee B, Kim K, Yoo GY. Early thrombus detection in the extracorporeal membrane oxygenation circuit by noninvasive real-time ultrasonic sensors. Sci Rep 2024; 14:10438. [PMID: 38714704 DOI: 10.1038/s41598-024-59873-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 04/16/2024] [Indexed: 05/10/2024] Open
Abstract
Thrombus formation in extracorporeal membrane oxygenation (ECMO) remains a major concern as it can lead to fatal outcomes. To the best of our knowledge, there is no standard non-invasive method for quantitatively measuring thrombi. This study's purpose was to verify thrombus detection in an ECMO circuit using novel, non-invasive ultrasonic sensors in real-time, utilizing the fact that the ultrasonic velocity in a thrombus is known to be higher than that in the blood. Ultrasonic sensors with a customized chamber, an ultrasonic pulse-receiver, and a digital storage oscilloscope (DSO) were used to set up the measuring unit. The customized chamber was connected to an ECMO circuit primed with porcine blood. Thrombi formed from static porcine blood were placed in the circuit and ultrasonic signals were extracted from the oscilloscope at various ECMO flow rates of 1-4 L/min. The ultrasonic signal changes were successfully detected at each flow rate on the DSO. The ultrasonic pulse signal shifted leftward when a thrombus passed between the two ultrasonic sensors and was easily detected on the DSO screen. This novel real-time non-invasive thrombus detection method may enable the early detection of floating thrombi in the ECMO system and early management of ECMO thrombi.
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Affiliation(s)
- Gongmin Rim
- Department of Thoracic and Cardiovascular Surgery, The Catholic University of Korea, St. Vincent's Hospital, 93 Jungbu-Daero, Paldal-gu, Suwon-si, Gyeonggi-do, 16247, Republic of Korea
| | - Kwanyong Hyun
- Department of Thoracic and Cardiovascular Surgery, The Catholic University of Korea, St. Vincent's Hospital, 93 Jungbu-Daero, Paldal-gu, Suwon-si, Gyeonggi-do, 16247, Republic of Korea.
| | - Deog Gon Cho
- Department of Thoracic and Cardiovascular Surgery, The Catholic University of Korea, St. Vincent's Hospital, 93 Jungbu-Daero, Paldal-gu, Suwon-si, Gyeonggi-do, 16247, Republic of Korea.
| | | | - Byungdoo Lee
- Department of Thoracic and Cardiovascular Surgery, The Catholic University of Korea Seoul St. Mary's Hospital, Seoul, Republic of Korea
| | - Keunho Kim
- Department of Thoracic and Cardiovascular Surgery, The Catholic University of Korea Seoul St. Mary's Hospital, Seoul, Republic of Korea
| | - Ga Young Yoo
- Department of Thoracic and Cardiovascular Surgery, The Catholic University of Korea Seoul St. Mary's Hospital, Seoul, Republic of Korea
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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] [What about the content of this article? (0)] [Affiliation(s)] [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
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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
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Levy JH, Sniecinski RM, Rocca B, Ghadimi K, Douketis J, Frere C, Helms J, Iba T, Koster A, Lech TK, Maier CL, Neal MD, Scarlestscu E, Spyropoulos A, Steiner ME, Tafur AJ, Tanaka KA, Connors JM. Defining heparin resistance: communication from the ISTH SSC Subcommittee of Perioperative and Critical Care Thrombosis and Hemostasis. J Thromb Haemost 2023; 21:3649-3657. [PMID: 37619694 DOI: 10.1016/j.jtha.2023.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/09/2023] [Accepted: 08/10/2023] [Indexed: 08/26/2023]
Abstract
The term heparin resistance (HR) is used by clinicians without specific criteria. We performed a literature search and surveyed our SSC membership to better define the term when applied to medical and intensive care unit patients. The most common heparin dosing strategy reported in the literature (53%) and by survey respondents (80.4%) was the use of weight-based dosing. Heparin monitoring results were similar based on the proportion of publications and respondents that reported the use of anti-Xa and activated partial thromboplastin time. The most common literature definition of HR was >35 000 U/d, but no consensus was reported among survey respondents regarding weight-based and the total dose of heparin when determining resistance. Respondent consensus on treating HR included antithrombin supplementation, direct thrombin inhibitors, or administering more heparin as the strategies available for treating HR. A range of definitions for HR exist. Given the common use of heparin weight-based dosing, future publications employing the term HR should include weight-based definitions, monitoring assay, and target level used. Further work is needed to develop a consensus for defining HR.
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Affiliation(s)
- Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, North Carolina, USA.
| | - Roman M Sniecinski
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Bianca Rocca
- Department of Safety and Bioethics-Section of Pharmacology, Catholic University School of Medicine, Rome, Italy
| | - Kamrouz Ghadimi
- Department of Anesthesiology, Divisions of Cardiothoracic Anesthesiology and Critical Care Medicine, Clinical Research Unit, Duke University School of Medicine, Durham, North Carolina, USA
| | - James Douketis
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Corinne Frere
- UMRS 1166, Sorbonne Université, Pitié-Salpêtrière Hospital, Paris, France
| | - Julie Helms
- University Hospital, Medical Intensive Care Unit, Nouvel Hôpital Civil, Strasbourg, France; French National Institute of Health and Medical Research, UMR 1260, Regenerative Nanomedicine, FMTS, Strasbourg, France
| | - Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Andreas Koster
- Institute of Anesthesiology and Pain Therapy, Heart and Diabetes Center NRW, Ruhr University of Bochum, Bad Oeynhausen, Germany
| | - Tara K Lech
- Division of Pharmacy, Beth Israel Lahey Health, Westwood, Massachusetts, USA
| | - Cheryl L Maier
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Mathew D Neal
- Department of Surgery, Trauma and Transfusion Medicine Research Center, University of Pittsburgh, Pittsburgh, USA
| | - Ecatarina Scarlestscu
- Department of Anaesthesia and Intensive Care, Fundeni Clinical Institute, University of Medicine and Pharmacy "Carol Davila," Bucharest, Bucharest, Romania
| | - Alex Spyropoulos
- Department of Medicine, Anticoagulation and Clinical Thrombosis Service, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA; Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Marie E Steiner
- Department of Pediatrics, Divisions of Hematology/Oncology and Critical Care, University of Minnesota, Minneapolis, Minnesota, USA
| | - Alfonso J Tafur
- Department of Medicine, Vascular Medicine, NorthShore University Health System, Evanston, Illinois, USA; Pritzker School of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Kenichi A Tanaka
- Department of Anesthesiology, University of Oklahoma School of Medicine, Oklahoma City, Oklahoma, USA
| | - Jean M Connors
- Hematology Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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5
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Saito T, Hayakawa M, Kumano O, Honma Y, Murashita M, Kato J, Fukui S, Takahashi M, Takahashi Y, Tsuchida T, Mizugaki A, Takauji S, Hayamizu M, Yoshida T, Katabami K, Wada T, Maekawa K. Variation in coagulation factor activity levels cause discrepancies between activated partial thromboplastin time and anti-Xa activity for heparin monitoring: a retrospective observational study. J Intensive Care 2023; 11:54. [PMID: 37974289 PMCID: PMC10652491 DOI: 10.1186/s40560-023-00701-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 11/03/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Unfractionated heparin (UFH) is primarily monitored using activated partial thromboplastin time (APTT). However, the recent introduction of anti-activated factor X (anti-Xa) activity testing has provided a direct evaluation of Xa inhibition by anticoagulants. This study aimed to investigate discrepancies between APTT and anti-Xa activity during UFH monitoring in critically ill patients and explore their underlying causes. METHODS This study analyzed 271 pairs of laboratory test results from blood samples of 99 critically ill patients receiving continuous intravenous UFH. Theoretical APTT values were calculated using fitted curve equations from spiked sample measurements with anti-Xa activity. Samples were categorized into three groups based on the measurement of the APTT/theoretical APTT ratio: the lower group (< 80%), the concordant group (80-120%), and the upper group (> 120%). RESULTS The overall concordance rate between APTT and anti-Xa activity was 45%, with a 55% discrepancy rate. The lower group frequently showed apparent heparin overdoses, while coagulation factor activities in the lower and upper groups were higher and lower, respectively, than those in the concordant group. Particularly, the lower group exhibited higher factor VIII activity levels than the upper and concordant groups. CONCLUSIONS Discrepancies between APTT and anti-Xa activity were frequently observed, influenced by changes in coagulation factors activity levels. The lower and upper groups were classified as pseudo-heparin-resistant and coagulopathy types, respectively. Accurate monitoring of heparin in critically ill patients is crucial, especially in cases of pseudo-heparin resistance, where APTT values may wrongly indicate inadequate heparin dosing despite sufficient anti-Xa activity. Understanding these discrepancies is important for managing heparin therapy in critically ill patients. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Tomoyo Saito
- Emergency and Critical Care Center, Hokkaido University Hospital, Sapporo, Japan
| | - Mineji Hayakawa
- Emergency and Critical Care Center, Hokkaido University Hospital, Sapporo, Japan.
| | - Osamu Kumano
- Health and Medical Research Institute, National Institute of Advanced Industrial Science and Technology (AIST), Takamatsu, Japan
| | - Yoshinori Honma
- Emergency and Critical Care Center, Hokkaido University Hospital, Sapporo, Japan
| | - Mone Murashita
- Emergency and Critical Care Center, Hokkaido University Hospital, Sapporo, Japan
| | - Jun Kato
- Emergency and Critical Care Center, Hokkaido University Hospital, Sapporo, Japan
| | - Syouki Fukui
- Emergency and Critical Care Center, Hokkaido University Hospital, Sapporo, Japan
| | - Masaki Takahashi
- Emergency and Critical Care Center, Hokkaido University Hospital, Sapporo, Japan
| | - Yuki Takahashi
- Emergency and Critical Care Center, Hokkaido University Hospital, Sapporo, Japan
| | - Takumi Tsuchida
- Emergency and Critical Care Center, Hokkaido University Hospital, Sapporo, Japan
| | - Asumi Mizugaki
- Emergency and Critical Care Center, Hokkaido University Hospital, Sapporo, Japan
| | - Shuhei Takauji
- Emergency and Critical Care Center, Hokkaido University Hospital, Sapporo, Japan
| | - Mariko Hayamizu
- Emergency and Critical Care Center, Hokkaido University Hospital, Sapporo, Japan
| | - Tomonao Yoshida
- Emergency and Critical Care Center, Hokkaido University Hospital, Sapporo, Japan
| | - Kenichi Katabami
- Emergency and Critical Care Center, Hokkaido University Hospital, Sapporo, Japan
| | - Takeshi Wada
- Emergency and Critical Care Center, Hokkaido University Hospital, Sapporo, Japan
| | - Kunihiko Maekawa
- Emergency and Critical Care Center, Hokkaido University Hospital, Sapporo, Japan
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6
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Scott EJ, Rotar E, Dahl JJ, Beller JP, Money DT, Chancellor WZ, Mehaffey JH, Morisette M, Yarboro LT, Teman NR. Discordance among assays for monitoring? Anticoagulation during extracorporeal life support. Perfusion 2023; 38:1714-1721. [PMID: 36167522 DOI: 10.1177/02676591221129741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The optimal method for monitoring of anticoagulation in patients on extracorporeal life support (ECLS) is unknown. The objective of this study was to assess the relationship between anti-factor Xa level (anti-Xa; IU/mL) and activated partial thromboplastin time (aPTT; seconds) for monitoring intravenous unfractionated heparin anticoagulation in adult ECLS patients. METHODS Charts of all adult patients cannulated for ECLS from 2015 through 2017 were reviewed and laboratory and heparin infusion data were extracted for analysis. Time matched pairs of anti-Xa and aPTT were considered concordant if both laboratory values were within the same clinically utilized range. A hierarchical logistic regression model was used to determine factors associated with discordance while accounting for patient level effects. RESULTS A total of 1016 paired anti-Xa and aPTT values from 65 patients were evaluated. 500 (49.2%) paired samples were discordant with a degree of variability on linear regression (r2 = 0.315). The aPTT fell into a higher therapeutic range compared to the anti-Xa in 31.6% and lower in 17.3%. Logistic regression demonstrated that discordance was independently associated with time from initiation of ECLS (OR 1.17 per day, p < 0.001), average heparin infusion rate (OR 1.25 per U/kg/hr, p < 0.001), and INR (OR 3.22, p < 0.001). CONCLUSIONS Nearly half of all aPTT and anti-Xa values were in discordant ranges and discordance is more likely as the time on ECLS and the INR level increase. The use of either assay in isolation to guide heparin anticoagulation may lead to misestimation of the degree of anticoagulation in complex ECLS patients.
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Affiliation(s)
- Erik J Scott
- Division of Cardiac Surgery, Health System University of Virginia, Charlottesville, VA, USA
| | - Evan Rotar
- Division of Cardiac Surgery, Health System University of Virginia, Charlottesville, VA, USA
| | - Jolian J Dahl
- Division of Cardiac Surgery, Health System University of Virginia, Charlottesville, VA, USA
| | - Jared P Beller
- Division of Cardiac Surgery, Health System University of Virginia, Charlottesville, VA, USA
| | | | - W Z Chancellor
- Division of Cardiac Surgery, Health System University of Virginia, Charlottesville, VA, USA
| | - J H Mehaffey
- Division of Cardiac Surgery, Health System University of Virginia, Charlottesville, VA, USA
| | | | - Leora T Yarboro
- Division of Cardiac Surgery, Health System University of Virginia, Charlottesville, VA, USA
| | - Nicholas R Teman
- Division of Cardiac Surgery, Health System University of Virginia, Charlottesville, VA, USA
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7
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Shinn G, Berger K, Roh D, Doyle K, Boehme AK, Connolly ES, Park S, Agarwal S, Claassen J, Der-Nigoghossian C. Concordance Between Active Partial Thromboplastin Time and Anti-Factor Xa Assays in Neurocritically Ill Patients Receiving Subcutaneous Heparin Prophylaxis. Neurohospitalist 2023; 13:221-227. [PMID: 37441213 PMCID: PMC10334062 DOI: 10.1177/19418744231159917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/15/2023] Open
Abstract
Background Laboratory monitoring is not recommended when subcutaneous unfractionated heparin (SQ-UFH) is administered at prophylactic doses. However, aPTT prolongation and associated hemorrhage has been reported in the neurocritically ill. At our institution, Neuroscience Intensive Care Unit (Neuro-ICU) patients with prolonged aPTT are further evaluated with a follow up aPTT and anti-factor Xa. Purpose The purpose of this study was to describe concordance between aPTT and anti-factor Xa in neurocritically ill patients receiving prophylactic SQ-UFH with evidence of aPTT prolongation. Methods A retrospective chart review of adult patients admitted to the Neuro-ICU from June 2017 to June 2019 was performed. Patients were included if they received SQ-UFH with aPTT levels and at least one anti-factor Xa level drawn within one hour of each other. Concordance between paired aPTT and anti-factor Xa was evaluated using Cohen's weighted kappa. Results Forty two patients with 56 paired aPTT and anti-factor Xa levels were included. The most prescribed SQ-UFH regimen was 5000 units every 8 hours (60.7%) and anti-factor Xa levels were drawn a median (IQR) of 5.7 (3.1-10.7) hours after the SQ-UFH dose. Only 16 (28.6%) pairs were in concordance. The analysis showed a weighted kappa of .09; 95% CI [-.05 to .22] indicating poor agreement. Conclusions In neurocritically ill patients receiving prophylactic SQ-UFH with aPTT prolongation, there was poor concordance between aPTT and anti-factor Xa. This suggests that aPTT prolongation may not be solely driven by heparin activity and further evaluation of mechanistic drivers for coagulopathy in this population is necessary.
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Affiliation(s)
- Grace Shinn
- Department of Pharmacy, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - Karen Berger
- Department of Pharmacy, NewYork-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY, USA
| | - David Roh
- Department of Neurology, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - Kevin Doyle
- Department of Neurology, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - Amelia K. Boehme
- Department of Neurology, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - Edward Sander Connolly
- Department of Neurosurgery, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - Soojin Park
- Department of Neurology, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - Sachin Agarwal
- Department of Neurology, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - Jan Claassen
- Department of Neurology, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - Caroline Der-Nigoghossian
- Department of Pharmacy, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
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8
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Safani M, Appleby S, Chiu R, Favaloro EJ, Ferro ET, Johannes J, Sheth M. Application of anti-Xa assay in monitoring unfractionated heparin therapy in contemporary antithrombotic management. Expert Rev Hematol 2023; 16:1-8. [PMID: 36637400 DOI: 10.1080/17474086.2023.2169126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Unfractionated heparin remains the most widely used agent in the prevention and acute treatment of thrombosis. Pharmacological complexities of this intriguing agent mandate frequent monitoring of its anticoagulant properties to maintain safe and effective hematological outcomes. Although activated partial thromboplastin time has been the standard test to monitor unfractionated heparin therapy for many decades, the anti-Xa assay has emerged as a substitute or adjunct in many institutions. AREAS COVERED This brief report outlines the key features of anti-Xa assay in monitoring unfractionated heparin in acute management of thrombosis in various contemporary settings, with emphasis on evidence for clinical outcomes. PubMed.gov database was utilized to obtain the pertinent literature. EXPERT OPINION The anti-Xa activity is primarily a reflection of UFH concentration and does not account for other hematological variables frequently present in contemporary anticoagulation management. The advantage of the anti-Xa assay in monitoring UFH therapy is predicated upon its limitations to account for global physiological hemostasis. There are significant disease and drug interactions that may potentially result in false in-vitro analysis of anti-Xa activity. Routine application of the anti-Xa assay is not evidence-based at this time.
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Affiliation(s)
- Michael Safani
- MemorialCare Heart & Vascular Institute Long Beach, CA, USA.,University of California, San Francisco, CA, USA
| | - Steve Appleby
- Interventional Cardiology, Memorial Care Heart and Vascular Institute, Long Beach, CA, USA
| | - Ryan Chiu
- Cardiovascular Surgery, MemorialCare Heart & Vascular Institute Long Beach, CA, USA
| | - Emmanuel J Favaloro
- Institute of Clinical Pathology and Medical Research, Westmead Hospital, Australia.,School of Medical Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, Australia.,School of Dentistry and Medical Sciences, Faculty of Science and Health, Charles Sturt University, Australia.,Sydney Centres for Thrombosis and Haemostasis, Westmead Hospital, Westmead, NSW, Australia
| | | | - Jimmy Johannes
- Critical Care & Pulmonary Medicine, Memorial Care Long Beach, CA, USA
| | - Milan Sheth
- Hematology, Department of Medicine MemorialCare Long Beach, CA, USA
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Billoir P, Elie T, Levy JH, Besnier E, Dureuil B, Veber B, Le Cam-Duchez V, Clavier T. Anticoagulation Monitoring with Activated Partial ThromboPlastin Time and Anti-Xa Activity in Intensive Care Unit Patients: Interest of Thrombin Generation Assay. Int J Mol Sci 2022; 23. [PMID: 36232517 DOI: 10.3390/ijms231911219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 09/20/2022] [Accepted: 09/22/2022] [Indexed: 11/30/2022] Open
Abstract
Current guidelines recommend monitoring the anticoagulant effect of unfractionated heparin (UFH) by measuring anti-Xa activity rather than activated partial thromboplastin time (aPTT) in intensive care unit (ICU) patients. The primary objective of this study was to evaluate the correlation of aPTT, anti-Xa activity, and thrombin generation in UFH-treated ICU patients. A prospective observational pilot study was conducted in adult surgical ICU patients treated with UFH. aPTT and anti-Xa activity were monitored daily. The therapeutic target was aPTT between 50 s and 84 s, and/or anti-Xa between 0.3 and 0.7 U/mL. Correlation among aPTT, anti-Xa activity, and thrombin generation was determined by measuring endogenous thrombin potential (ETP), with the inflammatory response evaluated. C-reactive protein (CRP) was used as a marker of inflammatory response. The plasma of 107 samples from 30 ICU patients was analyzed. The correlation between aPTT and anti-Xa activity was 0.66, CI95% [0.54;0.76] (p < 0.0001). Although thrombin generation, aPTT, and anti-Xa were correlated with inflammatory responses, the correlation was higher with thrombin generation and anti-Xa activity compared to aPTT. When aPTT was in a therapeutic range, a low thrombin generation was observed but was 50% inhibited when anti-Xa was in a therapeutic range. Coagulation testing with aPTT, anti-Xa correlated with thrombin generation. A 50% decrease in thrombin generation was observed when anti-Xa was within a therapeutic range. Further work is needed to evaluate coagulation biomarker responses and clinical outcomes in specific ICU populations.
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10
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Apipongrat D, Police P, Lamool R, Butthep P, Chantkran W. Validation of high concentrated thrombin time assay for unfractionated heparin monitoring. J Clin Lab Anal 2022; 36:e24695. [PMID: 36099012 PMCID: PMC9550976 DOI: 10.1002/jcla.24695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 05/31/2022] [Accepted: 08/29/2022] [Indexed: 11/24/2022] Open
Abstract
Background The high concentrated thrombin time (hcTT), a thrombin time modified by increasing the thrombin concentration, is a possible alternative assay to activated partial thromboplastin time (aPTT) in unfractionated heparin (UFH) monitoring. This study aimed to determine the optimal thrombin concentration used in the hcTT assay for UFH monitoring. Methods A total of 30 blood samples obtained from healthy volunteers were included in this study. Thrombin concentrations of 10.0, 15.0, 20.0, and 25.0 IU/ml were used in the hcTT assay. The consistency between the hcTT and anti‐FXa assays was evaluated. To validate the hcTT assay, linearity, repeatability, reproducibility, and diagnostic performance of the assay were assessed. Results The hcTT assay using thrombin concentration of 15.0 IU/ml showed a strong correlation to the anti‐FXa assay with R2 of 0.72 and the Spearman's correlation coefficient (rs) of 0.97 (95% CI, 0.96–0.98). Within‐run and day‐to‐day run variabilities of the assay were satisfactory (all coefficients of variation <10%). We found an excellent correlation between the results which were measured using different reagents with intra‐ or inter‐laboratory instruments. Notably, as compared to the aPTT assay, the hcTT assay showed a significantly better performance in identifying the samples which contain UFH at the supratherapeutic level, with an AUC of 0.97 vs. 0.91, p = 0.049. Conclusion The hcTT assay can be used as an alternative assay for UFH therapy monitoring. A further study using clinical samples is recommended to confirm the appropriateness of the hcTT assay for clinical application.
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Affiliation(s)
- Dollapak Apipongrat
- Division of Hematology, Department of Medicine, Phramongkutklao Hospital, Bangkok, Thailand
| | - Pornnapa Police
- Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Rattapan Lamool
- Division of Hematology, Department of Medicine, Phramongkutklao Hospital, Bangkok, Thailand
| | - Punnee Butthep
- Department of Medical Technology, Faculty of Allied Health Sciences, Pathumthani University, Pathumthani, Thailand
| | - Wittawat Chantkran
- Department of Pathology, Phramongkutklao College of Medicine, Bangkok, Thailand
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11
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Neunert C, Chitlur M, van Ommen CH. The Changing Landscape of Anticoagulation in Pediatric Extracorporeal Membrane Oxygenation: Use of the Direct Thrombin Inhibitors. Front Med (Lausanne) 2022; 9:887199. [PMID: 35872781 PMCID: PMC9299072 DOI: 10.3389/fmed.2022.887199] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 06/10/2022] [Indexed: 11/13/2022] Open
Abstract
Bleeding and thrombosis frequently occur in pediatric patients with extracorporeal membrane oxygenation (ECMO) therapy. Until now, most patients are anticoagulated with unfractionated heparin (UFH). However, heparin has many disadvantages, such as binding to other plasma proteins and endothelial cells in addition to antithrombin, causing an unpredictable response, challenging monitoring, development of heparin resistance, and risk of heparin-induced thrombocytopenia (HIT). Direct thrombin inhibitors (DTIs), such as bivalirudin and argatroban, might be a good alternative. This review will discuss the use of both UFH and DTIs in pediatric patients with ECMO therapy.
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Affiliation(s)
- Cindy Neunert
- Department of Pediatrics, Columbia University Medical Center, New York, NY, United States
| | - Meera Chitlur
- Division of Hematology, Oncology, Carmen and Ann Adams Department of Pediatrics, Children’s Hospital of Michigan, Central Michigan University, Detroit, MI, United States
- *Correspondence: Cornelia Heleen van Ommen,
| | - Cornelia Heleen van Ommen
- Department of Pediatric Hematology and Oncology, Erasmus Medical Center University Medical Center Sophia Children’s Hospital, Rotterdam, Netherlands
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12
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Lardinois B, Hardy M, Michaux I, Horlait G, Rotens T, Jacqmin H, Lessire S, Bulpa P, Dive A, Mullier F. Monitoring of Unfractionated Heparin Therapy in the Intensive Care Unit Using a Point-of-Care aPTT: A Comparative, Longitudinal Observational Study with Laboratory-Based aPTT and Anti-Xa Activity Measurement. J Clin Med 2022; 11. [PMID: 35268436 DOI: 10.3390/jcm11051338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 02/20/2022] [Accepted: 02/26/2022] [Indexed: 12/18/2022] Open
Abstract
Continuous intravenous unfractionated heparin (UFH) is administered routinely in the intensive care unit (ICU) for the anticoagulation of patients, and monitoring is performed by the activated partial thromboplastin time (APTT) or anti-Xa activity. However, these strategies are associated with potentially large time intervals before dose adjustments, which could be detrimental to the patient. The aim of the study was to compare a point-of-care (POCT) version of the APTT to (i) laboratory-based APTT and (ii) measurements of anti-Xa activity in terms of correlation, agreement and turnaround time (TAT). Thirty-five ICU patients requiring UFH therapy were prospectively included and followed longitudinally for a maximum duration of 15 days. UFH was administered according to a local adaptation of Raschke and Amanzadeh’s aPTT nomograms. Simultaneous measurements of POCT-APTT (CoaguCheck® aPTT Test, Roche Diagnostics) on a drop of fresh whole blood, laboratory-based APTT (C.K. Prest®, Stago) and anti-Xa activity (STA®Liquid anti-Xa, Stago) were systematically performed two to six times a day. Antithrombin, C-reactive protein, fibrinogen, factor VIII and lupus anticoagulant were measured. The time tracking of sampling and analysis was recorded. The overall correlation between POCT-APTT and laboratory APTT (n = 795 pairs) was strongly positive (rs = 0.77, p < 0.0001), and between POCT-APTT and anti-Xa activity (n = 729 pairs) was weakly positive (rs = 0.46, p < 0.0001). Inter-method agreement (Cohen’s kappa (k)) between POCT and laboratory APTT was 0.27, and between POCT and anti-Xa activity was 0.30. The median TATs from sample collection to the lab delivery of results for lab-APTT and anti-Xa were 50.9 min (interquartile range (IQR), 38.4−69.1) and 66.3 min (IQR, 49.0−91.8), respectively, while the POCT delivered results in less than 5 min (p < 0.0001). Although the use of the POCT-APTT device significantly reduced the time to results, the results obtained were poorly consistent with those obtained by lab-APTT or anti-Xa activity, and therefore it should not be used with the nomograms developed for lab-APTT.
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13
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Savioli F, Claro M, da Silva Ramos FJ, Pastore L. Factor VIII, Fibrinogen and Heparin Resistance in COVID-19 Patients with Thromboembolism: How Should We Manage the Anticoagulation Therapy? Clin Appl Thromb Hemost 2022; 28:10760296221087692. [PMID: 35306858 PMCID: PMC8938685 DOI: 10.1177/10760296221087692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Felicio Savioli
- Critical Care Medicine Department, Hospital Sírio Libanês, Sao Paulo, Brazil
| | - Maurício Claro
- Critical Care Medicine Department, Hospital Sírio Libanês, Sao Paulo, Brazil
| | | | - Laerte Pastore
- Critical Care Medicine Department, Hospital Sírio Libanês, Sao Paulo, Brazil
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14
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Connell NT, Sylvester KW. To aPTT or not to aPTT: Evaluating the optimal monitoring strategy for unfractionated heparin. Thromb Res 2021; 218:199-200. [PMID: 34836631 DOI: 10.1016/j.thromres.2021.11.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 11/13/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Nathan T Connell
- Hematology Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States of America.
| | - Katelyn W Sylvester
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, United States of America
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15
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Barry R, Stevens CA, Huynh T, Lerner D. Impact of Protocolized Pharmacist Intervention on Critical Activated Partial Thromboplastin Time Values With Heparin Infusions. J Pharm Technol 2021; 37:225-233. [PMID: 34752562 DOI: 10.1177/87551225211031923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Unfractionated heparin (UFH) infusions are commonly managed with nurse-driven nomograms titrated to activated partial thromboplastin time (aPTT). In some patients, anti-Xa values may be more appropriate measures of anticoagulation. At the present institution, an update to the nurse-driven aPTT nomogram requires pharmacist notification and clinical assessment for critically supratherapeutic aPTT results. Objective: The purpose of this study was to evaluate the efficacy and safety of the nomogram update. Methods: A single-center, retrospective, pre-post analysis was conducted in patients treated with UFH who experienced a critical aPTT during the 6 months preceding and following the nomogram update. Patients with erroneous critical aPTT results were excluded. The primary endpoint was the time in therapeutic range (Rosendaal method) from the first critical aPTT until UFH discontinuation. Secondary endpoints included the proportion of patients transitioned to anti-Xa monitoring and the incidence of Bleeding Academic Research Consortium (BARC) 2, 3, 5 bleeding. Data were analyzed by the χ2 test. The study was institutional review board approved. Results: Of 277 UFH infusions, 142 belonged to the pre-implementation group and 135 to the post-implementation group. Baseline aPTTs were similar between the 2 groups. Time in therapeutic range was 58.1% versus 62.4% of between groups (P = .467). UFH was transitioned to pharmacist-driven anti-Xa monitoring in 16.2% versus 40.3% of patients (P < .001). BARC 2, 3, 5 bleeding occurred in 23.2% versus 13.4% of patients (P < .001). Conclusions: Application of these data suggest improved safety and efficacy outcomes with directed pharmacist management of UFH in patients with critically elevated aPTTs.
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Affiliation(s)
- Rachelle Barry
- University of California, Davis Health, Sacramento, CA, USA
| | - Craig A Stevens
- University of California, San Diego Health, San Diego, CA, USA
| | - Trina Huynh
- University of California, San Diego Health, San Diego, CA, USA
| | - Dmitri Lerner
- University of California, San Diego Health, San Diego, CA, USA
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16
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Swayngim R, Preslaski C, Burlew CC, Beyer J. Comparison of clinical outcomes using activated partial thromboplastin time versus antifactor-Xa for monitoring therapeutic unfractionated heparin: A systematic review and meta-analysis. Thromb Res 2021; 208:18-25. [PMID: 34678527 DOI: 10.1016/j.thromres.2021.10.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 09/21/2021] [Accepted: 10/12/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Continuous intravenous unfractionated heparin (UFH) is a mainstay of therapeutic anticoagulation in the acute setting. The two most common laboratory tests for monitoring UFH are the activated partial thromboplastin time (aPTT) and antifactor Xa (anti-Xa) heparin assay. We reviewed the available evidence to evaluate if the choice of monitoring test for UFH therapy is associated with a difference in the clinical outcomes of bleeding, thrombosis, or mortality. MATERIALS AND METHODS MEDLINE, Cochrane database, and conference abstracts from the Society of Critical Care Medicine, the American Society of Hematology, and the American College of Clinical Pharmacy were searched for all studies comparing aPTT and anti-Xa monitoring for therapeutic UFH that evaluated outcomes for bleeding, thrombotic events, or mortality. Risk of bias was assessed with the Cochrane Risk of Bias Tool and Newcastle Ottawa Scale. Pooled relative risk ratios were calculated using an inverse variance-weighted random-effects model. RESULTS Ten studies (n = 6677) were included for analysis. The use of anti-Xa compared to aPTT was not associated with an increased risk of bleeding (RR 1.03; 95% CI 0.8-1.22 I2 = 4%) or an increased risk of thrombotic events (RR 0.99; 95% CI 0.76-1.30, I2 = 3%). There was no difference in mortality within individual studies but the data were not suitable for pooled analysis. CONCLUSIONS Pooled data comparing aPTT vs. anti-Xa for monitoring therapeutic UFH did not suggest differences in the outcomes of bleeding or thrombosis.
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Affiliation(s)
- Rebecca Swayngim
- Department of Pharmacy, Denver Health Medical Center, 777 Bannock St, Denver 80204, CO, USA.
| | - Candice Preslaski
- Department of Surgery, Denver Health Medical Center, 777 Bannock St, Denver 80204, CO, USA.
| | - Clay Cothren Burlew
- Department of Surgery, Denver Health Medical Center, 777 Bannock St, Denver 80204, CO, USA.
| | - Jacob Beyer
- Department of Pharmacy, Denver Health Medical Center, 777 Bannock St, Denver 80204, CO, USA.
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17
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May JE, Siniard RC, Taylor LJ, Marques MB, Gangaraju R. From Activated Partial Thromboplastin Time to Antifactor Xa and Back Again. Am J Clin Pathol 2021; 157:321-327. [PMID: 34562001 PMCID: PMC8891818 DOI: 10.1093/ajcp/aqab135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 07/14/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Monitoring is essential to safe anticoagulation prescribing and requires close collaboration among pathologists, clinicians, and pharmacists. METHODS We describe our experience in the evolving strategy for laboratory testing of unfractionated heparin (UFH). RESULTS An intrainstitutional investigation revealed significant discordance between activated partial thromboplastin time (aPTT) and antifactor Xa (anti-Xa) assays, prompting a transition from the former to the latter in 2013. With the increasing use of oral factor Xa inhibitors (eg, apixaban, rivaroxaban, edoxaban, betrixaban), which interfere with the anti-Xa assay, we adapted our protocol again to incorporate aPTT in patients admitted on oral Xa inhibitors who require transition to UFH. CONCLUSIONS Our experience demonstrates key challenges in anticoagulation and highlights the importance of clinical pathologists in helping health systems adapt to the changing anticoagulation landscape.
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Affiliation(s)
- Jori E May
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, USA,Corresponding author: Jori E. May, MD;
| | - Rance Chad Siniard
- Division of Laboratory Medicine, Department of Pathology, School of Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - Laura J Taylor
- UAB Coagulation Service, School of Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - Marisa B Marques
- Division of Laboratory Medicine, Department of Pathology, School of Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - Radhika Gangaraju
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, USA,Institute for Cancer Outcomes and Survivorship, School of Medicine, University of Alabama at Birmingham, Birmingham, USA
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18
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Affiliation(s)
- Jerrold H Levy
- From the Departments of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC (J.H.L.); and the Hematology Division, Department of Medicine, Brigham and Women's Hospital, and Harvard Medical School - both in Boston (J.M.C.)
| | - Jean M Connors
- From the Departments of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC (J.H.L.); and the Hematology Division, Department of Medicine, Brigham and Women's Hospital, and Harvard Medical School - both in Boston (J.M.C.)
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19
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Shah K, Hanlon A, Onwuemene OA. Sometimes it is Not as Simple as Sepsis: An Unusual Cause of Coagulopathy. Am J Med 2021; 134:e409-e411. [PMID: 33444591 PMCID: PMC10175946 DOI: 10.1016/j.amjmed.2020.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 12/09/2020] [Accepted: 12/09/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Kunal Shah
- Duke University School of Medicine, Durham, NC
| | - Ashley Hanlon
- Department of Medicine, Duke University Medical Center, Durham, NC
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20
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Weeks LD, Sylvester KW, Connors JM, Connell NT. Management of therapeutic unfractionated heparin in COVID-19 patients: A retrospective cohort study. Res Pract Thromb Haemost 2021; 5:e12521. [PMID: 34013153 PMCID: PMC8114028 DOI: 10.1002/rth2.12521] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/23/2021] [Accepted: 03/30/2021] [Indexed: 12/22/2022] Open
Abstract
Background Patients hospitalized with severe acute respiratory syndrome coronavirus 2 infection are at risk for thrombotic complications necessitating use of therapeutic unfractionated heparin (UFH). Full-dose anticoagulation limits requirements for organ support interventions in moderately ill patients with coronavirus disease 2019 (COVID-19). Given this benefit, it is important to evaluate response to therapeutic anticoagulation in this population. Objectives The aim of this study was to assess therapeutic UFH infusions and associated bleeding risk in patients with COVID-19. Patients/Methods This retrospective cohort study includes patients at Brigham and Women's Hospital, Boston, Massachusetts, receiving weight-based nursing-nomogram titrated UFH infusion during a 10-week surge in COVID-19 hospitalizations. Of 358 patients on therapeutic UFH during this interval, 97 (27.1%) had confirmed COVID-19. Patient characteristics, laboratory values, and information regarding UFH infusion and bleeding events were obtained from the electronic medical record. Results Patients who were COVID-19 positive had fewer therapeutic activatrd partial thromboplastin times (aPTTs) compared to COVID-19-negative patients (median rate, 40.0% vs 53.1%; P < .0005). Both major and clinically relevant nonmajor bleeding were increased in COVID-19-positive patients, with major bleeding observed in 10.3% (95% confidence interval [CI], 5.7%-17.9%) of patients who were COVID-19 positive and 3.1% (95% CI, 1.6%-5.9%) of patients who were COVID-19 negative (P < .005). In logistic regression, bleeding events were associated with receiving UFH for longer than 7 days, but not platelet count, coagulation, or inflammatory measurements. Conclusions Our data indicate a higher incidence of bleeding complications in patients with COVID-19 receiving weight-based nursing-nomogram titrated UFH infusions despite a higher prevalence of subtherapeutic aPTTs in this population. These data underscore the need for prospective studies aimed at improving the quality and safety of therapeutic anticoagulation in patients with COVID-19.
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Affiliation(s)
- Lachelle D Weeks
- Department of Medical Oncology Dana Farber Cancer Institute Boston MA USA.,Harvard Medical School Boston MA USA
| | | | - Jean M Connors
- Harvard Medical School Boston MA USA.,Hematology Division, Department of Medicine Brigham and Women's Hospital Boston MA USA
| | - Nathan T Connell
- Harvard Medical School Boston MA USA.,Hematology Division, Department of Medicine Brigham and Women's Hospital Boston MA USA
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21
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Brescia AA, Haft J. Commentary: Anti-Xa Levels Are More Accurate Than aPTT for CTEPH, But Does It Matter? Semin Thorac Cardiovasc Surg 2021; 34:324-325. [PMID: 34004300 DOI: 10.1053/j.semtcvs.2021.04.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 04/28/2021] [Indexed: 11/11/2022]
Affiliation(s)
| | - Jonathan Haft
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
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22
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Nykänen AI, Selby R, McRae KM, Zhao Y, Asghar UM, Donahoe L, Granton J, de Perrot M. Pseudo Heparin Resistance After Pulmonary Endarterectomy: Role of Thrombus Production of Factor VIII. Semin Thorac Cardiovasc Surg 2021; 34:315-323. [PMID: 33984481 DOI: 10.1053/j.semtcvs.2021.03.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 03/11/2021] [Indexed: 11/11/2022]
Abstract
Pulmonary endarterectomy (PEA) is the main treatment for chronic thromboembolic pulmonary hypertension (CTEPH). Postoperative unfractionated heparin dosing can be monitored by activated partial thromboplastin time (APTT) or by anti-factor Xa activity (anti-Xa). In pseudo heparin resistance, APTT response to heparin is blunted due to elevated Factor VIII (FVIII) which can underestimate anticoagulation. We examined possible pseudo heparin resistance after PEA and assessed the impact of FVIII. APTT response to heparin before and after operation was determined in 13 PEA patients anticoagulated with unfractionated heparin. APTT and anti-Xa concordance was analyzed from paired postoperative samples, and antithrombin, fibrinogen and FVIII levels were measured. Single-cell RNA sequencing was used to characterize FVIII gene expression in PEA specimens of 5 patients. APTT response to heparin was blunted after PEA. APTT and anti-Xa were discordant in 36% of postoperative samples and most common discordant patterns were subtherapeutic APTT with therapeutic (16%) or supratherapeutic (11%) anti-Xa. Overall, APTT underestimated anticoagulation relative to anti-Xa in one-third of the samples. FVIII levels were elevated before surgery, increased substantially 1 and 3 days (median 4.32 IU/mL) after PEA, and were higher in discordant than concordant samples. Single-cell RNA sequencing showed FVIII gene expression in PEA specimen endothelial cells. Pseudo heparin resistance is common after PEA likely due to highly elevated postoperative FVIII levels indicating that anti-Xa reflects postoperative heparinization better than APTT in these patients. FVIII production by the pulmonary artery endothelium may participate in local prothrombotic processes important for CTEPH pathogenesis.
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Affiliation(s)
- Antti I Nykänen
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Rita Selby
- Coagulation Laboratory, University Health Network, Toronto, Ontario, Canada
| | - Karen M McRae
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Yidan Zhao
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Usman M Asghar
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Laura Donahoe
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - John Granton
- Division of Respirology, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Marc de Perrot
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada.
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23
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Morita N, Sakota D, Oota-Ishigaki A, Kosaka R, Maruyama O, Nishida M, Kondo K, Takeshita T, Iwasaki W. Real-time, non-invasive thrombus detection in an extracorporeal circuit using micro-optical thrombus sensors. Int J Artif Organs 2020; 44:565-573. [PMID: 33300399 PMCID: PMC8366175 DOI: 10.1177/0391398820978656] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Introduction: Real-time, non-invasive monitoring of thrombus formation in extracorporeal circuits has yet to be achieved. To address the challenges of conventional optical thrombus detection methods requiring large devices that limit detection capacity, we developed a micro-optical thrombus sensor. Methods: The proposed micro-optical thrombus sensor can detect the intensity of light scattered by blood at wavelengths of 660 and 855 nm. Two thrombus sensors were installed on in vitro circuit: one at the rotary blood pump and one at a flow channel. To evaluate the variation in the ratio of incident light intensity at each wavelength of the two sensors, Rfluct (for 660 nm) and Ifluct (for 855 nm) were defined. Using fresh porcine blood as a working fluid, we performed in vitro tests of haematocrit (Hct) and oxygen saturation (SaO2) variation and thrombus detection. Thrombus tests were terminated after Rfluct or Ifluct showed a larger change than the maximum range of those in the Hct and SaO2 variation test. Results: In all three thrombus detection tests, Ifluct showed a larger change than the maximum range of those in the Hct and SaO2 variation test. After the tests, thrombus formation was confirmed in the pump, and there was no thrombus in the flow channel. The results indicate that Ifluct is an effective parameter for identifying the presence of a thrombus. Conclusion: Thrombus detection in an extracorporeal circuit using the developed micro-optical sensors was successfully demonstrated in an in vitro test.
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Affiliation(s)
- Nobutomo Morita
- Sensing System Research Center, National Institute of Advanced Industrial Science and Technology (AIST), Tosu, Saga, Japan
| | - Daisuke Sakota
- Health and Medical Research Institute, National Institute of Advanced Industrial Science and Technology (AIST), Tsukuba, Ibaraki, Japan
| | - Akiko Oota-Ishigaki
- Health and Medical Research Institute, National Institute of Advanced Industrial Science and Technology (AIST), Tsukuba, Ibaraki, Japan
| | - Ryo Kosaka
- Health and Medical Research Institute, National Institute of Advanced Industrial Science and Technology (AIST), Tsukuba, Ibaraki, Japan
| | - Osamu Maruyama
- Health and Medical Research Institute, National Institute of Advanced Industrial Science and Technology (AIST), Tsukuba, Ibaraki, Japan
| | - Masahiro Nishida
- Health and Medical Research Institute, National Institute of Advanced Industrial Science and Technology (AIST), Tsukuba, Ibaraki, Japan
| | - Kazuki Kondo
- Health and Medical Research Institute, National Institute of Advanced Industrial Science and Technology (AIST), Tsukuba, Ibaraki, Japan
| | - Toshihiro Takeshita
- Sensing System Research Center, National Institute of Advanced Industrial Science and Technology (AIST), Tosu, Saga, Japan
| | - Wataru Iwasaki
- Sensing System Research Center, National Institute of Advanced Industrial Science and Technology (AIST), Tosu, Saga, Japan
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24
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Kelly A, Head L, Garcia M, Hayes T, Charlesworth M. Anticoagulation Strategies and Determining the Rate of Fatal Intracerebral Hemorrhage Associated With Venovenous Extracorporeal Membrane Oxygenation in Patients With Coronavirus Disease 2019. J Cardiothorac Vasc Anesth 2020; 35:1554-1555. [PMID: 33189536 PMCID: PMC7584492 DOI: 10.1053/j.jvca.2020.10.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/16/2020] [Accepted: 10/21/2020] [Indexed: 11/14/2022]
Affiliation(s)
- Adam Kelly
- Department of Cardiothoracic Anaesthesia, Critical Care and ECMO, Wythenshawe Hospital, Manchester, UK
| | - Laura Head
- Department of Cardiothoracic Anaesthesia, Critical Care and ECMO, Wythenshawe Hospital, Manchester, UK
| | - Miguel Garcia
- Department of Cardiothoracic Anaesthesia, Critical Care and ECMO, Wythenshawe Hospital, Manchester, UK
| | - Tim Hayes
- Department of Cardiothoracic Anaesthesia, Critical Care and ECMO, Wythenshawe Hospital, Manchester, UK
| | - Michael Charlesworth
- Department of Cardiothoracic Anaesthesia, Critical Care and ECMO, Wythenshawe Hospital, Manchester, UK
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25
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Mazzeffi M, Clark M, Grazioli A, Dugan C, Rector R, Dalton H, Madathil R, Menaker J, Herr D, Tanaka K. Platelet factor-4 concentration in adult veno-arterial ECMO patients. Perfusion 2020; 36:688-693. [PMID: 33070765 DOI: 10.1177/0267659120965104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Heparin induced thrombocytopenia (HIT) is reported at a variable rate in extracorporeal membrane oxygenation (ECMO) patients. A critical factor impacting platelet factor-4 (PF4)-heparin antibody formation is plasma PF4 concentration. We hypothesized that PF4 concentration would be increased during veno-arterial (VA) ECMO. METHODS Plasma PF4 concentration was measured during the first 5 ECMO days in 20 VA ECMO patients and 10 control plasma samples. PF4-heparin ratios were estimated using an assumed heparin concentration of 0.4 IU/mL. This correlates with an activated partial thromboplastin time of 60 to 80 seconds, which is the anticoagulation target in our center. RESULTS Twenty VA ECMO patients were enrolled, 10 of which had pulmonary embolism. Median PF4 concentration was 0.03 µg/mL [0.01, 0.13] in control plasma. Median PF4 concentration was 0.21 µg/mL [0.12, 0.34] on ECMO day 1 or 2, 0.16 µg/mL [0.09, 0.25] on ECMO day 3, and 0.12 µg/mL [0.09, 0.22] on ECMO day 5. Estimated median PF4-heparin ratios were 0.04, 0.03, and 0.02 respectively. Two patients (10%) developed HIT that was confirmed by serotonin release assay. PF4 concentration did not differ significantly in these patients compared to non-HIT patients (p = 0.37). No patient had an estimated PF4-heparin ratio between 0.7 and 1.4, which is the reported optimal range for PF4-heparin antibody formation. CONCLUSION Our data suggest that PF4 concentration is mildly elevated during VA ECMO compared to control plasma. Estimated PF4-heparin ratios were not optimal for HIT antibody formation. These data support epidemiologic studies where HIT incidence is low during VA ECMO.
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Affiliation(s)
- Michael Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Madeline Clark
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Alison Grazioli
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institute of Health, Bethesda, MD, USA.,Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Colleen Dugan
- University of Maryland Medical Center, Baltimore, MD, USA
| | - Raymond Rector
- University of Maryland Medical Center, Baltimore, MD, USA
| | | | - Ronson Madathil
- Division of Cardiothoracic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jay Menaker
- Department of Surgery, University of Maryland School of Medicine, Program in Trauma, Baltimore, MD, USA
| | - Daniel Herr
- Department of Medicine, University of Maryland School of Medicine, Program in Trauma, Baltimore, MD, USA
| | - Kenichi Tanaka
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
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26
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Ząbczyk M, Natorska J, Malinowski KP, Undas A. Effect of enoxaparin on plasma fibrin clot properties and fibrin structure in patients with acute pulmonary embolism. Vascul Pharmacol 2020; 133-134:106783. [DOI: 10.1016/j.vph.2020.106783] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/28/2020] [Accepted: 08/17/2020] [Indexed: 11/23/2022]
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27
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Kindelin NM, Anthes AM, Providence SM, Zhao X, Aspinall SL. Effectiveness of a Calculation-Free Weight-Based Unfractionated Heparin Nomogram With Anti-Xa Level Monitoring Compared With Activated Partial Thromboplastin Time. Ann Pharmacother 2020; 55:575-583. [PMID: 32964730 DOI: 10.1177/1060028020961503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Accurate monitoring of intravenous unfractionated heparin (UFH) is essential to mitigate the risk of adverse drug events associated with dosing errors. Although recent data support anti-factor Xa (anti-Xa) monitoring preferentially over activated partial thromboplastin time (aPTT) to improve time to therapeutic anticoagulation, the utility of incorporating anti-Xa monitoring with a calculation-free weight-based UFH nomogram has not been formally evaluated. OBJECTIVE The primary objective of this study was to evaluate the time to therapeutic anticoagulation of a calculation-free weight-based UFH nomogram integrated with anti-Xa monitoring versus a historical control of aPTT monitoring utilizing manual dose calculations. METHODS This was a retrospective analysis of patients with anti-Xa monitoring and a novel calculation-free weight-based UFH nomogram compared with a historical control with aPTT monitoring and manual calculations. RESULTS A total of 103 patients in the aPTT cohort and 100 patients in the anti-Xa cohort were analyzed. The anti-Xa cohort achieved goal therapeutic target 3.8 hours sooner than the aPTT cohort (P = 0.03). Patients with anti-Xa monitoring required 1 fewer adjustment per 2.5 patient-days of UFH with the venous thromboembolism nomogram (P = 0.02). Patients in the aPTT cohort required more infusion interruptions because of supratherapeutic values (P = 0.007) and boluses because of subtherapeutic values (P = 0.044). There were no differences in rates of thromboembolism, major bleeding, or clinically relevant nonmajor bleeding between the cohorts. CONCLUSION AND RELEVANCE This study demonstrated that anti-Xa UFH monitoring integrated with a calculation-free nomogram results in faster time to therapeutic anticoagulation and fewer dose adjustments compared with aPTT monitoring with manual calculations.
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Affiliation(s)
| | | | | | - Xinhua Zhao
- VA Center for Health Equity Research and Promotion, Pittsburgh, PA, USA
| | - Sherrie L Aspinall
- VA Center for Health Equity Research and Promotion, Pittsburgh, PA, USA.,VA Center for Medication Safety, Hines, IL, USA
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28
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Kostousov V, Devaraj S, Bruzdoski K, Hensch L, Hui SK, Teruya J. C-reactive protein-induced activated partial thromboplastin time prolongation in heparinized samples is attenuated by elevated factor VIII. Int J Lab Hematol 2020; 43:139-142. [PMID: 32812381 DOI: 10.1111/ijlh.13314] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/07/2020] [Accepted: 07/26/2020] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Activated partial thromboplastin time (aPTT) and antifactor Xa (anti-Xa) activity are used to monitor unfractionated heparin therapy in children on extracorporeal membrane oxygenation (ECMO). Elevated C-reactive protein (CRP) can prolong aPTT and cause discrepancy between these two assays. We aimed to evaluate CRP effect on aPTT and anti-Xa assays in the presence of heparin and to determine whether elevated CRP affects laboratory monitoring in pediatric ECMO patients. MATERIALS AND METHODS Citrated normal specimens were spiked with CRP, heparin, and recombinant factor VIII (FVIII) and followed by measurement of aPTT and anti-Xa activity. Additionally, aPTT, anti-Xa activity, FVIII, fibrinogen, and CRP were measured in 18 ECMO specimens. RESULTS Elevated CRP prolonged aPTT in normal specimens with or without heparin, but did not affect anti-Xa assay. In contrast, ECMO specimens showed similar aPTT and anti-Xa values regardless of CRP level. Elevated CRP in specimens was accompanied by increased fibrinogen and FVIII activity. Additional in vitro experiments confirmed that FVIII spiked simultaneously with CRP attenuated CRP-induced aPTT prolongation in heparinized specimens. CONCLUSION In vitro CRP-induced aPTT prolongation is not observed in pediatric ECMO samples due to concomitant FVIII increase. Discordant changes of CRP and FVIII in plasma could contribute to aPTT/anti-Xa discrepancies observed during heparin therapy in the pediatric population. The anti-Xa assay is preferable for heparin monitoring in pediatric ECMO settings.
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Affiliation(s)
- Vadim Kostousov
- Departments of Pathology & Immunology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Sridevi Devaraj
- Departments of Pathology & Immunology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Karen Bruzdoski
- Departments of Pathology & Immunology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Lisa Hensch
- Departments of Pathology & Immunology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Shiu-Ki Hui
- Departments of Pathology & Immunology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.,Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Jun Teruya
- Departments of Pathology & Immunology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.,Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.,Department of Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
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29
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Williams-Norwood T, Caswell M, Milner B, Vescera JC, Prymicz K, Ciszak AG, Ingle C, Lacey C, Stavrou EX. Design and Implementation of an Anti-Factor Xa Heparin Monitoring Protocol. AACN Adv Crit Care 2020; 31:129-137. [PMID: 32526007 DOI: 10.4037/aacnacc2020132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND The VA Northeast Ohio Healthcare System introduced a new nurse-driven anti-factor Xa (anti-Xa) protocol for monitoring unfractionated heparin to replace the previous activated partial thromboplastin time protocol. OBJECTIVE To design, implement, and evaluate the efficacy of the anti-Xa monitoring protocol. METHODS An interdisciplinary team of providers collaborated to develop and implement a nurse-driven, facility-wide anti-factor Xa protocol for monitoring unfractionated heparin therapy. The effectiveness of this protocol was evaluated by retrospective analysis. RESULTS We reviewed 100 medical records for compliance with the new anti-Xa monitoring protocol. We then evaluated 178 patients whose anticoagulation was monitored with the anti-Xa assay to determine the time to therapeutic range. We found that 80% of patients receiving the anti-Xa protocol achieved therapeutic anticoagulation within 24 hours, as compared with 54% of patients receiving the activated partial thromboplastin time protocol (P < .001). Protocol conversion also yielded a decrease in blood draws, dose adjustments, and potential calculation errors. CONCLUSIONS Monitoring intravenous heparin therapy with the anti-Xa assay rather than activated partial thromboplastin time resulted in a shorter time to therapeutic anticoagulation, longer maintenance of therapeutic levels, and fewer laboratory tests and heparin dosage changes. We believe the current practice of monitoring heparin treatment with activated partial thromboplastin time assays should be reexamined.
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Affiliation(s)
- Tanya Williams-Norwood
- Tanya Williams-Norwood is a Clinical Nurse Specialist; Barbara Milner is a Clinical Nurse Specialist; Joseph C. Vescera is Associate Chief of Inpatient Pharmacy; Amy G. Ciszak is Clinical Applications Coordinator, Informatics and Analytics; Carol Ingle is Clinical Pharmacy Manager of the Anticoagulation Clinic; Christopher Lacey is Associate Chief, Clinical Pharmacy Service; VA Northeast Ohio Healthcare System, Cleveland, Ohio
| | - Megan Caswell
- Megan Caswell is Board-Certified Pharmacotherapy Specialist, Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Barbara Milner
- Tanya Williams-Norwood is a Clinical Nurse Specialist; Barbara Milner is a Clinical Nurse Specialist; Joseph C. Vescera is Associate Chief of Inpatient Pharmacy; Amy G. Ciszak is Clinical Applications Coordinator, Informatics and Analytics; Carol Ingle is Clinical Pharmacy Manager of the Anticoagulation Clinic; Christopher Lacey is Associate Chief, Clinical Pharmacy Service; VA Northeast Ohio Healthcare System, Cleveland, Ohio
| | - Joseph C Vescera
- Tanya Williams-Norwood is a Clinical Nurse Specialist; Barbara Milner is a Clinical Nurse Specialist; Joseph C. Vescera is Associate Chief of Inpatient Pharmacy; Amy G. Ciszak is Clinical Applications Coordinator, Informatics and Analytics; Carol Ingle is Clinical Pharmacy Manager of the Anticoagulation Clinic; Christopher Lacey is Associate Chief, Clinical Pharmacy Service; VA Northeast Ohio Healthcare System, Cleveland, Ohio
| | - Kelly Prymicz
- Kelly Prymicz is Consultant, Chelko Consulting Group, Westlake, Ohio
| | - Amy G Ciszak
- Tanya Williams-Norwood is a Clinical Nurse Specialist; Barbara Milner is a Clinical Nurse Specialist; Joseph C. Vescera is Associate Chief of Inpatient Pharmacy; Amy G. Ciszak is Clinical Applications Coordinator, Informatics and Analytics; Carol Ingle is Clinical Pharmacy Manager of the Anticoagulation Clinic; Christopher Lacey is Associate Chief, Clinical Pharmacy Service; VA Northeast Ohio Healthcare System, Cleveland, Ohio
| | - Carol Ingle
- Tanya Williams-Norwood is a Clinical Nurse Specialist; Barbara Milner is a Clinical Nurse Specialist; Joseph C. Vescera is Associate Chief of Inpatient Pharmacy; Amy G. Ciszak is Clinical Applications Coordinator, Informatics and Analytics; Carol Ingle is Clinical Pharmacy Manager of the Anticoagulation Clinic; Christopher Lacey is Associate Chief, Clinical Pharmacy Service; VA Northeast Ohio Healthcare System, Cleveland, Ohio
| | - Christopher Lacey
- Tanya Williams-Norwood is a Clinical Nurse Specialist; Barbara Milner is a Clinical Nurse Specialist; Joseph C. Vescera is Associate Chief of Inpatient Pharmacy; Amy G. Ciszak is Clinical Applications Coordinator, Informatics and Analytics; Carol Ingle is Clinical Pharmacy Manager of the Anticoagulation Clinic; Christopher Lacey is Associate Chief, Clinical Pharmacy Service; VA Northeast Ohio Healthcare System, Cleveland, Ohio
| | - Evi X Stavrou
- Evi X. Stavrou is Staff Physician and Medical Director of Anticoagulation Clinic, VA Northeast Ohio Healthcare System; Oscar D. Ratnoff Professor in Medicine and Hematology; Assistant Professor in the Department of Medicine at Case Western Reserve University School of Medicine, 10701 East Blvd, Cleveland, OH, 44106
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30
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McLaughlin K, Rimsans J, Sylvester KW, Fanikos J, Dorfman DM, Senna P, Connors JM, Goldhaber SZ. Evaluation of Antifactor-Xa Heparin Assay and Activated Partial Thromboplastin Time Values in Patients on Therapeutic Continuous Infusion Unfractionated Heparin Therapy. Clin Appl Thromb Hemost 2020; 25:1076029619876030. [PMID: 31530176 PMCID: PMC6829967 DOI: 10.1177/1076029619876030] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Clinical uncertainty exists regarding which assay should be designated as the standard
monitoring coagulation test for intravenous unfractionated heparin (UFH). Several studies
have compared the use of activated partial thromboplastin time (aPTT) and antifactor-Xa
(anti-Xa) and have come out with varying results. The correlation between these 2 tests
varied, markedly from strong to weak. Some have demonstrated that monitoring with anti-Xa
heparin assay leads to fewer dose adjustments, resulting in fewer laboratory tests, while
others have not. In the current study, we evaluated the correlation between aPTT and
anti-Xa values to guide clinical management of UFH, with the intention to develop a new
correlation nomogram.
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Affiliation(s)
- Kevin McLaughlin
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Jessica Rimsans
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | | | - John Fanikos
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - David M Dorfman
- Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA
| | - Patricia Senna
- Department of Clinical Laboratories, Brigham and Women's Hospital, Boston, MA, USA
| | - Jean M Connors
- Hematology Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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31
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Arnouk S, Altshuler D, Lewis TC, Merchan C, Smith DE, Toy B, Zakhary B, Papadopoulos J. Evaluation of Anti-Xa and Activated Partial Thromboplastin Time Monitoring of Heparin in Adult Patients Receiving Extracorporeal Membrane Oxygenation Support. ASAIO J 2020; 66:300-6. [DOI: 10.1097/mat.0000000000001004] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Saifee NH, Brogan TV, Mcmullan DM, Yalon L, Matthews DC, Burke CR, Chandler WL. Monitoring Hemostasis During Extracorporeal Life Support. ASAIO J 2020; 66:230-7. [DOI: 10.1097/mat.0000000000000993] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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33
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Spadarella G, Di Minno A, Donati MB, Mormile M, Ventre I, Di Minno G. From unfractionated heparin to pentasaccharide: Paradigm of rigorous science growing in the understanding of the in vivo thrombin generation. Blood Rev 2020; 39:100613. [DOI: 10.1016/j.blre.2019.100613] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 08/19/2019] [Accepted: 08/22/2019] [Indexed: 12/20/2022]
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34
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Coons JC, Iasella CJ, Thornberg M, Fitzmaurice MG, Goehring K, Jablonski L, Leader D, Meyer A, Seo H, Benedict NJ, Smith RE. Clinical outcomes with unfractionated heparin monitored by anti-factor Xa vs. activated partial Thromboplastin time. Am J Hematol 2019; 94:1015-1019. [PMID: 31243789 DOI: 10.1002/ajh.25565] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 06/14/2019] [Accepted: 06/24/2019] [Indexed: 12/11/2022]
Abstract
Anti-factor Xa (anti-Xa) monitoring of unfractionated heparin (UFH) is associated with less time to achieve therapeutic anticoagulation compared to the activated partial thromboplastin time (aPTT). However, it is unknown whether clinical outcomes differ between these methods of monitoring. The aim of this research was to compare the rate of venous thrombosis and bleeding events in patients that received UFH monitored by anti-Xa compared to the aPTT. A retrospective review of electronic health records identified adult patients that received UFH given intravenously (IV) for ≥2 days, with either anti-Xa or aPTT monitoring at an academic tertiary care hospital. This was a pre/post study design conducted between January 1 to December 30, 2014 (aPTT), and January 1 to December 30, 2016 (anti-Xa). All UFH adjustments were based on institutional nomograms. The primary outcome was venous thrombosis and the secondary outcome was bleeding, both of which occurred between UFH administration and discharge from the index hospitalization. A total of 2500 patients were in the anti-Xa group and 2847 patients aPTT group. Venous thrombosis occurred in 10.2% vs 10.8% of patients in the anti-Xa and aPTT groups, respectively (P = .49). Bleeding occurred in 33.7% vs 33.6% of patients in the anti-Xa and aPTT groups, respectively (P = .94). Anti-Xa monitoring was not an independent predictor of either outcome in multivariate logistic regression analyses. Our study found no difference in clinical outcomes between anti-Xa and aPTT-based monitoring of UFH IV.
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Affiliation(s)
- James C. Coons
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy Pittsburgh Pennsylvania
- Department of Pharmacy and Therapeutics, UPMC Presbyterian‐Shadyside Hospital Pittsburgh Pennsylvania
| | - Carlo J. Iasella
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy Pittsburgh Pennsylvania
- Department of Pharmacy and Therapeutics, UPMC Presbyterian‐Shadyside Hospital Pittsburgh Pennsylvania
| | - Megan Thornberg
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy Pittsburgh Pennsylvania
| | - Mary Grace Fitzmaurice
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy Pittsburgh Pennsylvania
| | - Kimberly Goehring
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy Pittsburgh Pennsylvania
| | - Lindsay Jablonski
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy Pittsburgh Pennsylvania
| | - Dominic Leader
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy Pittsburgh Pennsylvania
| | - Abby Meyer
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy Pittsburgh Pennsylvania
| | - Hangil Seo
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy Pittsburgh Pennsylvania
| | - Neal J. Benedict
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy Pittsburgh Pennsylvania
- Department of Pharmacy and Therapeutics, UPMC Presbyterian‐Shadyside Hospital Pittsburgh Pennsylvania
| | - Roy E. Smith
- Department of Pharmacy and Therapeutics, UPMC Presbyterian‐Shadyside Hospital Pittsburgh Pennsylvania
- Hematology/Oncology Division, UPMC Presbyterian‐Shadyside Hospital Pittsburgh Pennsylvania
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35
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Khan J, Chandler WL. Interference in the anti‐Xa heparin activity assay due to hemolysis and icterus during pediatric extracorporeal life support. Artif Organs 2019; 43:880-887. [DOI: 10.1111/aor.13467] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 03/25/2019] [Accepted: 04/01/2019] [Indexed: 01/04/2023]
Affiliation(s)
- Jenna Khan
- Department of Laboratory Medicine University of Washington Seattle Washington
| | - Wayne L. Chandler
- Department of Laboratory Medicine University of Washington Seattle Washington
- Department of Laboratories Seattle Children’s Hospital Seattle Washington
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36
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Lehot JJ, Clec’h C, Bonhomme F, Brauner M, Chemouni F, de Mesmay M, Gayat E, Guidet B, Hejblum G, Hernu R, Jauréguy F, Martin C, Rousson R, Samama M, Schwebel C, Van de Putte H, Lemiale V, Ausset S. Pertinence de la prescription des examens biologiques et de la radiographie thoracique en réanimation RFE commune SFAR-SRLF. Méd Intensive Réa 2019. [DOI: 10.3166/rea-2018-0004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Abstract
OBJECTIVES To determine the relationship between baseline variations in the partial thromboplastin time (PTT) and the discordance between the PTT and anti-Xa heparin activity (anti-Xa) during heparin therapy. METHODS The baseline PTT on heparin was determined using automated heparin neutralization with protamine (prPTT). The prPTT was used to calculate a baseline-corrected PTT on heparin to reduce discordance with anti-Xa measurements. RESULTS The prPTT removed up to 1 U/mL of heparin, returning baseline values for normal, factor-deficient, and lupus inhibitor plasmas. A prolonged prPTT was seen in 97 (53%) of 182 samples from heparinized patients. The heparinized PTT was discordant compared with anti-Xa in 64 (35%) of 182 samples and 43 (67%) of 64 discordant samples, and 46% of concordant samples showed a prolonged prPTT. A baseline-corrected PTT reduced discordance with anti-Xa measurements by 64%. CONCLUSIONS PTT/anti-Xa discordance due to baseline PTT prolongation could be reduced using a baseline-corrected PTT.
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Affiliation(s)
- Jenna Khan
- Department of Laboratory Medicine, University of Washington, Seattle
| | - Wayne L Chandler
- Department of Laboratory Medicine, University of Washington, Seattle
- Department of Laboratories, Seattle Children’s Hospital, Seattle, WA
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Artzner T, Clere-Jehl R, Schenck M, Greget M, Merdji H, De Marini P, Tuzin N, Helms J, Meziani F. Spontaneous ilio-psoas hematomas complicating intensive care unit hospitalizations. PLoS One 2019; 14:e0211680. [PMID: 30794573 PMCID: PMC6386274 DOI: 10.1371/journal.pone.0211680] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 01/20/2019] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Ilio-psoas hematoma is a potentially lethal condition that can arise during hospital stay. However, neither the incidence nor the prognosis of patients whose stay in intensive care units (ICU) is complicated by a iatrogenic ilio-psoas hematoma is known. METHODS A bicentric retrospective study was conducted to compile the patients who developed an ilio-psoas hematoma while they were hospitalized in ICU between January 2009 and December 2016. Their biometric characteristics, pre-existing conditions, the circumstances in which the hematoma was diagnosed, the treatments they received and their prognosis were recorded. RESULTS Forty patients were diagnosed with an ilio-psoas hematoma during their ICU stay. The incidence of this complication was 3.8 cases for 1000 admissions, taking into account only patients who stayed more than three days in ICU. The median age of patients was 74 years old and the median time between admission and the diagnosis of ilio-psoas hematoma was 12.6 days. A large proportion of them was obese (42.5%) and/or under dialysis (50%) prior to developing their hematoma. Ninety-five percent of the patients had heparin at prophylactic or therapeutic doses. Only 10% of them were above the therapeutic range of anticoagulation. The ICU mortality rate was of 50% following this complication (versus a general mortality rate of 22% for the patients without IPH over the same period of time). Patients with IPH that were complicated by disseminated intravascular coagulopathy had a significantly higher mortality rate than those with IPH and no disseminated intravascular coagulopathy (OR 6.91, 95% CI [1.28; 58.8], p = 0.04). CONCLUSION Age, anticoagulation, a high body mass index and dialysis seem to be risk factors of developing an ilio-psoas hematoma in ICU. Iatrogenic ilio-psoas hematomas complicated by disseminated intravascular coagulopathies are more at risk of leading to death. It is noteworthy that activated partial thromboplastin time above the therapeutic range was not a good predictor of developing a hematoma for patients who received unfractioned heparin therapy.
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Affiliation(s)
- Thierry Artzner
- Université de Strasbourg (UNISTRA), Faculté de Médecine, Hôpitaux universitaires de Strasbourg, Service de Réanimation Médicale, Nouvel Hôpital Civil, Strasbourg, France
| | - Raphaël Clere-Jehl
- Université de Strasbourg (UNISTRA), Faculté de Médecine, Hôpitaux universitaires de Strasbourg, Service de Réanimation Médicale, Nouvel Hôpital Civil, Strasbourg, France
- ImmunoRhumatologie Moléculaire, INSERM UMR_S1109, LabEx TRANSPLANTEX, Centre de Recherche d’Immunologie et d’Hématologie, Faculté de Médecine, Fédération Hospitalo-Universitaire (FHU) OMICARE, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Strasbourg, France
| | - Malika Schenck
- Service de Réanimation Médicale, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Michel Greget
- Service d’Imagerie Interventionnelle, Hôpitaux Universitaires de Strasbourg, France
| | - Hamid Merdji
- Université de Strasbourg (UNISTRA), Faculté de Médecine, Hôpitaux universitaires de Strasbourg, Service de Réanimation Médicale, Nouvel Hôpital Civil, Strasbourg, France
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Strasbourg, France
| | - Pierre De Marini
- Service d’Imagerie Interventionnelle, Hôpitaux Universitaires de Strasbourg, France
| | - Nicolas Tuzin
- Laboratoire de Biostatistique et d’Informatique Médicale, ICube UMR 7357, Faculté de Médecine, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
- Groupe Méthode en Recherche Clinique, Service de Santé Publique, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Julie Helms
- Université de Strasbourg (UNISTRA), Faculté de Médecine, Hôpitaux universitaires de Strasbourg, Service de Réanimation Médicale, Nouvel Hôpital Civil, Strasbourg, France
- ImmunoRhumatologie Moléculaire, INSERM UMR_S1109, LabEx TRANSPLANTEX, Centre de Recherche d’Immunologie et d’Hématologie, Faculté de Médecine, Fédération Hospitalo-Universitaire (FHU) OMICARE, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Strasbourg, France
| | - Ferhat Meziani
- Université de Strasbourg (UNISTRA), Faculté de Médecine, Hôpitaux universitaires de Strasbourg, Service de Réanimation Médicale, Nouvel Hôpital Civil, Strasbourg, France
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Strasbourg, France
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Ratano D, Alberio L, Delodder F, Faouzi M, Berger MM. Agreement between activated partial thromboplastin time and anti-Xa activity in critically ill patients receiving therapeutic unfractionated heparin. Thromb Res 2019; 175:53-58. [PMID: 30708169 DOI: 10.1016/j.thromres.2019.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 12/04/2018] [Accepted: 01/03/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND No study supports the use of either aPTT or anti-Xa activity for heparin monitoring in critical care patients. There are no strong data on the agreement between aPTT and anti-Xa. The aims of this study were to: 1. Analyse the agreement between aPTT and anti-Xa in a large population of critically ill patients under unfractionated heparin therapy (UFH), 2. Identify clinical and biological factors associated to agreement or disagreement, and 3. Analyse the impact of anti-Xa availability on the use of aPTT and UFH therapy. METHODS Retrospective study in a 35 beds mixed-ICU population between 2006 and 2016 in a University teaching hospital. INCLUSION CRITERIA delivery of a UFH dose >15,000 U/24 h during at least one day with one anti-Xa determination. DATA demographic variables, aPTT, anti-Xa, laboratory variables, presence of extracorporeal devices (ECD). Pairs of simultaneously dosed aPTT and anti-Xa [aPTT:anti-Xa] were analysed on the basis of their agreement within the sub-therapeutic, therapeutic (aPTT 50-80″, anti-Xa 0.3-0.7 U/ml) or supra-therapeutic ranges. RESULTS 2283 patient admissions (2085 patients) were analysed. 35,595 [aPTT:anti-Xa] pairs were found. The overall [aPTT:anti-Xa] agreement was 59.6% and lowest (54.3%) in presence of ECD compared to non-ECD patients (61.6%; p < 0.001). Sixteen demographic and biological variables were analysed and were not predictive of [aPTT:anti-Xa] agreement. No significant difference in administered UFH dose was observed after anti-Xa introduction. CONCLUSION In this large cohort, the [aPTT:anti-Xa] agreement is <60% and significantly lower in patients with ECD. None of the variables identified as potentially affecting the agreement were predictive. Availability of anti-Xa had neither effect on aPTT use nor on UFH-dose. These results call for a prospective study to determine the optimal UFH-therapy monitoring tool.
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Affiliation(s)
- Damian Ratano
- Service of Intensive Care and Burn Unit, Lausanne University Hospital (CHUV) and Faculty of Biology & Medicine, University of Lausanne, Lausanne, Switzerland.
| | - Lorenzo Alberio
- Division of Haematology and Central Haematology Laboratory, Lausanne University Hospital (CHUV) and Faculty of Biology & Medicine, University of Lausanne, Lausanne, Switzerland.
| | - Frederik Delodder
- Service of Intensive Care and Burn Unit, Lausanne University Hospital (CHUV) and Faculty of Biology & Medicine, University of Lausanne, Lausanne, Switzerland
| | - Mohamed Faouzi
- Institute of Social and Preventive Medicine (IUMSP), Faculty of Biology & Medicine, University of Lausanne, Lausanne, Switzerland.
| | - Mette M Berger
- Service of Intensive Care and Burn Unit, Lausanne University Hospital (CHUV) and Faculty of Biology & Medicine, University of Lausanne, Lausanne, Switzerland.
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Siriez R, Evrard J, Dogné J, Pochet L, Bouvy C, Lessire S, Mullier F, Douxfils J. Development of new methodologies for the chromogenic estimation of betrixaban concentrations in plasma. Int J Lab Hematol 2019; 41:250-261. [DOI: 10.1111/ijlh.12963] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 11/16/2018] [Accepted: 11/27/2018] [Indexed: 12/30/2022]
Affiliation(s)
- Romain Siriez
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for LIfe Sciences (NARILIS) University of Namur Namur Belgium
| | - Jonathan Evrard
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for LIfe Sciences (NARILIS) University of Namur Namur Belgium
| | - Jean‐Michel Dogné
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for LIfe Sciences (NARILIS) University of Namur Namur Belgium
| | - Lionel Pochet
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for LIfe Sciences (NARILIS) University of Namur Namur Belgium
| | | | - Sarah Lessire
- Department of Anesthesiology, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS) Université Catholique de Louvain, CHU UCL Namur Yvoir Belgium
| | - François Mullier
- Hematology Laboratory, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS) Université Catholique de Louvain, CHU UCL Namur Yvoir Belgium
| | - Jonathan Douxfils
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for LIfe Sciences (NARILIS) University of Namur Namur Belgium
- Qualiblood s.a Namur Belgium
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Jeevarathinam AS, Pai N, Huang K, Hariri A, Wang J, Bai Y, Wang L, Hancock T, Keys S, Penny W, Jokerst JV. A cellulose-based photoacoustic sensor to measure heparin concentration and activity in human blood samples. Biosens Bioelectron 2018; 126:831-837. [PMID: 30602265 DOI: 10.1016/j.bios.2018.11.052] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 11/28/2018] [Accepted: 11/29/2018] [Indexed: 01/05/2023]
Abstract
Heparin is an indispensable drug in anticoagulation therapy but with a narrow therapeutic window, which dictates regular testing and dose adjustment. However, current monitoring tools have a long turnaround time or are operator intensive. In this work, we describe a cellulose-based photoacoustic sensor for heparin. The sensors have a turnaround time of 6 min for whole blood samples and 3 min for plasma samples regardless of heparin concentration. These sensors have a limit of detection of 0.28 U/ml heparin in human plasma and 0.29 U/ml in whole blood with a linear response (Pearson's r = 0.99) from 0 to 2 U/ml heparin in plasma and blood samples. The relative standard deviation was < 12.5% in plasma and < 17.5% in whole blood. This approach was validated with heparin-spiked whole human blood and had a linear correlation with the activated partial thromboplastin time (aPTT) (r = 0.99). We then studied 16 sets of clinical samples-these had a linear correlation with the activated clotting time (ACT) (Pearson's r = 0.86, P < 0.0001). The photoacoustic signal was also validated against the cumulative heparin dose (Pearson's r = 0.71, P < 0.0001). This approach could have applications in bed-side heparin assays for continuous heparin monitoring.
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Affiliation(s)
| | - Navin Pai
- Department of NanoEngineering, University of California San Diego, La Jolla, CA 92093, United States
| | - Kevin Huang
- Department of NanoEngineering, University of California San Diego, La Jolla, CA 92093, United States
| | - Ali Hariri
- Department of NanoEngineering, University of California San Diego, La Jolla, CA 92093, United States
| | - Junxin Wang
- Department of NanoEngineering, University of California San Diego, La Jolla, CA 92093, United States
| | - Yuting Bai
- Department of NanoEngineering, University of California San Diego, La Jolla, CA 92093, United States
| | - Lu Wang
- Department of NanoEngineering, University of California San Diego, La Jolla, CA 92093, United States
| | - Tiffany Hancock
- Cardiology Unit, VA Healthcare System, San Diego, La Jolla, CA 92161, United States
| | - Stanley Keys
- Cardiology Unit, VA Healthcare System, San Diego, La Jolla, CA 92161, United States
| | - William Penny
- Cardiology Unit, VA Healthcare System, San Diego, La Jolla, CA 92161, United States
| | - Jesse V Jokerst
- Department of NanoEngineering, University of California San Diego, La Jolla, CA 92093, United States; Materials Science Program and Department of Radiology, University of California San Diego, La Jolla, CA 92093, United States.
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Oladunjoye OO, Sleeper LA, Nair AG, Trenor CC, VanderPluym C, Kheir JN, Emani SM. Partial thromboplastin time is more predictive of bleeding than anti-Xa levels in heparinized pediatric patients after cardiac surgery. J Thorac Cardiovasc Surg 2018; 156:332-340.e1. [DOI: 10.1016/j.jtcvs.2018.02.101] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 11/30/2017] [Accepted: 02/11/2018] [Indexed: 11/28/2022]
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Wong SSM, Lau WY, Chan PK, Wan CK, Cheng YL. Correlation between activated partial thromboplastin time and anti-Xa activity in patients who received low-molecular weight heparin as anticoagulation for haemodialysis. Nephrology (Carlton) 2018; 22:921-924. [PMID: 28767200 DOI: 10.1111/nep.13122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2017] [Indexed: 11/27/2022]
Abstract
Plasma anti-Xa activity, the recommended test to monitor low-molecular weight heparin (LMWH) therapy, is not readily available in many laboratories. In our clinical trials on the use of LMWH as anticoagulation for haemodialysis, a consistent prolongation of APTT in addition to the elevated anti-Xa activity was observed in the patients after LMWH administration. Hence, the paired anti-Xa activity and APTT data were re-analyzed. The APTT ratio, which was the proportional change in APTT from the baseline value after LMWH administration, was found to have a strong correlation with anti-Xa activity (coefficient of determination, R 2 = 0.72, P < 0.001). In the receiver operating characteristic analysis, the APTT ratio was also found to be an excellent predictor of therapeutic anti-Xa activity ≧0.5 IU/mL (area under curve = 0.93, P < 0.001). The sensitivity was 88% and the specificity was 83.3% when an APTT ratio ≧1.4 was used as the cut point to predict the achievement of therapeutic anti-Xa activity. Our results illustrated that APTT is a potentially useful screening test to assess the degree of anticoagulation achieved by LMWH during haemodialysis, if the testing for plasma anti-Xa activity is not available.
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Affiliation(s)
- Steve Siu-Man Wong
- Department of Medicine, Alice Ho Miu Ling Nethersole Hospital, Tai Po, Hong Kong
| | - Wai-Yan Lau
- Department of Medicine, Alice Ho Miu Ling Nethersole Hospital, Tai Po, Hong Kong
| | - Ping-Kwan Chan
- Department of Medicine, Alice Ho Miu Ling Nethersole Hospital, Tai Po, Hong Kong
| | - Ching-Kit Wan
- Department of Medicine, Alice Ho Miu Ling Nethersole Hospital, Tai Po, Hong Kong
| | - Yuk-Lun Cheng
- Department of Medicine, Alice Ho Miu Ling Nethersole Hospital, Tai Po, Hong Kong
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Bürki S, Brand B, Escher R, Wuillemin WA, Nagler M. Accuracy, reproducibility and costs of different laboratory assays for the monitoring of unfractionated heparin in clinical practice: a prospective evaluation study and survey among Swiss institutions. BMJ Open 2018; 8:e022943. [PMID: 29886450 PMCID: PMC6009553 DOI: 10.1136/bmjopen-2018-022943] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVES To investigate the accuracy, reproducibility and costs of different laboratory assays for the monitoring of unfractionated heparin (UFH) in clinical practice and to study test utilisation in Switzerland. DESIGN Prospective evaluation study and survey among Swiss hospitals and laboratories. SETTING Secondary care hospital in rural Switzerland (evaluation study); all Swiss hospitals and laboratories (survey). PARTICIPANTS All consecutive patients, monitored for treatment with UFH during two time periods, were included (May to July 2014 and January to February 2015; n=254). OUTCOME MEASURES Results of activated partial thromboplastin time (aPTT), thrombin time (TT), prothrombinase-induced clotting time (PiCT) and anti-Xa activity with respect to UFH concentration RESULTS: Spearman's correlation coefficient (rs) with regard to anti-Xa activity was 0.68 (95% CI 0.60 to 0.75) for aPTT, 0.79 (0.69 to 0.86) for TT and 0.94 (0.93 to 0.95) for PiCT. The correlation (rs) between anti-Xa activity and heparin concentration as determined by spiking plasma samples was 1.0 (1.0 to 1.0). The coefficient of variation was at most 5% for PiCT and anti-Xa activity (within-run as well as day-to-day variability). The total costs per test in Swiss Francs (SFr) were SFr23.40 for aPTT, SFr33.30 for TT, SFr15.70 for PiCT and SFr24.15 for anti-Xa activity. The various tests were employed in Swiss institutions with the following frequencies: aPTT 53.2%, TT 21.6%, anti-Xa activity 7.2%, PiCT 1.4%; 16.6% of hospitals performed more than one test. CONCLUSIONS The accuracy and reproducibility of PiCT and anti-Xa activity for monitoring of UFH was superior, and analytical costs were equivalent to or lower than aPTT and TT.
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Affiliation(s)
- Susanne Bürki
- Department of Haematology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Béatrice Brand
- Department of Medicine, Spital Emmental, Burgdorf, Switzerland
| | - Robert Escher
- Department of Medicine, Spital Emmental, Burgdorf, Switzerland
| | - Walter A Wuillemin
- Division of Haematology and Central Haematology Laboratory, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Michael Nagler
- Department of Haematology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department for BioMedical Research, University of Bern, Bern, Switzerland
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Sinauridze EI, Vuimo TA, Tarandovskiy ID, Ovsepyan RA, Surov SS, Korotina NG, Serebriyskiy II, Lutsenko MM, Sokolov AL, Ataullakhanov FI. Thrombodynamics, a new global coagulation test: Measurement of heparin efficiency. Talanta 2017; 180:282-291. [PMID: 29332812 DOI: 10.1016/j.talanta.2017.12.055] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Revised: 12/14/2017] [Accepted: 12/17/2017] [Indexed: 01/06/2023]
Abstract
The actual coagulation status may be reliably measured using only highly sensitive global functional tests; however, they are not numerous and all of them have disadvantages. Thrombodynamics (TD), a novel global coagulation test, is sensitive to hypo- and hypercoagulable states. The main properties of this test were investigated, and its capabilities for hemostasis analysis were verified through pharmacodynamic monitoring of the most widely used anticoagulants, heparins. The anticoagulant effects in the plasma of donors (n = 20) and patients after hip replacement (n = 20) spiked with unfractionated heparin or enoxaparin were measured in vitro to eliminate the influence of pharmacokinetic factors. Sensitivity for heparins was compared for activated partial thromboplastin time, thrombin generation tests and TD. TD was shown to reliably characterize the pharmacodynamics of any heparin in the entire range of its prophylactic and therapeutic concentrations. Inter-individual variability for the anticoagulant action of heparins was also calculated using the TD data. This variability did not differ between the investigated groups and did not exceed 12% and 20% for the stationary clot growth rate in the presence of unfractionated heparin and enoxaparin, respectively. That finding was in accordance with the values determined earlier using the thrombin generation test. The study results showed that TD has advantages over the other global methods of coagulation analysis. These advantages are good standardization, high reproducibility, independence of the parameter values from patient age and gender, and a narrower parameter distribution in a normal population. These results indicate that TD is a promising universal assessment method that improves the quality of hemostasis analysis because it more reliably detects deviations from the parameters' reference values.
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Affiliation(s)
- Elena I Sinauridze
- Laboratory of Biophysics, Dmitriy Rogachev National Medical Research Center of Pediatric Hematology, Oncology, and Immunology, Samory Mashela str., 1, GSP-7, Moscow 117997, Russia; Laboratory of Biophysics of the Cell, Center for Theoretical Problems of Physicochemical Pharmacology, Russian Academy of Sciences, Kosygina str., 4, Moscow 119334, Russia.
| | - Tatiana A Vuimo
- Laboratory of Translational Medicine, Dmitriy Rogachev National Medical Research Center of Pediatric Hematology, Oncology, and Immunology, Samory Mashela str., 1, GSP-7, Moscow 117997, Russia.
| | - Ivan D Tarandovskiy
- Laboratory of Physical Biochemistry, National Research Center for Hematology, Novyi Zykovskii pr., 4, Moscow 125167, Russia.
| | - Ruzanna A Ovsepyan
- Laboratory of Translational Medicine, Dmitriy Rogachev National Medical Research Center of Pediatric Hematology, Oncology, and Immunology, Samory Mashela str., 1, GSP-7, Moscow 117997, Russia.
| | - Stepan S Surov
- Laboratory of Biophysics of the Cell, Center for Theoretical Problems of Physicochemical Pharmacology, Russian Academy of Sciences, Kosygina str., 4, Moscow 119334, Russia.
| | - Natalia G Korotina
- Scientific Department, Hematological Corporation HemaCore LLC, Nauchnyi pr., 20, build. 2, Moscow 117246, Russia.
| | - Ilya I Serebriyskiy
- Scientific Department, Hematological Corporation HemaCore LLC, Nauchnyi pr., 20, build. 2, Moscow 117246, Russia.
| | - Maxim M Lutsenko
- Department of Low Invasive Surgery, Treatment and Rehabilitation Center, Ivankovskoe shosse, 3, Moscow 125367, Russia.
| | - Alexander L Sokolov
- Department of Low Invasive Surgery, Treatment and Rehabilitation Center, Ivankovskoe shosse, 3, Moscow 125367, Russia.
| | - Fazoil I Ataullakhanov
- Laboratory of Biophysics, Dmitriy Rogachev National Medical Research Center of Pediatric Hematology, Oncology, and Immunology, Samory Mashela str., 1, GSP-7, Moscow 117997, Russia; Laboratory of Biophysics of the Cell, Center for Theoretical Problems of Physicochemical Pharmacology, Russian Academy of Sciences, Kosygina str., 4, Moscow 119334, Russia; Scientific Department, Hematological Corporation HemaCore LLC, Nauchnyi pr., 20, build. 2, Moscow 117246, Russia; Department of Physics, Moscow State University, Leninskie Gory, 1, build. 2, GSP-1, Moscow 119991, Russia; Department of Biological and Medical Physics, Moscow Institute of Physics and Technology, Institutskii per., 9, Dolgoprudny, Moscow Region 141701, Russia.
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Whitman-Purves E, Coons JC, Miller T, DiNella JV, Althouse A, Schmidhofer M, Smith RE. Performance of Anti-Factor Xa Versus Activated Partial Thromboplastin Time for Heparin Monitoring Using Multiple Nomograms. Clin Appl Thromb Hemost 2017; 24:310-316. [PMID: 29212374 PMCID: PMC6714688 DOI: 10.1177/1076029617741363] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The purpose of this study was to compare the performance of anti-factor Xa concentration versus activated partial thromboplastin time (aPTT) monitoring with multiple indication-specific heparin nomograms. This was a prospective, nonrandomized study with historical control at a large academic medical center. A total of 201 patients who received intravenous heparin in the cardiology units were included. The prospective cohort included patients (n = 101) with anti-factor Xa (anti-Xa) monitoring, and the historical control group included patients (n = 100) who had aPTT monitoring. Patients in the prospective group had both anti-Xa and aPTT samples drawn, but anti-Xa was used for dosing adjustment. The anti-Xa cohort achieved a significantly faster time to therapeutic range (P < .01) and required fewer dose adjustments per 24-hour period compared to the aPTT control (P = .01). Results were consistent across heparin nomograms. The overall discordance rate between the 2 tests was 49%. No significant differences in clinical outcomes were observed. In summary, anti-Xa monitoring improved the time to therapeutic anticoagulation and led to fewer dose adjustments compared to the aPTT with multiple indication-based heparin nomograms.
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Affiliation(s)
- Emily Whitman-Purves
- 1 Presbyterian-Shadyside Hospital, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
| | - James C Coons
- 1 Presbyterian-Shadyside Hospital, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA.,2 Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Taylor Miller
- 1 Presbyterian-Shadyside Hospital, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
| | - Jeannine V DiNella
- 1 Presbyterian-Shadyside Hospital, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
| | - Andrew Althouse
- 1 Presbyterian-Shadyside Hospital, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
| | - Mark Schmidhofer
- 1 Presbyterian-Shadyside Hospital, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
| | - Roy E Smith
- 1 Presbyterian-Shadyside Hospital, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
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Abstract
INTRODUCTION Heparin is one of the oldest biological medicines with an established role in prevention and treatment of arterial and venous thromboembolism. Published therapeutic ranges for unfractionated heparin (UFH) mostly precede the large increase in the number of activated partial thromboplastin time (APTT) reagent/instrument combinations that now show wide variability. Areas covered: This paper explores the use of UFH, the development of heparin therapeutic ranges (HTRs), and the strengths and limitations of the methods used to monitor heparin's anticoagulant effect. Expert commentary: Despite longstanding use of UFH for management of thromboembolic conditions, the optimal test for monitoring UFH remains undetermined. Although used extensively for monitoring UFH, routine APTT-derived HTRs are based on limited science that may have little relevance to current laboratory practice. Anti-FXa levels may provide better and more reliable HTRs; however, even these levels show considerable inter-laboratory variation, and there are insufficient clinical studies proving improved clinical efficacy. Alternative tests for monitoring UFH reported over time have not been proven effective nor feasible, secondary to technical or cost issues, or lack of general adoption. Thus, despite limited evidence of clinical utility, an uncomfortable marriage of convenience represented by heparin laboratory monitoring is unlikely to be terminated in the immediate future.
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Affiliation(s)
- Israfil Baluwala
- a Department of Haematology, Institute of Clinical Pathology and Medical Research, NSW Health Pathology , Westmead Hospital , Westmead , Australia
| | - Emmanuel J Favaloro
- a Department of Haematology, Institute of Clinical Pathology and Medical Research, NSW Health Pathology , Westmead Hospital , Westmead , Australia.,b Sydney Centres for Thrombosis and Haemostasis , Westmead , Australia
| | - Leonardo Pasalic
- a Department of Haematology, Institute of Clinical Pathology and Medical Research, NSW Health Pathology , Westmead Hospital , Westmead , Australia.,b Sydney Centres for Thrombosis and Haemostasis , Westmead , Australia
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Schurr JW, Stevens CA, Bane A, Luppi C, Culbreth SE, Miller AL, Connors JM, Sylvester KW. Description and Evaluation of the Implementation of a Weight-Based, Nurse-Driven Heparin Nomogram in a Tertiary Academic Medical Center. Clin Appl Thromb Hemost 2017; 24:248-253. [PMID: 28774195 DOI: 10.1177/1076029617721009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Weight-based, nurse-driven heparin nomograms are reported in the medical literature to improve the time it takes to reach a minimum threshold for anticoagulation without compromising patient safety in specific indications or patient populations. This is the first report in the literature of an institution-wide protocol implementation and evaluation of effectiveness with simultaneous transition to an electronic health record. The purpose of implementing this practice change at our institution was to standardize practice, improve time to reach therapeutic anticoagulation, and improve patient safety. We conducted a retrospective analysis utilizing a pre/postimplementation design to compare outcomes. The primary end point evaluated was the time to reach minimum threshold value for therapeutic anticoagulation. Additionally, we assessed the percentage of patients who reached minimum threshold therapeutic anticoagulation within 24 hours, the percentage of patients with a critically supratherapeutic activated partial thromboplastin time (aPTT) value (≥120 seconds) during therapy, and a description of heparin titration for the first 4 aPTT results with nomogram use. Overall time to therapeutic anticoagulation decreased from a mean 18.7 to 11.7 hours (hazard ratio [HR] 1.59; 95% confidence interval 1.22-2.08; P < .0005). Percentage of patients receiving therapeutic anticoagulation within 24 hours increased from 74.4 to 88.5 (odds ratio [OR 2.97, P = .002) and the percentage of patients with an aPTT ≥120 seconds remained constant at 49.9 versus 46.8 (OR 0.92, P = .73). This practice change reduced time to therapeutic anticoagulation without an increase in the proportion of patients with a critically supratherapeutic aPTT at our institution.
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Affiliation(s)
- James W Schurr
- 1 Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Craig A Stevens
- 2 Department of Pharmacy, UC San Diego Medical Center, San Diego, CA, USA
| | - Anne Bane
- 3 Department of Nursing, Center for Nursing Excellence, Brigham and Women's Hospital, Boston, MA, USA
| | - Carol Luppi
- 3 Department of Nursing, Center for Nursing Excellence, Brigham and Women's Hospital, Boston, MA, USA
| | - Sarah E Culbreth
- 1 Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Amy Leigh Miller
- 4 Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,5 Harvard Medical School, Boston, MA, USA
| | - Jean M Connors
- 5 Harvard Medical School, Boston, MA, USA.,6 Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
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49
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Arachchillage DRJ, Kamani F, Deplano S, Banya W, Laffan M. Should we abandon the APTT for monitoring unfractionated heparin? Thromb Res 2017; 157:157-161. [PMID: 28759760 DOI: 10.1016/j.thromres.2017.07.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 06/23/2017] [Accepted: 07/05/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The activated partial thromboplastin time (APTT) is commonly used to monitor unfractionated heparin (UFH) but may not accurately measure the amount of heparin present. The anti-Xa assay is less susceptible to confounding factors and may be a better assay for this purpose. MATERIALS AND METHODS The validity of the APTT for monitoring UFH was assessed by comparing with an anti-Xa assay on 3543 samples from 475 patients (infants [n=165], children 1-15years [n=60] and adults [n=250]) receiving treatment dose UFH. RESULTS Overall concordance was poor. The highest concordance (66%; 168/254) was seen in children. Concordance (51.8%) or discordance (48.4%) was almost equal in adult patients. Among adult patients whose anti-Xa level was within 0.3-0.7IU/mL, only 38% had an APTT in the therapeutic range whilst 56% were below and 6% were above therapeutic range. Children and adult patients with anti-Xa of 0.3-0.7IU/mL but sub- therapeutic APTT had significantly higher fibrinogen levels compared to those with therapeutic or supra-therapeutic APTT. CONCLUSIONS When the anti-Xa level was 0.3-0.7IU/mL, the majority of samples from infants demonstrated a supra-therapeutic APTT, whilst adults tended to have a sub-therapeutic APTT. This may lead to under anticoagulation in infants or over anticoagulation in adults with risk of bleeding if APTT is used to monitor UFH. These results further strengthen existing evidence of the limitation of APTT in monitoring UFH. Discordance of APTT and anti-Xa level in adults and children may be due to elevation of fibrinogen level.
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Affiliation(s)
- D R J Arachchillage
- Department of Haematology, Royal Brompton & Harefield NHS Foundation Trust, London, UK; Department of Haematology, Imperial College Healthcare NHS Trust and Imperial College London, London, UK.
| | - F Kamani
- Department of Haematology, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - S Deplano
- Department of Haematology, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - W Banya
- Department of Haematology, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - M Laffan
- Department of Haematology, Imperial College Healthcare NHS Trust and Imperial College London, London, UK
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Affiliation(s)
| | - James Duffy
- CRANN, School of Physics, Trinity College Dublin, Dublin 2, Ireland
| | - Martin Hegner
- CRANN, School of Physics, Trinity College Dublin, Dublin 2, Ireland
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