scholarly journals Management of Coagulopathy in Bleeding Patients

2021 ◽  
Vol 11 (1) ◽  
pp. 1
Author(s):  
Stefan Hofer ◽  
Christoph J. Schlimp ◽  
Sebastian Casu ◽  
Elisavet Grouzi
Keyword(s):  
Early Recognition ◽  
Point Of Care ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Coagulation Factor ◽  
Blood Gas Analysis ◽  
Coagulation Factors ◽  
Gas Analysis ◽  
Coagulation Management ◽  
Reversal Agents

Early recognition of coagulopathy is necessary for its prompt correction and successful management. Novel approaches, such as point-of-care testing (POC) and administration of coagulation factor concentrates (CFCs), aim to tailor the haemostatic therapy to each patient and thus reduce the risks of over- or under-transfusion. CFCs are an effective alternative to ratio-based transfusion therapies for the correction of different types of coagulopathies. In case of major bleeding or urgent surgery in patients treated with vitamin K antagonist anticoagulants, prothrombin complex concentrate (PCC) can effectively reverse the effects of the anticoagulant drug. Evidence for PCC effectiveness in the treatment of direct oral anticoagulants-associated bleeding is also increasing and PCC is recommended in guidelines as an alternative to specific reversal agents. In trauma-induced coagulopathy, fibrinogen concentrate is the preferred first-line treatment for hypofibrinogenaemia. Goal-directed coagulation management algorithms based on POC results provide guidance on how to adjust the treatment to the needs of the patient. When POC is not available, concentrate-based management can be guided by other parameters, such as blood gas analysis, thus providing an important alternative. Overall, tailored haemostatic therapies offer a more targeted approach to increase the concentration of coagulation factors in bleeding patients than traditional transfusion protocols.

scholarly journals Point-of-Care Diagnostics in Coagulation Management

Sensors ◽  
2020 ◽  
Vol 20 (15) ◽  
pp. 4254
Author(s):  
Sebastian D. Sahli ◽  
Julian Rössler ◽  
David W. Tscholl ◽  
Jan-Dirk Studt ◽  
Donat R. Spahn ◽  
...  
Keyword(s):  
Point Of Care ◽  
Blood Gas Analysis ◽  
Gas Analysis ◽  
Coagulation Management ◽  
Point Of Care Diagnostics ◽  
Reliable Assessment ◽  
Coagulation Tests ◽  
Visualization Technology ◽  
Patient’S Outcome ◽  
Routine Coagulation

This review provides a comprehensive and up-to-date overview of point-of-care (POC) devices most commonly used for coagulation analyses in the acute settings. Fast and reliable assessment of hemostasis is essential for the management of trauma and other bleeding patients. Routine coagulation assays are not designed to visualize the process of clot formation, and their results are obtained only after 30–90 m due to the requirements of sample preparation and the analytical process. POC devices such as viscoelastic coagulation tests, platelet function tests, blood gas analysis and other coagulometers provide new options for the assessment of hemostasis, and are important tools for an individualized, goal-directed, and factor-based substitution therapy. We give a detailed overview of the related tests, their characteristics and clinical implications. This review emphasizes the evident advantages of the speed and predictive power of POC clot measurement in the context of a goal-directed and algorithm-based therapy to improve the patient’s outcome. Interpretation of viscoelastic tests is facilitated by a new visualization technology.

Reversal of oral anticoagulants

ESC CardioMed ◽  
2018 ◽  
pp. 278-281
Author(s):  
Joanne van Ryn
Keyword(s):  
Clinical Trials ◽  
Vitamin K ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Factor Xa ◽  
Coagulation Factor ◽  
Vitamin K Antagonist ◽  
Reversal Agent ◽  
Reversal Agents ◽  
Trial Testing

Oral anticoagulation reduces the risk of stroke in patients with atrial fibrillation and is effective in treating or preventing thromboembolic events. These indications have been the mainstay of vitamin K antagonist therapy for decades; however, in recent years a number of direct oral anticoagulants have also been approved for these indications. They circumvent many of the disadvantages associated with vitamin K antagonist use; however, the lack of a rapid and safe reversal strategy in emergency settings is often considered a hurdle to their more widespread use. Historically, coagulation factor concentrates have been used for rapid vitamin K antagonist reversal, though evidence from clinical trials has only been established in recent years. In addition, several new approaches to the specific reversal of anticoagulation have been developed. The first of these, idarucizumab, a specific reversal agent for dabigatran, was approved in 2015. A specific reversal agent for the factor Xa inhibitors, andexanet alfa, is currently in clinical trial testing, and a further compound, ciraparantag, is undergoing testing in healthy volunteers. This chapter discusses the mechanism of action of these reversal agents, their target anticoagulants, and the most recent data available in both volunteer and clinical trials.

A Novel Whole Blood Point-of-Care Coagulometer to Measure the Effect of Direct Oral Anticoagulants and Heparins

2018 ◽  
Vol 45 (03) ◽  
pp. 259-263 ◽  
Author(s):  
Jack Ansell ◽  
Stefan Zappe ◽  
Xuan Jiang ◽  
Lirong Chen ◽  
Solomon Steiner ◽  
...  
Keyword(s):  
High Risk ◽  
Whole Blood ◽  
Point Of Care ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Factor Xa ◽  
Pharmacokinetic Parameters ◽  
Reversal Agents ◽  
Emergency Situations ◽  
Risk Patients

AbstractThe direct oral anticoagulants (DOACs) currently require no monitoring for routine therapy of atrial fibrillation or venous thromboembolism. Measurement of activity, however, may be important in patients with major and life-threatening bleeding, patients needing emergent surgery, in reversal situations, or in patients at high risk of bleeding or thrombosis due to underlying conditions. For these patients, a widely available and rapid turnaround assay would be optimal. To date, there is no such assay available, especially for the direct factor Xa inhibitors. This report describes the performance of a new, rapid turnaround, point-of-care (PoC) assay for measuring the activity of a range of anticoagulants, including DOACs and heparins, in emergency situations and for routine measurement in high-risk patients. Perosphere Technologies' PoC coagulometer is a handheld instrument that performs individual coagulation tests on samples of fresh whole blood (∼10 µL) with clotting activated by glass contact and endpoint determination performed by infrared spectroscopy. In preclinical studies using rats anticoagulated with therapeutic doses of edoxaban or enoxaparin, the PoC coagulometer showed a strong linear correlation between pharmacokinetic parameters and clotting time with edoxaban (r 2 = 0.994) and with enoxaparin (r 2 = 0.967). These preclinical results suggest that this PoC coagulometer would be ideal to assess the pharmacodynamic effects of anticoagulants and their reversal agents. The PoC bedside instrument delivers results within minutes and requires no more than a drop of whole blood. Studies are underway to confirm these results in humans and to further characterize the performance of the instrument.

scholarly journals Diagnostic Modalities in Critical Care: Point-of-Care Approach

Diagnostics ◽  
2021 ◽  
Vol 11 (12) ◽  
pp. 2202
Author(s):  
Sasa Rajsic ◽  
Robert Breitkopf ◽  
Mirjam Bachler ◽  
Benedikt Treml
Keyword(s):  
Critical Care ◽  
Early Recognition ◽  
Point Of Care ◽  
Prehospital Care ◽  
Blood Gas Analysis ◽  
Gas Analysis ◽  
Special Focus ◽  
Icu Patients ◽  
Care Approach ◽  
Diagnostic Modalities

The concept of intensive care units (ICU) has existed for almost 70 years, with outstanding development progress in the last decades. Multidisciplinary care of critically ill patients has become an integral part of every modern health care system, ensuing improved care and reduced mortality. Early recognition of severe medical and surgical illnesses, advanced prehospital care and organized immediate care in trauma centres led to a rise of ICU patients. Due to the underlying disease and its need for complex mechanical support for monitoring and treatment, it is often necessary to facilitate bed-side diagnostics. Immediate diagnostics are essential for a successful treatment of life threatening conditions, early recognition of complications and good quality of care. Management of ICU patients is incomprehensible without continuous and sophisticated monitoring, bedside ultrasonography, diverse radiologic diagnostics, blood gas analysis, coagulation and blood management, laboratory and other point-of-care (POC) diagnostic modalities. Moreover, in the time of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, particular attention is given to the POC diagnostic techniques due to additional concerns related to the risk of infection transmission, patient and healthcare workers safety and potential adverse events due to patient relocation. This review summarizes the most actual information on possible diagnostic modalities in critical care, with a special focus on the importance of point-of-care approach in the laboratory monitoring and imaging procedures.

A Review on the Use of Reversal Agents of Direct Oral Anticogulant Drugs in Case of Gastrointestinal Bleeding

2020 ◽  
Vol 15 ◽  
Author(s):  
Veronica Ojetti ◽  
Angela Saviano ◽  
Mattia Brigida ◽  
Luisa Saviano ◽  
Alessio Migneco ◽  
...  
Keyword(s):  
Gastrointestinal Bleeding ◽  
Major Bleeding ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Medical Emergency ◽  
Management Approach ◽  
Emergency Setting ◽  
Reversal Agents ◽  
Life Threatening ◽  
Andexanet Alfa

Background : Major bleeding is a life-threatening condition and a medical emergency with high mortality risk. It is often the complication of anticoagulant’s intake. Anticoagulants are commonly used for the prevention and the treatment of thrombotic events. The standard therapy with vitamin K antagonist (warfarin) has been frequently replaced by direct oral anticoagulants (DOACs). The latter agents (rivaroxaban, apixaban, edoxaban, dabigatran, betrixaban) showed a better efficacy and safety compared to standard warfarin treatment and they are recommended for the reduction of ischemic stroke. Literature data reported a high risk of gastrointestinal bleeding with DOACs, in particular with dabigatran and rivaroxaban. In case of life-threatening gastrointestinal bleeding, these patients could benefit from the use of reversal agents. Methods: We performed an electronic search on PUBMED of the literature concerning reversal agents for DOACs and gastrointestinal bleeding in the Emergency Department from 2004 to 2020. AIM: This review summarizes the current evidences about three reversal agents idarucizumab, andexanet alfa and ciraparantag, and the use of the first two in the emergency setting in patients with an active major bleeding or who need urgent surgery to offer physicians indications for a better management approach in order to increase patient’s safety. Conclusion: Although these agents have been marketed for five years (idarucizumab) and two years (andexanet alfa) respectively, and despite guidelines considering antidotes as first-line agents in treating life-threatening hemorrhage when available, these antidotes seem to gain access very slowly in the clinical practice. Cost, logistical aspects and need for plasma level determination of DOAC for an accurate therapeutic use probably have an impact on this phenomenon.. An expert multidisciplinary bleeding team should be established so as to implement international guidelines based on local resources and organization.

scholarly journals Heparin is more effective than apixaban in inhibiting in vitro contact activated coagulation

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
M.M Engelen ◽  
C Van Laer ◽  
M Jacquemin ◽  
C Vandenbriele ◽  
K Peerlinck ◽  
...  
Keyword(s):  
Thrombin Generation ◽  
Heart Valves ◽  
Thrombus Formation ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Factor Xa ◽  
Coagulation Factor ◽  
Mechanical Heart Valves ◽  
Contact Activation

Abstract Introduction Contact of blood with artificial surfaces such as mechanical support devices, catheters, and mechanical heart valves activates the contact activation (CA) pathway of coagulation. Furthermore, recent animal data and clinical studies suggest a more important contribution of CA in pathological thrombus formation in other cardiovascular diseases. Direct oral anticoagulants (DOACs) are recommended as first-line treatment in most patients who require long-term anticoagulation. However, because DOACs directly inhibit a single downstream coagulation factor (thrombin (fXIIa) or factor Xa (fXa)), it has been suggested that their efficacy could be reduced in the presence of strong activation of the CA pathway as compared to anticoagulants that target multiple, more upstream located coagulation factors. Purpose To compare the efficacy of a DOAC (apixaban) and heparin to suppress thrombin generation in the presence of strong CA pathway activation. Methods Pooled platelet-poor plasma was spiked with either apixaban (dissolved in DMSO and PBS) or unfractionated heparin to achieve therapeutic plasma levels. SynthASil, a commercially available mixture of phospholipids and silica, was used to stimulate the CA pathway in two different dilutions (1–80 and 5–80). Downstream coagulation was accessed by Thrombin Generation Test using Thrombinoscope by Stago and associated Thrombin Calibrator (activity 640 nM). The endogenous thrombin potential (area under the thrombin generation curve; ETP), peak thrombin generation (PTG), time to peak (ttPeak) and time to start (ttStart) were accessed. Results With decreasing concentrations of apixaban, stimulation with the lower dose SynthASil reveals an increasing ETP and PTG. As expected, ttPeak and ttStart decreased. Even supratherapeutic levels of apixaban (i.e. 1120 ng/mL) could not inhibit thrombin from being generated, in striking contrast with UFH where no thrombin was formed. Using a five times higher dose of SynthASil showed comparable ETP for all concentrations of apixaban, allocated around the control value. PTG, however, slightly increased with decreasing concentrations of apixaban. ttPeak and ttStart slightly decreased. Except for the subtherapeutic UFH concentration of 0,114 IU/mL, no thrombin was generated with UFH. Conclusion UFH is more effective in inhibiting downstream thrombin generation compared to apixaban as a response to activation of the CA pathway in vitro. These findings could help explain why direct inhibitors were not able to show non-inferiority in patients with mechanical heart valves and support the development of specific CA pathway inhibitors for patients with conditions that activate the CA pathway. Thrombin generation curves Funding Acknowledgement Type of funding source: None

StatPal II pH and Blood Gas Analysis System evaluated

1994 ◽  
Vol 40 (1) ◽  
pp. 124-129 ◽  
Author(s):  
R J Wong ◽  
J J Mahoney ◽  
J A Harvey ◽  
A L Van Kessel
Keyword(s):  
Point Of Care ◽  
Blood Gases ◽  
Blood Gas Analysis ◽  
Gas Analysis ◽  
Portable Instrument ◽  
Blood Gas ◽  
Target Value ◽  
Analysis System

Abstract We evaluated a new portable instrument, the PPG StatPal II pH and Blood Gas Analysis System, designed for "point-of-care" measurements of blood gases and pH. Inaccuracy (% of target value) and imprecision (CV%) were assessed by blood tonometry and comparison with a Corning 178. Within-day results for PCO2 inaccuracy and imprecision ranged from 98.2% to 102.9% and 3.3% to 3.9%, respectively; for PO2, these were 95.5% to 102.3% and 2.3% to 3.0%, respectively. Between-day results for PCO2 inaccuracy and imprecision ranged from 99.2% to 99.3% and from 2.9% to 3.2%, respectively; for PO2, the ranges were 96.2% to 98.2% and 2.6% to 3.0%, respectively. Two PCO2 outliers (in 645 samples = 0.3%) were observed. In general, tonometry recovery, measurement stability, and pH bias results for the StatPal II and Corning 178 were comparable. We conclude that the StatPal II performs within acceptable ranges of inaccuracy and imprecision.

scholarly journals Reversal Strategies for Intracranial Hemorrhage Related to Direct Oral Anticoagulant Medications

2018 ◽  
Vol 2018 ◽  
pp. 1-11 ◽  
Author(s):  
Alok Dabi ◽  
Aristides P. Koutrouvelis
Keyword(s):  
Side Effects ◽  
Intracranial Hemorrhage ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Factor Xa ◽  
Coagulation Cascade ◽  
Reversal Agents ◽  
United States Food ◽  
Life Threatening

Direct oral anticoagulants (DOACs) are a new class of anticoagulants that directly inhibit either thrombin or factor Xa in the coagulation cascade. They are being increasingly used instead of warfarin or other vitamin K antagonists (VKAs). Adverse side effects of DOACs may result in hemorrhagic complications, including life-threatening intracranial hemorrhage (ICH), though to a much lesser degree than VKAs. Currently there are relatively limited indications for DOACS but their usage is certain to expand with the availability of their respective specific reversal agents. Currently, only idarucizumab (antidote for dabigatran) has been United States Food and Drug Administration- (FDA-) approved, but others (andexanet-α and ciraparantag) may be approved in near future, and the development and availability of such reversal agents have the potential to dramatically change the current anticoagulant use by providing reversal of multiple oral anticoagulants. Until all the DOACs have FDA-approved reversal agents, the treatment of the dreaded side effects of bleeding is challenging. This article is an attempt to provide an overview of the management of hemorrhage, especially ICH, related to DOAC use.

scholarly journals Emergency Cardiac Surgery in Patients on Oral Anticoagulants

2021 ◽  
Author(s):  
Rami Akhrass ◽  
A. Marc Gillinov ◽  
Faisal Bakaeen ◽  
Scott Cameron ◽  
Jay Bishop ◽  
...  
Keyword(s):  
Circulatory Arrest ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Difficult Patient ◽  
Disseminated Intravascular Coagulopathy ◽  
Reversal Agents ◽  
Coagulation Profile ◽  
Intravascular Coagulopathy ◽  
Time To Onset ◽  
Case Basis

Emergency surgery, blood transfusion, and reoperation for bleeding have been associated with increased morbidity and mortality. Every effort is made to optimize patients preoperatively including cessation of oral anticoagulants in an attempt to normalize the coagulation profile. The recent explosive use of direct oral anticoagulants (DOACs) and antiplatelet medications has made the above more difficult. Cardiopulmonary bypass (CPB), with its associated fibrinolysis and platelet consumption, may exacerbate a pre-existing coagulopathy. In addition, the underlying surgical pathology, such as endocarditis accompanied by sepsis and disseminated intravascular coagulopathy (DIC) or aortic dissection requiring hypothermia and circulatory arrest, can aggravate an already challenged hematological profile. Ensuring a dry operative field upon entry by correcting the coagulopathy is offset by the concern of potentially hindering efforts to anticoagulate the patient in preparation for CPB, in addition to possibly creating a hypercoagulable state that could increase the risk of thromboembolic events. Management is challenging and decisions are typically made on a case-by-case basis. Surgery is delayed when possible and less invasive percutaneous options should be considered if feasible. If surgery is unavoidable, attention is paid to exercising meticulous techniques, avoiding excessive hypothermia, treating coexisting issues such as sepsis and correcting the coagulopathy with antidotes, reversal agents and blood products, with the understanding that a normal coagulation profile does not necessarily translate into hemostasis or the absence of thrombosis. Proper knowledge of the mechanism of action of the oral anticoagulants, available antidotes and their time to onset are essential in properly treating this difficult patient population.

Sign in / Sign up

Export Citation Format

Share Document