Coagulation Management Research Articles

Typical causes and clinical presentations of traumatic and nontraumatic soft tissue and organ haemorrhage in emergency departments

Acute bleeding often occurs in awide variety of forms in clinical emergency medicine. In traumatic bleeding, soft tissue injuries to the head or extremities are common, while severe bleeding is less common in chest injuries or pelvic trauma. In nontraumatic emergencies, gastrointestinal bleeding is the leading cause, but many other bleeding entities are possible. Structured management helps to detect the critically ill patient, identify the possible source of bleeding and provide appropriate radiological diagnostics and therapy. Clinical examination, blood gas analyses and emergency ultrasound are crucial in the initial phase of diagnosis. Initially, symptomatic therapy is usually indicated to stabilize the patient, and then interventional or surgical care is indicated in the course of the disease, depending on the location of the bleeding. Volume and catecholamine therapy, coagulation management and emergency transfusion are important components of interdisciplinary emergency care, in addition to primary bleeding control, especially in the case of open injuries.

Perioperative Application of Point-of-care Test for Blood Viscoelasticity: A Good Choice for Coagulation Management

Point-of-care test (POCT) of blood viscoelasticity can reflect the coagulation status of patients accurately and timely. POCT can be used to monitor the effect of preoperative antithrombotic drugs on coagulation function, which will inform the selection of appropriate surgical timing. It can also be applied to analyze the reasons of intraoperative bleeding and guide the transfusion of blood products. Also, it is useful to assess the risk of postoperative thromboembolism and hint the need for prophylactic anticoagulation. This article mainly introduces the principles and clinical application of several frequently used POCTs for blood viscoelasticity, with a focus on their role in special types of diseases in which coagulation function changes significantly, such as cardiac disease, trauma, pathological obstetrics, and liver disease. Furthermore, we describe the role of microparticle in coagulation, which is a novel potential biomarker for diagnosing thrombotic disorders and possesses potential to be applied in POCTs of blood viscoelasticity.

The TEG 6s Global Hemostasis System is Useful for Coagulation Management in Simultaneous Pancreas and Kidney Transplantation: The First Two Cases

Introduction: Hypercoagulability-related graft thrombosis is the leading cause of graft failure after simultaneous pancreas-kidney transplantation (SPK). Addressing this issue is crucial to improve the outcomes of SPK recipients. Thromboelastography (TEG) has been used to assess the coagulation profiles of SPK recipients. Recently, a new-generation TEG device, the TEG 6s Global Hemostasis System, was introduced. This device offers advantages over TEG 5000, including less frequent calibration requirements, ease of use, and reduced sensitivity to movement. We hypothesized that TEG 6s would enhance coagulation management in SPK. Methods: We report two cases of Asian female SPK recipients in whom TEG 6s was used to assess coagulation status at six preset times during and after surgery. Results: Preoperatively, both patients exhibited hypercoagulability on TEG 6s. Postoperative intravenous heparin was administered, and the dose was titrated based on the TEG 6s results. Vascular thrombosis was not observed in either patient. Detailed TEG 6s and standard laboratory test results are reported. This pilot study demonstrates that TEG 6s monitoring can effectively assess coagulation status in SPK recipients, aiding in optimal coagulation management and reducing the risk of thrombotic complications leading to graft loss. The TEG 6s facilitated real-time and accurate coagulation assessment, allowing for tailored anticoagulant therapy. Conclusions: This is the first observational study to use TEG 6s in SPK recipients, indicating its potential benefits in improving patient outcomes. Further studies with larger sample sizes are warranted to validate these findings and establish comprehensive guidelines for using TEG 6s in SPK procedures.

Evolution of the Use of Therapeutic Fibrinogen Concentrate in the Massive Bleeding Guidelines

Fibrinogen concentrate was approved for the first time in the European Union by the German Federal Ministry of Health on January 4th, 1966. Since then, its use has been shown to be effective and well-tolerated in numerous clinical studies with congenital or acquired fibrinogen deficiency. In this review, we analyze the evolution of the indications for the use of fibrinogen concentrate in massive bleeding guidelines in three main clinical scenarios of acquired hypofibrinogenemia, such as cardiac, obstetric, and polytrauma patients. In cardiac surgery, the administration of fibrinogen has become a noteworthy tool in the management of perioperative haemostasis. The implementation of therapeutic algorithms, together with the use of viscoelastic coagulation tests, has allowed a faster and more personalized diagnosis and treatment of perioperative bleeding. In obstetrics, fibrinogen administration has evolved significantly over the years to a part of the management of massive obstetric haemorrhage, with early administration of fibrinogen now considered important in cases of hypofibrinogenemia during haemorrhage, helping to effectively correct coagulopathy and improve maternal outcomes. Currently, the implementation of protocols based on point-of-care viscoelastic testing has proven to be useful in the management of obstetric haemorrhage. In polytrauma patients with severe bleeding, fibrinogen administration is recommended based on clinical criteria and prior to laboratory test outcomes. After this first approach, guidelines recommend goal-directed coagulation management based on the results of viscoelastic tests and, in their absence, classical laboratory tests are recommended.

Protocol for a phase 3, randomised, active-control study of four-factor prothrombin complex concentrate versus frozen plasma in bleeding adult cardiac surgery patients requiring coagulation factor replacement: the LEX-211 (FARES-II) trial

IntroductionReduced thrombin generation is an important component of post cardiopulmonary bypass (CPB) coagulopathy. To replenish coagulation factors and enhance thrombin generation in bleeding surgical patients, frozen plasma (FP) and four-factor...

Evaluation of Point-of-Care-Directed Coagulation Management in Pediatric Cardiac Surgery.

Coagulatory alterations are common after pediatric cardiac surgery and can be addressed with point-of-care (POC) coagulation analysis. The aim of the present study is to evaluate a preventive POC-controlled coagulation algorithm in pediatric cardiac surgery. This single-center, retrospective data analysis included patients younger than 18 years who underwent cardiac surgery with cardiopulmonary bypass (CPB) and received a coagulation therapy according to a predefined POC-controlled coagulation algorithm. Patients were divided into two groups (<10 and >10 kg body weight) because of different CPB priming strategies. In total, 173 surgeries with the use of the POC-guided hemostatic therapy were analyzed. In 71% of cases, target parameters were achieved and only in one case primary sternal closure was not possible. Children with a body weight ≤10 kg underwent surgical re-evaluation in 13.2% (15/113), and respectively 6.7% (4/60) in patients >10 kg. Hemorrhage in children ≤10 kg was associated with cyanotic heart defects, deeper intraoperative hypothermia, longer duration of CPB, more complex procedures (RACHS-1 score), and with more intraoperative platelets, and respectively red blood cell concentrate transfusions (all p-values < 0.05). In children ≤10 kg, fibrinogen levels were significantly lower over the 12-hour postoperative period (without revision: 3.1 [2.9-3.3] vs. with revision 2.8 [2.3-3.4]). Hemorrhage in children >10 kg was associated with a longer duration of CPB (p = 0.042), lower preoperative platelets (p = 0.026), and over the 12-hour postoperative period lower platelets (p = 0.002) and fibrinogen (p = 0.05). The use of a preventive, algorithm-based coagulation therapy with factor concentrates after CPB followed by POC created intraoperative clinical stable coagulation status with a subsequent executable thorax closure, although the presented algorithm in its current form is not superior in the reduction of the re-exploration rate compared to equivalent collectives. Reduced fibrinogen concentrations 12 hours after surgery may be associated with an increased incidence of surgical revisions.

Correction of Trauma-induced Coagulopathy by Goal-directed Therapy: A Secondary Analysis of the ITACTIC Trial.

Trauma hemorrhage induces a coagulopathy with a high associated mortality rate. The Implementing Treatment Algorithms for the Correction of Trauma Induced Coagulopathy (ITACTIC) randomized trial tested two goal-directed treatment algorithms for coagulation management: one guided by conventional coagulation tests and one by viscoelastic hemostatic assays (viscoelastic). The lack of a difference in 28-day mortality led the authors to hypothesize that coagulopathic patients received insufficient treatment to correct coagulopathy. During ITACTIC, two sites were coenrolling patients into an ongoing prospective observational study, which included serial blood sampling at the same intervals as in ITACTIC. The subgroup in both studies had conventional and viscoelastic test results for each patient available for analysis. A goal-directed treatment was defined as one triggered by an ITACTIC algorithm. Coagulopathy was defined as rotational thromboelastometry EXTEM A5 less than 40 mm. The primary outcome was correction of coagulopathy by the 12th unit of erythrocyte transfusion during resuscitation. Full viscoelastic and conventional coagulation test results were available for 133 patients. Of these patients, 71% were coagulopathic on admission, and 16% developed a coagulopathy during resuscitation. ITACTIC viscoelastic hemostatic assay group patients were more likely to receive goal-directed treatment than the standard group (76% vs. 47%; odds ratio, 3.73; 95% CI, 1.64 to 8.49; P = 0.002). However, only 54% of patients received goal-directed treatment, and only 20% corrected their coagulopathy (vs. 0% with empiric treatment alone; not significant). Median time to first goal-directed treatment was 68 (53 to 88) min for viscoelastic and 110 (77 to 123) min for standard (P = 0.005). In ITACTIC, many bleeding trauma patients did not receive an indicated goal-directed treatment. Interventions arrived late during resuscitation and were only partially effective at correcting coagulopathy.

Intrinsic or Nonintrinsic End-stage Liver Disease and Its Association With Thromboelastography-based Coagulation States in Patients Undergoing Liver Transplantation: A Retrospective Cohort Study

Perioperative coagulation management in liver transplantation recipients is challenging. Viscoelastic testing with rotational thromboelastography (TEG) can help quantify hemostatic profiles. The current work aimed to investigate whether the etiology of end-stage liver disease, pretransplant disease severity, or pretransplant thrombotic or bleeding complications are associated with specific TEG patterns. Retrospective cohort study. Single quaternary care hospital. A total of 1,078 adult liver transplant patients. The primary exposure was the etiology of end-stage liver disease classified as either intrinsic or nonintrinsic (eg, biliary obstruction or cardiovascular). Secondary exposures were patients' preoperative Model for End-Stage Liver Disease (MELD) score, Child-Pugh class, presence of major preoperative thrombotic complications, and major bleeding complications. Patients with intrinsic liver disease (84%) showed higher odds of hypocoagulable (odds ratio [OR]: 3.70, 95% confidence interval [CI]: 1.94-7.07, p < 0.0001) and mixed TEG patterns (OR: 4.59, 95% CI: 2.07-10.16, p = 0.0002) compared with those with nonintrinsic disease. Increasing MELD scores correlated with higher odds of hypocoagulable (OR: 1.14, 95% CI: 1.08-1.19, p < 0.0001) and mixed TEG patterns (OR: 1.08, 95% CI: 1.03-1.14, p = 0.0036). Child-Pugh class C was associated with higher odds of hypocoagulable (OR: 8.55, 95% CI: 3.26-22.42, p < 0.0001) and mixed patterns (OR: 12.48, 95% CI: 3.89-40.03, p < 0.0001). Major preoperative thrombotic complications were not associated with specific TEG patterns, although an interaction with liver disease severity was observed. Liver transplantation candidates with intrinsic liver disease tend to exhibit hypocoagulable TEG patterns, while nonintrinsic disease is associated with hypercoagulability. Increasing end-stage liver disease severity, as evidenced by increasing MELD scores and higher Child-Pugh classification, was also associated with hypocoagulable TEG patterns.

Strategic reuse of rapid antigen tests for coagulation status assessment: an integrated machine learning approach

Addressing the pressing demand for rapid and inexpensive coagulation testing in cardiovascular care, this study introduces a novel application of repurposed COVID-19 rapid antigen tests (RATs) as paper-based lateral flow assays (LFAs) combined with machine learning for coagulation status evaluation. By further developing a mobile app prototype, we present a platform that enables clinicians to perform immediate and accurate anticoagulant dosing adjustments using existing post-pandemic resources. Our proof-of-concept employs a random forest machine learning classifier to interpret image feature variations on RAT NC membrane, correlating red blood cell (RBC) wicked diffusion distance in recalcified citrated whole blood with changes in coagulative viscosity, easily interpreted. Enhanced by confocal imaging studies of paper microfluidics, our approach provides insights into the mechanisms dissecting coagulation components, achieving high classification precision, recall, and F1-scores. The inverse relationship between RBC wicked diffusion distance and enoxaparin concentration paves the way for machine learning to inform real-time dose prescription adjustments, aligning with individual patient profiles to optimize therapeutic outcomes. This study not only demonstrates the potential of leveraging surplus RATs for coagulation management but also exemplifies a cost-effective, rapid, and smart strategy to enhance clinical decision-making in the post-pandemic era.Graphical

Early Point-of-Care Thromboelastometry Reduces Mortality in Patients with Severe Trauma and Risk of Transfusion: An Analysis Based on the TraumaRegister DGU®.

Background: Thromboelastometry like ROTEM® is a point-of-care method used to assess the coagulation status of patients in a rapid manner being particularly useful in critical care settings, such as trauma, where quick and accurate assessment of coagulation can guide timely and appropriate treatment. Currently, this method is not yet comprehensively available with sparse data on its effectiveness in resuscitation rooms. The aim of this study was to assess the effect of early thromboelastometry on the probability of mass transfusions and mortality of severely injured patients. Methods: The TraumaRegister DGU® was retrospectively analyzed for severely injured patients (2011 until 2020) with information available regarding blood transfusions and Trauma-Associated Severe Hemorrhage (TASH) score components. Patients with an estimated risk of mass transfusion >2% were included in a matched-pair analysis. Cases with and without use of ROTEM® diagnostic were matched based on risk categories for mass transfusion. A total of 1722 patients with ROTEM® diagnostics could be matched with a non-ROTEM® patient with an identical risk category. Adult patients (≥16) admitted to a trauma center in Germany, Austria, or Switzerland with Maximum Abbreviated Injury Scale severity ≥3 were included. Results: A total of 83,798 trauma victims were identified after applying the inclusion and exclusion criteria. For 7740 of these patients, the use of ROTEM® was documented. The mean Injury Severity Score (ISS) in patients with ROTEM® was 24.3 compared to 19.7 in the non-ROTEM® group. The number of mass transfusions showed no significant difference (14.9% ROTEM® group vs. 13.4% non-ROTEM® group, p = 0.45). Coagulation management agents were given significantly more often in the ROTEM® subgroup. Mortality in the ROTEM® group was 4.1% less than expected (estimated mortality based on RISC II 34.6% vs. observed mortality 30.5% (n = 525)). In the non-ROTEM® group, observed mortality was 1.6% less than expected. Therefore, by using ROTEM® analysis, the expected mortality could be reduced by 2.5% (number needed to treat (NNT) 40; SMR of ROTEM® group: 1:0.88; SMR of non-ROTEM® group: 1:0.96; p = 0.081). Conclusions: Hemorrhage is still one of the leading causes of death of severely injured patients in the first hours after trauma. Early thromboelastometry can lead to a more targeted coagulation management, but is not yet widely available. This study demonstrated that ROTEM® was used for the more severely injured patients and that its use was associated with a less than expected mortality as well as a higher utilization of hemostatic products.

Impacts of COVID-19 on hemostasis: coagulation abnormalities and management perspectives

The coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has transcended its initial characterization as a respiratory illness, revealing substantial implications for hemostasis and coagulation pathways. COVID-19-associated coagulopathies have emerged as critical determinants of disease severity and prognosis, presenting a multifaceted challenge in clinical management. This paper aims to elucidate the intricate interplay between COVID-19 and hemostasis, delving into the underlying mechanisms of coagulation abnormalities, exploring the spectrum of thrombotic complications, and discussing evolving management strategies. Therapeutic interventions and anticoagulation strategies tailored for managing COVID-19-related coagulopathies form a significant focus, encompassing prophylactic and therapeutic approaches, heparin-based therapies, and individualized treatment paradigms. This paper underscores the imperative for ongoing research endeavors to refine diagnostic modalities, identify novel therapeutic targets, and ascertain long-term sequelae of COVID-19-induced coagulation abnormalities. Ultimately, a comprehensive understanding of the intricate relationship between COVID-19 and hemostasis is pivotal in devising effective management strategies to mitigate thrombotic risks, improve clinical outcomes, and pave the way for tailored interventions in affected individuals.

Coagulation management in patients requiring extracorporeal membrane oxygenation support: a comprehensive narrative review

Coagulation management in patients requiring extracorporeal membrane oxygenation support: a comprehensive narrative review

The Influence of Preoperative Anticoagulant and Antiplatelet Therapy on Rebleeding Rates in Patients Suffering from Spinal Metastatic Cancer: A Retrospective Cohort Study.

The age of patients requiring surgery for spinal metastasis, primarily those over 65, has risen due to improved cancer treatments. Surgical intervention targets acute neurological deficits and instability. Anticoagulants are increasingly used, especially in the elderly, but pose challenges in managing bleeding complications. The study examines the correlation between preoperative anticoagulant/antiplatelet use and bleeding risks in spinal metastasis surgery, which is crucial for optimizing patient outcomes. In a retrospective study at our department from 2010 to 2023, spinal tumor surgery patients were analyzed. Data included demographics, neurological status, surgical procedure, preoperative anticoagulant/antiplatelet use, intra-/postoperative coagulation management, and the incidence of rebleeding. Coagulation management involved blood loss assessment, coagulation factor administration, and fluid balance monitoring post-surgery. Lab parameters were documented at admission, preop, postop, and discharge. A cohort of 290 patients underwent surgical treatment for spinal metastases, predominantly males (63.8%, n = 185) with a median age of 65 years. Preoperatively, 24.1% (n = 70) were on oral anticoagulants or antiplatelet therapy. Within 30 days, a rebleeding rate of 4.5% (n = 9) occurred, unrelated to preoperative anticoagulation status (p > 0.05). A correlation was found between preoperative neurologic deficits (p = 0.004) and rebleeding risk and the number of levels treated surgically, with fewer levels associated with a higher incidence of postoperative bleeding (p < 0.01). Surgical intervention for spinal metastatic cancer appears to be safe regardless of the patient's preoperative anticoagulation status. However, it remains imperative to customize preoperative planning and preparation for each patient, emphasizing meticulous risk-benefit analysis and optimizing perioperative care.

Polytrauma in Children.

Inadequate clinical experience still causes uncertainty in the acute diagnostic evaluation and treatment of polytrauma in children (with or without coagulopathy). This review deals with the main aspects of the acute care of severely injured children in the light of current guidelines and other relevant literature, in particular airway control, volume and coagulation management, acute diagnostic imaging, and blood coagulation studies in the shock room. This review is based on literature retrieved by a selective search in PubMed, Medline (OVIDSP), the Cochrane Central Register of Controlled Trials, and Epistemonikos covering the period January 2001 to August 2023. Review articles and the updated S2k clinical practice guideline on polytrauma management in childhood were considered. Most accidents in childhood occur at home and in the child's free time, with varying mechanisms and patterns of injury depending on age. The outcome of treatment depends largely on the presence or absence or traumatic brain injury, which affects 66% of children with polytrauma and is thus the most common type of injury in this group, and of hemorrhagic shock with or without coagulopathy. Acute care follows the ABCDE algorithms with attention to special features in children, including age-specific reference values. According to a registry study, coagulopathy and hypovolemic shock are associated with 22% and 17% mortality, respec - tively. Treatment in a pediatric trauma reference center of the trauma network is recommended. Computed tomography (CT) should be carried out in children in accordance with defined criteria (PECARN), as a team decision and with the use of age-specific low-dose CT protocols. In children as in adults, viscoelasticity-based point-of-care tests enable the prompt diagnosis of relevant coagulopathies and their treatment in consideration of age-specific target values. The administration of tranexamic acid remains controversial. 4% of polytrauma patients are children. Because children differ from adults both anatomically and physiologically, the diagnostic evaluation and management of polytrauma in children presents a special challenge. The evidence base for pediatric polytrauma management is still inadequate; current recommendations are based on consensus, in consideration of the special features of children compared to adults.

Revolutionizing trauma care: advancing coagulation management and damage control anesthesia.

Despite advances in emergency transfer systems and trauma medicine, the incidence of preventable deaths due to massive hemorrhage remains high. Recent immunological research has elucidated key mechanisms underlying trauma-induced coagulopathy in the early stages of trauma, including sympathoadrenal stimulation, shedding of the glycocalyx, and endotheliopathy. Consequently, the condition progresses to fibrinogen depletion, hyperfibrinolysis, and platelet dysfunction. Coexisting factors such as uncorrected acidosis, hypothermia, excessive crystalloid administration, and a history of anticoagulant use exacerbate coagulopathy. This study introduces damage-control anesthetic management based on recent insights into damage-control resuscitation, emphasizing the importance of rapid transport, timely bleeding control, early administration of antifibrinolytics and fibrinogen concentrates, and maintenance of calcium levels and body temperature. Additionally, this study discusses brain-protective strategies for trauma patients with brain injuries and the utilization of cartridge-based viscoelastic assays for goal-directed coagulation management in trauma settings. This comprehensive approach may provide potential insights for anesthetic management in the fast-paced field of trauma medicine.

Effect of ultrafiltration on whole blood coagulation profile during cardiopulmonary bypass in cardiac surgery: a retrospective analysis.

Ultrafiltration (UF) would enhance coagulation profiles by concentrating coagulation elements during cardiopulmonary bypass (CPB) for cardiac surgery. We retrospectively reviewed electronic medical records of 75 patients who had undergone cardiac surgery with rotational thromboelastometry-based coagulation management in a university hospital and analyzed the UF-induced changes in the maximum clot firmness (MCF) of extrinsically activated test with tissue factor (EXTEM) during CPB in 30 patients. The median volume of filtered-free water was 1,350 ml, and median hematocrit was significantly increased from 22.5% to 25.5%. As the primary measure, UF significantly increased the median MCF-EXTEM from 48.0 mm to 50.5 mm (P = 0.015, effect size r = 0.44). The area under the receiver operating characteristic curve pre-UF MCF-EXTEM for discrimination of any increase of MCF-EXTEM after applying UF was 0.89 (95% CI [0.77, 1.00], P < 0.001), and its cut-off value was 50.5 mm (specificity of 81.8% and sensitivity of 84.2% in Youden's J statistic). In the secondary analyses using the cut-off value, UF significantly increased the median MCF-EXTEM from 40.5 mm to 42.5 mm in 18 patients with pre-UF MCF-EXTEM ≤ 50.5 mm. However, it did not increase MCF-EXTEM in 12 patients with pre-UF MCF-EXTEM > 50.5 mm. There was a significant interaction between pre-UF MCF-EXTEM values and applying UF (P < 0.001 for the subgroup, P = 0.046 for UF, P = 0.003 for interaction). Applying UF improved clot firmness, and the improvement was more pronounced when pre-UF MCF-EXTEM had been reduced during CPB.

Consensus of the Brazilian association of hematology, hemotherapy and cellular therapy on patient blood management: Assessment and management of coagulation in the preoperative period

Managing coagulation disorders and potential bleeding risks, especially in the context of anticoagulant medications, is of immense value both clinically and prior to surgery. Coagulation disorders can lead to bleeding complications, affecting patient safety and surgical outcomes. The use of Patient Blood Management protocols offers a comprehensive, evidence-based approach that effectively addresses these challenges. The problem is to find a delicate balance between preventing thromboembolic events (blood clots) and reducing the risk of bleeding. Anticoagulant medications, although crucial to preventing clot formation, can increase the potential for bleeding during surgical procedures. Patient blood management protocols aim to optimize patient outcomes by minimizing blood loss and unnecessary transfusions.

Between arock and ahard place: anticoagulation management for ECMO.

Anticoagulation is an essential component of optimal extracorporeal membrane oxygenation (ECMO) management. Unfractionated heparin is still the anticoagulant of choice in most centers due to longstanding familiarity with the agent. Disadvantages include alterations in drug responses due to its capability to bind multiple heparin-binding proteins that compete with antithrombin and the potential for heparin-induced thrombocytopenia. In such cases, direct thrombin inhibitors are the treatment of choice but pose difficulties in monitoring due to the limited experience and target ranges for non-aPTT-guided management (aPTT: activated partial thromboplastin time). The current trend toward low-dose anticoagulation, especially for venovenous ECMO, is supported by data associating bleeding complications with mortality but not thromboembolic events, which include circuit thrombosis. However, only prospective data will provide appropriate answers to how to individualize anticoagulation, transfusions, and bleeding management which is currently only supported by expert opinion. Empiric therapy for ECMO patients based on laboratory coagulation alone should always be critically questioned. In summary, only collaboration and future studies of coagulation management during ECMO will help us to make this life-saving therapy that has become part of daily life of the intensivist even safer and more effective. Until then, afundamental understanding of coagulation and bleeding management, as well as pearls and pitfalls of monitoring, is essential to optimize anticoagulation during ECMO. This article is freely available.

Anticoagulation Management in V-V ECMO Patients: A Multidisciplinary Pragmatic Protocol

(1) Background: Extracorporeal membrane oxygenation (ECMO) is a complex procedure affecting both the risk of thrombosis and bleeding. High-quality data to personalize anticoagulation management in ECMO are lacking, resulting in a high variability in practice among centers. For this reason, we review coagulation methods and monitoring and share a pragmatic proposal of coagulation management, as performed in our high-volume ECMO Referral Centre; (2) Methods: We revised the anticoagulation options and monitoring methods available for coagulation management in ECMO through PubMed search based on words including “anticoagulation,” “coagulation assays,” “ECMO,” “ELSO,” and “ISTH”; (3) Results: Actual revision of the literature was described as our routine practice regarding ECMO anticoagulation and monitoring; (4) Conclusions: No coagulation test is exclusively predictive of bleeding or thrombotic risk in patients undergoing ECMO support. An approach that allows for a tailored regimen of anticoagulation (regardless of agent used) and monitoring is mandatory. To accomplish this, we propose that the titration of anticoagulation therapies should include multiple laboratory tests, including anti-Xa, aPTT, ACT, viscoelastic tests, AT levels, platelet count, fibrinogen, and FXIII levels. Anticoagulation regimens should be tailored to a specific patient and personalized based on this complex array of essays.

User Perceptions of Visual Clot in a High-Fidelity Simulation Study: Mixed Qualitative-Quantitative Study.

Viscoelastic hemostatic assays, such as rotational thromboelastometry (ROTEM) or thromboelastography, enable prompt diagnosis and accelerate targeted treatment. However, the complex interpretation of the results remains challenging. Visual Clot-a situation awareness-based visualization technology-was developed to assist clinicians in interpreting viscoelastic tests. Following a previous high-fidelity simulation study, we analyzed users' perceptions of the technology, to identify its strengths and limitations from clinicians' perspectives. This is a mixed qualitative-quantitative study consisting of interviews and a survey. After solving coagulation scenarios using Visual Clot in high-fidelity simulations, we interviewed anesthesia personnel about the perceived advantages and disadvantages of the new tool. We used a template approach to identify dominant themes in interview responses. From these themes, we defined 5 statements, which were then rated on Likert scales in a questionnaire. We interviewed 77 participants and 23 completed the survey. We identified 9 frequently mentioned topics by analyzing the interview responses. The most common themes were "positive design features," "intuitive and easy to learn," and "lack of a quantitative component." In the survey, 21 respondents agreed that Visual Clot is easy to learn and 16 respondents stated that a combination of Visual Clot and ROTEM would help them manage complex hemostatic situations. A group of anesthesia care providers found Visual Clot well-designed, intuitive, and easy to learn. Participants highlighted its usefulness in emergencies, especially for clinicians inexperienced in coagulation management. However, the lack of quantitative information is an area for improvement.