RESUMEN
Current guidelines recommend monitoring the anticoagulant effect of unfractionated heparin (UFH) by measuring anti-Xa activity rather than activated partial thromboplastin time (aPTT) in intensive care unit (ICU) patients. The primary objective of this study was to evaluate the correlation of aPTT, anti-Xa activity, and thrombin generation in UFH-treated ICU patients. A prospective observational pilot study was conducted in adult surgical ICU patients treated with UFH. aPTT and anti-Xa activity were monitored daily. The therapeutic target was aPTT between 50 s and 84 s, and/or anti-Xa between 0.3 and 0.7 U/mL. Correlation among aPTT, anti-Xa activity, and thrombin generation was determined by measuring endogenous thrombin potential (ETP), with the inflammatory response evaluated. C-reactive protein (CRP) was used as a marker of inflammatory response. The plasma of 107 samples from 30 ICU patients was analyzed. The correlation between aPTT and anti-Xa activity was 0.66, CI95% [0.54;0.76] (p < 0.0001). Although thrombin generation, aPTT, and anti-Xa were correlated with inflammatory responses, the correlation was higher with thrombin generation and anti-Xa activity compared to aPTT. When aPTT was in a therapeutic range, a low thrombin generation was observed but was 50% inhibited when anti-Xa was in a therapeutic range. Coagulation testing with aPTT, anti-Xa correlated with thrombin generation. A 50% decrease in thrombin generation was observed when anti-Xa was within a therapeutic range. Further work is needed to evaluate coagulation biomarker responses and clinical outcomes in specific ICU populations.
Asunto(s)
Heparina , Trombina , Adulto , Anticoagulantes/farmacología , Anticoagulantes/uso terapéutico , Biomarcadores , Proteína C-Reactiva , Monitoreo de Drogas , Inhibidores del Factor Xa/farmacología , Inhibidores del Factor Xa/uso terapéutico , Heparina/farmacología , Heparina de Bajo-Peso-Molecular , Humanos , Unidades de Cuidados Intensivos , Tiempo de Tromboplastina Parcial , Estudios ProspectivosRESUMEN
BACKGROUND: Changes in the health system in Western countries have increased the scope of the daily tasks assigned to physicians', anesthetists included. As already shown in other specialties, increased non-clinical burden reduces the clinical time spent with patients. METHODS: This was a multicenter, prospective, observational study conducted in 6 public and private hospitals in France. The primary endpoint was the evaluation by an external observer of the time spent per day (in minutes) by anesthetists on clinical tasks in the operating room. Secondary endpoints were the time spent per day (in minutes) on non-clinical organizational tasks and the number of task interruptions per hour of work. RESULTS: Between October 2017 and April 2018, 54 anesthetists from six hospitals (1 public university hospital, two public general hospitals and three private hospitals) were included. They were followed for 96 days corresponding to 550 hours of work. The proportion of overall clinical time was 62% (58% 95%CI [53; 63] for direct care. The proportion of organizational time was higher in public hospitals (11% in the university hospital (p < 0.001) and 4% in general hospitals (p < 0.01)) compared to private hospitals (1%). The number of task interruptions (1.5/h ± 1.4 in all hospitals) was 4 times higher in the university hospital (2.2/h ± 1.6) compared to private hospitals (0.5/h ± 0.3) (p < 0.05). CONCLUSIONS: Most time in the operating room was spent on clinical care with a significant contrast between public and private hospitals for organizational time.