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Singleton L, Kennedy C, Philip B, Navaei A, Bhar S, Ankola A, Doane K, Ontaneda A. Use of Inhaled Tranexamic Acid for Pulmonary Hemorrhage in Pediatric Patients on Extracorporeal Membrane Oxygenation Support. ASAIO J 2025:00002480-990000000-00675. [PMID: 40193587 DOI: 10.1097/mat.0000000000002430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2025] Open
Abstract
Bleeding is a common complication of extracorporeal membrane oxygenation (ECMO), is multifactorial, and results in significant morbidity and mortality. Pulmonary hemorrhage represents a serious adverse event in pediatric patients on ECMO and remains a challenging complication to manage. Its occurrence highlights the importance of identifying treatments that address bleeding complications in this population. This retrospective cohort study, from January 2018 to August 2022, explores the use of inhaled tranexamic acid (TXA), a clot-stabilizing agent, in 53 pediatric ECMO patients with new pulmonary hemorrhage. Primary diagnoses included respiratory failure (34%) and structural abnormalities (34%), such as congenital heart defects, congenital diaphragmatic hernia, and tracheal stenosis, with viral pneumonia being the leading cause of respiratory failure (47%). Results indicated that 48 of 53 (91%) patients showed cessation of pulmonary hemorrhage within 48 hours of inhaled TXA administration as measured by a decrease in our institution-specific bleeding scale from moderate to minor or no bleeding. In ECMO-managed pediatric patients with pulmonary hemorrhage, treatment with inhaled TXA demonstrated safety, with no observed adverse effects, and showed promising signs of contributing to the cessation of bleeding.
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Affiliation(s)
- Lynne Singleton
- From the Division of Critical Care, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Curtis Kennedy
- From the Division of Critical Care, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Blessy Philip
- Department of Pharmacy, Texas Children's Hospital, Houston, Texas
| | - Amir Navaei
- From the Division of Critical Care, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
- Division of Transfusion Medicine and Coagulation, Texas Children's Hospital, Houston, Texas
| | - Saleh Bhar
- From the Division of Critical Care, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
- Cancer and Hematology Centers, Texas Children's Hospital, Houston, Texas
| | - Ashish Ankola
- From the Division of Critical Care, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
- Division of Cardiology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Katherine Doane
- From the Division of Critical Care, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Andrea Ontaneda
- From the Division of Critical Care, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
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Helms J, Curtiaud A, Severac F, Tschirhart M, Merdji H, Bourdin M, Contant G, Depasse F, Abou Rjeily R, Sattler L, Meziani F, Angles-Cano E. Fibrinolysis as a Causative Mechanism for Bleeding Complications on Extracorporeal Membrane Oxygenation: A Pilot Observational Prospective Study. Anesthesiology 2024; 141:75-86. [PMID: 38502917 DOI: 10.1097/aln.0000000000004980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is associated with a high risk of bleeding complications. The specific impact of ECMO on fibrinolysis remains unexplored. The objective of the current pilot observational prospective study was to investigate the longitudinal dynamics of fibrinolytic markers-i.e., changes over time-in the context of bleeding events in patients on ECMO. METHODS Longitudinal dynamics of contact phase components (kininogen and bradykinin) and fibrinolysis markers (tissue plasminogen activator [tPA], plasminogen activator inhibitor-1 [PAI-1], their complexes [tPA•PAI-1], plasmin-antiplasmin complexes, plasminogen, and D-dimer) were measured in patients undergoing venovenous and venoarterial ECMO, before implantation, at 0, 6, and 12 h after implantation, and daily thereafter. RESULTS The cohort consisted of 30 patients (214 ECMO days). The concentrations of tPA, D-dimer, plasmin-antiplasmin complexes, PAI-1, and tPA•PAI-1 complexes were increased, whereas plasminogen decreased compared to normal values. A noteworthy divergence was observed between hemorrhagic and nonhemorrhagic patients: in bleeding patients, D-dimer, plasmin-antiplasmin, tPA, PAI-1, and tPA•PAI-1 followed an increasing kinetics before hemorrhage and then decreased to their baseline level; conversely, nonbleeding patients showed a decreasing kinetics in these markers. Also, D-dimer and tPA followed an increasing kinetics in bleeding patients compared to nonbleeding patients (median values for D-dimer dynamics: 1,080 vs. -440 ng/ml, P = 0.05; tPA dynamics: 0.130 vs. 0.100 nM, P = 0.038), and both markers significantly increased the day before hemorrhage. A tPA concentration above 0.304 nM was associated with bleeding events (odds ratio, 4.92; 95% CI, 1.01 to 24.08; P = 0.049). CONCLUSIONS Contact activation induces fibrinolysis in ECMO patients, especially in patients experiencing bleeding. This finding supports the role of this mechanism as a possible causal factor for hemorrhages during ECMO and open new avenues for novel therapeutic perspectives. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Julie Helms
- Strasbourg University (UNISTRA); Strasbourg University Hospital, Medical Intensive Care Unit (NHC), Strasbourg, France; INSERM (French National Institute of Health and Medical Research), Unit 1260, Regenerative Nanomedicine, Medicine Federation of Strasbourg, Strasbourg, France
| | - Anaïs Curtiaud
- Strasbourg University (UNISTRA); Strasbourg University Hospital, Medical Intensive Care Unit (NHC), Strasbourg, France; INSERM (French National Institute of Health and Medical Research), Unit 1260, Regenerative Nanomedicine, Medicine Federation of Strasbourg, Strasbourg, France
| | - François Severac
- Strasbourg University Hospital, Clinical Research Methods Group (GMRC), Strasbourg, France
| | - Marine Tschirhart
- INSERM (French National Institute of Health and Medical Research), Unit 1260, Regenerative Nanomedicine, Medicine Federation of Strasbourg, Strasbourg, France
| | - Hamid Merdji
- Strasbourg University (UNISTRA); Strasbourg University Hospital, Medical Intensive Care Unit (NHC), Strasbourg, France; INSERM (French National Institute of Health and Medical Research), Unit 1260, Regenerative Nanomedicine, Medicine Federation of Strasbourg, Strasbourg, France
| | - Matthieu Bourdin
- Diagnostica Stago, Prospective Research Department, Gennevilliers, France
| | - Geneviève Contant
- Diagnostica Stago, Prospective Research Department, Gennevilliers, France
| | - François Depasse
- Diagnostica Stago, Clinical Development, Asnières sur Seine, France
| | - Ramy Abou Rjeily
- Paris Cite University-INSERM U-1140, Innovative Therapies in Haemostasis, Paris, France
| | - Laurent Sattler
- Strasbourg University Hospital, Laboratory of Hematology, Hautepierre, Strasbourg, France
| | - Ferhat Meziani
- Strasbourg University (UNISTRA); Strasbourg University Hospital, Medical Intensive Care Unit (NHC), Strasbourg, France; INSERM (French National Institute of Health and Medical Research), Unit 1260, Regenerative Nanomedicine, Medicine Federation of Strasbourg, Strasbourg, France
| | - Eduardo Angles-Cano
- Paris Cite University-INSERM U-1140, Innovative Therapies in Haemostasis, Paris, France
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Zhang H, Zhao L, Jia B. Research progress on nutritional support in the neonatal and pediatric populations receiving extracorporeal membrane oxygenation. Front Nutr 2024; 11:1370286. [PMID: 38887500 PMCID: PMC11180743 DOI: 10.3389/fnut.2024.1370286] [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: 01/14/2024] [Accepted: 05/13/2024] [Indexed: 06/20/2024] Open
Abstract
Nutritional support is crucial for the prognosis of children supported by extracorporeal membrane oxygenation (ECMO). This article discusses the latest research progress and guideline recommendations for nutritional support during ECMO. We summarize the nutritional status and evaluation of ECMO patients, nutritional support methods and timing, trace elements, the impact of continuous renal replacement therapy (CRRT), and energy requirements and algorithms. The article shows that malnutrition is high in ECMO patients compared to other critically ill patients, with nearly one-third of patients experiencing a decrease in nutritional indicators. The timing of the initiation of nutrition is very important for the nutritional status of the child. Early enteral nutrition can improve patient prognosis, which is the most commonly used, with parenteral nutrition as a supplement. However, the proportion of enteral nutrition is relatively low, and a stepwise nutrition algorithm can determine when to initiate early enteral nutrition and parenteral nutrition. Malnourishment during critical illness have been associated with increased morbidity as well as increased mortality. Nutritional status should be evaluated at admission by screening tools. In addition, changes in the levels of several metabolites in vivo, such as blood lipids, carnitine, and thiamine, can also reflect the degree of nutritional deficiency in critically ill children. This article provides a reference for the implementation of nutrition of pediatric ECMO patients and further research on nutritional support.
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Affiliation(s)
- Hongquan Zhang
- Zhengzhou Railway Vocational and Technical College, Zhengzhou, Henan Province, China
- Department of Emergency and ICU, Fourth Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Lizhuo Zhao
- Department of Pediatric ICU, Henan Provincial People’s Hospital, Zhengzhou, Henan Province, China
| | - Baohui Jia
- Department of Emergency and ICU, Fourth Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
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Herrera-Camino A, Sweet SC, Pendino R, Brill Chod K, Eghtesady P, Gazit AZ, Lin JC. Lung Re-transplantation after prolonged veno-venous extracorporeal membrane oxygenation (ECMO) in a child with chronic lung allograft dysfunction. Pediatr Transplant 2024; 28:e14579. [PMID: 37458318 DOI: 10.1111/petr.14579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 05/17/2023] [Accepted: 07/03/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND Extracorporeal Membrane Oxygenation (ECMO) may be used as a bridge to lung transplantation in selected patients with end-stage respiratory failure. Historically, ECMO use in this setting has been associated with poor outcomes Puri V et.al, J Thorac Cardiovasc Surg, 140:427. More recently, technical advances and the implementation of rehabilitation and ambulation while awaiting transplantation on ECMO have led to improved surgical and post-transplant outcomes Kirkby S et.al, J Thorac Dis, 6:1024. METHODS We illustrate the case of a 6-year-old child who received prolonged ECMO support as a bridge to lung re-transplantation secondary to Chronic Lung Allograft Dysfunction (CLAD). RESULTS Early rehabilitation was key in improving the overall pre-transplant conditioning during ECMO. CONCLUSIONS Despite challenges associated with awake/ambulatory ECMO, the use of this strategy as a bridge to lung transplantation is feasible and has resulted in improved pre-transplant conditioning and post-transplant outcomes.
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Affiliation(s)
- Andres Herrera-Camino
- Division of Pediatric Critical Care Medicine, Washington University in St. Louis, St Louis, Missouri, USA
- Division of Pediatric Pulmonary Medicine, Washington University in St. Louis, St Louis, Missouri, USA
| | - Stuart C Sweet
- Division of Pediatric Pulmonary Medicine, Washington University in St. Louis, St Louis, Missouri, USA
| | - Rebecca Pendino
- Therapy Services, St. Louis Children's Hospital, St Louis, Missouri, USA
| | - Kirsten Brill Chod
- Therapy Services, St. Louis Children's Hospital, St Louis, Missouri, USA
| | - Pirooz Eghtesady
- Department of Cardiothoracic Surgery, Washington University in St. Louis, St Louis, Missouri, USA
| | - Avihu Z Gazit
- Division of Pediatric Critical Care Medicine, Washington University in St. Louis, St Louis, Missouri, USA
| | - John C Lin
- Division of Pediatric Critical Care Medicine, Washington University in St. Louis, St Louis, Missouri, USA
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Deng L, Xia Q, Chi C, Hu G. Awake veno-arterial extracorporeal membrane oxygenation in patients with perioperative period acute heart failure in cardiac surgery. J Thorac Dis 2020; 12:2179-2187. [PMID: 32642123 PMCID: PMC7330313 DOI: 10.21037/jtd.2020.04.38] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Extracorporeal membrane oxygenation (ECMO) is an effective extracorporeal life support technology that has been applied to treat cardiorespiratory failure patients. Some medical centers have started using ECMO on awake, non-intubated, spontaneously breathing patients, as this strategy offers several benefits over mechanical ventilation. However, most awake-ECMO methods focus on venovenous ECMO, and few cases of awake veno-arterial ECMO (V-A ECMO) have been reported, especially in perioperative acute heart failure. Therefore, our study aimed to examine awake—V-A ECMO cases that were not given continuous sedation or invasive mechanical ventilation (IMV) during perioperative heart failure. Method In total, 40 ECMO patients from December 2013 to November 2019 were divided into 2 groups (the awake-ECMO group and the asleep-ECMO group) according to the ventilation use. The demographics, patient outcomes, and ECMO parameters were collected and retrospectively analyzed. Results We identified 12 cases of awake ECMO without continuous ventilation, and 28 cases of simultaneous IMV and ECMO (asleep ECMO). Awake-ECMO patients showed fewer complications and better outcomes compared to ventilation patients. All patients in the awake group were successfully weaned off ECMO, while only 5 (18%) patients were weaned off ECMO in the asleep group. Furthermore, 9 (75%) patients survived until discharge in the awake group vs. 3 (11%) in the asleep group; 3 patients died of septic shock after weaning in the awake group, while 25 patients died of septic shock, hemodynamic disorder, bleeding, cerebral hemorrhage, etc., in the asleep group. These complications, including bleeding, pneumonia, hemolysis, and abdominal distension, etc., occurred less frequently in the asleep group compared to the awake group (P<0.05). Conclusions Awake V-A ECMO is an effective, feasible, and safe strategy in patients with perioperatively acute heart failure and can be applied as a bridge to cardiac function recovery or transplantation.
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Affiliation(s)
- Li Deng
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, China
| | - Qingping Xia
- Department of Medical Research Center, Mudanjiang Medical University, Mudanjiang 157011, China
| | - Chao Chi
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, China
| | - Guang Hu
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, China
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Mazzeffi MA, Tanaka K, Roberts A, Rector R, Menaker J, Kon Z, Deatrick KB, Kaczorowski D, Griffith B, Herr D. Bleeding, Thrombosis, and Transfusion With Two Heparin Anticoagulation Protocols in Venoarterial ECMO Patients. J Cardiothorac Vasc Anesth 2018; 33:1216-1220. [PMID: 30181084 DOI: 10.1053/j.jvca.2018.07.045] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To compare the incidence of bleeding and thrombosis between adult venoarterial (VA) extracorporeal membrane oxygenation (ECMO) patients managed with an activated clotting time (ACT)-guided heparin anticoagulation protocol and activated partial thromboplastin time (aPTT) protocol. DESIGN Retrospective cohort study. SETTING Tertiary care, academic medical center. PARTICIPANTS Consecutive adult VA ECMO patients during a 6-year period. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Demographic, medical, transfusion, and ECMO data were collected for all patients. Primary study outcomes were bleeding and thrombosis. Secondary outcomes were stroke and in-hospital mortality. One hundred twenty-one patients were included in the cohort. Fifty patients had ACT monitoring, and 71 had aPTT monitoring. There was no difference in the incidence of bleeding or thrombosis between the 2 groups (78.0% v 67.6% for bleeding [p = 0.21] and 16.0% v 19.7% for thrombosis [p = 1.0]). After adjusting for age and total ECMO days, patients managed with ACT received approximately 30% more red blood cell, fresh frozen plasma, and platelet transfusion (all p < 0.05). CONCLUSION There is no apparent difference in the incidence rate of bleeding or thrombosis between VA ECMO patients managed with an ACT- or aPTT-guided heparin anticoagulation protocol. Patients managed with an ACT-guided protocol received more blood transfusion, which could reflect greater total bleeding. Future randomized controlled trials would help to elucidate optimal anticoagulation strategies for VA ECMO patients.
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Affiliation(s)
- Michael A Mazzeffi
- University of Maryland School of Medicine, Department of Anesthesiology, Baltimore, MD.
| | - Kenichi Tanaka
- University of Maryland School of Medicine, Department of Anesthesiology, Baltimore, MD
| | - Alia Roberts
- University of Maryland School of Medicine, Department of Anesthesiology, Baltimore, MD
| | - Raymond Rector
- University of Maryland School of Medicine, Department of Surgery, Division of Cardiothoracic Surgery, Baltimore, MD
| | - Jay Menaker
- University of Maryland School of Medicine, Department of Surgery Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD
| | - Zachary Kon
- New York University, Langone Health, New York, NY
| | - Kristopher B Deatrick
- University of Maryland School of Medicine, Department of Surgery, Division of Cardiothoracic Surgery, Baltimore, MD
| | - David Kaczorowski
- University of Maryland School of Medicine, Department of Surgery, Division of Cardiothoracic Surgery, Baltimore, MD
| | - Bartley Griffith
- University of Maryland School of Medicine, Department of Surgery, Division of Cardiothoracic Surgery, Baltimore, MD
| | - Daniel Herr
- University of Maryland School of Medicine, Department of Surgery Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD
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