Managing therapeutic anticoagulation in patients with multiorgan dysfunction is challenging, like an Odyssey navigating bleeding and thrombosis risks. Argatroban, a direct thrombin inhibitor (DTI), is increasingly being used in critically ill patients for high-risk medical conditions such as heparin-induced thrombocytopenia and, more recently, in COVID-19–associated coagulopathy including heparin resistance.

In this issue of Anesthesiology, Heubner et al. investigate critically ill patients treated with argatroban to correlate results of coagulation assays used clinically to measure DTIs that include activated partial thromboplastin time (PTT), diluted thrombin time (TT), and point-of-care whole blood viscoelastic ecarin clotting time to argatroban plasma concentrations. Unlike previous studies, argatroban was not measured by a calibrated anti-factor II assay but by the most accurate method: chemical analysis using liquid chromatography with tandem mass spectrometry.2–4  While the activated PTT and the whole blood viscoelastic ecarin clotting time showed a modest correlation with mass spectrometry results,...

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