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Assessing Coagulation by Rotational Thromboelastometry (ROTEM) in Rivaroxaban-Anticoagulated Blood Using Hemostatic Agents

Published online by Cambridge University Press:  19 June 2017

Jonathan Bar Open the ORCID record for Jonathan Bar [Opens in a new window] ,
Alexa David ,
Tarek Khader ,
Mary Mulcare  and
Christopher Tedeschi
Jonathan Bar*
Affiliation:
Weill Cornell Medical College, New York, New YorkUSA
Alexa David
Affiliation:
Weill Cornell Medical College, New York, New YorkUSA
Tarek Khader
Affiliation:
Weill Cornell Medical College, New York, New YorkUSA
Mary Mulcare
Affiliation:
Weill Cornell Medical College, New York, New YorkUSA Department of Emergency Medicine, New York-Presbyterian Hospital, New York, New YorkUSA
Christopher Tedeschi
Affiliation:
Department of Emergency Medicine, New York-Presbyterian Hospital, New York, New YorkUSA Columbia University College of Physicians and Surgeons, New York, New YorkUSA
*
Correspondence: Jonathan Bar, MD 619 S 16th St #2F Philadelphia, Pennsylvania 19146 USA E-mail: Jonathan.Bar@uphs.upenn.edu
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Abstract

Introduction

The use of direct oral anticoagulants (DOACs) such as rivaroxaban (Xarelto) is increasingly common. However, therapies for reversing anticoagulation in the event of hemorrhage are limited. This study investigates the ability of hemostatic agents to improve the coagulation of rivaroxaban-anticoagulated blood, as measured by rotational thromboelastometry (ROTEM).

Hypothesis/Problem

If a chitosan-based hemostatic agent (Celox), which works independently of the clotting cascade, is applied to rivaroxaban-anticoagulated blood, it should improve coagulation by decreasing clotting time (CT), decreasing clot formation time (CFT), and increasing maximum clot firmness (MCF). If a kaolin-based hemostatic agent (QuikClot Combat Gauze), which works primarily by augmenting the clotting cascade upstream of factor Xa (FXa), is applied to rivaroxaban-anticoagulated blood, it will not be effective at improving coagulation.

Methods

Patients (age >18 years; non-pregnant) on rivaroxaban, presenting to the emergency department (ED) at two large, university-based medical centers, were recruited. Subjects (n=8) had blood drawn and analyzed using ROTEM with and without the presence of a kaolin-based and a chitosan-based hemostatic agent. The percentage of patients whose ROTEM parameters responded to the hemostatic agent and percent changes in coagulation parameters were calculated.

Results

Data points analyzed included: CT, CFT, and MCF. Of the samples treated with a kaolin-based hemostatic agent, seven (87.5%) showed reductions in CT, eight (100.0%) showed reductions in CFT, and six (75.0%) showed increases in MCF. The average percent change in CT, CFT, and MCF for all patients was 32.5% (Standard Deviation [SD]: 286; Range:-75.3 to 740.7%); -66.0% (SD:14.4; Range: -91.4 to -44.1%); and 4.70% (SD: 6.10; Range: -4.8 to 15.1%), respectively. The corresponding median percent changes were -68.1%, -64.0%, and 5.2%. Of samples treated with a chitosan-based agent, six (75.0%) showed reductions in CT, three (37.5%) showed reductions in CFT, and five (62.5%) showed increases in MCF. The average percent changes for CT, CFT, and MCF for all patients were 165.0% (SD: 629; Range:-96.9 to 1718.5%); 139.0% (SD: 174; Range: -83.3 to 348.0%); and -8.38% (SD: 32.7; Range:-88.7 to 10.4%), respectively. The corresponding median percent changes were -53.7%, 141.8%, and 3.0%.

Conclusions

Rotational thromboelastometry detects changes in coagulation parameters caused by hemostatics applied to rivaroxaban-anticoagulated blood. These changes trended in the direction towards improved coagulability, suggesting that kaolin-based and chitosan-based hemostatics may be effective at improving coagulation in these patients.

BarJ, DavidA, KhaderT, MulcareM, TedeschiC. Assessing Coagulation by Rotational Thromboelastometry (ROTEM) in Rivaroxaban-Anticoagulated Blood Using Hemostatic Agents. Prehosp Disaster Med. 2017;32(5):580–587.

Keywords

Celoxfactor Xa inhibitorshemostatic techniquesKaolinthromboelastography
Type
Brief Report
Information
Prehospital and Disaster Medicine , Volume 32 , Issue 5 , October 2017 , pp. 580 - 587
Copyright
© World Association for Disaster and Emergency Medicine 2017 

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Footnotes

Conflict of interest/funding: Jonathan Bar, Alexa David, and Tarek Khader received Federal Work-Study funds for personal expenses incurred as part of this project. All authors have no conflicts of interest to declare.

References

1. Gómez-Outes, A, Suárez-Gea, ML, Lecumberri, R, Terleira-Fernández, AI, Vargas-Castrillón, E. Direct acting oral anticoagulants: pharmacology, indications, management, and future perspectives. Eur J Haematol. 2015;95:389-404.CrossRefGoogle ScholarPubMed
2. Desai, NR, Krumme, AA, Schneeweiss, S, et al. Patterns of initiation of oral anti-coagulants in patients with atrial fibrillation quality and cost implications. Am J Med. 2014;127(11):1075.e1-1082.e1.CrossRefGoogle Scholar
3. Young, SK, Al-Mondhiry, HA, Vaida, SJ, Ambrose, A, Botti, JJ. Successful use of argatroban during the third trimester of pregnancy: case report and review of the literature. Pharmacotherapy. 2008;28(12):1531-1536.CrossRefGoogle ScholarPubMed
4. Hart, RG, Pearce, LA, Aguilar, MI. Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med. 2007;146:857-867.CrossRefGoogle ScholarPubMed
5. Kakkos, SK, Kirkilesis, GI, Tsolakis, IA. Editor’s Choice – efficacy and safety of the new oral anticoagulants dabigatran, rivaroxaban, apixaban, and edoxaban in the treatment and secondary prevention of venous thromboembolism: a systematic review and meta-analysis of phase III trials. Eur J Vasc Endovasc Surg. 2014;48:565-575.Google Scholar
6. Sartori, MT, Prandoni, P. How to effectively manage the event of bleeding complications when using anticoagulants. Expert Review of Hematology. 2015: 37-50.Google ScholarPubMed
7. Sorensen, B, Spahn, DR, Innerhofer, P, Spannagl, M, Rossaint, R. Clinical review: prothrombin complex concentrates–evaluation of safety and thrombogenicity. Crit Care. 2011;15:201.CrossRefGoogle ScholarPubMed
8. Makris, M, Van Veen, JJ, Tait, CR, Mumford, AD, Laffan, M. Guideline on the management of bleeding in patients on anti- thrombotic agents. Br J Haematol. 2013;160:35-46.CrossRefGoogle Scholar
9. Yogaratnam, D, Ditch, K, Medeiros, K, Doyno, C, Fong, JJ. Idarucizumab for reversal of dabigatran. Ann Pharmacother. 2016;pii: 1060028016659504.Google Scholar
10. Kubitza, D, Haas, S. Novel factor Xa inhibitors for prevention and treatment of thromboembolic diseases. Expert Opin Investig Drugs. 2006;15:843-855.CrossRefGoogle ScholarPubMed
11. Gordy, SD, Rhee, P, Schreiber, MA. Military applications of novel hemostatic devices. Expert Rev Med Devices. 2011;8(1):41-47.CrossRefGoogle ScholarPubMed
12. Cox, ED, Schreiber, MA, McManus, J, Wade, CE, Holcomb, JB. New hemostatic agents in the combat setting. Transfusion. 2009;49(Suppl):248S-255S.CrossRefGoogle ScholarPubMed
13. Granville-Chapman, J, Jacobs, N, Midwinter, M. Prehospital hemostatic dressings: a systematic review. Injury. 2011;42(5):447-459.CrossRefGoogle ScholarPubMed
14. Rhee, P, Brown, C, Martin, M, et al. QuikClot use in trauma for hemorrhage control: case series of 103 documented uses. J Trauma. 2008;64:1093-1099.Google ScholarPubMed
15. Walsh, PN. The effects of Collagen and Kaolin on the intrinsic coagulant activity of platelets. Evidence for an alternative pathway in intrinsic coagulation not requiring factor XII. Br J Haematol. 1972;22:393-405.CrossRefGoogle Scholar