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Samimi MN, Hale A, Schults J, Fischer A, Roberts JA, Dhanani J. Clinical guidance for unfractionated heparin dosing and monitoring in critically ill patients. Expert Opin Pharmacother 2024. [PMID: 38825778 DOI: 10.1080/14656566.2024.2364057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 05/31/2024] [Indexed: 06/04/2024]
Abstract
INTRODUCTION Unfractionated heparin is a widely used anticoagulant in critically ill patients. It has a well-established safety profile and remains an attractive option for clinicians due to its short half-life and reversibility. Heparin has a unique pharmacokinetic profile, which contributes to significant inter-patient and intra-patient variability in effect. The variability in anticoagulant effect combined with heparin's short half-life mean close monitoring is required for clinical efficacy and preventing adverse effects. To optimize heparin use in critically ill patients effective monitoring assays and dose adjustment strategies are needed. AREAS COVERED This paper explores the use of heparin as an anticoagulant and optimal approaches to monitoring in critically ill patients. EXPERT OPINION Conventional monitoring assays for heparin dosing have significant limitations. Emerging data appears to favor using anti-Xa assay monitoring for heparin anticoagulation which many centers have successfully adopted as the standard. The anti-Xa assay appears have important benefits relative to the aPTT for heparin monitoring in critically ill patients, and should be considered for broader use.
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Affiliation(s)
- May N Samimi
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia
- Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Andrew Hale
- Discipline of Pharmacy, School of Clinical Sciences, Queensland University of Technology
| | - Jessica Schults
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia
- School of Nursing, Midwifery and Social Work, University of Queensland
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia
| | - Andreas Fischer
- Pharmacy Department, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Jason A Roberts
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia
- Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Jayesh Dhanani
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
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Mazzeffi M, Lin D, Gonzalez-Almada A, Stombaugh DK, Curley J, Mangunta V, Teman N, Yarboro LT, Thiele R. Outcomes of heparinized adult veno-arterial extracorporeal membrane oxygenation patients managed with low and high activated partial thromboplastin time targets: A systematic review and meta-analysis. Perfusion 2024; 39:525-535. [PMID: 36595340 DOI: 10.1177/02676591221150880] [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] [Indexed: 01/04/2023]
Abstract
INTRODUCTION There are no randomized controlled trials comparing low and high activated partial thromboplastin time (aPTT) targets in heparinized adult veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) patients. Our systematic review and meta-analysis summarized complication rates in adult VA ECMO patients treated with low and high aPTT targets. METHODS Studies published from January 2000 to May 2022 were identified using Pubmed, Embase, Cochrane Library, and LILACS (Latin American and Caribbean Health Sciences Literature). Studies were included if aPTT was primarily used to guide heparin anticoagulation. For the low aPTT group, we included studies where aPTT goal was ≤60 seconds and for the high aPTT group, we included studies where aPTT goal was ≥60 seconds. Proportional meta-analysis with a random effects model was used to calculate pooled complication rates for patients in the two aPTT groups. RESULTS Twelve studies met inclusion criteria (5 in the low aPTT group and 7 in the high aPTT group). The pooled bleeding complication incidence for low aPTT studies was 53.6% (95% CI = 37.4%-69.4%, I2 = 60.8%) and for high aPTT studies was 43.8% (95% CI = 21.7%-67.1%, I2 = 91.8%). No studies in the low aPTT group reported overall thrombosis incidence, while three studies in the high aPTT group reported overall thrombosis incidence. The pooled thrombosis incidence for high aPTT studies was 16.1% (95% CI = 9.0%-24.5%, I2 = 13.1%). CONCLUSIONS Adult ECMO patients managed with low and high aPTT goals appeared to have similar bleeding and other complication rates further highlighting the need for a randomized controlled trial.
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Affiliation(s)
- Michael Mazzeffi
- Department of Anesthesiology, University of Virginia Health, Charlottesville, VA, USA
| | - Dora Lin
- Department of Anesthesiology, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Alberto Gonzalez-Almada
- Department of Anesthesiology, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - D Keegan Stombaugh
- Department of Anesthesiology, University of Virginia Health, Charlottesville, VA, USA
| | - Jonathan Curley
- Department of Anesthesiology, University of Virginia Health, Charlottesville, VA, USA
| | - Venkat Mangunta
- Department of Anesthesiology, University of Virginia Health, Charlottesville, VA, USA
| | - Nicholas Teman
- Department of Surgery Division of Cardiothoracic Surgery, University of Virginia Health, Charlottesville, VA, USA
| | - Leora T Yarboro
- Department of Surgery Division of Cardiothoracic Surgery, University of Virginia Health, Charlottesville, VA, USA
| | - Robert Thiele
- Department of Anesthesiology, University of Virginia Health, Charlottesville, VA, USA
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Butt SP, Razzaq N, Saleem Y, Cook B, Abdulaziz S. Improving ECMO therapy: Monitoring oxygenator functionality and identifying key indicators, factors, and considerations for changeout. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2024; 56:20-29. [PMID: 38488715 PMCID: PMC10941833 DOI: 10.1051/ject/2023047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 12/09/2023] [Indexed: 03/17/2024]
Abstract
INTRODUCTION The optimal timing for extracorporeal membrane oxygenation (ECMO) circuit change-out is crucial for the successful management of patients with severe cardiopulmonary failure. This comprehensive review examines the various factors that influence the timing of oxygenator replacement in the ECMO circuit. By considering these factors, clinicians can make informed decisions to ensure timely and effective change-out, enhancing patient outcomes and optimizing the delivery of ECMO therapy. METHODOLOGY A thorough search of relevant studies on ECMO circuits and oxygenator change-out was conducted using multiple scholarly databases and relevant keywords. Studies published between 2017 and 2023 were included, resulting in 40 studies that met the inclusion criteria. DISCUSSION Thrombosis within the membrane oxygenator and its impact on dysfunction were identified as significant contributors, highlighting the importance of monitoring coagulation parameters and gas exchange. Several factors, including fibrinogen levels, pre and post-membrane blood gases, plasma-free hemoglobin, D-dimers, platelet function, flows and pressures, and anticoagulation strategy, were found to be important considerations when determining the need for an oxygenator or circuit change-out. The involvement of a multidisciplinary team and thorough preparation were also highlighted as crucial aspects of this process. CONCLUSION In conclusion, managing circuit change-outs in ECMO therapy requires considering factors such as fibrinogen levels, blood gases, plasma-free hemoglobin, D-dimers, platelet function, flows, pressures, and anticoagulation strategy. Monitoring these parameters allows for early detection of issues, timely interventions, and optimized ECMO therapy. Standardized protocols, personalized anticoagulation approaches, and non-invasive monitoring techniques can improve the safety and effectiveness of circuit change-outs. Further research and collaboration are needed to advance ECMO management and enhance patient outcomes.
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Affiliation(s)
- Salman Pervaiz Butt
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Perfusionist & ECMO Specialist, Heart Vascular and Thoracic Institute, Cleveland Clinic PO BOX: 112412 Abu Dhabi United Arab Emirates
| | - Nabeel Razzaq
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Perfusion Department, Cleveland Clinic PO BOX: 112412 Abu Dhabi United Arab Emirates
| | - Yasir Saleem
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Clinical Perfusionist, Department of CTVS, All India Institute of Medical Science Rishikesh
| | - Bill Cook
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Clinical Perfusionist, Perfusion Department, Glenfield Hospital Leicester UK
| | - Salman Abdulaziz
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Consultant of Cardiovascular Critical Care, Co-Chair of ECMO Task Force, Department of Health United Arab Emirates
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Reid TD, Crespo Regalado R, Carlson R, Schneider A, Boone JS, Hockran S, Butler LR, Perez DL, Holloway AD, Nguyen PG, Gallaher J, Charles AG, Raff L. Outcomes in Obese Adult Veno-Venous Extracorporeal Membrane Oxygenation: A Systematic Review. ASAIO J 2024; 70:86-92. [PMID: 37850988 DOI: 10.1097/mat.0000000000002068] [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: 10/19/2023] Open
Abstract
Obesity is associated with an overall increased risk of morbidity and mortality. However, in patients with critical illness, sepsis, and acute respiratory distress syndrome, obesity may be protective, termed "the obesity paradox." This is a systematic literature review of articles published from 2000 to 2022 evaluating complications and mortality in adults with respiratory failure on veno-venous extracorporeal membrane oxygenation (VV ECMO) based on body mass index (BMI). Eighteen studies with 517 patients were included. Common complications included acute renal failure (175/377, 46.4%), venous thrombosis (175/293, 59.7%), and bleeding (28/293, 9.6%). Of the six cohort studies, two showed improved mortality among obese patients, two showed a trend toward improved mortality, and two showed no difference. Comparing all patients in the studies with BMI of less than 30 to those with BMI of greater than or equal to 30, we noted decreased mortality with obesity (92, 37.1% of BMI <30 vs. 30, 11% of BMI ≥30, p ≤ 0.0001). Obesity may be protective against mortality in adult patients undergoing VV ECMO. Morbid and super morbid obesity should not be considered a contraindication to cannulation, with patients with BMI ≥ 80 surviving to discharge. Complications may be high, however, with higher rates of continuous renal replacement therapy and thrombosis among obese patients.
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Affiliation(s)
- Trista D Reid
- From the Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Ricardo Crespo Regalado
- From the Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Rebecca Carlson
- Health Sciences Library, University Libraries, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Andrew Schneider
- From the Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Joshua S Boone
- From the Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Sophie Hockran
- From the Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Logan R Butler
- From the Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Dakota L Perez
- From the Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Alexa D Holloway
- From the Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Phu G Nguyen
- From the Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jared Gallaher
- From the Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Anthony G Charles
- From the Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Lauren Raff
- From the Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Graboyes SDT, Owen PS, Evans RA, Berei TJ, Hryniewicz KM, Hollis IB. Review of anticoagulation considerations in extracorporeal membrane oxygenation support. Pharmacotherapy 2023; 43:1339-1363. [PMID: 37519116 DOI: 10.1002/phar.2857] [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: 01/27/2023] [Revised: 06/10/2023] [Accepted: 06/16/2023] [Indexed: 08/01/2023]
Abstract
Since its first success in 1975, extracorporeal membrane oxygenation (ECMO) has been used with increasing frequency for pulmonary and cardiopulmonary bypass. Use in adults has increased exponentially since the early 2000s, but despite thousands of international cannulations using both veno-arterial (VA) and veno-venous (VV) ECMO, there are still significant hemocompatibility-related adverse events. Current management of anticoagulation has been based on the Extracorporeal Life Support Organization guidance published in 2014 with recent updates published in 2022. Despite this guidance, there is still limited international consensus on how to manage anticoagulation in ECMO. For this review, we completed a comprehensive search of multiple electronic databases to identify studies pertaining to anticoagulation of adult patients on VV or VA-ECMO. The highest priority was given to sources that were prospective, randomized, controlled studies, but in the absence of such resources, observational studies, retrospective uncontrolled studies, and case series/reports were considered for inclusion. This document serves to provide a comprehensive review of the current understanding of management pertaining to anticoagulation relating to ECMO.
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Affiliation(s)
- Sydney D T Graboyes
- Department of Pharmacy, University of California, Davis Medical Center, Sacramento, California, USA
| | - Phillip S Owen
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
| | - Rickey A Evans
- Department of Pharmacy, University of Kentucky HealthCare, Lexington, Kentucky, USA
| | - Theodore J Berei
- Department of Pharmacy, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin, USA
| | - Katarzyna M Hryniewicz
- Heart Failure Section, Minneapolis Heart Institute at Abbot Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Ian B Hollis
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
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Aubron C, Chapalain X, Bailey M, Board J, Buhr H, Cartwright B, Dennis M, Hodgson C, Forrest P, McIlroy D, Murphy D, Murray L, Pellegrino V, Pilcher D, Sheldrake J, Tran H, Vallance S, Cooper DJ, McQuilten Z. Anti-Factor-Xa and Activated Partial Thromboplastin Time Concordance and Outcomes in Adults Undergoing Extracorporeal Membrane Oxygenation: A Secondary Analysis of the Pilot Low-Dose Heparin in Critically Ill Patients Undergoing Extracorporeal Membrane Oxygenation Randomized Trial. Crit Care Explor 2023; 5:e0999. [PMID: 37954899 PMCID: PMC10635598 DOI: 10.1097/cce.0000000000000999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023] Open
Abstract
OBJECTIVES To determine the concordance between activated partial thromboplastin time (aPTT) and anti-factor-Xa (anti-Xa) in adults undergoing extracorporeal membrane oxygenation (ECMO) and to identify the factors associated with discordant paired aPTT/anti-Xa. DESIGN Pre-planned secondary analysis of the Low-Dose Heparin in Critically Ill Patients Undergoing Extracorporeal Membrane Oxygenation pilot randomized unblinded, parallel-group controlled trial. SETTING Two ICUs in two university hospitals. PATIENTS Thirty-two critically ill patients who underwent ECMO and who had at least one paired aPTT and anti-Xa assay performed at the same time. INTERVENTIONS We analyzed the concordance between aPTT and anti-Xa and identified factors associated with discordant paired aPTT/anti-Xa based on their respective therapeutic ranges. We also compared biological parameters between heparin resistance episode and no heparin resistance. MEASUREMENTS AND MAIN RESULTS Of the 32 patients who were included in this study, 24 (75%) had at least one discordant paired aPTT/anti-Xa. Of the 581 paired aPTT/anti-Xa that were analyzed, 202 were discordant. The aPTT was relatively lower than anti-Xa in 66 cases (32.7%) or relatively higher than anti-Xa in 136 cases (67.3%). Thirty-three heparin resistance episodes were identified in six patients (19%). CONCLUSIONS In these critically ill patients undergoing ECMO, one third of paired aPTT/anti-Xa measures was discordant. Coagulopathy and heparin resistance might be the reasons for discordance. Our results support the potential importance of routinely monitoring both tests in this setting.
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Affiliation(s)
- Cécile Aubron
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, VIC, Australia
- Département de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Brest, site La Cavale Blanche, Université de Bretagne Occidentale, Brest, France
| | - Xavier Chapalain
- Département d'anesthésie réanimation, Centre Hospitalier Universitaire de Brest, site La Cavale Blanche, Université de Bretagne Occidentale, Brest, France
| | - Michael Bailey
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, VIC, Australia
| | - Jasmin Board
- Intensive Care Unit, Alfred Hospital, Melbourne, VIC, Australia
| | - Heidi Buhr
- Intensive Care Service, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Bruce Cartwright
- Department of Anaesthesia, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Mark Dennis
- Cardiology Department, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Carol Hodgson
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, VIC, Australia
| | - Paul Forrest
- Department of Anaesthesia, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - David McIlroy
- Department of Anaesthesia & Perioperative Medicine, Alfred Hospital, Melbourne, VIC, Australia
| | - Deirdre Murphy
- Intensive Care Unit, Alfred Hospital, Melbourne, VIC, Australia
| | - Lynne Murray
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, VIC, Australia
| | - Vincent Pellegrino
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, VIC, Australia
- Intensive Care Unit, Alfred Hospital, Melbourne, VIC, Australia
| | - David Pilcher
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, VIC, Australia
- Intensive Care Unit, Alfred Hospital, Melbourne, VIC, Australia
| | - Jayne Sheldrake
- Intensive Care Unit, Alfred Hospital, Melbourne, VIC, Australia
| | - Huyen Tran
- Clinical Haematology Department, Alfred Hospital, Melbourne, VIC, Australia
| | | | - D James Cooper
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, VIC, Australia
- Intensive Care Unit, Alfred Hospital, Melbourne, VIC, Australia
| | - Zoe McQuilten
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, VIC, Australia
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Sun J, Ma Y, Su W, Miao H, Guo Z, Chen Q, Zhang Y, Ma X, Chen S, Ding R. Comparison of anticoagulation monitoring strategies for adults supported on extracorporeal membrane oxygenation: A systematic review. Heart Lung 2023; 61:72-83. [PMID: 37167901 DOI: 10.1016/j.hrtlng.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 04/19/2023] [Accepted: 05/06/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND Anticoagulation is critical in patients supported on extracorporeal membrane oxygenation (ECMO). The appropriate monitoring strategies for heparin remain unclear. OBJECTIVES This systematic review aimed to compare the accuracy and safety of various monitoring strategies for patients supported on ECMO. METHODS The PubMed and Web of Science databases were searched for articles in March 2023 without restrictions on publication date. Anticoagulation monitoring strategies for adults supported on ECMO were compared across all included studies. The incidence of bleeding, thrombosis, mortality, blood transfusion, correlation between tests and heparin dose, and the discordance between different tests were discussed in the included studies. The risk of bias was assessed using the Newcastle-Ottawa Scale and Cochrane Collaboration's tool. RESULTS Twenty-six studies, including a total of 1,684 patients, met the inclusion criteria. The monitoring of anticoagulation by activated partial thromboplastin time (aPTT) resulted in less blood product transfusion than that by activated clotting time (ACT). Moreover, the monitoring of anticoagulation by anti-factor Xa (Anti-Xa) resulted in a more stable anticoagulation than that by aPTT. Anti-Xa and aPTT correlated with heparin dose better than ACT, and the discordance between different monitoring tests was common. Finally, combined monitoring showed some advantages in reducing mortality and blood product transfusion. CONCLUSION Anti-Xa and aPTT are more suitable for anticoagulation monitoring for patients supported on ECMO than ACT. Thromboelastography and combination strategies are less applied. Most of the studies were retrospective, and their sample sizes were relatively small; thus, more appropriate monitoring strategies and higher quality research are needed.
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Affiliation(s)
- Jinhe Sun
- Department of Intensive Care Unit, The First Hospital of China Medical University, Shenyang, China
| | - Yuteng Ma
- Department of Gastrointestinal Surgery, The First Hospital of China Medical University, Shenyang, China
| | - Wanting Su
- Department of Intensive Care Unit, The First Hospital of China Medical University, Shenyang, China
| | - He Miao
- Department of Intensive Care Unit, The First Hospital of China Medical University, Shenyang, China
| | - Zhaotian Guo
- Department of Intensive Care Unit, The First Hospital of China Medical University, Shenyang, China
| | - Qianhui Chen
- Department of Intensive Care Unit, The First Hospital of China Medical University, Shenyang, China
| | - Yuzhong Zhang
- Department of Intensive Care Unit, The First Hospital of China Medical University, Shenyang, China
| | - Xiaochun Ma
- Department of Intensive Care Unit, The First Hospital of China Medical University, Shenyang, China
| | - Song Chen
- Department of Intensive Care Unit, Wanning People's Hospital, Wanning, China.; Key Laboratory of Emergency and Trauma of Ministry of Education, Hainan Medical University, Haikou, China.
| | - Renyu Ding
- Department of Intensive Care Unit, The First Hospital of China Medical University, Shenyang, China.
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8
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Guan C, Shen H, Dong S, Zhan Y, Yang J, Zhang Q, Wang R. Research status and development trend of extracorporeal membrane oxygenation based on bibliometrics. Front Cardiovasc Med 2023; 10:1048903. [PMID: 36970366 PMCID: PMC10036781 DOI: 10.3389/fcvm.2023.1048903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 02/20/2023] [Indexed: 03/12/2023] Open
Abstract
BackgroundUsing bibliometric method to analyze the research status and development trend of extracorporeal membrane oxygenation (ECMO), we aim to provide clinicians, scientists, and stakeholders with the most up-to-date and comprehensive overview of ECMO research.Materials and methodsUsing Excel and VOSviewer, the literature on ECMO was systematically analyzed regarding publication trends, journal source, foundation, countries, institutions, core authors, research hotspots, and market distribution.ResultsThere were five important time nodes in the research process of ECMO, including the success of the first ECMO operation, the establishment of ELSO, and the outbreak of influenza A/H1N1 and COVID-19. The R&D centers of ECMO were the United States, Germany, Japan, and Italy, and the attention to ECMO was gradually increasing in China. The products most used in the literature were from Maquet, Medtronic, and LivaNova. Medicine enterprises attached great importance to the funding of ECMO research. In recent years, the literature has mainly focused on the following aspects: the treatment of ARDS, the prevention of coagulation system-related complications, the application in neonatal and pediatric patients, mechanical circulatory support for cardiogenic shock, and ECPR and ECMO during the COVID-19 pandemic.ConclusionThe frequent epidemic occurrence of viral pneumonia and the technical advancement of ECMO in recent years have caused an increase in clinical applications. The hot spots of ECMO research are shown in the treatment of ARDS, mechanical circulatory support for cardiogenic shock, and the application during the COVID-19 pandemic.
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Affiliation(s)
- Cuizhong Guan
- Tsinghua University Library, Tsinghua University, Beijing, China
| | - Hua Shen
- Department of Adult Cardiac Surgery, The Sixth Medical Centre of PLA General Hospital, Beijing, China
| | - Shiyong Dong
- Department of Cardiovascular Surgery, The First Medical Centre of PLA General Hospital, Beijing, China
| | - Yuhua Zhan
- Tsinghua University Library, Tsinghua University, Beijing, China
| | - Jie Yang
- Tsinghua University Library, Tsinghua University, Beijing, China
| | - Qiu Zhang
- Tsinghua University Library, Tsinghua University, Beijing, China
- Correspondence: Qiu Zhang Rong Wang
| | - Rong Wang
- Department of Adult Cardiac Surgery, The Sixth Medical Centre of PLA General Hospital, Beijing, China
- Correspondence: Qiu Zhang Rong Wang
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Bailly DK, Reeder RW, Muszynski JA, Meert KL, Ankola AA, Alexander PM, Pollack MM, Moler FW, Berg RA, Carcillo J, Newth C, Berger J, Bell MJ, Dean JM, Nicholson C, Garcia-Filion P, Wessel D, Heidemann S, Doctor A, Harrison R, Dalton H, Zuppa AF. Anticoagulation practices associated with bleeding and thrombosis in pediatric extracorporeal membrane oxygenation; a multi-center secondary analysis. Perfusion 2023; 38:363-372. [PMID: 35220828 DOI: 10.1177/02676591211056562] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
To determine associations between anticoagulation practices and bleeding and thrombosis during pediatric extracorporeal membrane oxygenation (ECMO), we performed a secondary analysis of prospectively collected data which included 481 children (<19 years), between January 2012 and September 2014. The primary outcome was bleeding or thrombotic events. Bleeding events included a blood product transfusion >80 ml/kg on any day, pulmonary hemorrhage, or intracranial bleeding, Thrombotic events included pulmonary emboli, intracranial clot, limb ischemia, cardiac clot, and arterial cannula or entire circuit change. Bleeding occurred in 42% of patients. Five percent of subjects thrombosed, of which 89% also bled. Daily bleeding odds were independently associated with day prior activated clotting time (ACT) (OR 1.03, 95% CI= 1.00, 1.05, p=0.047) and fibrinogen levels (OR 0.90, 95% CI 0.84, 0.96, p <0.001). Thrombosis odds decreased with increased day prior heparin dose (OR 0.88, 95% CI 0.81, 0.97, p=0.006). Lower ACT values and increased fibrinogen levels may be considered to decrease the odds of bleeding. Use of this single measure, however, may not be sufficient alone to guide optimal anticoagulation practice during ECMO.
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Affiliation(s)
- David K Bailly
- Department of Pediatrics, Division of Pediatric Critical Care, 14434University of Utah, Salt Lake, UT, USA
| | - Ron W Reeder
- Department of Pediatrics, 14434University of Utah, Salt Lake, UT, USA
| | - Jennifer A Muszynski
- Division of Critical Care, 2650Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, 2650Nationwide Children's Hospital, Columbus, OH, USA.,Center for Clinical and Translational Research, 2650The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Kathleen L Meert
- Department of Pediatrics, 2969Children's Hospital of Michigan, Detroit, MI, USA.,2969Central Michigan University, Mt. Pleasant, MI, USA
| | - Ashish A Ankola
- Department of Anesthesiology, Critical Care, and Pain Medicine, 1862Boston Children's Hospital, Boston, MA, USA.,Department of Cardiology, 1862Boston Children's Hospital, Boston, MA, USA
| | - Peta Ma Alexander
- Department of Pediatrics, 14434Harvard Medical School, Boston, MA, USA
| | - Murray M Pollack
- Department of Pediatrics, 8404Children's National Hospital, Washington, DC, USA
| | - Frank W Moler
- Department of Pediatrics and Communicable Diseases, 1259University of Michigan, Ann Arbor, MI, USA
| | - Robert A Berg
- Department of Anesthesia and Critical Care, 6567Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Joseph Carcillo
- Department of Critical Care Medicine, 6619Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Christopher Newth
- Department of Anesthesiology and Critical Care Medicine, 5150Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - John Berger
- Department of Pediatrics, 8404Children's National Hospital, Washington, DC, USA
| | - Michael J Bell
- Department of Pediatrics, 8404Children's National Hospital, Washington, DC, USA
| | - J M Dean
- Department of Pediatrics, Division of Pediatric Critical Care, 14434University of Utah, Salt Lake, UT, USA
| | - Carol Nicholson
- Trauma and Critical Illness Branch, 35040National Institute of Child Health and Human Development (NICHD), Bethesda, MD, USA.,35040National Institutes of Health, Bethesda, MD, USA
| | - Pamela Garcia-Filion
- Department of Biomedical Informatics, 14524Phoenix Children's Hospital, Phoenix, AZ, USA
| | - David Wessel
- Department of Pediatrics, 8404Children's National Hospital, Washington, DC, USA
| | - Sabrina Heidemann
- Department of Pediatrics, 2969Children's Hospital of Michigan, Detroit, MI, USA.,2969Central Michigan University, Mt. Pleasant, MI, USA
| | - Allan Doctor
- Department of Pediatrics and Center for Blood Oxygen Transport and Hemostasis, 12264University of Maryland, School of Medicine, Baltimore, MD, USA
| | - Rick Harrison
- Department of Pediatrics, 21785Mattel Children's Hospital UCLA, Los Angeles, CA, USA
| | - Heidi Dalton
- Department of Pediatrics and Heart and Vascular Institute, 3313Inova Fairfax Hospital, Fall Church, VA, USA
| | - Athena F Zuppa
- Department of Anesthesia and Critical Care, 6567Children's Hospital of Philadelphia, Philadelphia, PA, USA
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10
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Helms J, Frere C, Thiele T, Tanaka KA, Neal MD, Steiner ME, Connors JM, Levy JH. Anticoagulation in adult patients supported with extracorporeal membrane oxygenation: guidance from the Scientific and Standardization Committees on Perioperative and Critical Care Haemostasis and Thrombosis of the International Society on Thrombosis and Haemostasis. J Thromb Haemost 2023; 21:373-396. [PMID: 36700496 DOI: 10.1016/j.jtha.2022.11.014] [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: 09/19/2022] [Revised: 11/08/2022] [Accepted: 11/09/2022] [Indexed: 01/26/2023]
Abstract
Anticoagulation of patients supported by extracorporeal membrane oxygenation is challenging because of a high risk of both bleeding and thrombotic complications, and often empirical. Practice in anticoagulation management is therefore highly variable. The scope of this guidance document is to provide clinicians with practical advice on the choice of an anticoagulant agent, dosing, and the optimal anticoagulant monitoring strategy during extracorporeal membrane oxygenation support in adult patients.
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Affiliation(s)
- Julie Helms
- Strasbourg University (UNISTRA), Strasbourg University Hospital, Medical Intensive Care Unit - NHC, INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Strasbourg, France.
| | - Corinne Frere
- Sorbonne Université, UMRS 1166, AP-HP. Sorbonne Université, Pitié-Salpêtrière Hospital, Paris, France
| | - Thomas Thiele
- Institut für Transfusionsmedizin, Universitätsmedizin Rostock, Schillingallee 36, Rostock, Germany
| | - Kenichi A Tanaka
- Department of Anesthesiology, Universit of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Matthew D Neal
- Department of Surgery, Trauma and Transfusion Medicine Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Marie E Steiner
- Division of Hematology/Oncology and Division of Critical Care, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - Jean M Connors
- Hematology Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC, USA
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11
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Zeibi Shirejini S, Carberry J, McQuilten ZK, Burrell AJC, Gregory SD, Hagemeyer CE. Current and future strategies to monitor and manage coagulation in ECMO patients. Thromb J 2023; 21:11. [PMID: 36703184 PMCID: PMC9878987 DOI: 10.1186/s12959-023-00452-z] [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: 09/23/2022] [Accepted: 01/18/2023] [Indexed: 01/27/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) can provide life-saving support for critically ill patients suffering severe respiratory and/or cardiac failure. However, thrombosis and bleeding remain common and complex problems to manage. Key causes of thrombosis in ECMO patients include blood contact to pro-thrombotic and non-physiological surfaces, as well as high shearing forces in the pump and membrane oxygenator. On the other hand, adverse effects of anticoagulant, thrombocytopenia, platelet dysfunction, acquired von Willebrand syndrome, and hyperfibrinolysis are all established as causes of bleeding. Finding safe and effective anticoagulants that balance thrombosis and bleeding risk remains challenging. This review highlights commonly used anticoagulants in ECMO, including their mechanism of action, monitoring methods, strengths and limitations. It further elaborates on existing anticoagulant monitoring strategies, indicating their target range, benefits and drawbacks. Finally, it introduces several highly novel approaches to real-time anticoagulation monitoring methods including sound, optical, fluorescent, and electrical measurement as well as their working principles and future directions for research.
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Affiliation(s)
- Saeedreza Zeibi Shirejini
- grid.1002.30000 0004 1936 7857NanoBiotechnology Laboratory, Central Clinical School, Australian Centre for Blood Diseases, Monash University, Melbourne, VIC Australia ,grid.1002.30000 0004 1936 7857Cardiorespiratory Engineering and Technology Laboratory, Department of Mechanical and Aerospace Engineering, Monash University, Clayton, VIC Australia
| | - Josie Carberry
- grid.1002.30000 0004 1936 7857Department of Mechanical and Aerospace Engineering, Monash University, Clayton, VIC Australia
| | - Zoe K. McQuilten
- grid.1002.30000 0004 1936 7857Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, and Department of Clinical Haematology, Monash Health, Melbourne, VIC Australia
| | - Aidan J. C. Burrell
- grid.1623.60000 0004 0432 511XSchool of Medicine, Nursing, and Health Sciences, Clayton and Intensive Care Unit, Monash University, Alfred Hospital, Melbourne, VIC Australia ,grid.1002.30000 0004 1936 7857Department of Epidemiology and Preventative Medicine, School of Public Health, Monash University, Melbourne, VIC Australia
| | - Shaun D. Gregory
- grid.1002.30000 0004 1936 7857Cardiorespiratory Engineering and Technology Laboratory, Department of Mechanical and Aerospace Engineering, Monash University, Clayton, VIC Australia
| | - Christoph E. Hagemeyer
- grid.1002.30000 0004 1936 7857NanoBiotechnology Laboratory, Central Clinical School, Australian Centre for Blood Diseases, Monash University, Melbourne, VIC Australia
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12
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Muacevic A, Adler JR. Perioperative Challenges in a Septic Shock Patient With Extensive Splanchnic and Extra-Splanchnic Vein Thrombosis Up to the Right Atrium. Cureus 2022; 14:e32935. [PMID: 36712719 PMCID: PMC9873450 DOI: 10.7759/cureus.32935] [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] [Accepted: 12/25/2022] [Indexed: 12/27/2022] Open
Abstract
Venous thromboembolism (VTE) has a significant disease burden worldwide and comprises deep vein thrombosis (DVT) and pulmonary embolism (PE). DVT most commonly occurs in the lower extremities, very rarely it can present in the splanchnic venous circulation or inferior vena cava or both. We report an unusual presentation of a 68-year-old woman with septic shock secondary to ischemic bowel, complicated by non-tumor related, extensive right hepatic vein thrombosis extending up to the inferior vena cava (IVC) and right atrium. She underwent bowel resection surgery emergently and was started on systemic anticoagulation in the perioperative period after an extensive evaluation and resuscitation. She was managed by a multidisciplinary team during her admission and was discharged after four weeks. This case poses an interesting therapeutic challenge to the team as there is little literature to guide treatment in a critically ill patient with ischemic bowel, septic shock with extensive splanchnic and IVC thrombosis who also had likely pseudo-heparin resistance with artifactual activated partial thromboplastin time (aPTT) values. This case report seeks to share our experience of a multidisciplinary and patient-centric approach in this rare presentation of a disease spectrum.
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13
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Sommer P, Nunnally M. Mechanical circulatory support in the intensive care unit. Int Anesthesiol Clin 2022; 60:46-54. [PMID: 35993668 DOI: 10.1097/aia.0000000000000381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Philip Sommer
- Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Langone Health, New York, New York
| | - Mark Nunnally
- Departments of Anesthesiology, Perioperative Care and Pain Medicine, Medicine, Surgery, Neurology, NYU Langone Medical Center, New York, New York
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14
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Rajsic S, Breitkopf R, Jadzic D, Popovic Krneta M, Tauber H, Treml B. Anticoagulation Strategies during Extracorporeal Membrane Oxygenation: A Narrative Review. J Clin Med 2022; 11:jcm11175147. [PMID: 36079084 PMCID: PMC9457503 DOI: 10.3390/jcm11175147] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 08/24/2022] [Accepted: 08/29/2022] [Indexed: 11/30/2022] Open
Abstract
The development of extracorporeal life support technology has added a new dimension to the care of critically ill patients who fail conventional treatment options. Extracorporeal membrane oxygenation (ECMO)—specialized temporary life support for patients with severe cardiac or pulmonary failure—plays a role in bridging the time for organ recovery, transplant, or permanent assistance. The overall patient outcome is dependent on the underlying disease, comorbidities, patient reaction to critical illness, and potential adverse events during ECMO. Moreover, the contact of the blood with the large artificial surface of an extracorporeal system circuit triggers complex inflammatory and coagulation responses. These processes may further lead to endothelial injury and disrupted microcirculation with consequent end-organ dysfunction and the development of adverse events like thromboembolism. Therefore, systemic anticoagulation is considered crucial to alleviate the risk of thrombosis and failure of ECMO circuit components. The gold standard and most used anticoagulant during extracorporeal life support is unfractionated heparin, with all its benefits and disadvantages. However, therapeutic anticoagulation of a critically ill patient carries the risk of clinically relevant bleeding with the potential for permanent injury or death. Similarly, thrombotic events may occur. Therefore, different anticoagulation strategies are employed, while the monitoring and the balance of procoagulant and anticoagulatory factors is of immense importance. This narrative review summarizes the most recent considerations on anticoagulation during ECMO support, with a special focus on anticoagulation monitoring and future directions.
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Affiliation(s)
- Sasa Rajsic
- Department of Anaesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Robert Breitkopf
- Department of Anaesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Dragana Jadzic
- Anaesthesia and Intensive Care Department, Pain Therapy Service, Cagliari University, 09042 Cagliari, Italy
| | | | - Helmuth Tauber
- Department of Anaesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Benedikt Treml
- Department of Anaesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
- Correspondence: ; Tel.: +43-50504-82231
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15
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Levy JH, Staudinger T, Steiner ME. How to manage anticoagulation during extracorporeal membrane oxygenation. Intensive Care Med 2022; 48:1076-1079. [PMID: 35689697 PMCID: PMC9187844 DOI: 10.1007/s00134-022-06723-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 04/29/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Jerrold H Levy
- Departments of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Duke University Medical Center, 2301 Erwin Rd., 5691H HAFS, Box 3094, Durham, NC, 27710, USA.
| | - Thomas Staudinger
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Marie E Steiner
- Divisions of Critical Care and Hematology/Oncology, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
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16
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Teng Y, Yan S, Liu G, Lou S, Zhang Y, Ji B. An Agreement Study Between Point-of-Care and Laboratory Activated Partial Thromboplastin Time for Anticoagulation Monitoring During Extracorporeal Membrane Oxygenation. Front Med (Lausanne) 2022; 9:931863. [PMID: 35847800 PMCID: PMC9276956 DOI: 10.3389/fmed.2022.931863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 06/07/2022] [Indexed: 11/30/2022] Open
Abstract
Background Laboratory activated partial thromboplastin time (LAB-aPTT) is a widely used laboratory assay for monitoring unfractionated heparin (UFH) therapy during extracorporeal membrane oxygenation (ECMO). But LAB-aPTT is confined to a central laboratory, and the procedure is time-consuming. In comparison, point-of-care aPTT (POC-aPTT) is a convenient and quick assay, which might be a promising method for anticoagulation monitoring in ECMO. This study was aimed to evaluate the agreement between POC-aPTT (hemochron Jr. Signature instruments) and LAB-aPTT for anticoagulation monitoring in adult ECMO patients. Methods Data of ECMO-supported adult patients anticoagulated with UFH in our institute from January 2017 to December 2020 was retrospectively reviewed. POC-aPTT and LAB-aPTT results measured simultaneously were paired and included in the analysis. The correlation between POC-aPTT and LAB-aPTT was assessed using Spearman’s correlation coefficient. Bias between POC-aPTT and LAB-aPTT were described with the Bland-Altman method. Influence factors for bias were identified using multinomial logistic regression analysis. Results A total 286 pairs of aPTT results from 63 patients were included in the analysis. POC-aPTT and LAB-aPTT correlated weakly (r = 0.385, P < 0.001). The overall bias between POC-aPTT and LAB-aPTT was 7.78 [95%CI (−32.49, 48.05)] s. The overall bias between POC-aPTT and LAB-aPTT ratio (to normal value) was 0.54 [95%CI (−0.68, 1.76)]. A higher plasma fibrinogen level [OR 1.353 (1.057, 1.733), P = 0.017] was associated with a higher chance of POC-aPTT underestimating LAB-aPTT. While a lower plasma fibrinogen level [OR 0.809 (0.679, 0.963), P = 0.017] and lower UFH rate [OR 0.928 (0.868, 0.992), P = 0.029] were associated with a higher chance of POC-aPTT overestimating LAB-aPTT. Conclusion The present study showed poor agreement between POC-aPTT and LAB-aPTT. POC-aPTT was not suitable for anticoagulation monitoring in adult ECMO patients.
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Affiliation(s)
- Yuan Teng
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Diseases, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Shujie Yan
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Diseases, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Gang Liu
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Diseases, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Song Lou
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Diseases, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yang Zhang
- Center of Laboratory Medicine, National Center for Cardiovascular Diseases, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Bingyang Ji
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Diseases, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
- *Correspondence: Bingyang Ji,
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17
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Regling K, Saini A, Cashen K. Viscoelastic Testing in Pediatric Mechanical Circulatory Support. Front Med (Lausanne) 2022; 9:854258. [PMID: 35602480 PMCID: PMC9120594 DOI: 10.3389/fmed.2022.854258] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 04/14/2022] [Indexed: 11/13/2022] Open
Abstract
Pediatric mechanical circulatory support can be lifesaving. However, managing anticoagulation is one of the most challenging aspects of care in patients requiring mechanical circulatory support. Effective anticoagulation is even more difficult in pediatric patients due to the smaller size of their blood vessels, increased turbulent flow, and developmental hemostasis. Recently, viscoelastic testing (VET) has been used as a qualitative measure of anticoagulation efficacy in patients receiving extracorporeal membrane oxygenation (ECMO) and ventricular assist devices (VAD). Thromboelastography (TEG®) and thromboelastometry (ROTEM®) provide a global qualitative assessment of hemostatic function from initiation of clot formation with the platelet-fibrin interaction, platelet aggregation, clot strength, and clot lysis. This review focuses on the TEG®/ROTEM® and important laboratory and patient considerations for interpretation in the ECMO and VAD population. We summarize the adult and pediatric ECMO/VAD literature regarding VET values, VET-platelet mapping, utility over standard laboratory monitoring, and association with outcome measures such as blood product utilization, bleeding, and thrombosis.
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Affiliation(s)
- Katherine Regling
- Division of Hematology Oncology, Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University School of Medicine, Detroit, MI, United States
- *Correspondence: Katherine Regling
| | - Arun Saini
- Division of Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor University School of Medicine, Houston, TX, United States
- Arun Saini
| | - Katherine Cashen
- Division of Critical Care Medicine, Department of Pediatrics, Duke Children's Hospital, Duke University School of Medicine, Durham, NC, United States
- Katherine Cashen
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18
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Brokmeier HM, Wieruszewski ED, Nei SD, Loftsgard TO, Wieruszewski PM. Hemostatic Management in Extracorporeal Membrane Oxygenation. Crit Care Nurs Q 2022; 45:132-143. [PMID: 35212653 DOI: 10.1097/cnq.0000000000000396] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The use of extracorporeal membrane oxygenation (ECMO) for acute cardiac and/or respiratory failure has grown exponentially in the past several decades. Systemic anticoagulation is a fundamental element of caring for ECMO patients. Hemostatic management during ECMO walks a fine line to balance the risk of safe and effective anticoagulant delivery to mitigate thromboembolic complications and minimizing hemorrhagic sequelae. This review discusses the pharmacology, monitoring parameters, and special considerations for anticoagulation in patients requiring ECMO.
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Affiliation(s)
- Hannah M Brokmeier
- Departments of Pharmacy (Drs Brokmeier, E. D. Wieruszewski, Nei, and P. M. Wieruszewski), Cardiovascular Surgery (Mr Loftsgard), and Anesthesiology (Dr P. M. Wieruszewski), Mayo Clinic, Rochester, Minnesota
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19
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Patel SP, Solomon BJ, Pascotto RD, D'Orazio SE, Navas EV, Cubeddu RJ, Cudemus GA. Uninterrupted Continuation of VV-ECMO without Anticoagulation for 44 days in COVID-19 ARDS: A Precarious Quandary. J Cardiothorac Vasc Anesth 2022; 36:3193-3196. [PMID: 35545457 PMCID: PMC8994674 DOI: 10.1053/j.jvca.2022.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 03/01/2022] [Accepted: 04/05/2022] [Indexed: 11/11/2022]
Abstract
Venovenous extracorporeal membrane oxygenation (VV-ECMO) has become a mainstay treatment modality for a select patient population who do not respond to conventional medical therapy suffering from severe acute respiratory distress syndrome (ARDS) due to COVID-19. This therapy necessitates the utilization of anticoagulation, whether unfractionated heparin or bivalirudin, to prevent thrombotic complications. Scarce are reports of VV-ECMO implementation leading to acute hemorrhage mandating cessation of anticoagulation in a patient suffering from COVID-19 ARDS. Herein, the authors report a case of a successful outcome in a COVID-19 ARDS patient who suffered an acute hemorrhagic complication leading to pre-emptive termination of systemic anticoagulation. The authors believe this to be one of the first such cases in the literature.
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20
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Zarragoikoetxea I, Pajares A, Moreno I, Porta J, Koller T, Cegarra V, Gonzalez A, Eiras M, Sandoval E, Sarralde J, Quintana-Villamandos B, Vicente Guillén R. Documento de consenso SEDAR/SECCE sobre el manejo de ECMO. CIRUGIA CARDIOVASCULAR 2021. [DOI: 10.1016/j.circv.2021.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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21
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Zarragoikoetxea I, Pajares A, Moreno I, Porta J, Koller T, Cegarra V, Gonzalez AI, Eiras M, Sandoval E, Aurelio Sarralde J, Quintana-Villamandos B, Vicente Guillén R. SEDAR/SECCE ECMO management consensus document. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 68:443-471. [PMID: 34535426 DOI: 10.1016/j.redare.2020.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 12/14/2020] [Indexed: 06/13/2023]
Abstract
ECMO is an extracorporeal cardiorespiratory support system whose use has been increased in the last decade. Respiratory failure, postcardiotomy shock, and lung or heart primary graft failure may require the use of cardiorespiratory mechanical assistance. In this scenario perioperative medical and surgical management is crucial. Despite the evolution of technology in the area of extracorporeal support, morbidity and mortality of these patients continues to be high, and therefore the indication as well as the ECMO removal should be established within a multidisciplinary team with expertise in the area. This consensus document aims to unify medical knowledge and provides recommendations based on both the recent bibliography and the main national ECMO implantation centres experience with the goal of improving comprehensive patient care.
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Affiliation(s)
- I Zarragoikoetxea
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, Valencia, Spain.
| | - A Pajares
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - I Moreno
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - J Porta
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - T Koller
- Servicio de Anestesiología y Reanimación, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - V Cegarra
- Servicio de Anestesiología y Reanimación, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - A I Gonzalez
- Servicio de Anestesiología y Reanimación, Hospital Puerta de Hierro, Madrid, Spain
| | - M Eiras
- Servicio de Anestesiología y Reanimación, Hospital Clínico Universitario de Santiago, La Coruña, Spain
| | - E Sandoval
- Servicio de Cirugía Cardiovascular, Hospital Clínic de Barcelona, Barcelona, Spain
| | - J Aurelio Sarralde
- Servicio de Cirugía Cardiovascular, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - B Quintana-Villamandos
- Servicio de Anestesiología y Reanimación, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - R Vicente Guillén
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, Valencia, Spain
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22
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Roth S, Jansen C, M'Pembele R, Stroda A, Boeken U, Akhyari P, Lichtenberg A, Hollmann MW, Huhn R, Lurati Buse G, Aubin H. Fibrinogen-Albumin-Ratio is an independent predictor of thromboembolic complications in patients undergoing VA-ECMO. Sci Rep 2021; 11:16648. [PMID: 34404824 PMCID: PMC8371004 DOI: 10.1038/s41598-021-95689-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 07/22/2021] [Indexed: 12/30/2022] Open
Abstract
Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) supports patients suffering from refractory cardiogenic shock. Thromboembolic complications (TeC) are common in VA-ECMO patients and are associated with increased morbidity and mortality. Valid markers to predict TeC in VA-ECMO patients are lacking. The present study investigated the predictive value of baseline Fibrinogen-Albumin-Ratio (FAR) for in-hospital TeC in patients undergoing VA-ECMO. This retrospective cohort study included patients who underwent VA-ECMO therapy due to cardiogenic shock at the University Hospital Duesseldorf, Germany between 2011 and 2018. Main exposure was baseline FAR measured at initiation of VA-ECMO therapy. The primary endpoint was the in-hospital incidence of TeC. In total, 344 patients were included into analysis (74.7% male, mean age 59 ± 14 years). The in-hospital incidence of TeC was 34%. Receiver operating characteristics (ROC) curve of FAR for in-hospital TeC revealed an area under the curve of 0.67 [95% confidence interval (CI) 0.61-0.74]. Youden index determined a cutoff of 130 for baseline FAR. Multivariate logistic regression revealed an adjusted odds-ratio of 3.72 [95% CI 2.26-6.14] for the association between FAR and TeC. Baseline FAR is independently associated with in-hospital TeC in patients undergoing VA-ECMO. Thus, FAR might contribute to the prediction of TeC in this cohort.
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Affiliation(s)
- Sebastian Roth
- Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Catrin Jansen
- Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - René M'Pembele
- Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Alexandra Stroda
- Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Udo Boeken
- Department of Cardiac Surgery, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Payam Akhyari
- Department of Cardiac Surgery, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Artur Lichtenberg
- Department of Cardiac Surgery, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany.
| | - Markus W Hollmann
- Department of Anesthesiology, Amsterdam University Medical Center (AUMC), Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Ragnar Huhn
- Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Giovanna Lurati Buse
- Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Hug Aubin
- Department of Cardiac Surgery, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
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Wehner JE, Boehne M, David S, Brand K, Tiede A, Bikker R. Activated Clotting Time (ACT) for Monitoring of Low-Dose Heparin: Performance Characteristics in Healthy Adults and Critically Ill Patients. Clin Appl Thromb Hemost 2021; 26:1076029620975494. [PMID: 33350327 PMCID: PMC7758671 DOI: 10.1177/1076029620975494] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Dose adjustment of unfractionated heparin (UFH) anticoagulation is an important factor to reduce hemorrhagic events. High doses of heparin can be monitored by Activated Clotting Time (ACT). Because of limited information about the monitoring of low-dose heparin we assessed monitoring by ACT, aPTT and anti-Xa. Blood samples from healthy volunteers (n = 54) were treated ex vivo with increasing UFH doses (0-0.4 IU/ml). Samples from ICU-patients (n = 60), were drawn during continuous UFH infusion. Simultaneous ACT measurements were performed using iSTAT and Hemochron. In UFH treated blood, iSTAT and Hemochron showed a significant change of ACT at ≥0.075 IU/ml and ≥0.1 IU/ml UFH, respectively. In ICU-patients no relationship between ACT and either UFH dose, aPTT and anti-Xa was observed. Hemochron was affected by antithrombin and platelet count. iSTAT was sensitive to CRP and hematocrit. A moderate correlation was identified between UFH dose and aPTT (R2 = 0.196) or anti-Xa (R2 = 0.162). In heparin-spiked blood, ACT is sensitive to heparin at levels of ≥0.1 IU/ml heparin. In ICU-patients, ACT did not correlate with UFH dose or other established methods. Both systems were differently influenced by certain parameters.
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Affiliation(s)
- Johannes E Wehner
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Martin Boehne
- Department of Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - Sascha David
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Korbinian Brand
- Institute of Clinical Chemistry, Hannover Medical School, Hannover, Germany
| | - Andreas Tiede
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Rolf Bikker
- Institute of Clinical Chemistry, Hannover Medical School, Hannover, Germany
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Song H, Yuan Z, Peng Y, Luo G. Extracorporeal membrane oxygenation combined with continuous renal replacement therapy for the treatment of severe burns: current status and challenges. BURNS & TRAUMA 2021; 9:tkab017. [PMID: 34212063 PMCID: PMC8240511 DOI: 10.1093/burnst/tkab017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 02/26/2021] [Indexed: 11/25/2022]
Abstract
Severe burns often cause various systemic complications and multiple organ dysfunction syndrome, which is the main cause of death. The lungs and kidneys are vulnerable organs in patients with multiple organ dysfunction syndrome after burns. Extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT) have been gradually applied in clinical practice and are beneficial for severe burn patients with refractory respiratory failure or renal dysfunction. However, the literature on ECMO combined with CRRT for the treatment of severe burns is limited. Here, we focus on the current status of ECMO combined with CRRT for the treatment of severe burns and the associated challenges, including the timing of treatment, nutrition support, heparinization and wound management, catheter-related infection and drug dosing in CRRT. With the advancement of medical technology, ECMO combined with CRRT will be further optimized to improve the outcomes of patients with severe burns.
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Affiliation(s)
- Huapei Song
- State Key Laboratory of Trauma, Burn and Combined Injury, Institute of Burn Research, Southwest Hospital, Third Military Medical University (Army Medical University), 30 Gaotanyan Street, Chongqing 400038, China
| | - Zhiqiang Yuan
- State Key Laboratory of Trauma, Burn and Combined Injury, Institute of Burn Research, Southwest Hospital, Third Military Medical University (Army Medical University), 30 Gaotanyan Street, Chongqing 400038, China
| | - Yizhi Peng
- State Key Laboratory of Trauma, Burn and Combined Injury, Institute of Burn Research, Southwest Hospital, Third Military Medical University (Army Medical University), 30 Gaotanyan Street, Chongqing 400038, China
| | - Gaoxing Luo
- State Key Laboratory of Trauma, Burn and Combined Injury, Institute of Burn Research, Southwest Hospital, Third Military Medical University (Army Medical University), 30 Gaotanyan Street, Chongqing 400038, China
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Moussa MD, Soquet J, Lamer A, Labreuche J, Gantois G, Dupont A, Abou-Arab O, Rousse N, Liu V, Brandt C, Foulon V, Leroy G, Schurtz G, Jeanpierre E, Duhamel A, Susen S, Vincentelli A, Robin E. Evaluation of Anti-Activated Factor X Activity and Activated Partial Thromboplastin Time Relations and Their Association with Bleeding and Thrombosis during Veno-Arterial ECMO Support: A Retrospective Study. J Clin Med 2021; 10:jcm10102158. [PMID: 34067573 PMCID: PMC8156165 DOI: 10.3390/jcm10102158] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/08/2021] [Accepted: 05/10/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND We aimed to investigate the relationship between anti-activated Factor X (anti-FXa) and activated Partial Thromboplastin Time (aPTT), and its modulation by other haemostasis co-variables during veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support. We further investigated their association with serious bleeding and thrombotic complications. METHODS This retrospective single-center study included 265 adults supported by VA-ECMO for refractory cardiogenic shock from January 2015 to June 2019. The concordance of anti-FXa and aPTT and their correlations were assessed in 1699 paired samples. Their independent associations with serious bleeding or thrombotic complications were also analysed in multivariate analysis. RESULTS The concordance rate of aPTT with anti-FXa values was 50.7%, with 39.3% subtherapeutic aPTT values. However, anti-FXa and aPTT remained associated (β = 0.43 (95% CI 0.4-0.45) 10-2 IU/mL, p < 0.001), with a significant modulation by several biological co-variables. There was no association between anti-FXa nor aPTT values with serious bleeding or with thrombotic complications. CONCLUSION During VA-ECMO, although anti-FXa and aPTT were significantly associated, their values were highly discordant with marked sub-therapeutic aPTT values. These results should favour the use of anti-FXa. The effect of biological co-variables and the failure of anti-FXa and aPTT to predict bleeding and thrombotic complications underline the complexity of VA-ECMO-related coagulopathy.
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Affiliation(s)
- Mouhamed Djahoum Moussa
- CHU Lille, Pôle d’Anesthésie-Réanimation, 59000 Lille, France; (A.L.); (G.G.); (V.L.); (C.B.); (V.F.); (G.L.); (E.R.)
- Correspondence: ; Tel.: +33-320-445-962
| | - Jérôme Soquet
- CHU Lille, Service de Chirurgie Cardiaque, 59000 Lille, France; (J.S.); (N.R.); (A.V.)
| | - Antoine Lamer
- CHU Lille, Pôle d’Anesthésie-Réanimation, 59000 Lille, France; (A.L.); (G.G.); (V.L.); (C.B.); (V.F.); (G.L.); (E.R.)
- Univ. Lille, INSERM, CHU Lille, CIC-IT 1403, 59000 Lille, France
- Univ. Lille, CHU Lille, ULR 2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, 59000 Lille, France; (J.L.); (A.D.)
| | - Julien Labreuche
- Univ. Lille, CHU Lille, ULR 2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, 59000 Lille, France; (J.L.); (A.D.)
- CHU Lille, Department of Biostatistics, 59000 Lille, France
| | - Guillaume Gantois
- CHU Lille, Pôle d’Anesthésie-Réanimation, 59000 Lille, France; (A.L.); (G.G.); (V.L.); (C.B.); (V.F.); (G.L.); (E.R.)
| | - Annabelle Dupont
- CHU Lille, Pôle d’Hématologie-Transfusion, Centre de Biologie Pathologie Génétique, 59000 Lille, France; (A.D.); (E.J.); (S.S.)
| | - Osama Abou-Arab
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, 80054 Amiens, France;
- MP3CV, EA7517, CURS, Jules Verne University of Picardie, 80054 Amiens, France
| | - Natacha Rousse
- CHU Lille, Service de Chirurgie Cardiaque, 59000 Lille, France; (J.S.); (N.R.); (A.V.)
| | - Vincent Liu
- CHU Lille, Pôle d’Anesthésie-Réanimation, 59000 Lille, France; (A.L.); (G.G.); (V.L.); (C.B.); (V.F.); (G.L.); (E.R.)
| | - Caroline Brandt
- CHU Lille, Pôle d’Anesthésie-Réanimation, 59000 Lille, France; (A.L.); (G.G.); (V.L.); (C.B.); (V.F.); (G.L.); (E.R.)
| | - Valentin Foulon
- CHU Lille, Pôle d’Anesthésie-Réanimation, 59000 Lille, France; (A.L.); (G.G.); (V.L.); (C.B.); (V.F.); (G.L.); (E.R.)
| | - Guillaume Leroy
- CHU Lille, Pôle d’Anesthésie-Réanimation, 59000 Lille, France; (A.L.); (G.G.); (V.L.); (C.B.); (V.F.); (G.L.); (E.R.)
| | | | - Emmanuel Jeanpierre
- CHU Lille, Pôle d’Hématologie-Transfusion, Centre de Biologie Pathologie Génétique, 59000 Lille, France; (A.D.); (E.J.); (S.S.)
| | - Alain Duhamel
- Univ. Lille, CHU Lille, ULR 2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, 59000 Lille, France; (J.L.); (A.D.)
- CHU Lille, Department of Biostatistics, 59000 Lille, France
| | - Sophie Susen
- CHU Lille, Pôle d’Hématologie-Transfusion, Centre de Biologie Pathologie Génétique, 59000 Lille, France; (A.D.); (E.J.); (S.S.)
| | - André Vincentelli
- CHU Lille, Service de Chirurgie Cardiaque, 59000 Lille, France; (J.S.); (N.R.); (A.V.)
| | - Emmanuel Robin
- CHU Lille, Pôle d’Anesthésie-Réanimation, 59000 Lille, France; (A.L.); (G.G.); (V.L.); (C.B.); (V.F.); (G.L.); (E.R.)
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Jiritano F, Fina D, Lorusso R, Ten Cate H, Kowalewski M, Matteucci M, Serra R, Mastroroberto P, Serraino GF. Systematic review and meta-analysis of the clinical effectiveness of point-of-care testing for anticoagulation management during ECMO. J Clin Anesth 2021; 73:110330. [PMID: 33962338 DOI: 10.1016/j.jclinane.2021.110330] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 04/17/2021] [Accepted: 04/20/2021] [Indexed: 12/26/2022]
Abstract
STUDY OBJECTIVE Viscoelastic point-of-care (POC) tests are commonly used to provide prompt diagnosis of coagulopathy and allow targeted treatments in bleeding patients on ECMO. We evaluated the clinical effectiveness of point-of-care (POC) testing for anticoagulation management in patients on extracorporeal membrane oxygenation (ECMO). DESIGN Systematic review and meta-analysis. Eligible studies evaluating the use of thromboelastography- or thromboelastometry-guided algorithms, anti-factor Xa and platelet function testing were selected after screening the literature from July 1975 to January 2020. SETTING Patients on ECMO support. PATIENTS Anticoagulation management on ECMO patients. INTERVENTIONS Rotational thromboelastometry, thromboelastography, alone or combined with platelet function testing. Trials monitoring the anticoagulation effects during ECMO using an anti-factor Xa assay were included in the systematic review. MEASUREMENTS The primary outcomes were bleeding events, surgical revisions, thrombosis events and ECMO circuit change/failure. Secondary outcomes were blood-product transfusions, cerebrovascular accidents, mortality on ECMO, ECMO duration, intensive care unit and hospital discharge rates, and in-hospital mortality. MAIN RESULTS Thirty-one trials enrolling 1684 participants were included in the systematic review. Four trials enrolling 547 subjects were included in the meta-analysis. The use of a POC testing device resulted in improved detection of surgical bleeding (RR: 0.68, 95% CI 0.49 to 0.94, I2 = 0%; χ2 test for heterogeneity, P = 0.02). The use of POC-guided algorithms did not affect bleeding (RR:0.78, 95% CI 0.58 to 1.04, I2 = 47%; χ2 test for heterogeneity, P = 0.09), thrombosis events (RR:1.35, 95% CI 0.86 to 2.12, I2 = 37%; χ2 test for heterogeneity, P = 0.19), or ECMO circuit/change (RR:0.90, 95% CI 0.48 to 1.71, I2 = 28%; χ2 test for heterogeneity, P = 0.75). CONCLUSION Routine use of POC tests did not improve the main clinical outcomes beyond suggesting a diagnosis of surgical bleeding in ECMO patients.
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Affiliation(s)
- Federica Jiritano
- Cardiac Surgery Unit, Dept. Experimental and Clinical Medicine, University "Magna Graecia" of Catanzaro, Catanzaro, Italy; Cardio-Thoracic Surgery Dept., Heart & Vascular Centre, Maastricht University Medical Centre (MUMC), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands.
| | - Dario Fina
- Cardio-Thoracic Surgery Dept., Heart & Vascular Centre, Maastricht University Medical Centre (MUMC), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands; Città di Lecce Hospital, GVM Care and Research, Lecce, Italy
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Dept., Heart & Vascular Centre, Maastricht University Medical Centre (MUMC), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | - Hugo Ten Cate
- Laboratory for Clinical Thrombosis and Haemostasis, Department of Internal Medicine, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Mariusz Kowalewski
- Cardio-Thoracic Surgery Dept., Heart & Vascular Centre, Maastricht University Medical Centre (MUMC), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands; Clinical Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior and Administration, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Matteo Matteucci
- Cardio-Thoracic Surgery Dept., Heart & Vascular Centre, Maastricht University Medical Centre (MUMC), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands; Department of Cardiac Surgery, Circolo Hospital, University of Insubria, Varese, Italy
| | - Raffaele Serra
- Department of Medical and Surgical Sciences, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - Pasquale Mastroroberto
- Cardiac Surgery Unit, Dept. Experimental and Clinical Medicine, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - Giuseppe Filiberto Serraino
- Cardiac Surgery Unit, Dept. Experimental and Clinical Medicine, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
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Buchtele N, Staudinger T, Schäfer AK, Bögl MS, Schoergenhofer C, Schwameis M. Anticoagulation in Critically Ill Adults during Extracorporeal Circulation. Hamostaseologie 2021; 41:294-306. [PMID: 33860514 DOI: 10.1055/a-1389-8216] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Extracorporeal circuits including renal replacement therapy, extracorporeal membrane oxygenation, and ventricular assist devices are increasingly used in critically ill patients. The need for anticoagulation to provide circuit patency and avoid thrombosis remains a challenging task for treating physicians. In the presence of overall low scientific evidence concerning the optimal anticoagulants, monitoring tests, and therapeutic target ranges, recommendations are largely expert opinions and most centers use individual "in-house" anticoagulation protocols. This review gives a practical view on current concepts of anticoagulation strategies in patients with extracorporeal assist devices.
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Affiliation(s)
- Nina Buchtele
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Thomas Staudinger
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Anne-Kristin Schäfer
- Division of Cardiac Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | | | | | - Michael Schwameis
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
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Descamps R, Moussa MD, Besnier E, Fischer MO, Preau S, Tamion F, Daubin C, Cousin N, Vincentelli A, Goutay J, Du Cheyron D. Anti-Xa activity and hemorrhagic events under extracorporeal membrane oxygenation (ECMO): a multicenter cohort study. Crit Care 2021; 25:127. [PMID: 33810800 PMCID: PMC8019180 DOI: 10.1186/s13054-021-03554-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 03/26/2021] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Hemorrhagic events remain a major concern in patients under extracorporeal membrane oxygenation (ECMO) support. We tested the association between anticoagulation levels and hemorrhagic events under ECMO using anti-Xa activity monitoring. METHODS We performed a retrospective multicenter cohort study in three ECMO centers. All adult patients treated with veno-venous (VV)- or veno-arterial (VA)-ECMO in 6 intensive care units between September 2017 and August 2019 were included. Anti-Xa activities were collected until a hemorrhagic event in the bleeding group and for the duration of ECMO in the non-bleeding group. All dosages were averaged to obtain means of anti-Xa activity for each patient, and patients were compared according to the occurrence or not of bleeding. RESULTS Among 367 patients assessed for eligibility, 121 were included. Thirty-five (29%) presented a hemorrhagic complication. In univariate analysis, anti-Xa activities were significantly higher in the bleeding group than in the non-bleeding group, both for the mean anti-Xa activity (0.38 [0.29-0.67] vs 0.33 [0.22-0.42] IU/mL; p = 0.01) and the maximal anti-Xa activity (0.83 [0.47-1.46] vs 0.66 [0.36-0.91] IU/mL; p = 0.05). In the Cox proportional hazard model, mean anti-Xa activity was associated with bleeding (p = 0.0001). By Kaplan-Meier analysis with the cutoff value at 0.46 IU/mL obtained by ROC curve analysis, the probability of survival under ECMO without bleeding was significantly lower when mean anti-Xa was > 0.46 IU/mL (p = 0.0006). CONCLUSION In critically ill patients under ECMO, mean anti-Xa activity was an independent risk factor for hemorrhagic complications. Anticoagulation targets could be revised downward in both VV- and VA-ECMO.
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Affiliation(s)
- Richard Descamps
- Department of Medical Intensive Care, Caen University Hospital, 14000, Caen, France.
| | - Mouhamed D Moussa
- Inserm, CHU Lille, Surgical Critical Care, Department of Anesthesiology and Critical Care, Institut Pasteur de Lille, UMR1011-EGID, Univ. Lille, 59000, Lille, France
| | - Emmanuel Besnier
- Department of Anesthesiology and Critical Care, Rouen University Hospital, 76000, Rouen, France
| | - Marc-Olivier Fischer
- Department of Anesthesiology and Critical Care, Caen University Hospital, 14000, Caen, France
| | - Sébastien Preau
- Department of Medical Intensive Care, Lille University Hospital, 59000, Lille, France
| | - Fabienne Tamion
- UNIROUEN, Inserm U1096, FHU- REMOD-VHF, Normandie Univ, 76000, Rouen, France
- Department of Medical Intensive Care, Rouen University Hospital, 76000, Rouen, France
| | - Cédric Daubin
- Department of Medical Intensive Care, Caen University Hospital, 14000, Caen, France
| | - Nicolas Cousin
- Department of Medical Intensive Care, Lille University Hospital, 59000, Lille, France
| | - André Vincentelli
- Inserm, CHU Lille, Department of Cardiac Surgery, Institut Pasteur de Lille, UMR1011-EGID, Univ. Lille, 59000, Lille, France
| | - Julien Goutay
- Department of Medical Intensive Care, Lille University Hospital, 59000, Lille, France
| | - Damien Du Cheyron
- Department of Medical Intensive Care, Caen University Hospital, 14000, Caen, France
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Extracorporeal Gas Exchange for Acute Respiratory Distress Syndrome: Open Questions, Controversies and Future Directions. MEMBRANES 2021; 11:membranes11030172. [PMID: 33670987 PMCID: PMC7997339 DOI: 10.3390/membranes11030172] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 02/23/2021] [Accepted: 02/24/2021] [Indexed: 02/06/2023]
Abstract
Veno-venous extracorporeal membrane oxygenation (V-V ECMO) in acute respiratory distress syndrome (ARDS) improves gas exchange and allows lung rest, thus minimizing ventilation-induced lung injury. In the last forty years, a major technological and clinical improvement allowed to dramatically improve the outcome of patients treated with V-V ECMO. However, many aspects of the care of patients on V-V ECMO remain debated. In this review, we will focus on main issues and controversies on caring of ARDS patients on V-V ECMO support. Particularly, the indications to V-V ECMO and the feasibility of a less invasive extracorporeal carbon dioxide removal will be discussed. Moreover, the controversies on management of mechanical ventilation, prone position and sedation will be explored. In conclusion, we will discuss evidences on transfusions and management of anticoagulation, also focusing on patients who undergo simultaneous treatment with ECMO and renal replacement therapy. This review aims to discuss all these clinical aspects with an eye on future directions and perspectives.
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Anticoagulation Monitoring During Extracorporeal Membrane Oxygenation: Continuing Progress. Crit Care Med 2020; 48:1920-1921. [PMID: 33255117 DOI: 10.1097/ccm.0000000000004635] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gordon SE, Heath TS, McMichael ABV, Hornik CP, Ozment CP. Evaluation of Heparin Anti-Factor Xa Levels Following Antithrombin Supplementation in Pediatric Patients Supported With Extracorporeal Membrane Oxygenation. J Pediatr Pharmacol Ther 2020; 25:717-722. [PMID: 33214783 DOI: 10.5863/1551-6776-25.8.717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2020] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Thrombotic events are potential complications in patients receiving extracorporeal membrane oxygenation (ECMO) necessitating the use of systemic anticoagulation with heparin. Heparin works by potentiating the effects of antithrombin (AT), which may be deficient in critically ill patients and can be replaced. The clinical benefits and risks of AT replacement in children on ECMO remain incompletely understood. METHODS This single-center, retrospective study reviewed 28 neonatal and pediatric patients supported on ECMO at a tertiary care hospital between April 1, 2013, and October 31, 2014, who received at least 1 dose of AT during their ECMO course. The primary outcome of the study was the change in anti-factor Xa levels after pooled human AT supplementation. Secondary outcomes included the percentage of anti-factor Xa levels within the therapeutic range surrounding AT administration; survival to decannulation; 30 days after cannulation and discharge; time to first circuit change; and incidence of bleeding and thrombotic events. RESULTS A total of 78 doses of AT were administered during the study period. The mean increase in anti-factor Xa level following AT administration in patients without a ≥10% concurrent change in heparin was 0.075 ± 0.13 international units/mL. A greater percentage of anti-factor Xa levels were therapeutic for the 48 hours following AT administration (64.2% vs 38.6%). Survival and adverse events were similar to Extracorporeal Life Support Organization averages, with the exception of a higher incidence of intracranial hemorrhage. CONCLUSIONS Patients experienced a small but significant increase in anti-factor Xa level and a greater percentage of therapeutic anti-factor Xa levels following AT supplementation.
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Affiliation(s)
- Sharon E Gordon
- Department of Pharmacy (SEG), Children's Hospital Colorado, Aurora, CO
| | - Travis S Heath
- Department of Pharmacy (TSH), Duke University Hospital, Durham, NC
| | - Ali B V McMichael
- Department of Pediatrics (ABVM), University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Caroline P Ozment
- Department of Pediatrics (CPO), Duke University Hospital, Durham, NC
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Nei SD, Pope HE. Part I: Anticoagulation for unique situations. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2020. [DOI: 10.1002/jac5.1313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Honore PM, Barreto Gutierrez L, Kugener L, Redant S, Attou R, Gallerani A, De Bels D. Use of multiple laboratory tests including anti-factor Xa to optimally manage anticoagulation during ECMO. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:427. [PMID: 32660540 PMCID: PMC7358299 DOI: 10.1186/s13054-020-03145-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 07/02/2020] [Indexed: 01/22/2023]
Affiliation(s)
- Patrick M Honore
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium.
| | - Leonel Barreto Gutierrez
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - Luc Kugener
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - Sebastien Redant
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - Rachid Attou
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - Andrea Gallerani
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - David De Bels
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
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Keller SP. Management of Peripheral Venoarterial Extracorporeal Membrane Oxygenation in Cardiogenic Shock. Crit Care Med 2020; 47:1235-1242. [PMID: 31219839 DOI: 10.1097/ccm.0000000000003879] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Cardiogenic shock is a highly morbid condition in which inadequate end-organ perfusion leads to death if untreated. Peripheral venoarterial extracorporeal membrane oxygenation is increasingly used to restore systemic perfusion despite limited understanding of how to optimally titrate support. This review provides insights into the physiologic basis of extracorporeal membrane oxygenation support and presents an approach to extracorporeal membrane oxygenation management in the cardiogenic shock patient. DATA SOURCES, STUDY SELECTION, AND DATA EXTRACTION Data were obtained from a PubMed search of the most recent medical literature identified from MeSH terms: extracorporeal membrane oxygenation, cardiogenic shock, percutaneous mechanical circulatory support, and heart failure. Articles included original articles, case reports, and review articles. DATA SYNTHESIS Current evidence detailing the use of extracorporeal membrane oxygenation to support patients in cardiogenic shock is limited to isolated case reports and single institution case series focused on patient outcomes but lacking in detailed approaches to extracorporeal membrane oxygenation management. Unlike medical therapy, in which dosages are either prescribed or carefully titrated to specific variables, extracorporeal membrane oxygenation is a mechanical support therapy requiring ongoing titration but without widely accepted variables to guide treatment. Similar to mechanical ventilation, extracorporeal membrane oxygenation can provide substantial benefit or induce significant harm. The widespread use and present lack of data to guide extracorporeal membrane oxygenation support demands that intensivists adopt a physiologically-based approach to management of the cardiogenic shock patient on extracorporeal membrane oxygenation. CONCLUSIONS Extracorporeal membrane oxygenation is a powerful mechanical circulatory support modality capable of rapidly restoring systemic perfusion yet lacking in defined approaches to management. Adopting a management approach based physiologic principles provides a basis for care.
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Affiliation(s)
- Steven P Keller
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.,Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA
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Chlebowski MM, Baltagi S, Carlson M, Levy JH, Spinella PC. Clinical controversies in anticoagulation monitoring and antithrombin supplementation for ECMO. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:19. [PMID: 31959232 PMCID: PMC6971875 DOI: 10.1186/s13054-020-2726-9] [Citation(s) in RCA: 108] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 01/01/2020] [Indexed: 12/15/2022]
Abstract
During extracorporeal membrane oxygenation (ECMO), a delicate balance is required to titrate systemic anticoagulation to prevent thrombotic complications within the circuit and prevent bleeding in the patient. Despite focused efforts to achieve this balance, the frequency of both thrombotic and bleeding events remains high. Anticoagulation is complicated to manage in this population due to the complexities of the hemostatic system that are compounded by age-related developmental hemostatic changes, variable effects of the etiology of critical illness on hemostasis, and blood-circuit interaction. Lack of high-quality data to guide anticoagulation management in ECMO patients results in marked practice variability among centers. One aspect of anticoagulation therapy that is particularly challenging is the use of antithrombin (AT) supplementation for heparin resistance. This is especially controversial in the neonatal and pediatric population due to the baseline higher risk of bleeding in this cohort. The indication for AT supplementation is further compounded by the potential inaccuracy of the diagnosis of heparin resistance based on the standard laboratory parameters used to assess heparin effect. With concerns regarding the adverse impact of bleeding and thrombosis, clinicians and institutions are faced with making difficult, real-time decisions aimed at optimizing anticoagulation in this setting. In this clinically focused review, the authors discuss the complexities of anticoagulation monitoring and therapeutic intervention for patients on ECMO and examine the challenges surrounding AT supplementation given both the historical and current perspectives summarized in the literature on these topics.
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Affiliation(s)
- Meghan M Chlebowski
- Department of Pediatrics, Division of Pediatric Cardiology, Cardiovascular Intensive Care Unit, Cincinnati Children's Hospital/University of Cincinnati College of Medicine, 3333 Burnet Ave, Cincinnati, OH, 45229, USA.
| | - Sirine Baltagi
- Department of Pediatrics, Division of Critical Care Medicine, St. Joseph's Children's Hospital/University of Pittsburg School of Medicine, Tampa, FL, USA
| | | | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Philip C Spinella
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, USA
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Colman E, Yin EB, Laine G, Chatterjee S, Saatee S, Herlihy JP, Reyes MA, Bracey AW. Evaluation of a heparin monitoring protocol for extracorporeal membrane oxygenation and review of the literature. J Thorac Dis 2019; 11:3325-3335. [PMID: 31559035 DOI: 10.21037/jtd.2019.08.44] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background Bleeding complications are common with extracorporeal membrane oxygenation (ECMO). We investigated whether a heparin monitoring protocol using activated partial thromboplastin time (aPTT) and thromboelastography (TEG) affected clinical outcomes. Methods This retrospective chart review stratified cohorts by study interval: pre-protocol (January 2016-March 2017) or post-protocol (March 2017-December 2017). The protocol defined therapeutic anticoagulation as aPTT of 60-80 seconds and a TEG reaction (TEG-R) time of 2-4× baseline; pre-protocol management used aPTT alone. The primary endpoints were the rates of bleeding and thrombotic events (clinical/device thrombosis) as defined by Extracorporeal Life Support Organization (ELSO) guidelines. Secondary endpoints included time in therapeutic aPTT range, rate of physician compliance with the protocol, time to heparin initiation, intensive care unit length of stay, mortality, and antithrombin III (ATIII) supplementation. Results The pre-protocol (n=72) and post-protocol (n=51) groups (age 60±12 years; 80% on venoarterial ECMO; average ECMO duration of 6 days) showed no difference in baseline characteristics. Major bleeding events occurred in 69% of pre-protocol patients, versus 67% of post-protocol patients (P=0.85). The post-protocol group had fewer retroperitoneal bleeds (P=0.01) and had a non-significantly lower rate of pulmonary or central nervous system (CNS) bleeding (P=0.07). Thrombotic events occurred in 21% of the pre-protocol group, versus 28% of the post-protocol group (P=0.39). Mortality during ECMO support was significantly lower in the post-protocol group (56.9% vs. 33.3%, P=0.01). The thrombosis rate was higher in patients who received ATIII than in those who did not (48.2% vs. 15.9%, P<0.01). Conclusions Major bleeding did not differ between the treatment groups. However, we observed significantly less mortality and retroperitoneal bleeding in the post-protocol group, suggesting an important gain from the intervention. Further study of the value of ATIII supplementation in ECMO patients is needed since we observed that a lower baseline ATIII level may indicate higher risk for thrombosis.
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Affiliation(s)
- Ellen Colman
- Department of Pharmacy, Houston Methodist The Woodlands Hospital, The Woodlands, TX, USA
| | - Ellen B Yin
- Department of Pharmacy, CHI St. Luke's Health-Baylor St. Luke's Medical Center, Houston, TX, USA
| | - Greg Laine
- Department of Pharmacy, CHI St. Luke's Health-Baylor St. Luke's Medical Center, Houston, TX, USA
| | - Subhasis Chatterjee
- Michael E. DeBakey Department of Surgery, Divisions of General and Cardiothoracic Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Siavosh Saatee
- Department of Anesthesiology and Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - J Patrick Herlihy
- Department of Anesthesiology and Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Meredith A Reyes
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, USA
| | - Arthur W Bracey
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, USA.,Department of Cardiovascular Pathology, Texas Heart Institute, Houston, TX, USA
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Koster A, Ljajikj E, Faraoni D. Traditional and non-traditional anticoagulation management during extracorporeal membrane oxygenation. Ann Cardiothorac Surg 2019; 8:129-136. [PMID: 30854322 DOI: 10.21037/acs.2018.07.03] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Unfractionated heparin (UFH) is the anticoagulant of choice during extracorporeal membrane oxygenation (ECMO) support. Despite its favorable pharmacologic properties, management of heparin anticoagulation during ECMO remains a major challenge. To date, little is known about the optimal monitoring strategy or the heparin dose offering the best safety/efficacy profile. Therefore, it remains unclear if the heparin dose should be adapted to target a specific "clotting time" [e.g., activated clotting time (ACT) or activated partial thromboplastin time (aPTT)] or a heparin concentration, measured by coagulation factor anti-Xa assay. In addition, no study has compared the relevance of modern viscoelastic coagulation tests over the single value of a clotting time or heparin concentration value. Although guidelines for anticoagulation during ECMO support have been published, the absence of evidence limits the quality of the recommendations provided, which explains the major intra- and inter-institutional variability observed. Large prospective multicenter trials are urgently needed to investigate the optimal anticoagulation management strategy during ECMO support.
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Affiliation(s)
- Andreas Koster
- Institute of Anesthesiology, Heart and Diabetes Center NRW, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Edis Ljajikj
- Department of Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - David Faraoni
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, University of Toronto, Toronto, Canada
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