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More than 80% of hospitals surveyed lacked a specific protocol for reversal of antithrombotic agents in critically ill patients in the ICU, according to research.

More than 80% of hospitals surveyed lack a specific protocol for the reversal of antithrombotic agents in critically ill patients in the ICU, according to a study published online ahead of print in the Journal of Critical Care.

“Reversing antithrombotic agents in critically ill patients is challenging due to patient factors that influence pharmacokinetics and pharmacodynamics, such as primary diagnosis, age, comorbidities, and concomitant medications,” explained corresponding author Marcella C.A. Müller, MD, PhD, of Amsterdam University Medical Center, and coauthors.

Survey Methodology & Respondent Demographics

To characterize current practices, researchers distributed an online questionnaire to critical care physicians worldwide. A total of 208 physician respondents from 49 countries completed the survey, with 79% practicing in European ICUs. The survey queried the presence of hospital- and ICU-specific reversal protocols, preferred reversal agents for various antithrombotics, monitoring strategies, and factors guiding decision-making in major bleeding scenarios.

Protocol Availability & Reversal Practices

Despite challenges, international guidelines lack recommendations for antithrombotic agent reversal for patients who are critically ill. According to the study, 42% of respondents reported the presence of a hospital-specific protocol for anticoagulation reversal, yet just 17% reported the presence of an ICU-specific reversal protocol.

“There is limited availability of reversal protocols in the ICU, and many reported practices do not appear to adhere to evidence-based methods for using reversal agents,” the authors noted.

Of the roughly one in five ICUs with a reversal protocol, practices varied by drug class:

• Vitamin K antagonists: 92%
• Unfractionated heparin: 75%
• Low-molecular-weight heparin: 58%
• Factor Xa inhibitors: 53%
• Platelet aggregation inhibitors: 50%
• Direct thrombin inhibitors: 44%
• Fibrinolytics: 31%

“There was heterogeneity in reported reversal practice for different antithrombotics in specific scenarios and between continents,” researchers reported. “However, dosing strategies of applicable reversal agents were similar.”

Monitoring Strategies & Regional Variations

With the exception of low-molecular-weight heparin and fibrinolytics, European respondents used reversal agents for antithrombotics more often than respondents from other regions. The study also reported diverse approaches, guided by individual situations, in reversing antithrombotics in patients with major bleeding.

Activated partial thromboplastin time (97%) and international normalized ratio (96%) were the most widely used tests for monitoring coagulation. Point-of-care platelet function (12%) and ecarin clotting time (5%) were least often.

“Interestingly, viscoelastic testing, including rotational thromboelastometry and thromboelastography, was relatively scarce among participants,” researchers wrote, “with access reported by only 42% and 24% of respondents, respectively.”

“The approach to reverse antithrombotic agents was primarily guided by the particular situation, emphasizing the need for ICU specific guidelines,” the researchers concluded.