How can I personalize hemostasis (coagulation) testing in intensive care unit (ICU) settings?

From the Guidelines

To personalize hemostasis testing in intensive care, implement a targeted approach using viscoelastic testing methods like thromboelastography (TEG) or rotational thromboelastometry (ROTEM) alongside conventional coagulation tests, as recommended by the European guideline on management of major bleeding and coagulopathy following trauma: sixth edition 1. This approach should begin with a baseline assessment including complete blood count, prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen level, and D-dimer upon ICU admission. For patients with active bleeding or at high risk, add viscoelastic testing to provide real-time assessment of clot formation, strength, and breakdown. Establish a protocol for repeat testing at regular intervals (every 6-12 hours) for unstable patients and after major interventions. Interpret results in the context of the patient's clinical condition, considering factors like liver function, kidney function, and medication effects. Use test results to guide specific interventions:

• for prolonged clotting times with normal fibrinogen, consider fresh frozen plasma (10-15 mL/kg);
• for hypofibrinogenemia (fibrinogen <1.5 g/L), administer cryoprecipitate or fibrinogen concentrate (25-50 mg/kg);
• for platelet dysfunction or thrombocytopenia (<50,000/μL with bleeding), give platelet transfusions. This personalized approach allows for targeted treatment of specific hemostatic defects rather than empiric therapy, reducing unnecessary blood product use and improving patient outcomes by addressing the individual's unique coagulation profile, as supported by the updated European guideline on management of bleeding and coagulopathy following major trauma 1. Some key points to consider when implementing this approach include:
• The importance of fibrinogen and platelet measurements in standard coagulation monitoring 1
• The limitations of conventional coagulation screens, such as INR and APTT, in monitoring coagulation 1
• The potential benefits of viscoelastic testing in detecting coagulation abnormalities and guiding therapy 1
• The need for standardization of viscoelastic testing methods and interpretation of results 1

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Personalising Haemostasis Testing in Intensive Care

To personalise haemostasis testing in intensive care, several factors and tests can be considered:

• The use of point-of-care assays and routine coagulation tests to assess haemostasis parameters in critically ill patients, as seen in the study by 2.
• The evaluation of coagulation and platelet function using devices such as Multiplate and ROTEM, which can indicate a hypocoagulative response in patients with disseminated intravascular coagulopathy (DIC) or in non-survivors 2.
• The assessment of fibrinolysis using tests such as D-dimer and fibrin degradation product (FDP), which can help identify patients with impaired fibrinolysis 2, 3.
• The use of clinical scoring systems, such as the Trauma Induced Coagulopathy Clinical Score, to diagnose trauma-induced coagulopathy (TIC) 4.
• The measurement of biomarkers such as thrombin-antithrombin complex, plasminogen activator inhibitor-1, and protein C activity to identify patients with severe coagulopathy in the initial phase of sepsis 5.

Tests and Biomarkers

Some specific tests and biomarkers that can be used to personalise haemostasis testing in intensive care include:

• Prothrombin time (PT) and activated partial thromboplastin time (aPTT) to assess coagulation 2, 4, 3, 6.
• Platelet count and fibrinogen concentration to evaluate platelet function and coagulation 2, 3.
• D-dimer and FDP to assess fibrinolysis 2, 3.
• Thrombin-antithrombin complex, plasminogen activator inhibitor-1, and protein C activity to identify patients with severe coagulopathy in the initial phase of sepsis 5.
• Antithrombin (AT) values to differentiate between acquired thrombotic thrombocytopenic purpura (TTP) and septic DIC 3.

Patient-Specific Factors

Patient-specific factors that can influence haemostasis testing in intensive care include:

• The presence of underlying conditions such as liver disease, vitamin K deficiency, or lupus anticoagulant 6.
• The use of anticoagulant or antiplatelet medications 4.
• The presence of trauma-induced coagulopathy (TIC) or disseminated intravascular coagulopathy (DIC) 2, 4.
• The severity of sepsis or organ failure 2, 5.