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Mansour A, Berahou M, Odot J, Pontis A, Parasido A, Reizine F, Launey Y, Garlantézec R, Flecher E, Lecompte T, Nesseler N, Gouin-Thibault I. Antithrombin Levels and Heparin Responsiveness during Venoarterial Extracorporeal Membrane Oxygenation: A Prospective Single-center Cohort Study. Anesthesiology 2024; 140:1153-1164. [PMID: 38271619 PMCID: PMC11097948 DOI: 10.1097/aln.0000000000004920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 01/17/2024] [Indexed: 01/27/2024]
Abstract
BACKGROUND Unfractionated heparin, administered during venoarterial extracorporeal membrane oxygenation to prevent thromboembolic events, largely depends on plasma antithrombin for its antithrombotic effects. Decreased heparin responsiveness seems frequent on extracorporeal membrane oxygenation; however, its association with acquired antithrombin deficiency is poorly understood. The objective of this study was to describe longitudinal changes in plasma antithrombin levels during extracorporeal membrane oxygenation support and evaluate the association between antithrombin levels and heparin responsiveness. The hypothesis was that extracorporeal membrane oxygenation support would be associated with acquired antithrombin deficiency and related decreased heparin responsiveness. METHODS Adults receiving venoarterial extracorporeal membrane oxygenation were prospectively included. All patients received continuous intravenous unfractionated heparin using a standardized protocol (target anti-Xa 0.3 to 0.5 IU/ml). For each patient, arterial blood was withdrawn into citrate-containing tubes at 11 time points (from hour 0 up to day 7). Anti-Xa (without dextran or antithrombin added) and antithrombin levels were measured. The primary outcome was the antithrombin plasma level. In the absence of consensus, antithrombin deficiency was defined as a time-weighted average of antithrombin less than or equal to 70%. Data regarding clinical management and heparin dosage were collected. RESULTS Fifty patients, including 42% postcardiotomy, were included between April 2020 and May 2021, with a total of 447 samples. Median extracorporeal membrane oxygenation duration was 7 (interquartile range, 4 to 12) days. Median antithrombin level was 48% (37 to 60%) at baseline. Antithrombin levels significantly increased throughout the follow-up. Time-weighted average of antithrombin levels was 63% (57 to 73%) and was less than or equal to 70% in 32 (64%) of patients. Overall, 45 (90%) patients had at least one antithrombin value less than 70%, and 35 (70%) had at least one antithrombin value less than 50%. Antithrombin levels were not significantly associated with heparin responsiveness evaluated by anti-Xa assay or heparin dosage. CONCLUSIONS Venoarterial extracorporeal membrane oxygenation support was associated with a moderate acquired antithrombin deficiency, mainly during the first 72 h, that did not correlate with heparin responsiveness. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Alexandre Mansour
- Department of Anesthesia and Critical Care, Pontchaillou, University Hospital of Rennes, Rennes, France; University of Rennes, National Institute of Health and Medical Research, Center of Clinical Investigation, Research Institute for Environmental and Occupational Health, University Hospital Federation Survival Optimization in Organ Transplantation, Univ Rennes, Rennes, France
| | - Mathilde Berahou
- Department of Anesthesia and Critical Care, Pontchaillou, University Hospital of Rennes, Rennes, France
| | - Joscelyn Odot
- Department of Anesthesia and Critical Care, Pontchaillou, University Hospital of Rennes, Rennes, France
| | - Adeline Pontis
- Department of Hematology, Pontchaillou, University Hospital of Rennes, Rennes, France; University of Rennes, National Institute of Health and Medical Research, Center of Clinical Investigation, Research Institute for Environmental and Occupational Health, University Hospital Federation Survival Optimization in Organ Transplantation, Univ Rennes, Rennes, France
| | - Alessandro Parasido
- Department of Thoracic and Cardiovascular Surgery, Pontchaillou, University Hospital of Rennes, Rennes, France
| | - Florian Reizine
- Department of Medical Intensive Care, University Hospital of Rennes, Rennes, France
| | - Yoann Launey
- Department of Anesthesia and Critical Care, Pontchaillou, University Hospital of Rennes, Rennes, France
| | - Ronan Garlantézec
- Department of Epidemiology and Public Health, Pontchaillou, University Hospital of Rennes, Rennes, France; University of Rennes, National Institute of Health and Medical Research, Center of Clinical Investigation, Research Institute for Environmental and Occupational Health, University Hospital Federation Survival Optimization in Organ Transplantation, Univ Rennes, Rennes, France
| | - Erwan Flecher
- Department of Thoracic and Cardiovascular Surgery, Pontchaillou, University Hospital of Rennes, University of Rennes, Signal and Image Treatment Laboratory, National Institute of Health and Medical Research U1099, Rennes, France
| | - Thomas Lecompte
- Department of Hematology, Pontchaillou, University Hospital of Rennes, Rennes, France
| | - Nicolas Nesseler
- Department of Anesthesia and Critical Care, Pontchaillou, University Hospital of Rennes, Rennes, France; University of Rennes, National Institute of Health and Medical Research, Center of Clinical Investigation, Nutrition, Metabolism, Cancer Mixed Research Unit, University Hospital Federation Survival Optimization in Organ Transplantation, Univ Rennes, Rennes, France
| | - Isabelle Gouin-Thibault
- Department of Hematology, Pontchaillou, University Hospital of Rennes, Rennes, France; University of Rennes, National Institute of Health and Medical Research, Research Institute for Environmental and Occupational Health, Rennes, France
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Iba T, Helms J, Maier CL, Levi M, Scarlatescu E, Levy JH. The role of thromboinflammation in acute kidney injury among patients with septic coagulopathy. J Thromb Haemost 2024; 22:1530-1540. [PMID: 38382739 DOI: 10.1016/j.jtha.2024.02.006] [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: 12/01/2023] [Revised: 01/22/2024] [Accepted: 02/07/2024] [Indexed: 02/23/2024]
Abstract
Inflammation and coagulation are critical self-defense mechanisms for mitigating infection that can nonetheless induce tissue injury and organ dysfunction. In severe cases, like sepsis, a dysregulated thromboinflammatory response may result in multiorgan dysfunction. Sepsis-associated acute kidney injury (AKI) is a significant contributor to patient morbidity and mortality. The connection between AKI and thromboinflammation is largely due to unique aspects of the renal vasculature. Specifically, the interaction between blood cells with the endothelial, glomerular, and peritubular capillary systems during thromboinflammation reduces oxygen supply to tubular epithelial cells. Previous studies have focused on tubular epithelial cell damage due to hypoxia, oxidative stress, and nephrotoxins. Although these factors are pivotal in acute tubular injury or necrosis, recent studies have demonstrated that AKI in sepsis encompasses a mixture of tubular and glomerular damage subtypes. In cases of sepsis-induced coagulopathy, thromboinflammation within the glomerulus and peritubular capillaries is an important pathogenic mechanism for AKI. Unfortunately, and despite the use of renal replacement therapy, the development of AKI in sepsis continues to be associated with high morbidity, mortality, and clinical challenges requiring alternative approaches. This review introduces the important role of thromboinflammation in AKI pathogenesis and details innovative vascular-targeting therapeutic strategies.
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Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan.
| | - Julie Helms
- French National Institute of Health and Medical Research, United Medical Resources 1260, Regenerative Nanomedicine, Federation de Medicine Translationnelle de Strasbourg, Strasbourg University Hospital, Medical Intensive Care Unit - NHC, Strasbourg University, Strasbourg, France
| | - Cheryl L Maier
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Marcel Levi
- Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands; Department of Medicine, University College London Hospitals National Health Service Foundation Trust, Cardio-metabolic Programme-National Institute for Health and Care Research University College London Hospitals/University College London Biomedical Research Centre, London, United Kingdom
| | - Ecaterina Scarlatescu
- University of Medicine and Pharmacy "Carol Davila," Bucharest, Romania; Department of Anaesthesia and Intensive Care, Fundeni Clinical Institute, Bucharest, Romania
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, North Carolina, USA
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Li T, Bo F, Meng X, Wang D, Ma J, Dai Z. The effect of perioperative antithrombin supplementation on blood conservation and postoperative complications after cardiopulmonary bypass surgery: A systematic review, meta-analysis and trial sequential analysis. Heliyon 2023; 9:e22266. [PMID: 38053853 PMCID: PMC10694320 DOI: 10.1016/j.heliyon.2023.e22266] [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] [Received: 04/07/2023] [Revised: 11/07/2023] [Accepted: 11/08/2023] [Indexed: 12/07/2023] Open
Abstract
Study objective Antithrombin (AT) activity is reduced during cardiopulmonary bypass (CPB) surgery. Guidelines has demonstrated that perioperative AT supplementation contributed to blood conservation and prevent perioperative thrombotic complications and target organ injury owing to its role in reducing thrombin generation. But these recommends is lack of support of meta-analysis in the guidelines. This meta-analysis aims to include all the relevant randomized controlled trails (RCT) on patients who experienced cardiac surgeries with CPB and investigate the effect of perioperative AT on blood conservation and complications after cardiac surgery. Methods Standard published RCTs were searched from bibliographic databases to identify all evidence reporting perioperative AT supplementation for patients undergoing cardiovascular surgeries. The primary outcome was postoperative blood loss, the secondary outcomes were blood component transfusion (red blood cell (RBC), fresh frozen plasma (FFP), platelet and autologous blood), postoperative morbidity and in hospital mortality. The relative risk (RR) for dichotomous outcomes and the standardized mean difference (SMD) for continuous outcomes were estimated using a random-effects model. Trial sequential analysis (TSA) was performed using TSA software 0.9.5.10. Results 13 RCTs with 996 participants undergoing different cardiovascular surgeries were included. Meta-analysis showed AT did not decrease postoperative blood loss (SMD -0.01, 95%CI -0.2 to 0.19). Subgroup analysis showed the effect of AT on postoperative blood loss was not associated with age, RCT type, surgery type, injection time of AT and AT deficiency. TSA further suggested that no additional studies were required for the stable result. Perioperative AT also did not reduce RBC ((SMD 0.10, 95%CI -0.66 to 0.85), (RR 0.99, 95%CI 0.83 to 1.19)), FFP ((SMD 0.11, 95%CI -0.19 to 0.41), (RR 1.30, 95%CI 0.90 to 1.87)), platelet (RR 1.10, 95%CI 0.83 to 1.46) and autologous blood (SMD 0.46, 95%CI -0.12 to 1.8504) transfusions. Perioperative AT significantly increased in hospital mortality (RR 2.53, 95%CI 1.02 to 6.28) and acute kidney injury (AKI) (RR 3.72, 95%CI 1.73 to 8.04) incidence. There was no significant difference in postoperative reexploration, thromboembolism, ECMO/IABP support, and stroke incidence between AT and non-AT group. Conclusions With the improvement of AT level and heparin sensitivity, perioperative AT has no significant effect on blood conservation. And it is noteworthy that the treatment increased in hospital mortality and the incidence of AKI after cardiac surgery.
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Affiliation(s)
- Tao Li
- Department of Anesthesiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, 264000, Shandong, China
| | - FengShan Bo
- Department of Anesthesiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, 264000, Shandong, China
| | - XiangRui Meng
- Department of Anesthesiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, 264000, Shandong, China
| | - Di Wang
- Department of Internal Medicine, Yantai Haigang Hospital, Yantai, 264000, Shandong, China
| | - Jiahai Ma
- Department of Anesthesiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, 264000, Shandong, China
| | - Zhao Dai
- Department of Anesthesiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, 264000, Shandong, China
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Tanaka KA, Buehler P, Stewart KE. "High plasma levels of C1-inhibitor are associated with lower risk of future venous thromboembolism": comment from Tanaka et al. J Thromb Haemost 2023; 21:2991-2992. [PMID: 37739597 DOI: 10.1016/j.jtha.2023.06.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 06/21/2023] [Indexed: 09/24/2023]
Affiliation(s)
- Kenichi A Tanaka
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA.
| | - Paul Buehler
- Department of Pathology, and the Department of Pediatrics, Center for Blood Oxygen Transport and Hemostasis University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Kenneth E Stewart
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA; Department of Surgery and Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
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Mazzeffi M, Tanaka K. Antithrombin Replacement in Cardiac Surgery: Was Too Much of a Good Thing Bad? Anesth Analg 2023; 136:1039-1042. [PMID: 37205799 DOI: 10.1213/ane.0000000000006392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Affiliation(s)
- Michael Mazzeffi
- From the Department of Anesthesiology, University of Virginia Health, Charlottesville, Virginia
| | - Kenichi Tanaka
- Department of Anesthesiology, Oklahoma University School of Medicine, Oklahoma City, Oklahoma
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Ranucci M, Baryshnikova E, Pistuddi V, Di Dedda U. The Rise and Fall of Antithrombin Supplementation in Cardiac Surgery. Anesth Analg 2022; 136:1043-1051. [PMID: 36853953 DOI: 10.1213/ane.0000000000006314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
Various cohort studies, both retrospective and prospective, showed that low antithrombin levels after cardiac surgery (at the arrival in the intensive care unit and during the next days) were associated with a number of adverse outcomes, including surgical reexploration and thromboembolic events, eventually leading to prolonged stay in the intensive care. Values lower than 58% to 64% of antithrombin activity were indicative of this higher morbidity with good sensitivity and specificity. The scenario generated the hypothesis that low antithrombin levels needed to be corrected by supplementation to improve postoperative outcome. However, randomized controlled studies run to test this idea failed to demonstrate any benefit of antithrombin supplementation, showing no effects on outcome, neither as preemptive preoperative strategy nor for treating postoperative low antithrombin values. In addition, randomized trials highlighted that those patients who received antithrombin experienced significantly higher incidence of acute kidney injury with a pooled odds ratio of 4.41 (95% CI, 1.90-10.23; P = .001). A strongly decreased thrombin activity after antithrombin correction may eventually affect the efficiency of the glomerular filtration and cause the deterioration of kidney function, but underlying biological mechanisms remain unclear. In conclusion, low levels of antithrombin activity after cardiac surgery should be considered as a marker of greater severity of the patient's conditions and/or of the complexity of the surgical procedure. There are no indications for antithrombin supplementation in cardiac surgery unless for correcting heparin resistance.
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Affiliation(s)
- Marco Ranucci
- From the Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, Milan, Italy
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