1
|
Saracoglu A, Fawzy I, Saracoglu KT, Abdallah BM, Arif M, Schmidt M. Point of care guided coagulation management in adult patients on ECMO: A systematic review and meta-analysis. J Crit Care 2024; 83:154830. [PMID: 38744017 DOI: 10.1016/j.jcrc.2024.154830] [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: 03/12/2024] [Revised: 04/02/2024] [Accepted: 05/06/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Despite the advancements in extracorporeal membrane oxygenation (ECMO) technology, balancing the prevention of thrombosis and the risk of bleeding in patients on ECMO is still a significant challenge for physicians. This systematic review and meta-analysis aimed to assess the efficacy and safety of viscoelastic point-of-care (POC)-guided coagulation management in adult patients on ECMO. METHODS PubMed Medline, Embase, Scopus, Web of Science, and Cochrane Library databases were searched. After quality assessment, meta-analysis was carried out using random effects model, heterogeneity using I2 and publication bias using Doi and Funnel plots. RESULTS A total of 1718 records were retrieved from the searches. Fifteen studies that enrolled a total of 583 participants met the inclusion criteria. Of those, 3 studies enrolling 181 subjects were eligible for meta-analysis. In patients managed with POC-guided algorithms, the odds were coherently lower for bleeding (OR 0.71, 95%CI 0.36-1.42), thrombosis (OR 0.91, 95%CI 0.32-2.60), and in-hospital mortality (OR 0.54, 95%CI 0.29-1.03), but not for circuit change or failure (OR 1.50, 95%CI 0.59-3.83). However, the differences were not statistically significant due to wide 95%CIs. CONCLUSION Viscoelastic POC monitoring demonstrates potential benefits for coagulation management in ECMO patients. Future research should focus on standardizing evidence to improve clinical decision-making. REGISTRATION The protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) with registration ID CRD42023486294.
Collapse
Affiliation(s)
- Ayten Saracoglu
- Department of Anaesthesiology, ICU, and Perioperative Medicine, Aisha Bint Hamad Al-Attiyah Hospital, Hamad Medical Corporation, Doha, Qatar; College of Medicine, QU Health, Qatar University, Doha, Qatar.
| | - Ibrahim Fawzy
- Department of Critical Care Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar; Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Kemal Tolga Saracoglu
- College of Medicine, QU Health, Qatar University, Doha, Qatar; Department of Anaesthesiology, ICU, and Perioperative Medicine, Hazm Mebaireek General Hospital, Hamad Medical Corporation, Doha, Qatar
| | | | - Mariah Arif
- College of Medicine, QU Health, Qatar University, Doha, Qatar
| | - Matthieu Schmidt
- Sorbonne Université, Institute of Cardiometabolism and Nutrition, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Paris, France
| |
Collapse
|
2
|
Madhok J, O'Donnell C, Jin J, Owyang CG, Weimer JM, Pashun RA, Shudo Y, McNulty J, Chadwick B, Ruoss SJ, Rao VK, Zehnder JL, Hsu JL. Impact of C-reactive Protein on Anticoagulation Monitoring in Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2024; 38:1885-1896. [PMID: 38960805 DOI: 10.1053/j.jvca.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 03/29/2024] [Accepted: 04/03/2024] [Indexed: 07/05/2024]
Abstract
OBJECTIVE To evaluate the impact of inflammation on anticoagulation monitoring for patients supported with extracorporeal membrane oxygenation (ECMO). DESIGN Prospective single-center cohort study. SETTING University-affiliated tertiary care academic medical center. PARTICIPANTS Adult venovenous and venoarterial ECMO patients anticoagulated with heparin/ MEASUREMENTS AND MAIN RESULTS: C-Reactive protein (CRP) was used as a surrogate for overall inflammation. The relationship between CRP and the partial thromboplastin time (PTT, seconds) was evaluated using a CRP-insensitive PTT assay (PTT-CRP) in addition to measurement using a routine PTT assay. Data from 30 patients anticoagulated with heparin over 371 ECMO days was included. CRP levels (mg/dL) were significantly elevated (median, 17.2; interquartile range [IQR], 9.2-26.1) and 93% of patients had a CRP of ≥5. The median PTT (median 58.9; IQR, 46.9-73.3) was prolonged by 11.3 seconds compared with simultaneously measured PTT-CRP (median, 47.6; IQR, 40.1-55.5; p < 0.001). The difference between PTT and PTT-CRP generally increased with CRP elevation from 2.7 for a CRP of <5.0 to 13.0 for a CRP between 5 and 10, 17.7 for a CRP between 10 and 15, and 15.1 for a CRP of >15 (p < 0.001). In a subgroup of patients, heparin was transitioned to argatroban, and a similar effect was observed (median PTT, 62.1 seconds [IQR, 53.0-78.5 seconds] vs median PTT-CRP, 47.6 seconds [IQR, 41.3-57.7 seconds]; p < 0.001). CONCLUSIONS Elevations in CRP are common during ECMO and can falsely prolong PTT measured by commonly used assays. The discrepancy due to CRP-interference is important clinically given narrow PTT targets and may contribute to hematological complications.
Collapse
Affiliation(s)
- Jai Madhok
- Department of Anesthesiology, Perioperative, and Pain Medicine. Division of Adult Cardiothoracic Anesthesiology, Stanford University School of Medicine, Stanford, CA.
| | - Christian O'Donnell
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA; Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Jing Jin
- Stanford Special Coagulation Laboratory, Stanford Health Care, Stanford, CA
| | - Clark G Owyang
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY
| | - Jonathan M Weimer
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Raymond A Pashun
- Department of Medicine, Division of Cardiology, NYU Grossman School of Medicine, New York, NY
| | - Yasuhiro Shudo
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA
| | - John McNulty
- Cardiovascular Perfusion, Stanford Health Care, Stanford, CA
| | - Blaine Chadwick
- Cardiovascular Perfusion, Stanford Health Care, Stanford, CA
| | - Stephen J Ruoss
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Stanford University School of Medicine, Stanford, CA
| | - Vidya K Rao
- Department of Anesthesiology, Perioperative, and Pain Medicine. Division of Adult Cardiothoracic Anesthesiology, Stanford University School of Medicine, Stanford, CA
| | - James L Zehnder
- Department of Pathology and Laboratory Medicine, Stanford University School of Medicine, Stanford, CA
| | - Joe L Hsu
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Stanford University School of Medicine, Stanford, CA
| |
Collapse
|
3
|
Trieu NHK, Pham HM, Mai TA, Huynh DQ, Tran LT, Phan XT, Pham TTN. Cannula-Associated Deep Vein Thrombosis Following Extracorporeal Membrane Oxygenation Decannulation: Incidence and Risk Factors. ASAIO J 2024:00002480-990000000-00538. [PMID: 39088722 DOI: 10.1097/mat.0000000000002289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2024] Open
Abstract
Thrombotic complications during and after extracorporeal membrane oxygenation (ECMO) are commonly observed clinically. The incidences of cannula-associated deep vein thrombosis (CaDVT) post-ECMO support have predominantly focused on Caucasian demographics. This study aims to determine the incidence and risk factors for CaDVT in Vietnamese patients following ECMO decannulation. The retrospective study from January 2019 to February 2020 observed ECMO weaning patients and screened for CaDVT using Doppler ultrasonography. Data were collected on patient demographics, ECMO parameters, and transfusion and coagulation profiles during ECMO support. Of the 82 patients successfully weaned ECMO, 89% were assessed for CaDVT. We observed a CaDVT incidence of 24.7%, and only one patient (5.6%) had a pulmonary embolism in the CaDVT group. Noteworthy is that the anticoagulation goals, transfusion during ECMO, and hospital mortality showed no significant difference between the CaDVT and non-CaDVT groups. The findings showed that the duration of ECMO support is a risk factor for CaDVT. The incidence of CaDVT following ECMO decannulation was 24.7%, and the diagnosis of CaDVT can be underestimated. Therefore, we suggest routine screening for CaDVT after cannula removal.
Collapse
Affiliation(s)
- Ngan Hoang Kim Trieu
- From the Department of Critical Care Medicine, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Huy Minh Pham
- From the Department of Critical Care Medicine, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Tuan Anh Mai
- University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam; and
| | - Dai Quang Huynh
- University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam; and
| | - Linh Thanh Tran
- From the Department of Critical Care Medicine, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | | | - Thao Thi Ngoc Pham
- From the Department of Critical Care Medicine, Cho Ray Hospital, Ho Chi Minh City, Vietnam
- University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam; and
| |
Collapse
|
4
|
Davies MG, Hart JP. Extracorporal Membrane Oxygenation in Massive Pulmonary Embolism. Ann Vasc Surg 2024; 105:287-306. [PMID: 38588954 DOI: 10.1016/j.avsg.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 02/09/2024] [Accepted: 02/10/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Massive pulmonary embolism (MPE) carries significant 30-day mortality risk, and a change in societal guidelines has promoted the increasing use of extracorporeal membrane oxygenation (ECMO) in the immediate management of MPE-associated cardiovascular shock. This narrative review examines the current status of ECMO in MPE. METHODS A literature review was performed from 1982 to 2022 searching for the terms "Pulmonary embolism" and "ECMO," and the search was refined by examining those publications that covered MPE. RESULTS In the patient with MPE, veno-arterial ECMO is now recommended as a bridge to interventional therapy. It can reliably decrease right ventricular overload, improve RV function, and allow hemodynamic stability and restoration of tissue oxygenation. The use of ECMO in MPE has been associated with lower mortality in registry reviews, but there has been no significant difference in outcomes between patients treated with and without ECMO in meta-analyses. Applying ECMO is also associated with substantial multisystem morbidity due to systemic inflammatory response, bleeding with coagulopathy, hemorrhagic stroke, renal dysfunction, and acute limb ischemia, which must be factored into the outcomes. CONCLUSIONS The application of ECMO in MPE should be combined with an aggressive interventional pulmonary interventional program and should strictly adhere to the current selection criteria.
Collapse
Affiliation(s)
- Mark G Davies
- Center for Quality, Effectiveness, and Outcomes in Cardiovascular Diseases, Houston, TX; Department of Vascular and Endovascular Surgery, Ascension Health, Waco, TX.
| | - Joseph P Hart
- Division of Vascular Surgery, Medical College of Wisconsin, Milwaukee, WI
| |
Collapse
|
5
|
Pratt EH, Pulsipher AM, Moulton NG, MacDonald A, Poehlein E, Green CL, Rackley CR. Association of RBC Transfusion Thresholds and Outcomes in Medical Patients With Acute Respiratory Failure Supported With Extracorporeal Membrane Oxygenation: A Single-Center Retrospective Cohort Study. Chest 2024:S0012-3692(24)04596-3. [PMID: 38986867 DOI: 10.1016/j.chest.2024.05.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 05/13/2024] [Accepted: 05/15/2024] [Indexed: 07/12/2024] Open
Abstract
BACKGROUND The hemoglobin value to trigger RBC transfusion for patients receiving venovenous extracorporeal membrane oxygenation (ECMO) is controversial. Previous guidelines recommended transfusing to a normal hemoglobin level, but recent studies suggest that more RBC transfusions are associated with increased adverse outcomes. RESEARCH QUESTION Is implementation of different institutional RBC transfusion thresholds for patients receiving venovenous ECMO associated with changes in RBC use and patient outcomes? STUDY DESIGN AND METHODS This single-center retrospective study of patients receiving venovenous ECMO used segmented regression to test associations between implementation of institutional transfusion thresholds and trends in RBC use. Associations with secondary outcomes, including in-hospital survival, also were assessed. RESULTS The study included 229 patients: 91 in the no threshold cohort, 48 in the hemoglobin < 8 g/dL cohort, and 90 in the hemoglobin < 7 g/dL cohort. Despite a decrease in number of RBC units transfused per day of ECMO support after implementation of different thresholds (mean ± SD: 0.6 ± 1.0 in the no threshold cohort, 0.3 ± 0.8 in the hemoglobin < 8 g/dL cohort, and 0.3 ± 1.1 in the hemoglobin < 7 g/dL cohort; P < .001), segmented regression showed no association between implementation of transfusion thresholds and changes in trends in number of RBC units per day of ECMO. We observed an increased hazard of death in the no threshold cohort compared with the hemoglobin < 8 g/dL cohort (adjusted hazard ratio [aHR], 2.08; 95% CI, 1.12-3.88) and in the hemoglobin < 7 g/dL cohort compared with the hemoglobin < 8 g/dL cohort (aHR, 1.93; 95% CI, 1.02-3.62). No difference was found in the hazard of death between the no threshold and hemoglobin < 7 g/dL cohorts (aHR, 1.08; 95% CI, 0.69-1.69). INTERPRETATION We observed a decrease in number of RBC units per day of ECMO over time, but changes were not associated temporally with implementation of transfusion thresholds. A transfusion threshold of hemoglobin < 8 g/dL was associated with a lower hazard of death, but these findings are limited by study methodology. Further research is needed to investigate optimal RBC transfusion practices for patients supported with venovenous ECMO.
Collapse
Affiliation(s)
- Elias H Pratt
- Division of Pulmonary Allergy, and Critical Care Medicine, Duke University School of Medicine, Durham, NC.
| | - Aaron M Pulsipher
- Department of Critical Care Medicine, Mayo Clinic Arizona, Phoenix, AZ
| | - Nathaniel G Moulton
- Division of Pulmonary and Critical Care Medicine, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Andrea MacDonald
- Division of Pulmonary Allergy, and Critical Care Medicine, Duke University School of Medicine, Durham, NC
| | - Emily Poehlein
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Cynthia L Green
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Craig R Rackley
- Division of Pulmonary Allergy, and Critical Care Medicine, Duke University School of Medicine, Durham, NC
| |
Collapse
|
6
|
Aljeaidi M, Fiorilla XM, Mammana B, Anstey M. Mucosal bleeding while on venovenous extracorporeal membrane oxygenation in the setting of vitamin C deficiency. BMJ Case Rep 2024; 17:e259185. [PMID: 38926124 DOI: 10.1136/bcr-2023-259185] [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: 06/28/2024] Open
Abstract
A major complication with extracorporeal membrane oxygenation (ECMO) is bleeding which can occur in up to 40% of cases and can be life-threatening. Minor bleeding may be overlooked and under-reported. While some of the underlying mechanisms such as platelet injury and anticoagulation therapy have been identified, several other factors are still under-researched. Here, we describe a unique case of a subtle mucosal membrane bleeding that is found to be associated with vitamin C deficiency while on treatment with ECMO. Investigating vitamin C levels may be useful in understanding causes of bleeding in some patients on ECMO therapy, particularly if there are risk factors for malnutrition.
Collapse
Affiliation(s)
- Muhamad Aljeaidi
- The University of Western Australia Medical School, Perth, Western Australia, Australia
- Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | | | - Bianca Mammana
- Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Matthew Anstey
- Intensive Care, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
- The University of Western Australia Medical School, Nedlands, Western Australia, Australia
- School of Public Health, Curtin University, Perth, Western Australia, Australia
| |
Collapse
|
7
|
Hileman BA, Martucci G, Rizzitello N, Occhipinti G, Rossetti M, Tuzzolino F, Lorusso R, Panigada M, Tanaka K, Arcadipane A, Panarello G. Antithrombin during veno-venous extracorporeal membrane oxygenation with heparin anticoagulation: A single-center cohort study. Perfusion 2024:2676591241258048. [PMID: 38833217 DOI: 10.1177/02676591241258048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Abstract
INTRODUCTION Antithrombin (AT) is a natural anticoagulant essential to enhancing the unfractionated heparin (UFH) anticoagulant effect. Its supplementation in the management of UFH-based anticoagulation during veno-venous extracorporeal membrane oxygenation (VV ECMO) has a strong pathophysiological rationale. METHODS This is a single-center, retrospective cohort study of adult VV ECMO patients with anticoagulation maintained by UFH targeting an activated partial thromboplastin time (aPTT) of 40-50 s and AT activity >80%. We compare anticoagulation management and survival outcomes between AT subpopulations, defined by a threshold AT activity ≥80%. Linear and logistic regression analyses were used to evaluate the variation in AT activity and its association with ICU survival. RESULTS In 244 patients enrolled from 2009 to 2022, anticoagulation was maintained by a median heparin dose of 11.4 IU/kg/h [IQR: 8.2-14.7] with a mean aPTT of 46.1 s (±7.3) and AT activity of 88.9% (±17.0). A lower mean aPTT, higher dose of UFH and shorter fraction of time without UFH were associated with higher AT activity (p < .01). Higher AT activity showed a consistent association with ICU survival (for 10% increase of AT, odds ratio for ICU mortality: 0.95; 95% CI 0.93-0.97; p value <.01). CONCLUSIONS There is a positive association between AT activity and UFH requirements but no significant difference in the rate of bleeding events. A higher mean AT during VV ECMO was associated with ICU survival. Future studies are needed to differentiate between exogenously supplemented versus endogenous AT effect.
Collapse
Affiliation(s)
| | - Gennaro Martucci
- Department of Anesthesia and Intensive Care, Istituto Mediterraneo per i Trapianti e Terapie ad alta Specializzazione (IRCCS-ISMETT), Palermo, Italy
| | | | - Giovanna Occhipinti
- Department of Anesthesia and Intensive Care, Istituto Mediterraneo per i Trapianti e Terapie ad alta Specializzazione (IRCCS-ISMETT), Palermo, Italy
| | - Matteo Rossetti
- Department of Anesthesia and Intensive Care, Istituto Mediterraneo per i Trapianti e Terapie ad alta Specializzazione (IRCCS-ISMETT), Palermo, Italy
| | - Fabio Tuzzolino
- Statistics and Data Management Services, Istituto Mediterraneo per i Trapianti e Terapie ad alta Specializzazione (IRCCS-ISMETT), Palermo, Italy
| | - Roberto Lorusso
- Cardiothoracic Surgery Department, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Mauro Panigada
- Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Kenichi Tanaka
- The University of Oklahoma Health Sciences Center, University of Oklahoma, Oklahoma City, OK, USA
| | - Antonio Arcadipane
- Department of Anesthesia and Intensive Care, Istituto Mediterraneo per i Trapianti e Terapie ad alta Specializzazione (IRCCS-ISMETT), Palermo, Italy
| | - Giovanna Panarello
- Department of Anesthesia and Intensive Care, Istituto Mediterraneo per i Trapianti e Terapie ad alta Specializzazione (IRCCS-ISMETT), Palermo, Italy
| |
Collapse
|
8
|
Zhang H, Xu Y, Huang X, Yang S, Li R, Wu Y, Zou X, Yu Y, Shang Y. Extracorporeal membrane oxygenation in adult patients with sepsis and septic shock: Why, how, when, and for whom. JOURNAL OF INTENSIVE MEDICINE 2024; 4:62-72. [PMID: 38263962 PMCID: PMC10800772 DOI: 10.1016/j.jointm.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 06/19/2023] [Accepted: 07/07/2023] [Indexed: 01/25/2024]
Abstract
Sepsis and septic shock remain the leading causes of death in intensive care units. Some patients with sepsis fail to respond to routine treatment and rapidly progress to refractory respiratory and circulatory failure, necessitating extracorporeal membrane oxygenation (ECMO). However, the role of ECMO in adult patients with sepsis has not been fully established. According to existing studies, ECMO may be a viable salvage therapy in carefully selected adult patients with sepsis. The choice of venovenous, venoarterial, or hybrid ECMO modes is primarily determined by the patient's oxygenation and hemodynamics (distributive shock with preserved cardiac output, septic cardiomyopathy (left, right, or biventricular heart failure), or right ventricular failure caused by acute respiratory distress syndrome). Veno-venous ECMO can be used in patients with sepsis and severe acute respiratory distress syndrome when conventional mechanical ventilation fails, and early application of veno-arterial ECMO in patients with sepsis-induced refractory cardiogenic shock may be critical in improving their chances of survival. When ECMO is indicated, the choice of an appropriate mode and determination of the optimal timing of initiation and weaning are critical, particularly in an experienced ECMO center. Furthermore, some special issues, such as ECMO flow, anticoagulation, and antibiotic therapy, should be noted during the management of ECMO support.
Collapse
Affiliation(s)
- Hongling Zhang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
- Department of Intensive Care Unit, Affiliated Lu'an Hospital, Anhui Medical University, Lu'an, Anhui, 237000, China
| | - Youdong Xu
- Department of Intensive Care Unit, Affiliated Lu'an Hospital, Anhui Medical University, Lu'an, Anhui, 237000, China
| | - Xin Huang
- Department of Intensive Care Unit, Affiliated Lu'an Hospital, Anhui Medical University, Lu'an, Anhui, 237000, China
| | - Shunyin Yang
- Department of Intensive Care Unit, Affiliated Lu'an Hospital, Anhui Medical University, Lu'an, Anhui, 237000, China
| | - Ruiting Li
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
| | - Yongran Wu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
| | - Xiaojing Zou
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
| | - Yuan Yu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
| | - You Shang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
| |
Collapse
|
9
|
Pong T, Cyr K, Aparicio-Valenzuela J, Carlton C, Lee AM. A Modified 4Ts Score for Heparin-Induced Thrombocytopenia in the Mechanical Circulatory Support Population. J Cardiothorac Vasc Anesth 2023; 37:2499-2507. [PMID: 37407329 DOI: 10.1053/j.jvca.2023.06.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 06/16/2023] [Accepted: 06/21/2023] [Indexed: 07/07/2023]
Abstract
OBJECTIVE To identify risk factors and develop a pretest scoring system to differentiate patients with heparin-induced thrombocytopenia (HIT) in the mechanical circulatory support (MCS) population. The authors present a modified "4TMCS" scoring system, which considers the "type of mechanical circulatory support" that may help identify patients at risk for developing postoperative HIT. DESIGN A retrospective cohort study. Patients who underwent cardiac surgery were categorized into 3 groups: (1) normal platelet count, (2) thrombocytopenia with a negative HIT test, and (3) thrombocytopenia with a positive HIT test. A comparison of diagnostic accuracy between the 4Ts and 4TMCS probability scores was performed. SETTING At a single adult tertiary-care center. PARTICIPANTS A total of 5,314 patients who underwent cardiac surgery between May 1, 2008 and December 31, 2016. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS In total, 125 out of 5,314 patients (2.4%) were diagnosed with HIT, of whom 75 out of 5,314 (1.4%) had clinical evidence of thrombosis. Overall, in-hospital mortality was 25.6%, 11.7%, and 1.5% in the HIT(+), HIT(-), and control groups, respectively (p < 0.001). Mechanical circulatory support was associated with a significantly increased risk for HIT, with an incidence of 5.9% in patients receiving MCS versus 1.9% in those without (p < 0.001). Area under the receiver operator curve (AUC) analysis demonstrated improved diagnostic accuracy of the 4TMCS score compared with the 4Ts (AUC = 0.83 v 0.77, p < 0.044). The 4TMCS score had higher sensitivity than the 4Ts, using the guideline-recommended score cutoff of ≥4 (95.2% v 85.7%). CONCLUSION Heparin-induced thrombocytopenia is associated with worse outcomes and increased morbidity and mortality in the MCS population. Awareness of patient risk factors and the application of a modified 4TMCS probability score may allow for more accurate screening and treatment of HIT in the MCS population.
Collapse
Affiliation(s)
- Terrence Pong
- Department of Cardiothoracic Surgery, School of Medicine, Stanford University, Stanford, Stanford, CA
| | - Kevin Cyr
- Department of Cardiothoracic Surgery, School of Medicine, Stanford University, Stanford, Stanford, CA
| | - Joy Aparicio-Valenzuela
- Department of Cardiothoracic Surgery, School of Medicine, Stanford University, Stanford, Stanford, CA
| | - Cody Carlton
- Department of Cardiothoracic Surgery, School of Medicine, Stanford University, Stanford, Stanford, CA
| | - Anson M Lee
- Department of Cardiothoracic Surgery, School of Medicine, Stanford University, Stanford, Stanford, CA.
| |
Collapse
|
10
|
Zhao J, Cui P, Zhou Z, Niu B, Pan C. Treatment of malignant airway stenosis with extracorporeal membrane oxygenation under low-dose anticoagulation: A case report. Heliyon 2023; 9:e23210. [PMID: 38144268 PMCID: PMC10746480 DOI: 10.1016/j.heliyon.2023.e23210] [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: 06/07/2023] [Revised: 11/24/2023] [Accepted: 11/29/2023] [Indexed: 12/26/2023] Open
Abstract
The occurrence of airway obstruction due to severe stenosis from lung cancer poses a significant risk of asphyxia. Although the placement of a metallic stent may relieve the obstruction, the procedure is associated with a high risk of asphyxia. To mitigate this risk, extracorporeal membrane pulmonary oxygenation (ECMO) has been proposed to temporarily substitute for cardiopulmonary function during the procedure. However, the use of systemic anticoagulation with heparin during ECMO may increase the likelihood of bleeding during surgery. This case report describes a successful treatment of a patient with malignant central airway obstruction through low-dose heparin veno-venous ECMO. This approach resulted in reduced intraoperative bleeding and invasive operation time, allowing for prompt postoperative withdrawal and recovery.
Collapse
Affiliation(s)
- Jingsha Zhao
- Department of Intensive Care Unit, The Third People's Hospital of Chengdu, Chengdu, Sichuan, China
- Department of Intensive Care Unit, Pujiang People's Hospital, Chengdu, Sichuan, China
| | - Peng Cui
- Department of Cardiovascular, The Third People's Hospital of Chengdu, Chengdu, Sichuan, China
| | - Ziwei Zhou
- Department of Intensive Care Unit, The Third People's Hospital of Chengdu, Chengdu, Sichuan, China
| | - Bin Niu
- Department of Respiratory, The Third People's Hospital of Chengdu, Chengdu, Sichuan, China
| | - Chuanliang Pan
- Department of Intensive Care Unit, The Third People's Hospital of Chengdu, Chengdu, Sichuan, China
| |
Collapse
|
11
|
Ehrenberger R, Németh BT, Kulyassa P, Fülöp GA, Becker D, Kiss B, Zima E, Merkely B, Édes IF. Acute coronary syndrome associated cardiogenic shock in the catheterization laboratory: peripheral veno-arterial extracorporeal membrane oxygenator management and recommendations. Front Med (Lausanne) 2023; 10:1277504. [PMID: 38020166 PMCID: PMC10661940 DOI: 10.3389/fmed.2023.1277504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 09/18/2023] [Indexed: 12/01/2023] Open
Abstract
Cardiogenic shock (CS) in acute coronary syndrome (ACS) is a critical disease with high mortality rates requiring complex treatment to maximize patient survival chances. Emergent coronary revascularization along with circulatory support are keys to saving lives. Mechanical circulatory support may be instigated in severe, yet still reversible instances. Of these, the peripheral veno-arterial extracorporeal membrane oxygenator (pVA-ECMO) is the most widely used system for both circulatory and respiratory support. The aim of our work is to provide a review of our current understanding of the pVA-ECMO when used in the catheterization laboratory in a CS ACS setting. We detail the workings of a Shock Team: pVA-ECMO specifics, circumstances, and timing of implantations and discuss possible complications. We place emphasis on how to select the appropriate patients for potential pVA-ECMO support and what characteristics and parameters need to be assessed. A detailed, stepwise implantation algorithm indicating crucial steps is also featured for practitioners in the catheter laboratory. To provide an overall aspect of pVA-ECMO use in CS ACS we further gave pointers including relevant human resource, infrastructure, and consumables management to build an effective Shock Team to treat CS ACS via the pVA-ECMO method.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | - István F. Édes
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| |
Collapse
|
12
|
Nangrani A, Chung J, Jyang E, Nangrani K, Schmidt M. A Rare Case of Diffuse Alveolar Hemorrhage Caused by Fentanyl Inhalation. Cureus 2023; 15:e47598. [PMID: 38022247 PMCID: PMC10665760 DOI: 10.7759/cureus.47598] [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: 10/23/2023] [Indexed: 12/01/2023] Open
Abstract
Diffuse alveolar hemorrhage (DAH) is a rare but life-threatening pulmonary disorder characterized by blood accumulation in alveolar spaces, often associated with autoimmune diseases and infections. Drug-induced causes of DAH, including inhalation of substances like fentanyl, are emerging concerns. A 40-year-old male with bipolar disorder and polysubstance abuse presented with altered mental status and hemoptysis after inhaling an unknown substance. Physical examination revealed respiratory distress, pinpoint pupils, and severe hypoxemia. Naloxone administration improved his condition. The workup showed negative infection markers, positive fentanyl-specific urine test, and diffuse bilateral opacities on imaging. Bronchoalveolar lavage confirmed DAH with >20% hemosiderin-laden macrophages. Steroid treatment resulted in marked improvement. Drug-induced DAH, such as fentanyl inhalation, should be considered in patients with altered mental status and pulmonary symptoms following substance use. Comprehensive evaluation and targeted treatment are crucial for optimal outcomes.
Collapse
Affiliation(s)
- Aneeta Nangrani
- Pulmonary and Critical Care Medicine, One Brooklyn Health, Brooklyn, USA
| | - Justin Chung
- Internal Medicine, State University of New York Downstate Medical Center, Brooklyn, USA
| | - Edison Jyang
- Internal Medicine, Medical University of Lublin, Lublin, POL
| | - Kunal Nangrani
- Pulmonary and Critical Care Medicine, Mount Sinai Hospital, Queens, USA
| | - Marie Schmidt
- Pulmonary and Critical Care Medicine, Interfaith Medical Center, Brooklyn, USA
| |
Collapse
|
13
|
Teixeira JP, Larson LM, Schmid KM, Azevedo K, Kraai E. Extracorporeal cardiopulmonary resuscitation. Int Anesthesiol Clin 2023; 61:22-34. [PMID: 37589133 DOI: 10.1097/aia.0000000000000415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Affiliation(s)
- J Pedro Teixeira
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Lance M Larson
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
- Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Kristin M Schmid
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
- Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Keith Azevedo
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
- Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Erik Kraai
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| |
Collapse
|
14
|
Cohan D, Uricchio MN, Konopka CI, Montepara CA, Verlinden NJ. Comparison of clinical outcomes with cangrelor plus aspirin versus oral dual antiplatelet therapy in patients supported with venoarterial extracorporeal membrane oxygenation. Artif Organs 2023; 47:1672-1677. [PMID: 37203212 DOI: 10.1111/aor.14590] [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: 11/14/2022] [Revised: 04/22/2023] [Accepted: 05/13/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Patients with refractory cardiogenic shock from an acute myocardial infarction may receive percutaneous coronary intervention (PCI) and require the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO). The purpose of this study was to compare bleeding and thrombotic events in patients treated with cangrelor plus aspirin versus oral dual antiplatelet therapy (DAPT) while supported with VA-ECMO. METHODS We conducted a retrospective review of patients who received PCI, were supported with VA-ECMO, and were treated with either cangrelor plus aspirin or oral DAPT from February 2016 through May 2021 at Allegheny General Hospital. The primary objective was the incidence of major bleeding, defined as Bleeding Academic Research Consortium (BARC) type 3 or greater. The incidence of thrombotic events was a secondary objective. RESULTS Thirty-seven patients were included, 19 in the cangrelor plus aspirin group, and 18 in the oral DAPT group. All the patients in the cangrelor group received a dose of 0.75 mcg/kg/min. Major bleeding occurred in 7 patients (36.8%) in the cangrelor group compared to 7 patients (38.9%) in the oral DAPT group (p = 0.90). No patient developed stent thrombosis. Two patients (10.5%) in the cangrelor group had a thrombotic event versus 3 patients (16.7%) in the oral DAPT group (p = 0.66). CONCLUSIONS Bleeding and thrombotic events were comparable between patients receiving cangrelor plus aspirin versus oral DAPT while on VA-ECMO.
Collapse
Affiliation(s)
- Dana Cohan
- Department of Pharmacy, Sentara Norfolk General Hospital, Norfolk, Virginia, USA
| | - Marissa N Uricchio
- Department of Pharmacy, Cooperman Barnabas Medical Center, Livingston, New Jersey, USA
| | - Chelsea I Konopka
- Department of Pharmacy, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Courtney A Montepara
- Department of Pharmacy, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
- Duquesne University School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Nathan J Verlinden
- Department of Pharmacy, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
15
|
Dave SB, Rabinowitz R, Shah A, Tabatabai A, Galvagno SM, Mazzeffi MA, Rector R, Kaczorowski DJ, Scalea TM, Menaker J. COVID-19 outcomes of venovenous extracorporeal membrane oxygenation for acute respiratory failure vs historical cohort of non-COVID-19 viral infections. Perfusion 2023; 38:1165-1173. [PMID: 35653427 PMCID: PMC9168413 DOI: 10.1177/02676591221105603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Veno-venous extracorporeal membrane oxygenation (VV ECMO) has become a support modality for patients with acute respiratory failure refractory to standard therapies. VV ECMO has been increasingly used during the current COVID-19 pandemic for patients with refractory respiratory failure. The object of this study was to evaluate the outcomes of VV ECMO in patients with COVID-19 compared to patients with non-COVID-19 viral infections. METHODS We retrospectively reviewed all patients supported with VV ECMO between 8/2014 and 8/2020 whose etiology of illness was a viral pulmonary infection. The primary outcome of this study was to evaluate in-hospital mortality. The secondary outcomes included length of ECMO course, ventilator duration, hospital length of stay, incidence of adverse events through ECMO course. RESULTS Eighty-nine patients were included (35 COVID-19 vs 54 non-COVID-19). Forty (74%) of the non-COVID-19 patients had influenza virus. Prior to cannulation, COVID-19 patients had longer ventilator duration (3 vs 1 day, p = .003), higher PaCO2 (64 vs 53 mmHg, p = .012), and white blood cell count (14 vs 9 ×103/μL, p = .004). Overall in-hospital mortality was 33.7% (n = 30). COVID-19 patients had a higher mortality (49% vs. 24%, p = .017) when compared to non-COVID-19 patients. COVID-19 survivors had longer median time on ECMO than non-COVID-19 survivors (24.4 vs 16.5 days p = .03) but had a similar hospital length of stay (HLOS) (41 vs 48 Extracorporeal Membrane Oxygenationdays p = .33). CONCLUSION COVID-19 patients supported with VV ECMO have a higher mortality than non-COVID-19 patients. While COVID-19 survivors had significantly longer VV ECMO runs than non-COVID-19 survivors, HLOS was similar. This data add to a growing body of literature supporting the use of ECMO for potentially reversible causes of respiratory failure.
Collapse
Affiliation(s)
- Sagar B Dave
- Department of Emergency Medicine,
Department of Anesthesiology, Division of Critical Care,
Emory
University School of Medicine, Atlanta,
GA, USA
| | - Ronald Rabinowitz
- Department of Medicine, Program in
Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of
Medicine, Baltimore, MD, USA
| | - Aakash Shah
- Department of Surgery, Division of
Cardiac Surgery, University of Maryland School of
Medicine, Baltimore, MD, USA
| | - Ali Tabatabai
- Department of Medicine, Division of
Pulmonary and Critical Care, Program in Trauma, R Adams Cowley Shock Trauma
Center, University
of Maryland School of Medicine,
Baltimore, MD, USA
| | - Samuel M Galvagno
- Department of Anesthesiology,
Program in Trauma, R Adams Cowley Shock Trauma Center,
University
of Maryland School of Medicine,
Baltimore, MD, USA
| | - Michael A Mazzeffi
- Department of Anesthesiology and
Critical Care Medicine, George Washington School of Medicine and
Health Sciences, Washington, DC,
USA
| | - Raymond Rector
- Perfusion Services,
University
of Maryland Medical Center, Baltimore,
MD, USA
| | - David J Kaczorowski
- Department of Cardiothoracic
Surgery, University
of Pittsburgh Medical Center,
Pittsburgh, PA, USA
| | - Thomas M Scalea
- Department of Surgery, Program in
Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of
Medicine, Baltimore, MD, USA
| | - Jay Menaker
- Department of Surgery, Johns
Hopkins Medicine, Howard County General
Hospital, Columbia, MD, USA
| |
Collapse
|
16
|
Scott Eldredge R, Russell KW. Pediatric surgical interventions on ECMO. Semin Pediatr Surg 2023; 32:151330. [PMID: 37931540 DOI: 10.1016/j.sempedsurg.2023.151330] [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: 11/08/2023]
Abstract
Extra Corporeal Membrane Oxygenation (ECMO) has historically been reserved for refractory pulmonary and cardiac support in children and adult. Operative intervention on ECMO was traditionally contraindicated due to hemorrhagic complications exacerbated by critical illness and anticoagulation needs. With advancements in ECMO circuitry and anticoagulation strategies operative procedures during ECMO have become feasible with minimal hemorrhagic risks. Here we review anticoagulation and operative intervention considerations in the pediatric population during ECMO cannulation. Pediatric surgical interventions currently described in the literature while on ECMO support include thoracotomy/thoracoscopy, tracheostomy, laparotomy, and injury related procedures i.e. wound debridement. A patient should not be precluded from a surgical intervention while on ECMO, if the surgery is indicated.
Collapse
Affiliation(s)
- R Scott Eldredge
- Department of Surgery, Mayo Clinic, Phoenix, AZ, United States; Department of Pediatric Surgery, Phoenix Children's, Phoenix, AZ, United States
| | - Katie W Russell
- Department of Surgery, Division of Pediatric Surgery, University of Utah, Salt Lake City, UT, United States.
| |
Collapse
|
17
|
Howick V JF, Rezkalla JA, Tilbury T, Mankad SV, Bennett CE, Herrmann J, Barsness G, Ansell SM, Read MD. Venoarterial Extracorporeal Membrane Oxygenation After Autologous Stem Cell Transplantation With Pancytopenia: JACC Patient Care Pathways. J Am Coll Cardiol 2023; 82:374-378. [PMID: 37294246 PMCID: PMC10894682 DOI: 10.1016/j.jacc.2023.04.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 04/28/2023] [Indexed: 06/10/2023]
Abstract
Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides temporary mechanical circulatory support and simultaneous extracorporeal gas exchange for acute cardiorespiratory failure. By providing circulatory support, VA-ECMO gives treatments time to reach optimal efficacy or may be used as a bridge to a more durable mechanical solution for patients with acute cardiopulmonary failure. It is commonly used when a readily reversible etiology of decompensation is identified with very strict inclusion criteria for extracorporeal cardiopulmonary resuscitation use. We present a unique case in which VA-ECMO/extracorporeal cardiopulmonary resuscitation was used after cardiac arrest with pulseless electrical activity in a patient with recurrent lymphoma of the left thigh with recent autologous stem cell transplant.
Collapse
Affiliation(s)
- James F Howick V
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Joshua A Rezkalla
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Thomas Tilbury
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Sunil V Mankad
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Courtney E Bennett
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Joerg Herrmann
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Gregory Barsness
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Stephen M Ansell
- Department of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew D Read
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| |
Collapse
|
18
|
Howick V JF, Rezkalla JA, Tilbury T, Mankad SV, Bennett CE, Herrmann J, Barsness G, Ansell SM, Read MD. Venoarterial Extracorporeal Membrane Oxygenation After Autologous Stem Cell Transplantation With Pancytopenia: JACC Patient Care Pathways. JACC Case Rep 2023; 18:101913. [PMID: 37545681 PMCID: PMC10401053 DOI: 10.1016/j.jaccas.2023.101913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 04/28/2023] [Indexed: 08/08/2023]
Abstract
Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides temporary mechanical circulatory support and simultaneous extracorporeal gas exchange for acute cardiorespiratory failure. By providing circulatory support, VA-ECMO gives treatments time to reach optimal efficacy or may be used as a bridge to a more durable mechanical solution for patients with acute cardiopulmonary failure. It is commonly used when a readily reversible etiology of decompensation is identified with very strict inclusion criteria for extracorporeal cardiopulmonary resuscitation use. We present a unique case in which VA-ECMO/extracorporeal cardiopulmonary resuscitation was used after cardiac arrest with pulseless electrical activity in a patient with recurrent lymphoma of the left thigh with recent autologous stem cell transplant.
Collapse
Affiliation(s)
- James F. Howick V
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Joshua A. Rezkalla
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Thomas Tilbury
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Sunil V. Mankad
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Courtney E. Bennett
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Joerg Herrmann
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Gregory Barsness
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Matthew D. Read
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
19
|
Bernhardt AM, Copeland H, Deswal A, Gluck J, Givertz MM. The International Society for Heart and Lung Transplantation/Heart Failure Society of America Guideline on Acute Mechanical Circulatory Support. J Heart Lung Transplant 2023; 42:e1-e64. [PMID: 36805198 DOI: 10.1016/j.healun.2022.10.028] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 10/28/2022] [Indexed: 02/08/2023] Open
Affiliation(s)
- Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany.
| | - Hannah Copeland
- Department of Cardiac Surgery, Lutheran Health Physicians, Fort Wayne, Indiana
| | - Anita Deswal
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jason Gluck
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Michael M Givertz
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| |
Collapse
|
20
|
Neubauer S, DelloStritto DJ, Capal N, Hotrum A, Henn L, Marchand T. Venovenous extracorporeal membrane oxygenation experience in a community level I trauma center. Perfusion 2023; 38:484-490. [PMID: 35236185 DOI: 10.1177/02676591211059743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND There is limited literature of venovenous extracorporeal membrane oxygenation use in a community, non-university, setting in the trauma population. METHODS We reviewed our cases over 2 years from March 2018 to March 2020. This study was conducted in a community hospital with a General Surgery residency with no direct affiliation to a medical school. Primary outcome reviewed was survival to discharge. Secondary outcomes included duration of extracorporeal membranous oxygenation (ECMO) support, blood transfusion requirement, complications, and disposition. RESULTS Five patients were cannulated during this time period. All patients survived to discharge. Mean time on ECMO was 153.4 h or 6.4 days (range 60-216 h). All patients required a transfusion while cannulated, with a mean of 10 units PRBC transfused (range 3-24). One patient required CPR, one required cessation of heparin drip for bleeding, and one had clinical signs of a stroke. Three patients were discharged to long-term acute care facilities and the other two to acute rehab. CONCLUSIONS Community level I trauma centers are capable of handling trauma patients requiring ECMO. It does require a multi-disciplinary team of surgical intensivists and cardiothoracic surgeons along with the support of nursing, respiratory therapists, and perfusionists. The outcomes in this limited series show that ECMO can be a tool utilized in the community setting.
Collapse
Affiliation(s)
- Steven Neubauer
- Department of General Surgery, 22987Mercy St. Elizabeth Hospital, Youngstown, OH, USA
| | - Daniel J DelloStritto
- Department of General Surgery, 22987Mercy St. Elizabeth Hospital, Youngstown, OH, USA
| | - Nicholas Capal
- Department of General Surgery, 22987Mercy St. Elizabeth Hospital, Youngstown, OH, USA
| | - Andrew Hotrum
- Department of General Surgery, 22987Mercy St. Elizabeth Hospital, Youngstown, OH, USA
| | - Lucas Henn
- Department of Cardiothoracic Surgery, 22987Mercy St. Elizabeth Hospital, Youngstown, OH, USA
| | - Tiffany Marchand
- Department of Trauma Surgery, 22987Mercy St. Elizabeth Hospital, Youngstown, OH, USA
| |
Collapse
|
21
|
Liang H, Fritz AV, Martin AK. Perioperative Circulatory Support and Management for Lung Transplantation: A Case-Based Review. Semin Cardiothorac Vasc Anesth 2023; 27:68-74. [PMID: 36250808 DOI: 10.1177/10892532221134574] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Lung transplantation (LTx) historically was performed with cardiopulmonary bypass (CPB) or Off-pump. Recent data suggest an increased interest in extracorporeal membrane oxygenation (ECMO) as perioperative circulatory support by many lung transplantation centers worldwide. However, there are no established guidelines for anesthetic management for LTx. We present a patient with a history of systemic sclerosis and interstitial lung disease complicated by acute onset of systemic pulmonary hypertension and right heart failure undergoing LTx. We aim to discuss perioperative circulatory support, including ECMO bridge to LTx, and how best to consider the varied intraoperative strategies of CPB vs ECMO vs off-pump during LTx, intraoperative maintenance, and coagulation management.
Collapse
Affiliation(s)
- Hong Liang
- Department of Anesthesiology and Perioperative Medicine, Division of Cardiovascular and Thoracic Anesthesiology, 156400Mayo Clinic, Jacksonville, FL, USA
| | - Ashley V Fritz
- Department of Anesthesiology and Perioperative Medicine, Division of Cardiovascular and Thoracic Anesthesiology, 156400Mayo Clinic, Jacksonville, FL, USA
| | - Archer K Martin
- Department of Anesthesiology and Perioperative Medicine, Division of Cardiovascular and Thoracic Anesthesiology, 156400Mayo Clinic, Jacksonville, FL, USA
| |
Collapse
|
22
|
Gao S, Zhang Y, Peng R, Yan S, Teng Y, Qi J, Cheng G, Yu D, Liu G, Xu Q, Cai X, Zhou Z, Ji B. Hemostatic alterations during extracorporeal membrane oxygenation in ovine veno-venous and veno-arterial models. Artif Organs 2023; 47:526-536. [PMID: 36310416 DOI: 10.1111/aor.14437] [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: 04/12/2022] [Revised: 08/10/2022] [Accepted: 10/11/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) has salvaged many people's life during global pandemics. However, ECMO is associated with a high incidence of hemostatic complications. This study aims to explore the effects of the ECMO system on the coagulation system in the healthy ovine ECMO model. METHODS Ten healthy male sheep were included. Five received the veno-arterial ECMO and five received the veno-venous ECMO. Heparin was infused for systemic anticoagulation and was adjusted according to the activated clotting time. Blood routine tests, coagulation factors, anticoagulation proteins, and fibrinolysis markers were tested at the baseline and every 24 h. After weaning, the pump heads were dissected to explore thrombosis. RESULTS Platelets decreased in the first 72 h and returned to the baseline at the 120th hour. The neutrophils increased in the first 24 h and returned to the baseline at the 48th hour. Factors II, VII, and X decreased in the first 24 h and gradually increased, while factors VIII, IX, XI, and XII decreased in the first 24 h and remained at a low level. The baseline antithrombin was 73.2 ± 14.4% and reduced to 42.6 ± 9.9% at the 168th hour. Pathology showed seven sheep developed thrombus, but no clinically relevant bleeding or thrombosis events occurred. CONCLUSIONS The study explored hemostatic alterations during ECMO in healthy animal models, which eliminated the confounding under critically ill conditions. The study may provide insights into ECMO hemostatic disorders and aid the design of optimal therapeutic strategies.
Collapse
Affiliation(s)
- Sizhe Gao
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Beijing, China
| | - Yang Zhang
- Department of Laboratory Medicine, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Beijing, China
| | - Rui Peng
- Department of Laboratory Medicine, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Beijing, China.,Center of Clinical Laboratory, Capital Medical University Affiliated Beijing Friendship Hospital, Beijing, China
| | - Shujie Yan
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Beijing, China
| | - Yuan Teng
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Beijing, China
| | - Jiachen Qi
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Beijing, China
| | - Gaowa Cheng
- Department of Laboratory Medicine, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Beijing, China
| | - Dongze Yu
- Department of Laboratory Medicine, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Beijing, China
| | - Gang Liu
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Beijing, China
| | - Qiang Xu
- Department of Laboratory Medicine, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Beijing, China
| | - Xiaohui Cai
- Department of Laboratory Medicine, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Beijing, China
| | - Zhou Zhou
- Department of Laboratory Medicine, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Beijing, China
| | - Bingyang Ji
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Beijing, China
| |
Collapse
|
23
|
Bernhardt AM, Copeland H, Deswal A, Gluck J, Givertz MM. The International Society for Heart and Lung Transplantation/Heart Failure Society of America Guideline on Acute Mechanical Circulatory Support. J Card Fail 2023; 29:304-374. [PMID: 36754750 DOI: 10.1016/j.cardfail.2022.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany.
| | - Hannah Copeland
- Department of Cardiac Surgery, Lutheran Health Physicians, Fort Wayne, Indiana
| | - Anita Deswal
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jason Gluck
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Michael M Givertz
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| |
Collapse
|
24
|
Northam KA, Nguyen B, Chen SL, Sredzienski E, Charles A. Evaluation of a Multimodal Heparin Laboratory Monitoring Protocol in Adult Extracorporeal Membrane Oxygenation Patients. J Pharm Pract 2023; 36:79-86. [PMID: 34109859 DOI: 10.1177/08971900211021249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Anticoagulation monitoring practices vary during extracorporeal membrane oxygenation (ECMO). The Extracorporeal Life Support Organization describes that a multimodal approach is needed to overcome assay limitations and minimize complications. OBJECTIVE Compare activated clotting time (ACT) versus multimodal approach (activated partial thromboplastin time (aPTT)/anti-factor Xa) for unfractionated heparin (UFH) monitoring in adult ECMO patients. METHODS We conducted a single-center retrospective pre- (ACT) versus post-implementation (multimodal approach) study. The incidence of major bleeding and thrombosis, blood product and antithrombin III (ATIII) administration, and UFH infusion rates were compared. RESULTS Incidence of major bleeding (69.2% versus 62.2%, p = 0.345) and thrombosis (23% versus 14.9%, p = 0.369) was similar between groups. Median number of ATIII doses was reduced in the multimodal group (1.0 [IQR 0.0-2.0] versus 0.0 [0.0 -1.0], p = 0.007). The median UFH infusion rate was higher in the ACT group, but not significant (16.9 [IQR 9.6-22.4] versus 13 [IQR 9.6-15.4] units/kg/hr, p = 0.063). Fewer UFH infusion rate changes occurred prior to steady state in the multimodal group (0.9 [IQR 0.3 -1.7] versus 0.1 [IQR 0.0-0.2], p < 0.001). CONCLUSION The incidence of major bleeding and thrombosis was similar between groups. Our multimodal monitoring protocol standardized UFH infusion administration and reduced ATIII administration.
Collapse
Affiliation(s)
- Kalynn A Northam
- Department of Pharmacy, 15521University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Bobbie Nguyen
- 15521Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Sheh-Li Chen
- Department of Pharmacy, 15521University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Edward Sredzienski
- Department of Pharmacy, 15521University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Anthony Charles
- Division of General and Acute Surgery, 2331University of North Carolina Medical Center, Chapel Hill, NC, USA
| |
Collapse
|
25
|
Bivalirudin Versus Unfractionated Heparin in Patients With Cardiogenic Shock Requiring Venoarterial Extracorporeal Membrane Oxygenation. ASAIO J 2023; 69:107-113. [PMID: 35412480 DOI: 10.1097/mat.0000000000001723] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
This study evaluated differences in efficacy and safety outcomes with bivalirudin compared with unfractionated heparin (UFH) in patients with cardiogenic shock requiring venoarterial extracorporeal membrane oxygenation (VA ECMO). We performed a retrospective study at an academic medical center that included patients greater than 18 years of age supported with VA ECMO due to cardiogenic shock from January 2009 to February 2021. The primary endpoint was ECMO-associated thrombotic events normalized to duration of ECMO support. Secondary safety endpoints included major bleeding (per ELSO criteria) and blood product administration. Overall, 143 patients were included in our analysis with 54 having received bivalirudin and 89 having received UFH. Median duration of ECMO support was 92 (interquartile range, 56-172) hours. ECMO-associated thrombotic events per ECMO day were significantly less among those that received bivalirudin ( P < 0.001). In adjusted regression, bivalirudin was independently associated with an increased time to thrombosis when compared with UFH (Exp[B] -3.8; 95% confidence interval, 1.7-8.8; P = 0.002). Patients receiving bivalirudin experienced less major bleeding events ( P = 0.02) with less total red blood cell and fresh frozen plasma administration ( P = 0.04 and P = 0.03, respectively). Bivalirudin is a safe and efficacious alternative to UFH in patients requiring VA ECMO for cardiogenic shock.
Collapse
|
26
|
Elmelliti H, Mutkule DP, Imran M, Shallik NA, Hssain AA, Shehatta AL. Bleeding Hazard of Percutaneous Tracheostomy in COVID-19 Patients Supported With Venovenous Extracorporeal Membrane Oxygenation: A Case Series. J Cardiothorac Vasc Anesth 2023; 37:73-80. [PMID: 36229290 PMCID: PMC9487148 DOI: 10.1053/j.jvca.2022.09.084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 09/12/2022] [Accepted: 09/14/2022] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Tracheostomy usually is performed to aid weaning from mechanical ventilation and facilitate rehabilitation and secretion clearance. Little is known about the safety of percutaneous tracheostomy in patients with severe COVID-19 supported on venovenous extracorporeal membrane oxygenation (VV-ECMO). This study aimed to investigate the bleeding risk of bedside percutaneous tracheostomy in patients with COVID-19 infection supported with VV-ECMO. DESIGN A Retrospective review of electronic data for routine care of patients on ECMO. SETTING Tertiary, university-affiliated national ECMO center. PARTICIPANTS Patients with COVID-19 who underwent percutaneous tracheostomy while on VV-ECMO support. INTERVENTIONS No intervention was conducted during this study. MEASUREMENTS AND MAIN RESULTS Electronic medical records of 16 confirmed patients with COVID-19 who underwent percutaneous tracheostomy while on VV-ECMO support, including patient demographics, severity of illness, clinical variables, procedural complications, and outcomes, were compared with 16 non-COVID-19 patients. The SPSS statistical software was used for statistical analysis. The demographic data were compared using the chi-square test, and normality assumption was tested using the Shapiro-Wilk test. The indications for tracheostomy in all the patients were prolonged mechanical ventilation and sedation management. None of the patients suffered a life-threatening procedural complication within 48 hours. Moderate-to-severe bleeding was similar in both groups. There was no difference in 30- and 90-days mortality between both groups. As per routine screening results, none of the staff involved contracted COVID-19 infection. CONCLUSIONS In this case series, percutaneous tracheostomy during VV-ECMO in patients with COVID-19 appeared to be safe and did not pose additional risks to patients or healthcare workers.
Collapse
Affiliation(s)
- Hussam Elmelliti
- Emergency Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar.
| | | | - Muhammad Imran
- Medical Intensive Care Unit, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Nabil Abdelhamid Shallik
- Department of Anesthesia, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar; Weill Cornell Medicine - Qatar, Doha, Qatar; Qatar University, Doha, Qatar; Tanta University, Tanta, Egypt
| | - Ali Ait Hssain
- Medical Intensive Care Unit, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar; Weill Cornell Medicine - Qatar, Doha, Qatar
| | - Ahmed Labib Shehatta
- Medical Intensive Care Unit, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar; Weill Cornell Medicine - Qatar, Doha, Qatar
| |
Collapse
|
27
|
Yang Y, Gowda SH, Hagan JL, Hensch L, Teruya J, Fernandes CJ, Hui SKR. Blood transfusion is associated with increased mortality for neonates with congenital diaphragmatic hernia on extracorporeal membrane oxygenation support. Vox Sang 2022; 117:1391-1397. [PMID: 36121192 DOI: 10.1111/vox.13363] [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: 02/10/2022] [Revised: 08/29/2022] [Accepted: 09/05/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND OBJECTIVES Blood transfusion is frequently needed to maintain adequate haemostasis and improve oxygenation for patients treated with extracorporeal membrane oxygenation (ECMO). It is more so for neonates with immature coagulation systems who require surgical intervention such as congenital diaphragmatic hernia (CDH) repair. There is growing evidence suggesting an association between blood transfusions and increased mortality. The aim of this study is to evaluate the association of blood transfusions during the peri-operative period of CDH repair, among other clinical parameters, with mortality in neonates undergoing on-ECMO CDH repair. MATERIALS AND METHODS We performed a single centre retrospective chart review of all neonates with CDH undergoing on-ECMO surgical repair from January 2010 to December 2020. Logistic regression was used to investigate associations with survival status. RESULTS Sixty-two patients met the inclusion criteria. Platelet transfusions (odds ratio [OR] 1.42, 95% confidence interval [CI]: 1.06-1.90) in the post-operative period and ECMO duration (OR 1.17, 95% CI: 1.05-1.30) were associated with increased mortality. Major bleeding complications had the strongest association with mortality (OR 10.98, 95% CI: 3.27-36.91). Gestational age, birth weight, Apgar scores, sex, blood type, right versus left CDH, venovenous versus venoarterial ECMO and duration of ECMO before CDH repair and circuit change after adjusting for ECMO duration were not significantly associated with survival. CONCLUSION Platelet transfusion in the post-operative period and major bleeding are associated with increased mortality in CDH neonates with surgical repair. The data suggest a need to develop robust plans for monitoring and preventing coagulation aberrancies during neonatal ECMO support.
Collapse
Affiliation(s)
- Yu Yang
- Department of Pathology and Immunology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Sharada H Gowda
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Joseph L Hagan
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Lisa Hensch
- Department of Pathology and Immunology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA.,Department of Anesthesiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Jun Teruya
- Department of Pathology and Immunology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA.,Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA.,Department of Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Caraciolo J Fernandes
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Shiu-Ki R Hui
- Department of Pathology and Immunology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA.,Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| |
Collapse
|
28
|
Misumi K, Hagiwara Y, Ogura T. Giant cylinder-shaped venous thrombus caused by extracorporeal membrane oxygenation cannula. Acute Med Surg 2022; 9:e791. [PMID: 36254311 PMCID: PMC9526802 DOI: 10.1002/ams2.791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 09/08/2022] [Indexed: 11/08/2022] Open
Affiliation(s)
- Kayo Misumi
- Department of Emergency and Critical CareSaiseikai Utsunomiya HospitalUtsunomiyaJapan,Department of CardiologySaiseikai Utsunomiya HospitalUtsunomiyaJapan
| | - Yoshihiro Hagiwara
- Department of Emergency and Critical CareSaiseikai Utsunomiya HospitalUtsunomiyaJapan
| | - Takayuki Ogura
- Department of Emergency and Critical CareSaiseikai Utsunomiya HospitalUtsunomiyaJapan
| |
Collapse
|
29
|
Volod O, Wegner J. Viscoelastic Testing in the Management of Adult Patients on Mechanical Circulatory Support Devices with Focus on Extracorporeal Membrane Oxygenation. Semin Thromb Hemost 2022; 48:814-827. [DOI: 10.1055/s-0042-1756303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
AbstractThromboembolic and hemorrhagic complications continue to remain frequent complications that significantly impact the morbidity and mortality of patients implanted with mechanical circulatory support devices (MCSDs). The severe acute respiratory syndrome caused by coronavirus 2 (SARS-CoV-2) has resulted in a number of COVID-19 patients being supported by MCSDs, specifically extracorporeal membrane oxygenation (ECMO), which in turn has created a crucial need for rapid assessment of hemostatic status in these patients to avoid bleeding and thrombotic complications. Currently, conventional plasma-based coagulation assays such as prothrombin time and activated partial thromboplastin time (aPTT) are used to assess hemostasis, and the activated clotting time (ACT) and aPTT are the most common tests used to monitor heparin anticoagulation in patients on ECMO. Unfractionated heparin remains the mainstay anticoagulation therapy for patients on ECMO. Extracorporeal Life Support Organization (ELSO) offers little guidance on the subject but does state that each institution should create its internal anticoagulation protocols. Viscoelastic assays (VEAs) are increasingly recognized by ELSO and ECMO community for their potential to assess hemostatic derangements in patients implanted with MCSDs as well as guidance for appropriate hemostatic therapy. This review focuses on the evidence for the use of viscoelastic assays to assess overall hemostasis and to guide the treatment of adult patients connected to an ECMO circuit. Limitations of the use of conventional assays, ACT, and VEA are also discussed.
Collapse
Affiliation(s)
- Oksana Volod
- Department of Pathology and Laboratory Medicine, Cedars Sinai Medical Center, Los Angeles, California
| | - Julie Wegner
- College of Health Professions, South University Online, Savannah, Georgia
| |
Collapse
|
30
|
Cercone JL, Kram SJ, Trammel MA, Rackley CR, Lee HJ, Merchant J, Kram BL. Effect of Initial Anticoagulation Targets on Bleeding and Thrombotic Complications for Patients With Acute Respiratory Distress Syndrome Receiving Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2022; 36:3561-3569. [PMID: 35691853 PMCID: PMC9101777 DOI: 10.1053/j.jvca.2022.05.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 04/19/2022] [Accepted: 05/08/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate the effect of anticoagulation targets and intensity on bleeding events, thrombotic events, and transfusion requirements in patients with acute respiratory distress syndrome (ARDS) receiving venovenous extracorporeal membrane oxygenation (ECMO) and continuous-infusion heparin. DESIGN A retrospective cohort study. SETTING At a single-center, large academic medical center. PARTICIPANTS One hundred thirty-six critically ill patients. INTERVENTIONS The following three therapeutic targets were implemented over time and evaluated: (1) no protocol (September 2013-August 2016): no standardized anticoagulation protocol or transfusion thresholds; (2) <50 seconds (September 2016-January 2018): standardized activated partial thromboplastin time (aPTT) goal of <50 seconds, maximum heparin infusion rate of 1,200 units/h, transfusion threshold of hemoglobin (Hgb) <8 g/dL; and (3) 40-to-50 seconds (February 2018-December 2019): aPTT goal of 40-to-50 sec, no maximum heparin infusion rate, transfusion threshold of Hgb <7 g/dL. MEASUREMENTS AND MAIN RESULTS Continuous variables were compared using the Kruskal-Wallis test, and categorical variables were compared using Fisher exact tests. The primary endpoint, an incidence of at least 1 bleeding event, was highest in the no-protocol group though not statistically different among groups (39.3% v 26.7% v 34%, p = 0.5). Thrombotic complications were similar. The median units of packed red blood cells transfused were highest in the no-protocol group (3 v 2 v 0.5, p < 0.001). CONCLUSION Anticoagulation protocols standardizing aPTT goals to <50 or 40-to-50 seconds may be a reasonable strategy for patients receiving venovenous ECMO for ARDS. More restrictive hemoglobin transfusion thresholds, in combination with lower aPTT targets, may be associated with a reduction in transfusion requirements.
Collapse
Affiliation(s)
- Jessica L Cercone
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD
| | - Shawn J Kram
- Department of Pharmacy, Duke University Hospital, Durham, NC
| | | | - Craig R Rackley
- Department of Medicine, Duke University Hospital, Durham, NC
| | - Hui-Jie Lee
- Office of Biostatistics and Bioinformatics, Duke University Hospital, Durham, NC
| | - James Merchant
- Office of Biostatistics and Bioinformatics, Duke University Hospital, Durham, NC
| | | |
Collapse
|
31
|
Liu Y, Yuan Z, Han X, Song K, Xing J. A Comparison of Activated Partial Thromboplastin Time and Activated Coagulation Time for Anticoagulation Monitoring during Extracorporeal Membrane Oxygenation Therapy. Hamostaseologie 2022. [PMID: 35882351 DOI: 10.1055/a-1796-8652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
Abstract
BACKGROUND Unfractionated heparin is used to prevent coagulation activation in patients undergoing extracorporeal membrane oxygenation (ECMO) support. We designed this study to determine the preferable indicator for anticoagulation monitoring. METHODS We conducted a retrospective study and divided the patients into an activated coagulation time (ACT)-target group and an activated partial thromboplastin time (aPTT)-target group. The correlations between ACT, aPTT, and the heparin dose were explored. RESULTS Thirty-six patients were included (19 aPTT-target and 17 ACT-target patients); a total of 555 matched pairs of ACT/aPTT results were obtained. The correlation between the ACT and aPTT measurements was Spearman's Rank Correlation Coefficient (rs) = 0.518 in all 555 pairs. The Bland-Altman plot showed data points outside the displayed range (51.2-127.7), suggesting that the agreement between ACT and aPTT was poor. The aPTT group had fewer heparin dose changes (2.12 ± 0.68 vs. 2.57 ± 0.64, p = 0.05) and a lower cumulative heparin dose (317.6 ± 108.5 vs. 396.3 ± 144.3, p = 0.00) per day than the ACT group. There was no difference in serious bleeding (9 vs. 5; p = 0.171) or embolism events (3 vs. 3; p = 1.0) or in the red blood cell and fresh frozen plasma transfusion volumes between the ACT- and aPTT-target groups. Similarly, there was no significant difference in the ECMO duration (9 [4-15] days vs. 4 [3-14] days; p = 0.124) or length of ICU hospitalization (17 [5-32] days vs. 13 [4-21] days; p = 0.451) between the groups. CONCLUSION The correlation between ACT and aPTT and the heparin dose was poor. The aPTT group had fewer daily heparin dose changes and a lower cumulative heparin dose per day than the ACT group, with no more bleeding and thrombotic events. Therefore, we recommend aPTT rather than ACT to adjust heparin dose in the absence of better monitoring indicators.
Collapse
Affiliation(s)
- Ying Liu
- Department of Critical Care Medicine, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, People's Republic of China
| | - Zhiyong Yuan
- Department of Critical Care Medicine, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, People's Republic of China
| | - Xiaoning Han
- Department of Critical Care Medicine, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, People's Republic of China
| | - Kai Song
- School of Mathematics and Statistics, Qingdao University, Qingdao, Shandong, People's Republic of China
| | - Jinyan Xing
- Department of Critical Care Medicine, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, People's Republic of China
| |
Collapse
|
32
|
Corey KM, Olson LB, Naqvi IA, Morrison SA, Davis C, Nimjee SM, Que LG, Bachelder RE, Kraft BD, Chen L, Nair SK, Levy JH, Sullenger BA. Suppression of Fibrinolysis and Hypercoagulability, Severity of Hypoxemia, and Mortality in COVID-19 Patients: A Retrospective Cohort Study. Anesthesiology 2022; 137:67-78. [PMID: 35412597 PMCID: PMC9250792 DOI: 10.1097/aln.0000000000004239] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND COVID-19 causes hypercoagulability, but the association between coagulopathy and hypoxemia in critically ill patients has not been thoroughly explored. This study hypothesized that severity of coagulopathy would be associated with acute respiratory distress syndrome severity, major thrombotic events, and mortality in patients requiring intensive care unit-level care. METHODS Viscoelastic testing by rotational thromboelastometry and coagulation factor biomarker analyses were performed in this prospective observational cohort study of critically ill COVID-19 patients from April 2020 to October 2020. Statistical analyses were performed to identify significant coagulopathic biomarkers such as fibrinolysis-inhibiting plasminogen activator inhibitor 1 and their associations with clinical outcomes such as mortality, extracorporeal membrane oxygenation requirement, occurrence of major thrombotic events, and severity of hypoxemia (arterial partial pressure of oxygen/fraction of inspired oxygen categorized into mild, moderate, and severe per the Berlin criteria). RESULTS In total, 53 of 55 (96%) of the cohort required mechanical ventilation and 9 of 55 (16%) required extracorporeal membrane oxygenation. Extracorporeal membrane oxygenation-naïve patients demonstrated lysis indices at 30 min indicative of fibrinolytic suppression on rotational thromboelastometry. Survivors demonstrated fewer procoagulate acute phase reactants, such as microparticle-bound tissue factor levels (odds ratio, 0.14 [0.02, 0.99]; P = 0.049). Those who did not experience significant bleeding events had smaller changes in ADAMTS13 levels compared to those who did (odds ratio, 0.05 [0, 0.7]; P = 0.026). Elevations in plasminogen activator inhibitor 1 (odds ratio, 1.95 [1.21, 3.14]; P = 0.006), d-dimer (odds ratio, 3.52 [0.99, 12.48]; P = 0.05), and factor VIII (no clot, 1.15 ± 0.28 vs. clot, 1.42 ± 0.31; P = 0.003) were also demonstrated in extracorporeal membrane oxygenation-naïve patients who experienced major thrombotic events. Plasminogen activator inhibitor 1 levels were significantly elevated during periods of severe compared to mild and moderate acute respiratory distress syndrome (severe, 44.2 ± 14.9 ng/ml vs. mild, 31.8 ± 14.7 ng/ml and moderate, 33.1 ± 15.9 ng/ml; P = 0.029 and 0.039, respectively). CONCLUSIONS Increased inflammatory and procoagulant markers such as plasminogen activator inhibitor 1, microparticle-bound tissue factor, and von Willebrand factor levels are associated with severe hypoxemia and major thrombotic events, implicating fibrinolytic suppression in the microcirculatory system and subsequent micro- and macrovascular thrombosis in severe COVID-19. EDITOR’S PERSPECTIVE
Collapse
Affiliation(s)
- Kristin M. Corey
- Department of Medicine, Duke University School of Medicine, Durham, NC 27710
| | - Lyra B. Olson
- Duke Medical Scientist Training Program, Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Durham, NC 27710
| | - Ibtehaj A. Naqvi
- Department of Surgery, Duke University School of Medicine, Durham, NC 27710
| | - Sarah A Morrison
- Department of Surgery, Duke University School of Medicine, Durham, NC 27710
| | - Connor Davis
- Duke Institute for Health Innovation, Duke University School of Medicine, Durham, NC 27710
| | - Shahid M. Nimjee
- Department of Neurosurgery, The Ohio State University Medical Center, Columbus, OH 43203
| | - Loretta G. Que
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University Medical Center, Durham, NC 27710
| | - Robin E. Bachelder
- Department of Surgery, Duke University School of Medicine, Durham, NC 27710
| | - Bryan D. Kraft
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University Medical Center, Durham, NC 27710
| | - Lingye Chen
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University Medical Center, Durham, NC 27710
| | - Smita K. Nair
- Department of Surgery, Duke University School of Medicine, Durham, NC 27710
| | - Jerrold H. Levy
- Departments of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC 27710
| | - Bruce A. Sullenger
- Department of Surgery, Duke University School of Medicine, Durham, NC 27710
| |
Collapse
|
33
|
Liu YB, Zhou XC, Liu Y, Zhang L, Zhou Y, Xu X, Zheng C, Zhao ZY, Wu CT, Jin JD. Inhibitory role of recombinant neorudin on canine coronary artery thrombosis. Pharmacol Res Perspect 2022; 10:e00956. [PMID: 35505637 PMCID: PMC9065819 DOI: 10.1002/prp2.956] [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: 10/29/2021] [Accepted: 04/17/2022] [Indexed: 11/26/2022] Open
Abstract
The anticoagulant application is an effective treatment modality for cardiovascular diseases such as coronary heart disease, unstable angina pectoris, and myocardial infarction. In this study, the antithrombotic effect of recombinant neorudin (EPR‐hirudin, EH) was evaluated using a canine model of coronary artery thrombosis. A canine model with platelet thrombosis in the left circumferent branch of the coronary artery was designed using Folt's method, and the anti‐thrombus activity of EH was investigated. Femoral administration of EH intravenously had a significant dose‐dependent inhibitory effect on canine coronary artery thrombosis and the effective rates were 66.7% (p < .05), 83.3% (p < .05), and 100% (p < .01) after injection of 0.3, 1.0, and 3.0 mg/kg EH, respectively. Furthermore, EH demonstrated lower bleeding, with shorter bleeding time and less bleeding loss than low molecular weight heparin (LMWH). Under the similar effect intensity of EH and LMWH (85 IU/kg), the bleeding time of the EH group at 30 min was shorter, and the blood loss at 30–120 min was less than that of LMWH (p < .05 and p < .05–.001, respectively). EH had a significant dose‐dependent inhibitory effect in the dose range of 0.3–3.0 mg/kg on the coronary artery thrombosis and lower bleeding side effects than LMWH with a similar antithrombosis effect.
Collapse
Affiliation(s)
- Yu-Bin Liu
- Beijing Institute of Radiation Medicine, Beijing, China
| | | | - Yun Liu
- Beijing Institute of Radiation Medicine, Beijing, China
| | - Lin Zhang
- Beijing Institute of Radiation Medicine, Beijing, China
| | - Ying Zhou
- Beijing Institute of Radiation Medicine, Beijing, China
| | - Xiao Xu
- Beijing Institute of Radiation Medicine, Beijing, China
| | - Can Zheng
- Beijing Institute of Radiation Medicine, Beijing, China
| | - Zhuan-You Zhao
- Center for Pharmacodynamic Research, Tianjin Institute of Pharmaceutical Research, Tianjin, China
| | - Chu-Tse Wu
- Beijing Institute of Radiation Medicine, Beijing, China
| | - Ji-de Jin
- Beijing Institute of Radiation Medicine, Beijing, China
| |
Collapse
|
34
|
Kalbhenn J, Zieger B. Bleeding During Veno-Venous ECMO: Prevention and Treatment. Front Med (Lausanne) 2022; 9:879579. [PMID: 35677828 PMCID: PMC9168900 DOI: 10.3389/fmed.2022.879579] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 04/27/2022] [Indexed: 11/26/2022] Open
Abstract
Veno-venous extracorporeal membrane oxygenation (vvECMO) has become a routine treatment for severe lung failure in specialized centers. Spontaneous bleeding complications, however, are observed in 30–60% of patients during vvECMO treatment. Bleeding increases mortality by factors 2–3. Anticoagulation in combination with several acquired bleeding disorders caused by the mechanical pump and the foreign layer of the extracorporeal system contribute to the risk of bleeding. In this review, the mechanisms of the underlying pathologies and the route from diagnosis to treatment are described.
Collapse
Affiliation(s)
- Johannes Kalbhenn
- Department of Anesthesiology and Critical Care, Faculty of Medicine, Medical Center—University of Freiburg, Freiburg im Breisgau, Germany
- *Correspondence: Johannes Kalbhenn ; orcid.org/0000-0001-7551-5082
| | - Barbara Zieger
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Faculty of Medicine, Medical Center—University of Freiburg, Freiburg im Breisgau, Germany
| |
Collapse
|
35
|
van Minnen O, Oude Lansink-Hartgring A, van den Boogaard B, van den Brule J, Bulpa P, Bunge JJH, Delnoij TSR, Elzo Kraemer CV, Kuijpers M, Lambermont B, Maas JJ, de Metz J, Michaux I, van de Pol I, van de Poll M, Raasveld SJ, Raes M, Dos Reis Miranda D, Scholten E, Simonet O, Taccone FS, Vallot F, Vlaar APJ, van den Bergh WM. Reduced anticoagulation targets in extracorporeal life support (RATE): study protocol for a randomized controlled trial. Trials 2022; 23:405. [PMID: 35578271 PMCID: PMC9108348 DOI: 10.1186/s13063-022-06367-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 04/28/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Although life-saving in selected patients, ECMO treatment still has high mortality which for a large part is due to treatment-related complications. A feared complication is ischemic stroke for which heparin is routinely administered for which the dosage is usually guided by activated partial thromboplastin time (aPTT). However, there is no relation between aPTT and the rare occurrence of ischemic stroke (1.2%), but there is a relation with the much more frequent occurrence of bleeding complications (55%) and blood transfusion. Both are strongly related to outcome. METHODS We will conduct a three-arm non-inferiority randomized controlled trial, in adult patients treated with ECMO. Participants will be randomized between heparin administration with a target of 2-2.5 times baseline aPTT, 1.5-2 times baseline aPTT, or low molecular weight heparin guided by weight and renal function. Apart from anticoagulation targets, treatment will be according to standard care. The primary outcome parameter is a combined endpoint consisting of major bleeding including hemorrhagic stroke, severe thromboembolic complications including ischemic stroke, and mortality at 6 months. DISCUSSION We hypothesize that with lower anticoagulation targets or anticoagulation with LMWH during ECMO therapy, patients will have fewer hemorrhagic complications without an increase in thromboembolic complication or a negative effect on their outcome. If our hypothesis is confirmed, this study could lead to a change in anticoagulation protocols and a better outcome for patients treated with ECMO. TRIAL REGISTRATION ClinicalTrials.gov NCT04536272 . Registered on 2 September 2020. Netherlands Trial Register NL7969.
Collapse
Affiliation(s)
- Olivier van Minnen
- Department of Critical Care, University Medical Center Groningen, Room R3.904, PO BOX 30001, 9700, RB, Groningen, The Netherlands.
| | - Annemieke Oude Lansink-Hartgring
- Department of Critical Care, University Medical Center Groningen, Room R3.904, PO BOX 30001, 9700, RB, Groningen, The Netherlands
| | | | - Judith van den Brule
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Pierre Bulpa
- Department of Intensive Care, CHU UCL Namur site Mont-Godinne, Yvoir, Belgium
| | - Jeroen J H Bunge
- Department of Intensive Care Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Thijs S R Delnoij
- Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Carlos V Elzo Kraemer
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Marijn Kuijpers
- Department of Intensive Care Medicine, Isala Clinics, Zwolle, The Netherlands
| | | | - Jacinta J Maas
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Jesse de Metz
- Department of Intensive Care, OLVG, Amsterdam, The Netherlands
| | - Isabelle Michaux
- Department of Intensive Care, CHU UCL Namur site Mont-Godinne, Yvoir, Belgium
| | - Ineke van de Pol
- Department of Intensive Care Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Marcel van de Poll
- Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - S Jorinde Raasveld
- Department of Intensive Care Medicine, Amsterdam University Medical Center, Location AMC, Amsterdam, The Netherlands
| | - Matthias Raes
- Department of Intensive Care, University Hospital Brussels, Brussels, Belgium
| | - Dinis Dos Reis Miranda
- Department of Intensive Care Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Erik Scholten
- Department of Intensive Care Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Olivier Simonet
- Department of Intensive Care, Centre Hospitalier de Wallonie Picarde (CHwapi), Tournai, Belgium
| | - Fabio S Taccone
- Department of Intensive Care, Hôpital Erasme Bruxelles, Brussels, Belgium
| | - Frederic Vallot
- Department of Intensive Care, Centre Hospitalier de Wallonie Picarde (CHwapi), Tournai, Belgium
| | - Alexander P J Vlaar
- Department of Intensive Care Medicine, Amsterdam University Medical Center, Location AMC, Amsterdam, The Netherlands
| | - Walter M van den Bergh
- Department of Critical Care, University Medical Center Groningen, Room R3.904, PO BOX 30001, 9700, RB, Groningen, The Netherlands
| |
Collapse
|
36
|
Shah A, Pasrija C, Kronfli A, Essien EO, Zhou Y, Brigante F, Bittle G, Menaker J, Herr D, Mazzeffi MA, Deatrick KB, Kon ZN. A Comparison of Anticoagulation Strategies in Veno-venous Extracorporeal Membrane Oxygenation. ASAIO J 2022; 68:738-743. [PMID: 34437329 DOI: 10.1097/mat.0000000000001560] [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: 11/26/2022] Open
Abstract
Bleeding remains a major source of morbidity associated with veno-venous extracorporeal membrane oxygenation (VV-ECMO). Moreover, there remains significant controversy, and a paucity of data regarding the ideal anticoagulation strategy for VV-ECMO patients. All patients undergoing isolated, peripheral VV-ECMO between January 2009 and December 2014 at our institution were retrospectively reviewed. Patients (n = 123) were stratified into one of three sequential eras of anticoagulation strategies: activated clotting time (ACT: 160-180 seconds, n = 53), high-partial thromboplastin time (H-PTT: 60-80 seconds, n = 25), and low-PTT (L-PTT: 45-55 seconds, n = 25) with high-flow (>4 L/min). Pre-ECMO APACHE II scores, SOFA scores, and Murray scores were not significantly different between the groups. Patients in the L-PTT group required less red blood cell units on ECMO than the ACT or H-PTT group (2.1 vs. 1.3 vs. 0.9; p < 0.001) and patients in the H-PTT and L-PTT group required less fresh frozen plasma than the ACT group (0.33 vs. 0 vs. 0; p = 0.006). Overall, major bleeding events were significantly lower in the L-PTT group than in the ACT and H-PTT groups. There was no difference in thrombotic events. In this single-institution experience, a L-PTT, high-flow strategy on VV-ECMO was associated with fewer bleeding and no difference in thrombotic events than an ACT or H-PTT strategy.
Collapse
Affiliation(s)
- Aakash Shah
- From the Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Chetan Pasrija
- From the Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Anthony Kronfli
- From the Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Eno-Obong Essien
- From the Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Ya Zhou
- From the Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Francis Brigante
- From the Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Gregory Bittle
- From the Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Jay Menaker
- Shock Trauma Critical Care, University of Maryland School of Medicine, Baltimore, MD
| | - Daniel Herr
- Shock Trauma Critical Care, University of Maryland School of Medicine, Baltimore, MD
| | - Michael A Mazzeffi
- Division of Cardiothoracic Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Kristopher B Deatrick
- From the Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Zachary N Kon
- Department of Cardiothoracic Surgery, New York University Medical Center, New York, NY
| |
Collapse
|
37
|
Gurnani PK, Michalak LA, Tabachnick D, Kotwas M, Tatooles AJ. Outcomes of Extubated COVID and Non-COVID Patients Receiving Awake Venovenous Extracorporeal Membrane Oxygenation. ASAIO J 2022; 68:478-485. [PMID: 35349522 DOI: 10.1097/mat.0000000000001632] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Cessation of continuous analgesia and sedation in patients with acute respiratory distress syndrome (ARDS) receiving venovenous (VV) extracorporeal membrane oxygenation (ECMO) facilitates early extubation, family, patient and provider engagement, and mobility. Outcomes associated with an awake ECMO strategy have not been well described in the literature. The purpose of this study was to evaluate outcomes in patients receiving this strategy. This was a retrospective review of ARDS patients receiving awake VV ECMO. The primary outcome was survival to hospital discharge. Secondary outcomes included days requiring ECMO, time from cannulation to extubation, complications, patients requiring tracheostomy, hospital and intensive care unit (ICU) length of stay (LOS), and discharge disposition. In a subgroup analysis, outcomes were compared between non-COVID and COVID ECMO patients. Sixty-two patients were included with a survival to hospital discharge of 85.5%. Days requiring ECMO was 33.0 (0.0-75.0) and cannulation to extubation was 6.0 (4.0-11.0). Three patients received a tracheostomy (4.8%). Bleeding and infection were reported in 80.6% and 82.3% of patients, respectively. Intensive care unit length of stay was 46.0 days (29.0-90.0) and hospital LOS was 51.0 days (32.0-91.0). Over half of the patients (51.6%) were discharged to an acute rehabilitation facility and 27.4% were discharged home. There was similar survival to hospital discharge between the COVID and non-COVID awake ECMO patients (85% in both groups, p = 1.000). This study highlights the impact of an awake ECMO approach on survival to hospital discharge. Future studies are needed to evaluate this approach as compared to current practice to determine if this should become the standard.
Collapse
Affiliation(s)
- Payal K Gurnani
- From the Department of Pharmacy, Rush University Medical Center, Chicago, Illinois
- Department of Internal Medicine, Rush Medical College, Chicago, Illinois
| | - Lauren A Michalak
- Department of Cardiovascular and Thoracic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Deborah Tabachnick
- Department of Cardiovascular and Thoracic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Michael Kotwas
- Department of Cardiovascular and Thoracic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Antone J Tatooles
- Department of Cardiovascular and Thoracic Surgery, Rush University Medical Center, Chicago, Illinois
| |
Collapse
|
38
|
Kelly DP, Grandin EW, O'Brien KL. How we manage blood product support and coagulation in the adult patient requiring extracorporeal membrane oxygenation. Transfusion 2022; 62:741-750. [PMID: 35170768 DOI: 10.1111/trf.16830] [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: 01/14/2019] [Revised: 02/02/2022] [Accepted: 02/02/2022] [Indexed: 11/29/2022]
Abstract
Use of extracorporeal membrane oxygenation (ECMO) is increasing among critically ill adults with cardiac and/or respiratory failure. Use of ECMO is associated with hemostatic alterations requiring use of anticoagulation and blood product support. There are limited guidelines to direct transfusion management in the adult patient supported with ECMO. The objective of this article is to describe (1) the role of the transfusion service in providing transfusion support and current understanding of transfusion thresholds, (2) the complexities of monitoring anticoagulation, and (3) the consideration regarding additional factor concentrates and antifibrinolytics within the context of ECMO support. The information provided should assist ECMO care teams in informing transfusion and anticoagulation practice while highlighting key areas for future research and collaboration.
Collapse
Affiliation(s)
- Daniel P Kelly
- Division of Medical Critical Care, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Edward Wilson Grandin
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Kerry L O'Brien
- Division of Laboratory Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| |
Collapse
|
39
|
Wong MJ, Bharadwaj S, Galey JL, Lankford AS, Galvagno S, Kodali BS. Extracorporeal Membrane Oxygenation for Pregnant and Postpartum Patients. Anesth Analg 2022; 135:277-289. [PMID: 35122684 DOI: 10.1213/ane.0000000000005861] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) has seen increasing use for critically ill pregnant and postpartum patients over the past decade. Growing experience continues to demonstrate the feasibility of ECMO in obstetric patients and attest to its favorable outcomes. However, the interaction of pregnancy physiology with ECMO life support requires careful planning and adaptation for success. Additionally, the maintenance of fetal oxygenation and perfusion is essential for safely continuing pregnancy during ECMO support. This review summarizes the considerations for use of ECMO in obstetric patients and how to address these concerns.
Collapse
Affiliation(s)
- Michael J Wong
- From the Division of Obstetric Anesthesiology, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Shobana Bharadwaj
- From the Division of Obstetric Anesthesiology, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jessica L Galey
- From the Division of Obstetric Anesthesiology, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Allison S Lankford
- Department of Obstetrics and Gynecology, University of Maryland School of Medicine and Program in Trauma and Anesthesia Critical Care, Shock Trauma Center, Baltimore, Maryland
| | - Samuel Galvagno
- Department of Anesthesiology, Multi Trauma Critical Care Unit, Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Bhavani Shankar Kodali
- From the Division of Obstetric Anesthesiology, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| |
Collapse
|
40
|
Lantry JH, Mason P, Logsdon MG, Bunch CM, Peck EE, Moore EE, Moore HB, Neal MD, Thomas SG, Khan RZ, Gillespie L, Florance C, Korzan J, Preuss FR, Mason D, Saleh T, Marsee MK, Vande Lune S, Ayoub Q, Fries D, Walsh MM. Hemorrhagic Resuscitation Guided by Viscoelastography in Far-Forward Combat and Austere Civilian Environments: Goal-Directed Whole-Blood and Blood-Component Therapy Far from the Trauma Center. J Clin Med 2022; 11:356. [PMID: 35054050 PMCID: PMC8778082 DOI: 10.3390/jcm11020356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 12/31/2021] [Accepted: 01/10/2022] [Indexed: 12/18/2022] Open
Abstract
Modern approaches to resuscitation seek to bring patient interventions as close as possible to the initial trauma. In recent decades, fresh or cold-stored whole blood has gained widespread support in multiple settings as the best first agent in resuscitation after massive blood loss. However, whole blood is not a panacea, and while current guidelines promote continued resuscitation with fixed ratios of blood products, the debate about the optimal resuscitation strategy-especially in austere or challenging environments-is by no means settled. In this narrative review, we give a brief history of military resuscitation and how whole blood became the mainstay of initial resuscitation. We then outline the principles of viscoelastic hemostatic assays as well as their adoption for providing goal-directed blood-component therapy in trauma centers. After summarizing the nascent research on the strengths and limitations of viscoelastic platforms in challenging environmental conditions, we conclude with our vision of how these platforms can be deployed in far-forward combat and austere civilian environments to maximize survival.
Collapse
Affiliation(s)
- James H. Lantry
- Department of Medicine Critical Care Services, Inova Fairfax Medical Campus, Falls Church, VA 22042, USA;
| | - Phillip Mason
- Department of Critical Care Medicine, San Antonio Military Medical Center, Fort Sam Houston, San Antonio, TX 78234, USA;
| | - Matthew G. Logsdon
- Department of Emergency Medicine, Indiana University School of Medicine—South Bend, Notre Dame, IN 46617, USA; (M.G.L.); (C.M.B.)
- Department of Emergency Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (E.E.P.); (C.F.); (J.K.)
| | - Connor M. Bunch
- Department of Emergency Medicine, Indiana University School of Medicine—South Bend, Notre Dame, IN 46617, USA; (M.G.L.); (C.M.B.)
- Department of Emergency Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (E.E.P.); (C.F.); (J.K.)
| | - Ethan E. Peck
- Department of Emergency Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (E.E.P.); (C.F.); (J.K.)
| | - Ernest E. Moore
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health and University of Colorado Health Sciences Center, Denver, CO 80204, USA; (E.E.M.); (H.B.M.)
| | - Hunter B. Moore
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health and University of Colorado Health Sciences Center, Denver, CO 80204, USA; (E.E.M.); (H.B.M.)
| | - Matthew D. Neal
- Pittsburgh Trauma Research Center, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA;
| | - Scott G. Thomas
- Department of Trauma Surgery, Memorial Leighton Trauma Center, Beacon Health System, South Bend, IN 46601, USA;
| | - Rashid Z. Khan
- Department of Hematology, Michiana Hematology Oncology, Mishawaka, IN 46545, USA;
| | - Laura Gillespie
- Department of Quality Assurance and Performance Improvement, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA;
| | - Charles Florance
- Department of Emergency Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (E.E.P.); (C.F.); (J.K.)
| | - Josh Korzan
- Department of Emergency Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (E.E.P.); (C.F.); (J.K.)
| | - Fletcher R. Preuss
- Department of Orthopaedic Surgery, UCLA Santa Monica Medical Center and Orthopaedic Institute, Santa Monica, CA 90404, USA;
| | - Dan Mason
- Department of Medical Science and Devices, Haemonetics Corporation, Braintree, MA 02184, USA;
| | - Tarek Saleh
- Department of Critical Care Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA;
| | - Mathew K. Marsee
- Department of Graduate Medical Education, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA;
| | - Stefani Vande Lune
- Department of Emergency Medicine, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA;
| | | | - Dietmar Fries
- Department of Surgical and General Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria;
| | - Mark M. Walsh
- Department of Emergency Medicine, Indiana University School of Medicine—South Bend, Notre Dame, IN 46617, USA; (M.G.L.); (C.M.B.)
- Department of Emergency Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (E.E.P.); (C.F.); (J.K.)
| |
Collapse
|
41
|
Willers A, Swol J, van Kuijk SMJ, Buscher H, McQuilten Z, Ten Cate H, Rycus PT, McKellar S, Lorusso R, Tonna JE. HEROES V-V-HEmorRhagic cOmplications in Veno-Venous Extracorporeal life Support-Development and internal validation of multivariable prediction model in adult patients. Artif Organs 2021; 46:932-952. [PMID: 34904241 DOI: 10.1111/aor.14148] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 12/08/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND During extracorporeal life support (ECLS), bleeding is one of the most frequent complications, associated with high morbidity and increased mortality, despite continuous improvements in devices and patient care. Risk factors for bleeding complications in veno-venous (V-V) ECLS applied for respiratory support have been poorly investigated. We aim to develop and internally validate a prediction model to calculate the risk for bleeding complications in adult patients receiving V-V ECLS support. METHODS Data from adult patients reported to the extracorporeal life support organization (ELSO) registry between the years 2010 and 2020 were analyzed. The primary outcome was bleeding complications recorded during V-V ECLS. Multivariable logistic regression with backward stepwise elimination was used to develop the predictive model. The performance of the model was tested by discriminative ability and calibration with receiver operating characteristic curves and visual inspection of the calibration plot. RESULTS In total, 18 658 adult patients were included, of which 3 933 (21.1%) developed bleeding complications. The prediction model showed a prediction of bleeding complications with an AUC of 0.63. Pre-ECLS arrest, surgical cannulation, lactate, pO2 , HCO3 , ventilation rate, mean airway pressure, pre-ECLS cardiopulmonary bypass or renal replacement therapy, pre-ECLS surgical interventions, and different types of diagnosis were included in the prediction model. CONCLUSIONS The model is based on the largest cohort of V-V ECLS patients and reveals the most favorable predictive value addressing bleeding events given the predictors that are feasible and when compared to the current literature. This model will help identify patients at risk of bleeding complications, and decision making in terms of anticoagulation and hemostatic management.
Collapse
Affiliation(s)
- Anne Willers
- ECLS Center, Cardio-Thoracic Surgery Department, Heart & Vascular Center, Maastricht University Medical Center (MUMC), Maastricht, The Netherlands
| | - Justyna Swol
- Department of Pulmonology, Paracelsus Medical University, Nuremberg, Germany
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Center (MUMC), Maastricht, The Netherlands
| | - Hergen Buscher
- Department of Intensive Care Medicine, Center of Applied Medical Research, St Vincent's Hospital, Sydney, New South Wales, Australia.,University of New South Wales, Sydney, New South Wales, Australia
| | - Zoe McQuilten
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne Australia Clinical Haematology, Monash Health, Melbourne, Victoria, Australia
| | - Hugo Ten Cate
- Department of Internal Medicine, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands.,Center for Thrombosis and Hemostasis (CTH), Gutenberg University Medical Center, Mainz, Germany.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Peter T Rycus
- Extracorporeal Life Support Organization, Ann Arbor, Michigan, USA
| | - Stephen McKellar
- Division of Cardiothoracic Surgery, University of Utah Health, Salt Lake City, Utah, USA
| | - Roberto Lorusso
- ECLS Center, Cardio-Thoracic Surgery Department, Heart & Vascular Center, Maastricht University Medical Center (MUMC), Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Joseph E Tonna
- Division of Cardiothoracic Surgery, University of Utah Health, Salt Lake City, Utah, USA.,Division of Emergency Medicine, University of Utah Health, Salt Lake City, Utah, USA
| |
Collapse
|
42
|
Feih JT, Wallskog KE, Rinka JRG, Juul JJ, Rein L, Gaglianello N, Baumann Kreuziger LM, Joyce DL, Tawil JN. Heparin Monitoring with an Anti-Xa Protocol Compared to Activated Clotting Time in Patients on Temporary Mechanical Circulatory Support. Ann Pharmacother 2021; 56:513-523. [PMID: 34423673 DOI: 10.1177/10600280211039582] [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] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Temporary mechanical circulatory support (tMCS) devices are used for patients with severe cardiac or respiratory failure; however, these patients are at high risk for clotting and bleeding. The best method to monitor heparin in these patients has not been established. OBJECTIVE To determine the risks for bleeding and clotting while monitoring heparin with either anti-Xa or activated clotting time (ACT) in tMCS patients. METHODS A retrospective cohort study was conducted on tMCS patients who received heparin adjusted according to an anti-Xa or ACT protocol. The primary outcome was incidence of major bleeding. Pertinent secondary outcomes were individual components of the primary outcome, clotting events, and time to therapeutic range. RESULTS There were 103 patients included in the study: 53 in the ACT group and 50 in the anti-Xa group. Overall, there were 30 (56.6%) patients with major bleeding in the ACT group, compared with 16 (32%) patients in the anti-Xa group (P = 0.017). An anti-Xa-based protocol was associated with a decreased hazard of major bleeding (hazard ratio = 0.388 [0.215-0.701]; P = 0.002) in the univariate analysis. In the multivariable analysis, an anti-Xa protocol remained associated with a significantly lower hazard of bleeding. Findings were similar when broken down into more discrete subgroups of the entire cohort, extracorporeal membrane oxygenation life support (ECMO), and non-ECMO groups. CONCLUSION AND RELEVANCE Anti-Xa monitoring was associated with a lower hazard of bleeding during tMCS compared to an ACT-based protocol. Further studies should evaluate if anti-Xa monitoring should be preferentially used in tMCS.
Collapse
Affiliation(s)
- Joel T Feih
- Froedtert & the Medical College of Wisconsin, Milwaukee, WI, USA.,Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Joseph R G Rinka
- Froedtert & the Medical College of Wisconsin, Milwaukee, WI, USA.,Concordia University Wisconsin, Mequon, WI, USA
| | - Janelle J Juul
- Froedtert & the Medical College of Wisconsin, Milwaukee, WI, USA
| | - Lisa Rein
- Medical College of Wisconsin, Milwaukee, WI, USA
| | | | | | | | | |
Collapse
|
43
|
Conversion From Activated Clotting Time to Anti-Xa Heparin Activity Assay for Heparin Monitoring During Extracorporeal Membrane Oxygenation. Crit Care Med 2021; 48:e1179-e1184. [PMID: 33009103 DOI: 10.1097/ccm.0000000000004615] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES Anticoagulation with unfractionated heparin remains the most common therapy used to prevent circuit thrombosis during extracorporeal membrane oxygenation, but no consensus exists on the optimal method or targets for heparin monitoring. From 2015 to 2018, we switched from monitoring heparin during extracorporeal membrane oxygenation using activated clotting times to anti-Xa heparin activity assays. This study describes the transition from activated clotting time to anti-Xa heparin activity assay monitoring and the associated clinical changes. DESIGN Retrospective analysis at single institution. SETTING Referral Children's Hospital. PATIENTS A total of 145 pediatric patients over 152 extracorporeal membrane oxygenation runs using 206 extracorporeal membrane oxygenation circuits. INTERVENTIONS Anticoagulation protocol quality improvement. MEASUREMENTS AND MAIN RESULTS From 2015 to 2018, heparin monitoring during extracorporeal membrane oxygenation changed from hourly activated clotting time to anti-Xa heparin activity assay every 6 hours with an associated 75% reduction in the circuit changes per extracorporeal membrane oxygenation day. Over the 4 years, patients with an average anti-Xa heparin activity assay of at least 0.25 U/mL showed a 59% reduction in circuit changes per extracorporeal membrane oxygenation day compared with less than 0.15 U/mL. In addition to its association with reduced circuit changes, anti-Xa heparin activity assay monitoring was also associated with reduced heparin dose changes per day from 11 ± 4 to 2 ± 1 (p < 0.001), smaller heparin dose changes (less variation in dose), and reduced diagnostic phlebotomy volumes from 41 ± 6 to 25 ± 11 mL/day (p < 0.001). The number of patients with reported bleeding decreased from 69% using activated clotting time to 51% (p = 0.03). Transfusion rates did not change. CONCLUSIONS Over 4 years, we replaced the activated clotting time assay with the anti-Xa heparin activity assay for heparin monitoring during extracorporeal membrane oxygenation. Minimum anti-Xa heparin activity assay levels of 0.25 U/mL were associated with reduced circuit changes. Further studies are needed to determine the optimum anti-Xa heparin activity assay therapeutic range during extracorporeal membrane oxygenation.
Collapse
|
44
|
Lv X, Deng M, Wang L, Dong Y, Chen L, Dai X. Low vs standardized dose anticoagulation regimens for extracorporeal membrane oxygenation: A meta-analysis. PLoS One 2021; 16:e0249854. [PMID: 33831104 PMCID: PMC8031334 DOI: 10.1371/journal.pone.0249854] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 03/25/2021] [Indexed: 11/18/2022] Open
Abstract
Background To compare the safety and efficacy of low-dose anticoagulation (LA) with that of standardized dose anticoagulation (SA) for patients supported with extracorporeal membrane oxygenation (ECMO). Methods PubMed, MEDLINE, the Cochrane Library, and Web of Science were screened for original articles. Screening was performed using predefined search terms to identify cohort studies reporting the comparison of LA with SA in patients supported with ECMO from Nov 1990 to Jun 2020. The effect size was determined by the odds ratio (OR) with the 95% confidence interval (CI). Results An analysis of 7 studies including a total of 553 patients was performed. LA (Low-heparin group) was administered to 255 patients, whereas the other 298 patients received SA (Full-heparin group). The incidence of gastrointestinal tract hemorrhage (OR 0.36, 95% CI 0.20–0.64) and surgical site hemorrhage (OR 0.43, 95% CI 0.20–0.94) were significantly lower in patients who underwent LA compared with that in those who underwent SA. The rates of hospital mortality (OR 0.81, 95% CI 0.42–1.56), successfully weaning off of ECMO (OR 0.80, 95% CI 0.30–2.14), pulmonary embolism (OR 0.79, 95% CI 0.24–2.65), intracardiac thrombus (OR 0.34, 95% CI 0.09–1.30), intracranial hemorrhage (OR 0.62, 95% CI 0.22–1.74), and pulmonary hemorrhage (OR 0.77, 95% CI 0.30–1.93) were similar between the two groups. Conclusions This meta-analysis confirms that LA is a feasible and safe anticoagulation strategy in patients supported by ECMO. Future studies should focus on the long-term benefits of LA compared with SA.
Collapse
Affiliation(s)
- Xiaochai Lv
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fujian, China
- Department of Fujian Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian, China
| | - Manjun Deng
- Department of Hepatopancreatobiliary Surgery, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fujian, China
| | - Lei Wang
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fujian, China
- Department of Fujian Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian, China
| | - Yi Dong
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fujian, China
- Department of Fujian Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian, China
| | - Liangwan Chen
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fujian, China
- Department of Fujian Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian, China
- * E-mail:
| | - Xiaofu Dai
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fujian, China
- Department of Fujian Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian, China
| |
Collapse
|
45
|
Kalbhenn J, Glonnegger H, Wilke M, Bansbach J, Zieger B. Hypercoagulopathy, acquired coagulation disorders and anticoagulation before, during and after extracorporeal membrane oxygenation in COVID-19: a case series. Perfusion 2021; 36:592-602. [PMID: 33719738 DOI: 10.1177/02676591211001791] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Thromboembolism and bleeding contribute to Coronavirus disease 2019 (COVID-19)'s morbidity and mortality and are also frequent complications of venovenous extracorporeal membrane oxygenation (vvECMO). As the interaction of the underlying pathologies caused by vvECMO in COVID-19 is barely understood, we designed this study to better differentiate coagulation disorders in COVID-19 patients before, during and after vvECMO-support. METHODS Observational case series, six consecutive patients with Coronavirus acute respiratory distress syndrome supported with vvECMO treated in the anaesthesiologic ICU in a third level University ECMO-centre. We measured routine coagulation parameters and assessed coagulation factors. We also conducted advanced von Willebrand factor (VWF) multimer analysis, platelet aggregometry and immunological screening. RESULTS We identified various phases of coagulation disorders: Initially, intensely activated coagulation with highly increased VWF and factor VIII activity in acute COVID-19, then severe acquired von Willebrand syndrome and platelet dysfunction during vvECMO leading to spontaneous bleeding and finally, hypercoagulopathy after vvECMO explantation. Five of six patients developed immunological abnormalities enhancing coagulation. CONCLUSIONS Coronavirus-induced coagulopathy and bleeding disorders during vvECMO cannot be discriminated via 'routine' coagulation tests. Precise and specific analyses followed by the appropriate treatment of coagulation disorders may help us develop tailored therapeutic concepts to better manage the phases described above.
Collapse
Affiliation(s)
- Johannes Kalbhenn
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Hannah Glonnegger
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Maya Wilke
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Joachim Bansbach
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Barbara Zieger
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| |
Collapse
|
46
|
Geli J, Capoccia M, Maybauer DM, Maybauer MO. Argatroban Anticoagulation for Adult Extracorporeal Membrane Oxygenation: A Systematic Review. J Intensive Care Med 2021; 37:459-471. [PMID: 33653194 DOI: 10.1177/0885066621993739] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Heparin is the widely used anti-coagulation strategy for patients on extracorporeal membrane oxygenation (ECMO). Nevertheless, heparin-induced thrombocytopenia (HIT) and acquired anti-thrombin (AT) deficiency preclude the use of heparin requiring utilization of an alternative anticoagulant agent. Direct thrombin inhibitors are being proposed as potential alternatives with argatroban as one of the main agents. We aimed to review the evidence with regard to safety and efficacy of argatroban as a potential definitive alternative to heparin in the adult patient population undergoing ECMO support. METHODS A web-based systematic literature search was performed in Medline (PubMed) and Embase from inception until June 18, 2020. RESULTS The search identified 13 publications relevant to the target (4 cohort studies and 9 case series). Case reports and case series with less than 3 cases were not included in the qualitative synthesis. The aggregate number of argatroban treated patients on ECMO was n = 307. In the majority of studies argatroban was used as a continuous infusion without loading dose. Starting doses on ECMO varied between 0.05 and 2 μg/kg/min and were titrated to achieve the chosen therapeutic target range. The activated partial thormboplastin time (aPTT) was the anticoagulation parameter used for monitoring purposes in most studies, whereas some utilized the activated clotting time (ACT). Optimal therapeutic targets varied between 43-70 and 60-100 seconds for aPTT and between 150-210 and 180-230 seconds for ACT. Bleeding and thromboembolic complication rates were comparable to patients treated with unfractionated heparin (UFH). CONCLUSIONS Argatroban infusion rates and anticoagulation target ranges showed substantial variations. The rational for divergent dosing and monitoring approaches are discussed in this paper. Argatroban appears to be a potential alternative to UFH in patients requiring ECMO. To definitively establish its safety, efficacy and ideal dosing strategy, larger prospective studies on well-defined patient populations are warranted.
Collapse
Affiliation(s)
- Janos Geli
- Department of Cardiothoracic Anaesthesia and Critical Care, 59562Karolinska University Hospital, Stockholm, Sweden
| | - Massimo Capoccia
- Department of Aortic and Cardiac Surgery, 156726Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | - Dirk M Maybauer
- Department of Anaesthesiology and Intensive Care Medicine, Philipps University, Marburg, Germany
| | - Marc O Maybauer
- Department of Anaesthesiology and Intensive Care Medicine, Philipps University, Marburg, Germany.,Department of Anaesthesia, 105551Manchester Royal Infirmary, Manchester University NHS Foundation Trust, The University of Manchester and Manchester Academic Health Science Centre, Manchester, United Kingdom.,Critical Care Research Group, The Prince Charles Hospital and The University of Queensland, Brisbane, Queensland, Australia.,Nazih Zuhdi Transplant Institute, Advanced Critical Care, Integris Baptist Medical Centre, Oklahoma City, and Oklahoma State University, Tulsa, Oklahoma, USA
| |
Collapse
|
47
|
Stubbs J, Klompas A, Thalji L. Transfusion Therapy in Specific Clinical Situations. Transfus Med 2021. [DOI: 10.1002/9781119599586.ch11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
|
48
|
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.
Collapse
|
49
|
Fleiss N, Klein-Cloud R, Gill B, Feldstein NA, Fallon EM, Ruzal-Shapiro C, Collins A. Subdural extravasation of crystalloids and blood products through a scalp peripheral intravenous catheter into the subdural space of a neonate on veno-arterial extracorporeal membrane oxygenation. J Neonatal Perinatal Med 2021; 14:601-605. [PMID: 33523026 DOI: 10.3233/npm-200610] [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] [Indexed: 11/15/2022]
Abstract
We describe a rare and devastating complication of a malpositioned scalp peripheral intravenous catheter (PIV) that resulted in subdural extravasation of infused fluids and midline shift in a critically ill neonate who required extracorporeal membrane oxygenation (ECMO). Recognition of increased intracranial pressure was hindered by the hemodynamic changes of being on ECMO and only identified by routine surveillance ultrasonography. Awareness of this complication may lead providers to seek alternate sites for vascular access in such patients, and encourage closer monitoring for this complication when an alternate site is unavailable.
Collapse
Affiliation(s)
- N Fleiss
- Department of Pediatrics, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - R Klein-Cloud
- Department of Surgery, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - B Gill
- Department of Neurosurgery, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - N A Feldstein
- Department of Neurosurgery, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - E M Fallon
- Department of Surgery, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - C Ruzal-Shapiro
- Department of Radiology, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - A Collins
- Department of Pediatrics, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY, USA
| |
Collapse
|
50
|
Disseminated Intravascular Coagulation Score Is Related to Short-term Mortality in Patients Undergoing Venoarterial Extracorporeal Membrane Oxygenation After Cardiac Surgery. ASAIO J 2021; 67:891-898. [PMID: 33470639 DOI: 10.1097/mat.0000000000001333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Disseminated intravascular coagulation (DIC) score is associated with short-term mortality in various conditions but has not been studied in postcardiotomy cardiogenic shock (PCS) patients supported with venoarterial extracorporeal membrane oxygenation (VA-ECMO). The objective of this study was to evaluate the relationship between DIC score at day 1 from VA-ECMO initiation and short-term mortality. We included all PCS patients supported with VA-ECMO at the Beijing Anzhen Hospital between January 2015 and December 2018. Multivariable logistic regression analysis was performed to assess the relationship between DIC score at day 1 and in-hospital mortality, and adjust for potential confounding variables. Of 222 PCS patients treated with VA-ECMO, 145 (65%) patients were weaned from VA-ECMO, and median (IQR) ECMO support duration was five (3-6) days. In-hospital mortality was 53%. The median (IQR) DIC score at day 1 was five (4-6). Patients with DIC score ≥5 at day 1 (overt DIC) had higher in-hospital mortality as compared with patients with DIC score <5 (64% vs. 22%; P < 0.001). After adjusting for age, sex, ECMO indication, and peak serum lactate, a one-point rise in DIC score [OR, 2.20; 95% confidence intervals (CI), 1.64-2.95] or DIC score ≥5 at day 1 (OR, 4.98; 95% CI, 2.42-10.24) was associated with an increased risk of in-hospital mortality. The area under the receiver operating characteristic curve for DIC score at day 1 was 0.76 (95% CI, 0.69-0.82). Our study suggests that DIC score at day 1 is associated with short-term mortality in patients undergoing VA-ECMO after cardiac surgery, independent of age, sex, disease characteristics, and severity of illness.
Collapse
|