In this issue of Critical Care Nursing Quarterly, our readership is provided with multiple reviews highlighting challenges faced regarding anticoagulation in critically ill patients. Patients in the intensive care unit (ICU) may present with a variety of indications that require use of anticoagulation as part of their treatment armamentarium. Over the last 2 years, the topic of anticoagulation in the critically ill has reemerged because of the pandemic, especially given the use of more advanced lifesaving therapies to treat those with severe COVID-19. Over the course of 7 reviews, readers will be provided with insight into various aspects of anticoagulation use in the ICU, including monitoring, use in special populations, and treatment of those who develop severe bleeding while on therapy.

First, Gilbert and colleagues discuss the various stages of the clotting cascade, the common coagulation tests used to monitor anticoagulation therapy, and where each agent exerts its effects overall. This article provides readers with the foundational concepts used regarding anticoagulation therapy in the ICU. Then, we dive into the first special population commonly faced in surgical critical care patients-perioperative management of anticoagulation. The review goes through several specific populations and provides a summary of appropriate strategies for the use of anticoagulation postprocedure.

Next, we gain an understanding of the use of anticoagulation during 2 of the highest levels of critical care medicine-extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT). Each article aims to discuss the pharmacology, monitoring, and special considerations for anticoagulation during these 2 complex forms of organ support. In our final special population article, Smetana and colleagues provide insight into the complex pathology of coagulopathy in liver disease, including its influence on laboratory values and considerations that critical care nurses should employ when assuming care for these patients.

Since the use of anticoagulation comes with an inherent risk of excessive bleeding, knowledge and understanding of agents that are able to rapidly overcome the anticoagulation effects of these medications are paramount to their use. Worldwide, the most commonly used agent used for this indication is prothrombin complex concentrate (PCC). Our first review by Lukas and colleagues summarizes the evidence on the use of PCC and provides practical information regarding patient-specific administration considerations. Then, we learn about more target-specific agents used to treat bleeding, focusing on protamine, idarucizumab, and andexanet alfa. The article closes with a look at agents in the pipeline that may come to market in the coming years as well.

To round out the issue, we have a bonus article within the cardiology realm. In recent years, the use of sodium-glucose cotransporter-2 (SGLT-2) inhibitors has drastically increased because of numerous randomized controlled trials demonstrating overall improvement in outcomes in certain patients with heart failure. This review summarizes the available literature on these agents and provides practical considerations for their use in the clinical setting.

-G. Morgan Jones, PharmD, BCCCP, FCCM, FNCS

Issue Editor