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Vertaisarvioitu. Akuutti verenvuoto tai verisuonitukos vaativat kliinikolta tietämystä veren hyytymisen periaatteista ja tutkimusmenetelmistä, niiden käyttöaiheista ja tulosten tulkinnasta. Hemostaasikokeiden valikoima on laaja ja monipuolinen, mutta käytännön työssä tarvitaan kohdennettuja tutkimuksia, joihin erikoissairaanhoidon kliinikon on syytä perehtyä. Niihin kuuluvat hemostaasin seulontakokeet (tromboplastiiniaika, TT ja aktivoitu partiaalinen tromboplastiiniaika, APTT), trombiiniaika, fibrinogeeni ja sen hajoamistuote D-dimeeri, hyytymistekijä VIII (FVIII) ja elimistön luonnollinen antikoagulantti antitrombiini (AT3). Yhdistettyinä kliiniseen tilaan laboratoriotutkimusten tulokset antavat kuvan hemostaasista, mahdollistavat hyytymishäiriöiden kokonaisvaltaista diagnostiikkaa ja kohdennettuja jatkoselvittelyitä erikoissairaanhoidossa sekä ovat keskeisiä hoitovasteiden seurannassa.

Anticoagulation therapy has been undergoing a transition during the last decade with the progressive availability of direct oral anticoagulants (DOACs). While DOACs are increasingly used in common indications for anticoagulation, including non-valvular atrial fibrillation (AF), deep vein thrombosis (DVT) and pulmonary embolism (PE), traditional anticoagulants, either warfarin or heparins, remain the primary choice for patients with cardiac valvular replacement, severe thrombophilia, pediatric, pregnant and many cancer patients. Laboratory monitoring of warfarin and heparins are well established, while under specific emergency conditions DOACs require specific assays, the availability of which may be limited. Finland benefits from centralized laboratory networks, offering harmonized services throughout our rather sparsely populated country. Specific assays for all DOACs are available 24/7 in the core laboratory (Southern Finland). Interaction, collaboration and continuous education between clinic and laboratory is increasingly needed, under the era of rapid change of traditions in anticoagulation management.

BACKGROUND: Uncontrollable bleeding is the leading cause of death in traumatically injured patients. The extent to which direct factor Xa inhibitors interfere with the applied resuscitation measures is presently unknown. STUDY DESIGN AND METHODS: In this study, we investigated the effect of the resuscitation fluids saline, albumin, fresh frozen plasma (FFP) and solvent/detergent (S/D)-treated plasma, fibrinogen concentrate, prothrombin complex concentrate (PCC), and combinations thereof on the hemostatic profile of rivaroxaban-anticoagulated whole blood and plasma. We used rivaroxaban-spiked whole blood and plasma from healthy donors, as well as plasma from patients on rivaroxaban, and mimicked a resuscitation approach in a 50% plasma dilution setting. Thromboelastography, thrombin generation, and fibrin generation clot lysis test were assessed using tissue factor to initiate coagulation and tissue plasminogen activator to induce clot lysis. RESULTS: Rivaroxaban resulted in a hypocoagulant state that remained largely unaltered upon subsequent 50% dilution with S/D-treated plasma or FFP. Using S/D-treated plasma as a diluent, clot stability decreased due to its low α2-antiplasmin. Dilution with saline and albumin induced a profibrinolytic state and further deteriorated the impaired hemostatic potential of rivaroxaban-anticoagulated blood, even after PCC and fibrinogen support. Combined use of plasma (either FFP or S/D treated) and PCC, however, considerably improved both coagulation and clot stability. CONCLUSION: In the setting of rivaroxaban anticoagulation and major blood loss, transfusing plasma together with PCC may provide the most effective resuscitation approach with the notion that additional antifibrinolytic drug support (e.g., tranexamic acid) is likely required.