Laboratory measures of coagulation among trauma patients on NOAs: Results of the AAST-MIT

Leslie M. Kobayashi, Alexandra Brito, Galinos Barmparas, Patrick Bosarge, Carlos V. Brown, Marko Bukur, Matthew M. Carrick, Richard D. Catalano, Jan Holly-Nicolas, Kenji Inaba, Stephen Kaminski, Amanda L. Klein, Tammy Kopelman, Eric J. Ley, Ericca M. Martinez, Forrest O. Moore, Jason Murry, Raminder Nirula, Douglas Paul, Jacob QuickOmar Rivera, Martin Schreiber, Raul Coimbra

    Research output: Contribution to journalArticle

    2 Citations (Scopus)

    Abstract

    background Warfarin is associated with poor outcomes after trauma, an effect correlated with elevations in the international normalized ratio (INR). In contrast, the novel oral anticoagulants (NOAs) have no validated laboratory measure to quantify coagulopathy. We sought to determine if use of NOAs was associated with elevated activated partial thromboplastin time (aPTT) or INR levels among trauma patients or increased clotting times on thromboelastography (TEG). Methods This was a post-hoc analysis of a prospective observational study across 16 trauma centers. Patients on dabigatran, rivaroxaban, or apixaban were included. Laboratory data were collected at admission and after reversal. Admission labs were compared between medication groups. Traditional measures of coagulopathy were compared with TEG results using Spearman’s rank coefficient for correlation. Labs before and after reversal were also analyzed between medication groups. results 182 patients were enrolled between June 2013 and July 2015: 50 on dabigatran, 123 on rivaroxaban, and 34 apixaban. INR values were mildly elevated among patients on dabigatran (median 1.3, IQR 1.1–1.4) and rivaroxaban (median 1.3, IQR 1.1–1.6) compared with apixaban (median 1.1, IQR 1.0–1.2). Patients on dabigatran had slightly higher than normal aPTT values (median 35, IQR 29.8–46.3), whereas those on rivaroxaban and apixaban did not. Fifty patients had TEG results. The median values for R, alpha, MA and lysis were normal for all groups. Prothrombin time (PT) and aPTT had a high correlation in all groups (dabigatran p=0.0005, rivaroxaban p<0.0001, and apixaban p<0.0001). aPTT correlated with the R value on TEG in patients on dabigatran (p=0.0094) and rivaroxaban (p=0.0028) but not apixaban (p=0.2532). Reversal occurred in 14%, 25%, and 18% of dabigatran, rivaroxaban, and apixaban patients, respectively. Both traditional measures of coagulopathy and TEG remained within normal limits after reversal. Discussion Neither traditional measures of coagulation nor TEG were able to detect coagulopathy in patients on NOAs. Level of evidence Level IV.

    Original languageEnglish (US)
    Article numbere000231
    JournalTrauma Surgery and Acute Care Open
    Volume3
    Issue number1
    DOIs
    StatePublished - Jan 1 2018

    Fingerprint

    Anticoagulants
    Thrombelastography
    Wounds and Injuries
    Partial Thromboplastin Time
    International Normalized Ratio
    Trauma Centers
    Prothrombin Time
    Warfarin
    Nonparametric Statistics
    Dabigatran
    Rivaroxaban
    apixaban
    Observational Studies
    Prospective Studies

    ASJC Scopus subject areas

    • Surgery
    • Critical Care and Intensive Care Medicine

    Cite this

    Kobayashi, L. M., Brito, A., Barmparas, G., Bosarge, P., Brown, C. V., Bukur, M., ... Coimbra, R. (2018). Laboratory measures of coagulation among trauma patients on NOAs: Results of the AAST-MIT. Trauma Surgery and Acute Care Open, 3(1), [e000231]. https://doi.org/10.1136/tsaco-2018-000231

    Laboratory measures of coagulation among trauma patients on NOAs : Results of the AAST-MIT. / Kobayashi, Leslie M.; Brito, Alexandra; Barmparas, Galinos; Bosarge, Patrick; Brown, Carlos V.; Bukur, Marko; Carrick, Matthew M.; Catalano, Richard D.; Holly-Nicolas, Jan; Inaba, Kenji; Kaminski, Stephen; Klein, Amanda L.; Kopelman, Tammy; Ley, Eric J.; Martinez, Ericca M.; Moore, Forrest O.; Murry, Jason; Nirula, Raminder; Paul, Douglas; Quick, Jacob; Rivera, Omar; Schreiber, Martin; Coimbra, Raul.

    In: Trauma Surgery and Acute Care Open, Vol. 3, No. 1, e000231, 01.01.2018.

    Research output: Contribution to journalArticle

    Kobayashi, LM, Brito, A, Barmparas, G, Bosarge, P, Brown, CV, Bukur, M, Carrick, MM, Catalano, RD, Holly-Nicolas, J, Inaba, K, Kaminski, S, Klein, AL, Kopelman, T, Ley, EJ, Martinez, EM, Moore, FO, Murry, J, Nirula, R, Paul, D, Quick, J, Rivera, O, Schreiber, M & Coimbra, R 2018, 'Laboratory measures of coagulation among trauma patients on NOAs: Results of the AAST-MIT', Trauma Surgery and Acute Care Open, vol. 3, no. 1, e000231. https://doi.org/10.1136/tsaco-2018-000231
    Kobayashi, Leslie M. ; Brito, Alexandra ; Barmparas, Galinos ; Bosarge, Patrick ; Brown, Carlos V. ; Bukur, Marko ; Carrick, Matthew M. ; Catalano, Richard D. ; Holly-Nicolas, Jan ; Inaba, Kenji ; Kaminski, Stephen ; Klein, Amanda L. ; Kopelman, Tammy ; Ley, Eric J. ; Martinez, Ericca M. ; Moore, Forrest O. ; Murry, Jason ; Nirula, Raminder ; Paul, Douglas ; Quick, Jacob ; Rivera, Omar ; Schreiber, Martin ; Coimbra, Raul. / Laboratory measures of coagulation among trauma patients on NOAs : Results of the AAST-MIT. In: Trauma Surgery and Acute Care Open. 2018 ; Vol. 3, No. 1.
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    title = "Laboratory measures of coagulation among trauma patients on NOAs: Results of the AAST-MIT",
    abstract = "background Warfarin is associated with poor outcomes after trauma, an effect correlated with elevations in the international normalized ratio (INR). In contrast, the novel oral anticoagulants (NOAs) have no validated laboratory measure to quantify coagulopathy. We sought to determine if use of NOAs was associated with elevated activated partial thromboplastin time (aPTT) or INR levels among trauma patients or increased clotting times on thromboelastography (TEG). Methods This was a post-hoc analysis of a prospective observational study across 16 trauma centers. Patients on dabigatran, rivaroxaban, or apixaban were included. Laboratory data were collected at admission and after reversal. Admission labs were compared between medication groups. Traditional measures of coagulopathy were compared with TEG results using Spearman’s rank coefficient for correlation. Labs before and after reversal were also analyzed between medication groups. results 182 patients were enrolled between June 2013 and July 2015: 50 on dabigatran, 123 on rivaroxaban, and 34 apixaban. INR values were mildly elevated among patients on dabigatran (median 1.3, IQR 1.1–1.4) and rivaroxaban (median 1.3, IQR 1.1–1.6) compared with apixaban (median 1.1, IQR 1.0–1.2). Patients on dabigatran had slightly higher than normal aPTT values (median 35, IQR 29.8–46.3), whereas those on rivaroxaban and apixaban did not. Fifty patients had TEG results. The median values for R, alpha, MA and lysis were normal for all groups. Prothrombin time (PT) and aPTT had a high correlation in all groups (dabigatran p=0.0005, rivaroxaban p<0.0001, and apixaban p<0.0001). aPTT correlated with the R value on TEG in patients on dabigatran (p=0.0094) and rivaroxaban (p=0.0028) but not apixaban (p=0.2532). Reversal occurred in 14{\%}, 25{\%}, and 18{\%} of dabigatran, rivaroxaban, and apixaban patients, respectively. Both traditional measures of coagulopathy and TEG remained within normal limits after reversal. Discussion Neither traditional measures of coagulation nor TEG were able to detect coagulopathy in patients on NOAs. Level of evidence Level IV.",
    author = "Kobayashi, {Leslie M.} and Alexandra Brito and Galinos Barmparas and Patrick Bosarge and Brown, {Carlos V.} and Marko Bukur and Carrick, {Matthew M.} and Catalano, {Richard D.} and Jan Holly-Nicolas and Kenji Inaba and Stephen Kaminski and Klein, {Amanda L.} and Tammy Kopelman and Ley, {Eric J.} and Martinez, {Ericca M.} and Moore, {Forrest O.} and Jason Murry and Raminder Nirula and Douglas Paul and Jacob Quick and Omar Rivera and Martin Schreiber and Raul Coimbra",
    year = "2018",
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    TY - JOUR

    T1 - Laboratory measures of coagulation among trauma patients on NOAs

    T2 - Results of the AAST-MIT

    AU - Kobayashi, Leslie M.

    AU - Brito, Alexandra

    AU - Barmparas, Galinos

    AU - Bosarge, Patrick

    AU - Brown, Carlos V.

    AU - Bukur, Marko

    AU - Carrick, Matthew M.

    AU - Catalano, Richard D.

    AU - Holly-Nicolas, Jan

    AU - Inaba, Kenji

    AU - Kaminski, Stephen

    AU - Klein, Amanda L.

    AU - Kopelman, Tammy

    AU - Ley, Eric J.

    AU - Martinez, Ericca M.

    AU - Moore, Forrest O.

    AU - Murry, Jason

    AU - Nirula, Raminder

    AU - Paul, Douglas

    AU - Quick, Jacob

    AU - Rivera, Omar

    AU - Schreiber, Martin

    AU - Coimbra, Raul

    PY - 2018/1/1

    Y1 - 2018/1/1

    N2 - background Warfarin is associated with poor outcomes after trauma, an effect correlated with elevations in the international normalized ratio (INR). In contrast, the novel oral anticoagulants (NOAs) have no validated laboratory measure to quantify coagulopathy. We sought to determine if use of NOAs was associated with elevated activated partial thromboplastin time (aPTT) or INR levels among trauma patients or increased clotting times on thromboelastography (TEG). Methods This was a post-hoc analysis of a prospective observational study across 16 trauma centers. Patients on dabigatran, rivaroxaban, or apixaban were included. Laboratory data were collected at admission and after reversal. Admission labs were compared between medication groups. Traditional measures of coagulopathy were compared with TEG results using Spearman’s rank coefficient for correlation. Labs before and after reversal were also analyzed between medication groups. results 182 patients were enrolled between June 2013 and July 2015: 50 on dabigatran, 123 on rivaroxaban, and 34 apixaban. INR values were mildly elevated among patients on dabigatran (median 1.3, IQR 1.1–1.4) and rivaroxaban (median 1.3, IQR 1.1–1.6) compared with apixaban (median 1.1, IQR 1.0–1.2). Patients on dabigatran had slightly higher than normal aPTT values (median 35, IQR 29.8–46.3), whereas those on rivaroxaban and apixaban did not. Fifty patients had TEG results. The median values for R, alpha, MA and lysis were normal for all groups. Prothrombin time (PT) and aPTT had a high correlation in all groups (dabigatran p=0.0005, rivaroxaban p<0.0001, and apixaban p<0.0001). aPTT correlated with the R value on TEG in patients on dabigatran (p=0.0094) and rivaroxaban (p=0.0028) but not apixaban (p=0.2532). Reversal occurred in 14%, 25%, and 18% of dabigatran, rivaroxaban, and apixaban patients, respectively. Both traditional measures of coagulopathy and TEG remained within normal limits after reversal. Discussion Neither traditional measures of coagulation nor TEG were able to detect coagulopathy in patients on NOAs. Level of evidence Level IV.

    AB - background Warfarin is associated with poor outcomes after trauma, an effect correlated with elevations in the international normalized ratio (INR). In contrast, the novel oral anticoagulants (NOAs) have no validated laboratory measure to quantify coagulopathy. We sought to determine if use of NOAs was associated with elevated activated partial thromboplastin time (aPTT) or INR levels among trauma patients or increased clotting times on thromboelastography (TEG). Methods This was a post-hoc analysis of a prospective observational study across 16 trauma centers. Patients on dabigatran, rivaroxaban, or apixaban were included. Laboratory data were collected at admission and after reversal. Admission labs were compared between medication groups. Traditional measures of coagulopathy were compared with TEG results using Spearman’s rank coefficient for correlation. Labs before and after reversal were also analyzed between medication groups. results 182 patients were enrolled between June 2013 and July 2015: 50 on dabigatran, 123 on rivaroxaban, and 34 apixaban. INR values were mildly elevated among patients on dabigatran (median 1.3, IQR 1.1–1.4) and rivaroxaban (median 1.3, IQR 1.1–1.6) compared with apixaban (median 1.1, IQR 1.0–1.2). Patients on dabigatran had slightly higher than normal aPTT values (median 35, IQR 29.8–46.3), whereas those on rivaroxaban and apixaban did not. Fifty patients had TEG results. The median values for R, alpha, MA and lysis were normal for all groups. Prothrombin time (PT) and aPTT had a high correlation in all groups (dabigatran p=0.0005, rivaroxaban p<0.0001, and apixaban p<0.0001). aPTT correlated with the R value on TEG in patients on dabigatran (p=0.0094) and rivaroxaban (p=0.0028) but not apixaban (p=0.2532). Reversal occurred in 14%, 25%, and 18% of dabigatran, rivaroxaban, and apixaban patients, respectively. Both traditional measures of coagulopathy and TEG remained within normal limits after reversal. Discussion Neither traditional measures of coagulation nor TEG were able to detect coagulopathy in patients on NOAs. Level of evidence Level IV.

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