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Masi P, Gendreau S, Moyon Q, Leguyader M, Lebreton G, Ropers J, Dangers L, Sitruk S, Bréchot N, Pineton de Chambrun M, Chommeloux J, Schmidt M, Luyt CE, Leprince P, Combes A, Frere C, Hékimian G. Bleeding complications, coagulation disorders, and their management in acute myocardial infarction-related cardiogenic shock rescued by veno-arterial ECMO: A retrospective cohort study. J Crit Care 2024; 82:154771. [PMID: 38471248 DOI: 10.1016/j.jcrc.2024.154771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 02/21/2024] [Accepted: 03/05/2024] [Indexed: 03/14/2024]
Abstract
PURPOSE Management of dual antiplatelet therapy (DAPT) in patients on venoarterial-extracorporeal membrane (VA-ECMO) after acute myocardial infarction (AMI) is challenging. Our objective was to describe the frequency, management and outcomes of severe bleeding complications and determine their occurrence risk factors. MATERIAL AND METHODS We conducted a retrospective observational cohort study including post-AMI cardiogenic shock patients requiring VA-ECMO. Severe bleeding was defined based on the Bleeding Academic Research Consortium classification. We calculated multivariable Fine-Gray models to assess factors associated with risk of severe bleeding. RESULTS From January 2015 to July 2019, 176 patients received VA-ECMO after AMI and 132 patients were included. Sixty-five (49%) patients died. Severe bleeding occurred in 39% of cases. Severe thrombocytopenia (< 50 G/L) and hypofibrinogenemia (<1,5 g/L) occurred in respectively 31% and 19% of patients. DAPT was stopped in 32% of patients with a 6% rate of stent thrombosis. Anticoagulation was stopped in 39% of patients. Using a multivariate competing risk model, female sex, time on ECMO, troponin at admission and Impella® implantation were independently associated with severe bleeding. CONCLUSIONS Bleeding complications and coagulation disorders were frequent and severe in patients on VA-ECMO after AMI, leading of antiplatelet therapy withdrawal in one third of patients.
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Affiliation(s)
- Paul Masi
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive Réanimation, Paris, France; AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, F-94010 Créteil, France.
| | - Ségolène Gendreau
- AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, F-94010 Créteil, France
| | - Quentin Moyon
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive Réanimation, Paris, France; Sorbonne Université, Inserm, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Paris, France
| | - Maxence Leguyader
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive Réanimation, Paris, France
| | - Guillaume Lebreton
- Sorbonne Université, Inserm, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Paris, France; Cardiothoracic surgery department, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, F-75013 Paris, France
| | - Jacques Ropers
- Assistance Publique Hôpitaux de Paris, Unité de Recherche Clinique des Hôpitaux Universitaires Pitié Salpêtrière -Hôpitaux Universitaires Pitié Salpêtrière - Charles Foix, Paris, France
| | - Laurence Dangers
- Réanimation Polyvalente, Centre Hospitalier Universitaire Félix Guyon, Saint-Denis, France
| | - Samuel Sitruk
- Assistance Publique Hôpitaux de Paris, Unité de Recherche Clinique des Hôpitaux Universitaires Pitié Salpêtrière -Hôpitaux Universitaires Pitié Salpêtrière - Charles Foix, Paris, France
| | - Nicolas Bréchot
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive Réanimation, Paris, France; Sorbonne Université, Inserm, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Paris, France
| | - Marc Pineton de Chambrun
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive Réanimation, Paris, France; Sorbonne Université, Inserm, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Paris, France
| | - Juliette Chommeloux
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive Réanimation, Paris, France; Sorbonne Université, Inserm, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Paris, France
| | - Matthieu Schmidt
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive Réanimation, Paris, France; Sorbonne Université, Inserm, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Paris, France
| | - Charles Edouard Luyt
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive Réanimation, Paris, France; Sorbonne Université, Inserm, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Paris, France
| | - Pascal Leprince
- Sorbonne Université, Inserm, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Paris, France; Cardiothoracic surgery department, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, F-75013 Paris, France
| | - Alain Combes
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive Réanimation, Paris, France; Sorbonne Université, Inserm, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Paris, France
| | - Corinne Frere
- Sorbonne Université, Inserm, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Paris, France; Department of Hematology, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, F-75013 Paris, France
| | - Guillaume Hékimian
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive Réanimation, Paris, France; Sorbonne Université, Inserm, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Paris, France
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2
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Martucci G, Giani M, Schmidt M, Tanaka K, Tabatabai A, Tuzzolino F, Agerstrand C, Riera J, Ramanan R, Grasselli G, Ait Hssain A, Gannon WD, Buabbas S, Gorjup V, Trethowan B, Rizzo M, Fanelli V, Jeon K, De Pascale G, Combes A, Ranieri MV, Duburcq T, Foti G, Chico JI, Balik M, Broman LM, Schellongowski P, Buscher H, Lorusso R, Brodie D, Arcadipane A. Anticoagulation and Bleeding during Veno-Venous Extracorporeal Membrane Oxygenation: Insights from the PROTECMO Study. Am J Respir Crit Care Med 2024; 209:417-426. [PMID: 37943110 DOI: 10.1164/rccm.202305-0896oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 11/08/2023] [Indexed: 11/10/2023] Open
Abstract
Rationale: Definitive guidelines for anticoagulation management during veno-venous extracorporeal membrane oxygenation (VV ECMO) are lacking, whereas bleeding complications continue to pose major challenges. Objectives: To describe anticoagulation modalities and bleeding events in adults receiving VV ECMO. Methods: This was an international prospective observational study in 41 centers, from December 2018 to February 2021. Anticoagulation was recorded daily in terms of type, dosage, and monitoring strategy. Bleeding events were reported according to site, severity, and impact on mortality. Measurements and Main Results: The study cohort included 652 patients, and 8,471 days on ECMO were analyzed. Unfractionated heparin was the initial anticoagulant in 77% of patients, and the most frequently used anticoagulant during the ECMO course (6,221 d; 73%). Activated partial thromboplastin time (aPTT) was the most common test for monitoring coagulation (86% of days): the median value was 52 seconds (interquartile range, 39 to 61 s) but dropped by 5.3 seconds after the first bleeding event (95% confidence interval, -7.4 to -3.2; P < 0.01). Bleeding occurred on 1,202 days (16.5%). Overall, 342 patients (52.5%) experienced at least one bleeding event (one episode every 215 h on ECMO), of which 10 (1.6%) were fatal. In a multiple penalized Cox proportional hazard model, higher aPTT was a potentially modifiable risk factor for the first episode of bleeding (for 20-s increase; hazard ratio, 1.07). Conclusions: Anticoagulation during VV ECMO was a dynamic process, with frequent stopping in cases of bleeding and restart according to the clinical picture. Future studies might explore lower aPTT targets to reduce the risk of bleeding.
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Affiliation(s)
| | - Marco Giani
- Fondazione IRCCS San Gerardo dei Tintori, Università degli Studi di Milano Bicocca, Monza, Italy
| | - Matthieu Schmidt
- Sorbonne University, Institute of Cardiometabolism and Nutrition, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Paris, France
| | - Kenichi Tanaka
- The University of Oklahoma Health Sciences Center, University of Oklahoma, Oklahoma City, Oklahoma
| | - Ali Tabatabai
- University of Maryland St. Joseph Medical Center, Towson, Maryland
| | - Fabio Tuzzolino
- Statistics and Data Management Services, Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (IRCCS-ISMETT), Palermo, Italy
| | - Cara Agerstrand
- Department of Medicine and Center for Acute Respiratory Failure, Irving Medical Center, Columbia University, New York, New York
| | - Jordi Riera
- Critical Care Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Shock Organ Dysfunction and Resuscitation (SODIR), Vall d'Hebron Institut de Recerca, Barcelona, Spain
- Centro de Investigacion en Red de Enfermedades Respiratorias (CIBERES) Instituto de Salud Carlos III, Barcelona, Spain
| | - Raj Ramanan
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Giacomo Grasselli
- Department of Anesthesia, Intensive Care, and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | | | - Whitney D Gannon
- Department of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sara Buabbas
- Kuwait Extracorporeal Life Support Program, Jaber Al-Ahmad Alsabah Hospital, Kuwait City, Kuwait
| | | | - Brian Trethowan
- Meijer Heart Center, Butterworth Hospital, Spectrum Health, Grand Rapids, Michigan
| | - Monica Rizzo
- Statistics and Data Management Services, Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (IRCCS-ISMETT), Palermo, Italy
| | - Vito Fanelli
- Department of Surgical Sciences and
- Department of Anesthesia, Critical Care, and Emergency, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Kyeongman Jeon
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Gennaro De Pascale
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alain Combes
- Sorbonne University, Institute of Cardiometabolism and Nutrition, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Paris, France
| | | | - Thibault Duburcq
- Centre Hospitalier Regional Universitaire (CHRU) Lille, Hôpital Roger Salengro, Lille, France
| | - Giuseppe Foti
- Fondazione IRCCS San Gerardo dei Tintori, Università degli Studi di Milano Bicocca, Monza, Italy
| | - Juan I Chico
- Critical Care Department, Alvaro Cunqueiro University Hospital, Vigo, Spain
| | - Martin Balik
- First Medical Faculty, General University Hospital, Prague, Czech Republic
| | - Lars Mikael Broman
- ECMO Centre Karolinska, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Peter Schellongowski
- Department of Medicine I, Intensive Care Unit 13i2, Center of Excellence in Medical Intensive Care, Medical University of Vienna, Vienna, Austria
| | - Hergen Buscher
- St. Vincent's Hospital Sydney, University of New South Wales, Sydney, New South Wales, Australia
| | - Roberto Lorusso
- Cardiothoracic Surgery Department, Maastricht University Medical Center, and
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands; and
| | - Daniel Brodie
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
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Helms J, Curtiaud A, Severac F, Merdji H, Angles-Cano E. Dynamic longitudinal increase in D-dimers: an early predictor of bleeding complications in ECMO. Intensive Care Med 2023; 49:1416-1417. [PMID: 37725117 DOI: 10.1007/s00134-023-07224-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2023] [Indexed: 09/21/2023]
Affiliation(s)
- Julie Helms
- Faculté de Médecine, Université de Strasbourg (UNISTRA), Hôpitaux Universitaires de Strasbourg, Service de Médecine Intensive-Réanimation Nouvel Hôpital Civil, 1, Place de L'Hôpital, 67091, Strasbourg Cedex, France.
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Strasbourg, France.
| | - Anaïs Curtiaud
- Faculté de Médecine, Université de Strasbourg (UNISTRA), Hôpitaux Universitaires de Strasbourg, Service de Médecine Intensive-Réanimation Nouvel Hôpital Civil, 1, Place de L'Hôpital, 67091, Strasbourg Cedex, France
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Strasbourg, France
| | - François Severac
- Hôpitaux Universitaires de Strasbourg, Groupe Méthodes en Recherche Clinique (GMRC, Hôpital Civil, Strasbourg, France
| | - Hamid Merdji
- Faculté de Médecine, Université de Strasbourg (UNISTRA), Hôpitaux Universitaires de Strasbourg, Service de Médecine Intensive-Réanimation Nouvel Hôpital Civil, 1, Place de L'Hôpital, 67091, Strasbourg Cedex, France
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Strasbourg, France
| | - Eduardo Angles-Cano
- Université Paris Cité, INSERM, Innovative Therapies in Haemostasis, 75006, Paris, France
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4
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Heubner L, Trautmann-Grill K, Tiebel O, Mirus M, Güldner A, Rand A, Spieth PM. Treatment of Acquired von Willebrand Disease due to Extracorporeal Membrane Oxygenation in a Pediatric COVID-19 Patient with Vonicog Alfa: A Case Report and Literature Review. TH OPEN 2023; 7:e76-e81. [PMID: 36846831 PMCID: PMC9949976 DOI: 10.1055/a-2008-4367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 01/02/2023] [Indexed: 01/07/2023] Open
Abstract
Acquired von Willebrand disease (aVWD) is frequently observed in patients with the need for extracorporeal membrane oxygenation (ECMO). aVWD can be treated by plasma-derived concentrates containing factor VIII (FVIII) and/or von Willebrand factor (VWF) and recombinant VWF concentrate as well as adjuvant therapies such as tranexamic acid and desmopressin. However, all of these therapeutic options possibly cause thromboembolism. Therefore, the optimal treatment remains uncertain. This report presents a case of a 16-year-old patient suffering from severe acute respiratory distress syndrome due to coronavirus disease 2019 with the need of ECMO support. Our patient developed aVWD under ECMO therapy characterized by loss of high-molecular-weight multimers (HMWM) and severe bleeding symptoms following endoscopic papillotomy due to sclerosing cholangitis. At the same time standard laboratory parameters showed hypercoagulability with increased fibrinogen level and platelet count. The patient was successfully treated with recombinant VWF concentrate (rVWF; vonicog alfa; Veyvondi) combined with topic tranexamic acid application and cortisone therapy. rVWF concentrate vonicog alfa is characterized by ultra-large multimers and absence of FVIII. Patient could be successfully weaned from ECMO support after 72 days. Multimer analysis 1 week after ECMO decannulation showed an adequate reappearance of HMWM.
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Affiliation(s)
- Lars Heubner
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Dresden, Germany,Address for correspondence Lars Heubner, MD Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus DresdenDresdenGermany
| | - Karolin Trautmann-Grill
- Department of Internal Medicine I, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Dresden. Germany
| | - Oliver Tiebel
- Institute of Clinical Chemistry, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Dresden. Germany
| | - Martin Mirus
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Dresden, Germany
| | - Andreas Güldner
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Dresden, Germany
| | - Axel Rand
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Dresden, Germany
| | - Peter Markus Spieth
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Dresden, Germany
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5
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Tóth K, Fresilli S, Paoli N, Maiucci G, Salvioni M, Kotani Y, Katzenschlager S, Weigand MA, Landoni G. D-dimer levels in non-COVID-19 ARDS and COVID-19 ARDS patients: A systematic review with meta-analysis. PLoS One 2023; 18:e0277000. [PMID: 36745595 PMCID: PMC9901787 DOI: 10.1371/journal.pone.0277000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 01/20/2023] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Hypercoagulability and thrombo-inflammation are the main reasons for death in COVID-19 patients. It is unclear whether there is a difference between D-dimer levels in patients without or with COVID-19 acute respiratory distress syndrome (ARDS). METHODS We searched PubMed, EMBASE, and ClinicalTrails.gov databases looking for studies reporting D-dimer levels in patients without or with COVID-19 ARDS. Secondary endpoints included length of hospital stay, and mortality data at the longest follow-up available. RESULTS We included 12 retrospective and 3 prospective studies with overall 2,828 patients, of whom 1,404 (49.6%) had non-COVID-19 ARDS and 1,424 had COVID-19 ARDS. D-dimer levels were not significantly higher in non-COVID-19 ARDS than in COVID-19 ARDS patients (mean 7.65 mg/L vs. mean 6.20 mg/L MD 0.88 [CI: -0.61 to 2.38] p = 0.25; I² = 85%) while the length of hospital stay was shorter (non-COVID-19 mean 37.4 days vs. COVID-19 mean 48.5 days, MD -10.92 [CI: -16.71 to -5.14] p < 0.001; I² = 44%). No difference in mortality was observed: non-COVID-19 ARDS 418/1167 (35.8%) vs. COVID-19 ARDS 467/1201 (38.8%). CONCLUSIONS We found no difference in the mean D-dimer levels between non-COVID-19 ARDS and COVID-19 ARDS patients.
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Affiliation(s)
- Krisztina Tóth
- Doctoral School of Theoretical and Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Stefano Fresilli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Nicola Paoli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giacomo Maiucci
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Mariateresa Salvioni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Yuki Kotani
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Stephan Katzenschlager
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
- University Center for ARDS and Weaning, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus A. Weigand
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
- University Center for ARDS and Weaning, Heidelberg University Hospital, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
- * E-mail:
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6
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Munshi L, Brodie D, Fan E. Extracorporeal Support for Acute Respiratory Distress Syndrome in Adults. NEJM EVIDENCE 2022; 1:EVIDra2200128. [PMID: 38319864 DOI: 10.1056/evidra2200128] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Extracorporeal Support for ARDS in AdultsThere is a subset of patients who develop severe ARDS for whom supportive care with mechanical ventilation is insufficient or possibly injurious. The use of ECMO as an adjunct to treat these patients is reviewed.
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Affiliation(s)
- Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, Sinai Health System/University Health Network, University of Toronto
- Institute of Health Policy, Management and Evaluation, University of Toronto
| | - Daniel Brodie
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York
- Center for Acute Respiratory Failure, NewYork-Presbyterian Hospital, New York
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Sinai Health System/University Health Network, University of Toronto
- Institute of Health Policy, Management and Evaluation, University of Toronto
- Toronto General Hospital Research Institute
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7
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Volod O, Wegner J. Viscoelastic Testing in the Management of Adult Patients on Mechanical Circulatory Support Devices with Focus on Extracorporeal Membrane Oxygenation. Semin Thromb Hemost 2022; 48:814-827. [DOI: 10.1055/s-0042-1756303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
AbstractThromboembolic and hemorrhagic complications continue to remain frequent complications that significantly impact the morbidity and mortality of patients implanted with mechanical circulatory support devices (MCSDs). The severe acute respiratory syndrome caused by coronavirus 2 (SARS-CoV-2) has resulted in a number of COVID-19 patients being supported by MCSDs, specifically extracorporeal membrane oxygenation (ECMO), which in turn has created a crucial need for rapid assessment of hemostatic status in these patients to avoid bleeding and thrombotic complications. Currently, conventional plasma-based coagulation assays such as prothrombin time and activated partial thromboplastin time (aPTT) are used to assess hemostasis, and the activated clotting time (ACT) and aPTT are the most common tests used to monitor heparin anticoagulation in patients on ECMO. Unfractionated heparin remains the mainstay anticoagulation therapy for patients on ECMO. Extracorporeal Life Support Organization (ELSO) offers little guidance on the subject but does state that each institution should create its internal anticoagulation protocols. Viscoelastic assays (VEAs) are increasingly recognized by ELSO and ECMO community for their potential to assess hemostatic derangements in patients implanted with MCSDs as well as guidance for appropriate hemostatic therapy. This review focuses on the evidence for the use of viscoelastic assays to assess overall hemostasis and to guide the treatment of adult patients connected to an ECMO circuit. Limitations of the use of conventional assays, ACT, and VEA are also discussed.
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Affiliation(s)
- Oksana Volod
- Department of Pathology and Laboratory Medicine, Cedars Sinai Medical Center, Los Angeles, California
| | - Julie Wegner
- College of Health Professions, South University Online, Savannah, Georgia
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8
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Bohman JJKK, Seelhammer TG, Mazzeffi M, Gutsche J, Ramakrishna H. The Year in Extracorporeal Membrane Oxygenation: Selected Highlights From 2021. J Cardiothorac Vasc Anesth 2022; 36:1832-1843. [PMID: 35367120 DOI: 10.1053/j.jvca.2022.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 03/01/2022] [Indexed: 11/11/2022]
Abstract
This review summarizes the extracorporeal membrane oxygenation (ECMO) or extracorporeal life support literature published in 2021. This Selected Highlights article is not intended to be an exhaustive review of the literature, but rather a summarizing of key themes that developed in the ECMO literature during 2021. The primary topics presented include the following: ECMO for coronavirus disease 2019, extracorporeal cardiopulmonary resuscitation, periprocedural cardiopulmonary support with ECMO, and anticoagulation for ECMO.
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Affiliation(s)
- John J Kyle K Bohman
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Troy G Seelhammer
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Michael Mazzeffi
- Department of Anesthesiology and Critical Care Medicine, The George Washington University, Washington, DC
| | - Jacob Gutsche
- Department of Anesthesiology and Critical Care Medicine, Penn Presbyterian Medical Center, University of Pennsylvania, Philadelphia, PA
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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9
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Chandler WL. Coagulation activation during extracorporeal membrane oxygenation (ECMO). Thromb Res 2022; 211:154-160. [DOI: 10.1016/j.thromres.2022.02.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 02/07/2022] [Accepted: 02/10/2022] [Indexed: 12/16/2022]
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Current and novel biomarkers of thrombotic risk in COVID-19: a Consensus Statement from the International COVID-19 Thrombosis Biomarkers Colloquium. Nat Rev Cardiol 2022; 19:475-495. [PMID: 35027697 PMCID: PMC8757397 DOI: 10.1038/s41569-021-00665-7] [Citation(s) in RCA: 151] [Impact Index Per Article: 75.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/16/2021] [Indexed: 02/06/2023]
Abstract
Coronavirus disease 2019 (COVID-19) predisposes patients to thrombotic and thromboembolic events, owing to excessive inflammation, endothelial cell activation and injury, platelet activation and hypercoagulability. Patients with COVID-19 have a prothrombotic or thrombophilic state, with elevations in the levels of several biomarkers of thrombosis, which are associated with disease severity and prognosis. Although some biomarkers of COVID-19-associated coagulopathy, including high levels of fibrinogen and D-dimer, were recognized early during the pandemic, many new biomarkers of thrombotic risk in COVID-19 have emerged. In this Consensus Statement, we delineate the thrombotic signature of COVID-19 and present the latest biomarkers and platforms to assess the risk of thrombosis in these patients, including markers of platelet activation, platelet aggregation, endothelial cell activation or injury, coagulation and fibrinolysis as well as biomarkers of the newly recognized post-vaccine thrombosis with thrombocytopenia syndrome. We then make consensus recommendations for the clinical use of these biomarkers to inform prognosis, assess disease acuity, and predict thrombotic risk and in-hospital mortality. A thorough understanding of these biomarkers might aid risk stratification and prognostication, guide interventions and provide a platform for future research.
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Massart N, Maxime V, Fillatre P, Razazi K, Ferré A, Moine P, Legay F, Voiriot G, Amara M, Santi F, Nseir S, Marque-Juillet S, Bounab R, Barbarot N, Bruneel F, Luyt CE. Characteristics and prognosis of bloodstream infection in patients with COVID-19 admitted in the ICU: an ancillary study of the COVID-ICU study. Ann Intensive Care 2021; 11:183. [PMID: 34952960 PMCID: PMC8708508 DOI: 10.1186/s13613-021-00971-w] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/12/2021] [Indexed: 12/28/2022] Open
Abstract
Background Patients infected with the severe acute respiratory syndrome coronavirus 2 (SARS-COV 2) and requiring intensive care unit (ICU) have a high incidence of hospital-acquired infections; however, data regarding hospital acquired bloodstream infections (BSI) are scarce. We aimed to investigate risk factors and outcome of BSI in critically ill coronavirus infectious disease-19 (COVID-19) patients. Patients and methods We performed an ancillary analysis of a multicenter prospective international cohort study (COVID-ICU study) that included 4010 COVID-19 ICU patients. For the present analysis, only those with data regarding primary outcome (death within 90 days from admission) or BSI status were included. Risk factors for BSI were analyzed using Fine and Gray competing risk model. Then, for outcome comparison, 537 BSI-patients were matched with 537 controls using propensity score matching. Results Among 4010 included patients, 780 (19.5%) acquired a total of 1066 BSI (10.3 BSI per 1000 patients days at risk) of whom 92% were acquired in the ICU. Higher SAPS II, male gender, longer time from hospital to ICU admission and antiviral drug before admission were independently associated with an increased risk of BSI, and interestingly, this risk decreased over time. BSI was independently associated with a shorter time to death in the overall population (adjusted hazard ratio (aHR) 1.28, 95% CI 1.05–1.56) and, in the propensity score matched data set, patients with BSI had a higher mortality rate (39% vs 33% p = 0.036). BSI accounted for 3.6% of the death of the overall population. Conclusion COVID-19 ICU patients have a high risk of BSI, especially early after ICU admission, risk that increases with severity but not with corticosteroids use. BSI is associated with an increased mortality rate. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-021-00971-w.
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Affiliation(s)
- Nicolas Massart
- Service de Réanimation, CH de St BRIEUC, 10, rue Marcel Proust, 22000, Saint-Brieuc, France
| | - Virginie Maxime
- Surgical and Medical Intensive Care Unit Hôpital, Raymond Poincaré, 9230, Garches, France
| | - Pierre Fillatre
- Service de Réanimation, CH de St BRIEUC, 10, rue Marcel Proust, 22000, Saint-Brieuc, France
| | - Keyvan Razazi
- AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, 94010, Créteil, France.,Univ Paris Est Créteil, INSERM, IMRB, 94010, Créteil, France.,Université Paris Est Créteil, Faculté de Médecine de Créteil, IMRB, GRC CARMAS, 94010, Créteil, France
| | - Alexis Ferré
- Service de Réanimation/USC, Hôpital Mignot, Centre hospitalier de Versailles, 177 rue de Versailles, 78150, Le Chesnay, France
| | - Pierre Moine
- Surgical and Medical Intensive Care Unit Hôpital, Raymond Poincaré, 9230, Garches, France
| | - Francois Legay
- Service de Réanimation, CH de St BRIEUC, 10, rue Marcel Proust, 22000, Saint-Brieuc, France
| | - Guillaume Voiriot
- Service de Médecine Intensive Réanimation, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, and Groupe de Recherche Clinique CARMAS, Collegium Galilée, Créteil, France
| | - Marlene Amara
- Service de Biologie (Unité de Microbiologie), Hôpital Mignot, Centre Hospitalier de Versailles, 177 rue de Versailles, 78150, Le Chesnay, France
| | - Francesca Santi
- Surgical and Medical Intensive Care Unit Hôpital, Raymond Poincaré, 9230, Garches, France
| | - Saad Nseir
- Centre de Réanimation, CHU de Lille, 59000, Lille, France.,INSERM U1285, Université de Lille, CNRS, UMR 8576 - UGSF - Unité de Glycobiologie Structurale et Fonctionnelle, 59000, Lille, France
| | - Stephanie Marque-Juillet
- Service de Biologie (Unité de Microbiologie), Hôpital Mignot, Centre Hospitalier de Versailles, 177 rue de Versailles, 78150, Le Chesnay, France
| | - Rania Bounab
- Surgical and Medical Intensive Care Unit Hôpital, Raymond Poincaré, 9230, Garches, France
| | - Nicolas Barbarot
- Service de Réanimation, CH de St BRIEUC, 10, rue Marcel Proust, 22000, Saint-Brieuc, France
| | - Fabrice Bruneel
- Service de Réanimation/USC, Hôpital Mignot, Centre hospitalier de Versailles, 177 rue de Versailles, 78150, Le Chesnay, France
| | - Charles-Edouard Luyt
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris (APHP), Sorbonne-Université, Hôpital Pitié-Salpêtrière, and Sorbonne Université, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, 47-83, Boulevard de l'Hôpital, 75651, Paris, France.
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Hvas CL, Larsen JB, Adelborg K, Christensen S, Hvas AM. Dynamic Hemostasis and Fibrinolysis Assays in Intensive Care COVID-19 Patients and Association with Thrombosis and Bleeding-A Systematic Review and a Cohort Study. Semin Thromb Hemost 2021; 48:31-54. [PMID: 34715692 DOI: 10.1055/s-0041-1735454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Patients admitted to the intensive care unit (ICU) with coronavirus disease 2019 (COVID-19), the infectious pathology caused by severe acute respiratory syndrome coronavirus 2, have a high risk of thrombosis, though the precise mechanisms behind this remain unclarified. A systematic literature search in PubMed and EMBASE identified 18 prospective studies applying dynamic coagulation assays in ICU COVID-19 patients. Overall, these studies revealed normal or slightly reduced primary hemostasis, prolonged clot initiation, but increased clot firmness. Thrombin generation assay parameters generally were equivalent to the control groups or within reference range. Fibrinolysis assays showed increased clot resistance. Only six studies related their findings to clinical outcome. We also prospectively included 51 COVID-19 patients admitted to the ICU. Blood samples were examined on day 1, 3-4, and 7-8 with platelet function tests, rotational thromboelastometry (ROTEM), in vivo and ex vivo thrombin generation, and clot lysis assay. Data on thrombosis, bleeding, and mortality were recorded during 30 days. Primary hemostasis was comparable to healthy controls, but COVID-19 patients had longer ROTEM-clotting times and higher maximum clot firmness than healthy controls. Ex vivo thrombin generation was similar to that of healthy controls while in vivo thrombin generation markers, thrombin-antithrombin (TAT) complex, and prothrombin fragment 1 + 2 (F1 + 2) were higher in ICU COVID-19 patients than in healthy controls. Impaired fibrinolysis was present at all time points. TAT complex and F1 + 2 levels were significantly higher in patients developing thrombosis (n = 16) than in those without. In conclusion, only few previous studies employed dynamic hemostasis assays in COVID-19 ICU-patients and failed to reveal a clear association with development of thrombosis. In ICU COVID-19 patients, we confirmed normal platelet aggregation, while in vivo thrombin generation was increased and fibrinolysis decreased. Thrombosis may be driven by increased thrombin formation in vivo.
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Affiliation(s)
- Christine Lodberg Hvas
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Julie Brogaard Larsen
- Thrombosis and Hemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Kasper Adelborg
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Thrombosis and Hemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Steffen Christensen
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Anne-Mette Hvas
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Thrombosis and Hemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
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