Bar Jonathan, David Alexa, Khader Tarek, Mulcare Mary, Tedeschi Christopher
1Weill Cornell Medical College, New York,New YorkUSA.
2Department of Emergency Medicine,New York-Presbyterian Hospital, New York,New YorkUSA.
Prehosp Disaster Med. 2017 Oct;32(5):580-587. doi: 10.1017/S1049023X17006641. Epub 2017 Jun 19.
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.
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.
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%.
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. Bar J , David A , Khader T , Mulcare M , Tedeschi C . Assessing coagulation by rotational thromboelastometry (ROTEM) in rivaroxaban-anticoagulated blood using hemostatic agents. Prehosp Disaster Med. 2017;32(5):580-587.
引言 利伐沙班（拜瑞妥）等直接口服抗凝剂（DOACs）的使用越来越普遍。然而，在出血情况下逆转抗凝的治疗方法有限。本研究通过旋转血栓弹力图（ROTEM）检测，调查止血剂改善利伐沙班抗凝血液凝血功能的能力。假设/问题 如果将一种独立于凝血级联起作用的基于壳聚糖的止血剂（Celox）应用于利伐沙班抗凝的血液，它应该通过缩短凝血时间（CT）、缩短凝血形成时间（CFT）和增加最大血凝块硬度（MCF）来改善凝血功能。如果将一种主要通过增强Xa因子（FXa）上游凝血级联起作用的基于高岭土的止血剂（快速凝血战斗纱布）应用于利伐沙班抗凝的血液，它在改善凝血方面将无效。
招募在两家大型大学医学中心急诊科就诊、正在服用利伐沙班的患者（年龄>18岁；非孕妇）。受试者（n = 8）抽血，并在有或没有基于高岭土和基于壳聚糖的止血剂的情况下使用ROTEM进行分析。计算ROTEM参数对止血剂有反应的患者百分比以及凝血参数的百分比变化。
分析的数据点包括：CT、CFT和MCF。在用基于高岭土的止血剂处理的样本中，7个（87.5%）显示CT缩短，8个（100.0%）显示CFT缩短，6个（75.0%）显示MCF增加。所有患者CT、CFT和MCF的平均百分比变化分别为32.5%（标准差[SD]：286；范围：-75.3至740.7%）；-66.0%（SD：14.4；范围：-91.4至-44.1%）；和4.70%（SD：6.10；范围：-4.8至15.1%）。相应的中位数百分比变化分别为-68.1%、-64.0%和5.2%。在用基于壳聚糖的止血剂处理的样本中，6个（75.0%）显示CT缩短，3个（37.5%）显示CFT缩短，5个（62.5%）显示MCF增加。所有患者CT、CFT和MCF的平均百分比变化分别为165.0%（SD：629；范围：-96.9至1718.5%）；139.0%（SD：174；范围：-83.3至348.0%）；和-8.38%（SD：32.7；范围：-88.7至10.4%）。相应的中位数百分比变化分别为-53.7%、141.8%和3.0%。
旋转血栓弹力图可检测应用于利伐沙班抗凝血液的止血剂引起的凝血参数变化。这些变化呈改善凝血能力的趋势，表明基于高岭土和基于壳聚糖的止血剂可能有效改善这些患者的凝血功能。巴尔·J、大卫·A、卡德尔·T、穆尔凯尔·M、泰德eschi·C。使用止血剂通过旋转血栓弹力图（ROTEM）评估利伐沙班抗凝血液的凝血功能。院前灾难医学。2017；32（5）：580 - 587。
