51
|
Mazzeffi M, Henderson R, Krause E, Rabin J, Madathil R, Chow J, Grazioli A, Meyer M, Wu Z, Tanaka K. In Vitro Comparison of Recombinant and Plasma-Derived von Willebrand Factor Concentrate for Treatment of Acquired von Willebrand Syndrome in Adult Extracorporeal Membrane Oxygenation Patients. Anesth Analg 2021; 134:312-321. [PMID: 34903705 DOI: 10.1213/ane.0000000000005831] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Coagulopathic bleeding is common during adult extracorporeal membrane oxygenation (ECMO), and acquired von Willebrand syndrome is a contributing factor. We compared ECMO patient blood samples that were treated in vitro with recombinant von Willebrand Factor concentrate and plasma-derived von Willebrand Factor concentrate. Our hypothesis was that recombinant von Willebrand Factor (vWF) would have greater efficacy in increasing vWF function. Secondarily, we hypothesized that recombinant vWF would have less impact on thrombin generation. METHODS Thirty ECMO patients and 10 cardiac surgical controls were enrolled in the study. ECMO patient blood samples were treated in vitro with low- and high-dose recombinant vWFs and low- and high-dose plasma-derived vWFs. Whole blood ristocetin-induced platelet aggregation (RIPA), plasma ristocetin cofactor activity (RCo), and thrombin generation were compared between ECMO patient blood samples and control blood samples and between vWF-treated ECMO patient blood samples and nontreated samples. RESULTS ECMO patient blood samples had severely reduced median RIPA compared to control samples 2 ohms (1-12 [25th-75th percentile]) vs 20 ohms (11-42) (P < .001). Treatment of ECMO patient blood samples with high-dose recombinant vWF significantly increased median RIPA to 10 ohms (2-15) (P < .001), while low-dose recombinant vWF and low- and high-dose plasma-derived vWFs did not significantly increase RIPA; 6 ohms (3-14), 4 ohms (1-13), and 6 ohms (2-10), respectively (P = .25, >.99, and >.99). Treatment with high-dose recombinant vWF and low- and high-dose plasma-derived vWFs significantly increased median plasma RCo to 4.7 international units (IU)/mL (3.7-5.9), 3.3 IU/mL (2.7-4.8), and 3.9 IU/mL (3.4-5.3), respectively, compared to controls 1.8 IU/mL (1.5-2.3) (all P < .001). Treatment with low- and high-dose plasma-derived vWFs significantly increased mean endogenous thrombin potential (6270.2 ± 2038.7 and 6313.1 ± 1913.3) compared to nontreated samples (5856.7 ± 1924.6) (P = .04 and .006), whereas treatment with low- and high-dose recombinant vWFs had no significant effect on mean endogenous thrombin potential (5776.1 ± 2087.3 and 5856.2 ± 1946.4) (P > .99 for both comparisons). CONCLUSIONS In vitro treatment of ECMO patient blood samples with high-dose recombinant vWF was superior to low-dose recombinant vWF and plasma-derived vWF in terms of improving RIPA. In addition, recombinant vWF treatment did not increase endogenous thrombin potential, which may reduce overall thrombotic risk if it used to treat acquired von Willebrand syndrome in ECMO patients.
Collapse
Affiliation(s)
- Michael Mazzeffi
- From the Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Reney Henderson
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Eric Krause
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Joseph Rabin
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Ronson Madathil
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jonathan Chow
- From the Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Alison Grazioli
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Michael Meyer
- Vitalant Coagulation Laboratory, Pittsburgh, Pennsylvania
| | - Zhongjun Wu
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kenichi Tanaka
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| |
Collapse
|
52
|
Garaj M, Durila M, Vajter J, Solcova M, Marecek F, Hrachovinová I. Extracorporeal membrane oxygenation seems to induce impairment of primary hemostasis pathology as measured by a Multiplate analyzer: An observational retrospective study. Artif Organs 2021; 46:899-907. [PMID: 34904233 DOI: 10.1111/aor.14142] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 11/12/2021] [Accepted: 12/10/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) support is often associated with bleeding complications caused by secondary or primary hemostasis pathology. However, there are limited data investigating primary hemostasis using Multiplate aggregometry with specific diagnostics tests for vWF (von Willebrand factor) deficiency. AIMS The aim of this study was to find out whether short-term ECMO produces the pathology of primary hemostasis that is detected by Multiplate aggregometry and to investigate the pathology of vWF. METHODS In this study, blood samples of 20 patients undergoing lung transplantations with short-term perioperative ECMO support were analyzed. The multimeric structure, the levels of von Willebrand factor antigen (vWF), ristocetin cofactor (RCo), collagen-binding protein (CB), and the results of multiple electrode aggregometry RISTO (ristocetin), ADP (adenosine diphosphate), ASPI (Aspirin®; arachidonic acid), and TRAP (thrombin receptor activating peptide) tests were compared to the samples obtained before and after ECMO support. RESULTS The Multiplate ADP and RISTO tests showed the presence of significant pathology in primary hemostasis after surgery (p < 0.05), suggesting the presence of acquired platelet dysfunction. Although the RISTO tests suggest the presence of acquired vWF deficiency, laboratory tests for vWF antigen and RCo and CB tests showed an increase in this case. The multimeric structure of vWF did not show clinically significant deterioration. CONCLUSIONS Multiple aggregometry ADP, ASPI, and TRAP tests seem to be able to detect primary hemostasis pathology (platelets aggregation and adhesion pathology) that is present during short-term perioperative ECMO support in lung transplantation procedures. Interestingly, RISTO tests seem to be more suitable for the diagnosis of platelet dysfunction than the diagnosis of acquired vWF deficiency in this situation.
Collapse
Affiliation(s)
- Michal Garaj
- Department of Anesthesiology and Intensive Care Medicine, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, the Czech Republic
| | - Miroslav Durila
- Department of Anesthesiology and Intensive Care Medicine, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, the Czech Republic
| | - Jaromir Vajter
- Department of Anesthesiology and Intensive Care Medicine, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, the Czech Republic
| | - Michaela Solcova
- Department of Clinical Hematology, Motol University Hospital, Prague, the Czech Republic
| | - Frantisek Marecek
- Institute of Hematology and Blood Transfusion, Prague, the Czech Republic
| | | |
Collapse
|
53
|
Mazzeffi MA, Rao VK, Dodd-O J, Del Rio JM, Hernandez A, Chung M, Bardia A, Bauer RM, Meltzer JS, Satyapriya S, Rector R, Ramsay JG, Gutsche J. Intraoperative Management of Adult Patients on Extracorporeal Membrane Oxygenation: An Expert Consensus Statement From the Society of Cardiovascular Anesthesiologists-Part I, Technical Aspects of Extracorporeal Membrane Oxygenation. Anesth Analg 2021; 133:1459-1477. [PMID: 34559089 DOI: 10.1213/ane.0000000000005738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) is used to support patients with refractory cardiopulmonary failure. Given ECMO's increased use in adults and the fact that many ECMO patients are cared for by anesthesiologists, the Society of Cardiovascular Anesthesiologists ECMO working group created an expert consensus statement that is intended to help anesthesiologists manage adult ECMO patients who are cared for in the operating room. In the first part of this 2-part series, technical aspects of ECMO are discussed, and related expert consensus statements are provided.
Collapse
Affiliation(s)
- Michael A Mazzeffi
- From the Department of Anesthesiology and Critical Care Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Vidya K Rao
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Jeffrey Dodd-O
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jose Mauricio Del Rio
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - Antonio Hernandez
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Mabel Chung
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard University School of Medicine, Boston, Massachusetts
| | - Amit Bardia
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut
| | - Rebecca M Bauer
- Department of Anesthesiology, University of Massachusetts School of Medicine, Worcester, Massachusetts
| | - Joseph S Meltzer
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles School of Medicine, Los Angeles, California
| | - Sree Satyapriya
- Department of Anesthesiology, Ohio State University School of Medicine, Columbus, Ohio
| | - Raymond Rector
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - James G Ramsay
- Department of Anesthesia and Perioperative Care, University of California San Francisco School of Medicine, San Francisco, California
| | - Jacob Gutsche
- Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| |
Collapse
|
54
|
Mazzeffi MA, Rao VK, Dodd-O J, Del Rio JM, Hernandez A, Chung M, Bardia A, Bauer RM, Meltzer JS, Satyapriya S, Rector R, Ramsay JG, Gutsche J. Intraoperative Management of Adult Patients on Extracorporeal Membrane Oxygenation: An Expert Consensus Statement From the Society of Cardiovascular Anesthesiologists-Part II, Intraoperative Management and Troubleshooting. Anesth Analg 2021; 133:1478-1493. [PMID: 34559091 DOI: 10.1213/ane.0000000000005733] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In the second part of the Society of Cardiovascular Anesthesiologists Extracorporeal Membrane Oxygenation (ECMO) working group expert consensus statement, venoarterial (VA) and venovenous (VV) ECMO management and troubleshooting in the operating room are discussed. Expert consensus statements are provided about intraoperative monitoring, anesthetic drug dosing, and management of intraoperative problems in VA and VV ECMO patients.
Collapse
Affiliation(s)
- Michael A Mazzeffi
- From the Department of Anesthesiology and Critical Care Medicine, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Vidya K Rao
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alton, California
| | - Jeffrey Dodd-O
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jose Mauricio Del Rio
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - Antonio Hernandez
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Mabel Chung
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard University School of Medicine, Boston, Massachusetts
| | - Amit Bardia
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut
| | - Rebecca M Bauer
- Department of Anesthesiology, University of Massachusetts School of Medicine, Worcester, Massachusetts
| | - Joseph S Meltzer
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles School of Medicine, Los Angeles, California
| | - Sree Satyapriya
- Department of Anesthesiology, Ohio State University School of Medicine, Columbus, Ohio
| | - Raymond Rector
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - James G Ramsay
- Department of Anesthesia and Perioperative Care, University of California San Francisco School of Medicine, San Francisco, California
| | - Jacob Gutsche
- Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| |
Collapse
|
55
|
Mazzeffi MA, Rao VK, Dodd-O J, Rio JMD, Hernandez A, Chung M, Bardia A, Bauer RM, Meltzer JS, Satyapriya S, Rector R, Ramsay JG, Gutsche J. Intraoperative Management of Adult Patients on Extracorporeal Membrane Oxygenation: an Expert Consensus Statement From the Society of Cardiovascular Anesthesiologists-Part I, Technical Aspects of Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2021; 35:3496-3512. [PMID: 34774252 DOI: 10.1053/j.jvca.2021.07.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) is used to support patients with refractory cardiopulmonary failure. Given ECMO's increased use in adults and the fact that many ECMO patients are cared for by anesthesiologists, the Society of Cardiovascular Anesthesiologists ECMO working group created an expert consensus statement that is intended to help anesthesiologists manage adult ECMO patients who are cared for in the operating room. In the first part of this 2-part series, technical aspects of ECMO are discussed, and related expert consensus statements are provided.
Collapse
Affiliation(s)
- Michael A Mazzeffi
- Department of Anesthesiology and Critical Care Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC.
| | - Vidya K Rao
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Jeffrey Dodd-O
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jose Mauricio Del Rio
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - Antonio Hernandez
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Mabel Chung
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard University School of Medicine, Boston, Massachusetts
| | - Amit Bardia
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut
| | - Rebecca M Bauer
- Department of Anesthesiology, University of Massachusetts School of Medicine, Worcester, Massachusetts
| | - Joseph S Meltzer
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles School of Medicine, Los Angeles, California
| | - Sree Satyapriya
- Department of Anesthesiology, Ohio State University School of Medicine, Columbus, Ohio
| | - Raymond Rector
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - James G Ramsay
- Department of Anesthesia and Perioperative Care, University of California San Francisco School of Medicine, San Francisco, California
| | - Jacob Gutsche
- Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| |
Collapse
|
56
|
Mazzeffi MA, Rao VK, Dodd-O J, Del Rio JM, Hernandez A, Chung M, Bardia A, Bauer RM, Meltzer JS, Satyapriya S, Rector R, Ramsay JG, Gutsche J. Intraoperative Management of Adult Patients on Extracorporeal Membrane Oxygenation: an Expert Consensus Statement From the Society of Cardiovascular Anesthesiologists- Part II, Intraoperative Management and Troubleshooting. J Cardiothorac Vasc Anesth 2021; 35:3513-3527. [PMID: 34774253 DOI: 10.1053/j.jvca.2021.07.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Michael A Mazzeffi
- Department of Anesthesiology and Critical Care Medicine, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia.
| | - Vidya K Rao
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alton, California
| | - Jeffrey Dodd-O
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jose Mauricio Del Rio
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - Antonio Hernandez
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Mabel Chung
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard University School of Medicine, Boston, Massachusetts
| | - Amit Bardia
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut
| | - Rebecca M Bauer
- Department of Anesthesiology, University of Massachusetts School of Medicine, Worcester, Massachusetts
| | - Joseph S Meltzer
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles School of Medicine, Los Angeles, California
| | - Sree Satyapriya
- Department of Anesthesiology, Ohio State University School of Medicine, Columbus, Ohio
| | - Raymond Rector
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - James G Ramsay
- Department of Anesthesia and Perioperative Care, University of California San Francisco School of Medicine, San Francisco, California
| | - Jacob Gutsche
- Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| |
Collapse
|
57
|
Copeland H, Levine D, Morton J, Hayanga JA. Acute respiratory distress syndrome in the cardiothoracic patient: State of the art and use of veno-venous extracorporeal membrane oxygenation. ACTA ACUST UNITED AC 2021; 8:97-103. [PMID: 34723221 PMCID: PMC8541831 DOI: 10.1016/j.xjon.2021.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 10/12/2021] [Indexed: 01/02/2023]
Affiliation(s)
- Hannah Copeland
- Division of Cardiovascular Surgery, Division of Heart Transplantation, Mechanical Circulatory Support and ECMO, Lutheran Hospital, Fort Wayne, Ind
- Indiana University School of Medicine Fort Wayne, Fort Wayne, Ind
- Address for reprints: Hannah Copeland, MD, Indiana University–Fort Wayne School of Medicine, 7910 W Jefferson Blvd, Suite 102, Fort Wayne, IN 46804.
| | - Deborah Levine
- Division of Pulmonary Critical Care and Lung Transplantation, Department of Medicine, University of Texas San Antonio, San Antonio, Tex
| | - John Morton
- Division of Cardiovascular Surgery, Division of Heart Transplantation, Mechanical Circulatory Support and ECMO, Lutheran Hospital, Fort Wayne, Ind
| | - J.W. Awori Hayanga
- Department of Thoracic and Cardiovascular Surgery, West Virginia University, Morgantown, WVa
| |
Collapse
|
58
|
Siegel PM, Chalupsky J, Olivier CB, Bojti I, Pooth JS, Trummer G, Bode C, Diehl P. Early platelet dysfunction in patients receiving extracorporeal membrane oxygenation is associated with mortality. J Thromb Thrombolysis 2021; 53:712-721. [PMID: 34529213 PMCID: PMC8444511 DOI: 10.1007/s11239-021-02562-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2021] [Indexed: 12/28/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is used for patients with cardiopulmonary failure and is associated with severe bleeding and poor outcome. Platelet dysfunction may be a contributing factor. The aim of this prospective observational study was to characterize platelet dysfunction and its relation to outcome in ECMO patients. Blood was sampled from thirty ECMO patients at three timepoints. Expression of CD62P, CD63, activated GPIIb/IIIa, GPVI, GPIbα and formation platelet-leukocyte aggregates (PLA) were analyzed at rest and in response to stimulation. Delta granule storage-pool deficiency and secretion defects were also investigated. Fifteen healthy volunteers and ten patients with coronary artery disease served as controls. Results were also compared between survivors and non-survivors. Compared to controls, expression of platelet surface markers, delta granule secretion and formation of PLA was reduced, particularly in response to stimulation. Baseline CD63 expression was higher and activated GPIIb/IIIa expression in response to stimulation was lower in non-survivors on day 1 of ECMO. Logistic regression analysis revealed that these markers were associated with mortality. In conclusion, platelets from ECMO patients are severely dysfunctional predisposing patients to bleeding complications and poor outcome. Platelet dysfunction on day 1 of ECMO detected by the platelet surface markers CD63 and activated GPIIb/IIIa is associated with mortality. CD63 and activated GPIIb/IIIa may therefore serve as novel prognostic biomarkers, but future studies are required to determine their true potential.
Collapse
Affiliation(s)
- Patrick Malcolm Siegel
- Department of Cardiology and Angiology I, University Heart Center Freiburg - Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Julia Chalupsky
- Department of Cardiology and Angiology I, University Heart Center Freiburg - Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph B Olivier
- Department of Cardiology and Angiology I, University Heart Center Freiburg - Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - István Bojti
- Department of Cardiology and Angiology I, University Heart Center Freiburg - Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jan-Steffen Pooth
- Department of Cardiovascular Surgery, University Heart Center Freiburg - Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Georg Trummer
- Department of Cardiovascular Surgery, University Heart Center Freiburg - Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Bode
- Department of Cardiology and Angiology I, University Heart Center Freiburg - Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Philipp Diehl
- Department of Cardiology and Angiology I, University Heart Center Freiburg - Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| |
Collapse
|
59
|
Möhnle P, Bruegel M, Spannagl M. [Anticoagulation in intensive care medicine]. Med Klin Intensivmed Notfmed 2021; 116:499-507. [PMID: 34432085 PMCID: PMC8385697 DOI: 10.1007/s00063-021-00849-6] [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] [Received: 06/10/2021] [Revised: 06/18/2021] [Accepted: 07/12/2021] [Indexed: 11/28/2022]
Abstract
Critically ill patients are at high risk of hemostasis disorders, which can be associated with both an increased risk of bleeding and an increased risk of thromboembolic events. In the case of acute vascular events, specific therapy with drug anticoagulation or platelet aggregation inhibition is essential. In patients with pre-existing conditions, the appropriate continuation of anticoagulation during intensive care treatment is important. Furthermore, in everyday clinical practice, prophylaxis of thromboembolism as well as the question of potential therapeutic options in the treatment of sepsis and infection-triggered disorders of blood coagulation are important. Specific questions arise with the use of extracorporeal devices such as renal replacement and circulatory assist systems. A number of new anticoagulation and anti-platelet drugs have become available in recent years. Laboratory monitoring of anticoagulation is central. In this overview, current aspects of these topics are presented.
Collapse
Affiliation(s)
- Patrick Möhnle
- Abteilung für Transfusionsmedizin, Zelltherapeutika und Hämostaseologie, Klinik für Anästhesiologie, LMU Klinikum München, Ziemssenstr. 1, 80336, München, Deutschland.
| | - Mathias Bruegel
- Institut für Laboratoriumsmedizin, LMU Klinikum München, München, Deutschland
| | - Michael Spannagl
- Abteilung für Transfusionsmedizin, Zelltherapeutika und Hämostaseologie, Klinik für Anästhesiologie, LMU Klinikum München, Ziemssenstr. 1, 80336, München, Deutschland
| |
Collapse
|
60
|
Abstract
Acquired von Willebrand syndrome can occur in the setting of myeloproliferative neoplasms; plasma cell dyscrasias and other lymphoproliferative disorders; autoimmune conditions; and causes of increased shear forces, such as aortic stenosis or other structural heart disease and mechanical circulatory support. The depletion of von Willebrand factor, especially high-molecular-weight multimers, can lead to mucocutaneous bleeding and the formation of arteriovenous malformations, particularly in the gastrointestinal tract. Management focuses on correction of the underlying cause when possible, but may include intravenous immunoglobulins, von Willebrand factor concentrate, rituximab, or antiangiogenic therapy depending on the clinical context.
Collapse
Affiliation(s)
- Arielle L Langer
- Division of Hematology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Nathan T Connell
- Division of Hematology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
| |
Collapse
|
61
|
Hensley NB, Mazzeffi MA. Pro-Con Debate: Fibrinogen Concentrate or Cryoprecipitate for Treatment of Acquired Hypofibrinogenemia in Cardiac Surgical Patients. Anesth Analg 2021; 133:19-28. [PMID: 34127586 DOI: 10.1213/ane.0000000000005513] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Cryoprecipitate has been the gold standard for treating acquired hypofibrinogenemia in cardiac surgery for nearly 50 years. More recently, fibrinogen concentrate has been used off-label in the United States and is the standard in European countries and Canada to treat the acquired hypofibrinogenemia during cardiac surgery. Fibrinogen concentrate has multiple potential advantages including rapid reconstitution, greater dose predictability, viral inactivation during processing, and reduced transfusion-related adverse events. However, because fibrinogen concentrate lacks the other components contained in the cryoprecipitate, it may not be the "ideal" product for replacing fibrinogen in all cardiac surgical patients, particularly those with longer cardiopulmonary bypass duration. In this Pro-Con commentary article, we discuss the advantages and disadvantages of using fibrinogen concentrate and cryoprecipitate to treat acquired hypofibrinogenemia in cardiac surgical patients.
Collapse
Affiliation(s)
- Nadia B Hensley
- From the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael A Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| |
Collapse
|
62
|
Li Y, Wang L, Zhang J, Han H, Liu H, Li C, Guo H, Chen Y, Chen X. Oseltamivir Improved Thrombocytopenia During Veno-Arterial Extracorporeal Membrane Oxygenation in Adults With Refractory Cardiac Failure: A Single-Center Retrospective Real-World Study. Front Cardiovasc Med 2021; 8:645867. [PMID: 34381822 PMCID: PMC8349981 DOI: 10.3389/fcvm.2021.645867] [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: 12/24/2020] [Accepted: 07/05/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Severe thrombocytopenia is a common complication of extracorporeal membrane oxygenation (ECMO). Oseltamivir can be used to treat infection-associated thrombocytopenia. Objective: To evaluate the effect of oseltamivir on attenuating severe thrombocytopenia during ECMO. Methods: This was a single-center real-world study in critically ill patients supported with venous-arterial extracorporeal membrane oxygenation (VA-ECMO). Patients suspected or confirmed with influenza received oseltamivir according to the Chinese guidelines. Thrombocytopenia and survival were compared between the oseltamivir-treated and untreated group. The factors associated with survival were analyzed by multivariable Cox analysis. Results: A total of 82 patients were included. All patients developed thrombocytopenia after initiating VA-ECMO. Twenty-three patients received oseltamivir (O+ group), and 59 did not use oseltamivir (O− group). During the first 8 days after VA-ECMO initiation, the platelet count in the O+ group was higher than that in the O− group (all P < 0.05). The patients in the O+ group had a higher median nadir platelet count (77,000/μl, 6,000–169,000/μl) compared with the O− group (49,000/μl, 2,000–168,000/μl; P = 0.04). A nadir platelet count of <50,000/μl was seen in 26% of the patients in the O+ group, compared with 53% in the O− group (P = 0.031). No significant difference in survival from cardiac failure was seen between the O+ and O− group (48 vs. 56%, P = 0.508). The Sequential Organ Failure Assessment (SOFA) score on initiation of VA-ECMO were independently associated with survival (OR = 1.12, 95% confidence interval (95% CI): 1.02–1.22, P = 0.015). Conclusions: Oseltamivir could ameliorate VA-ECMO-related thrombocytopenia. These findings suggested the prophylactic potential of oseltamivir on severe thrombocytopenia associated with the initiation of VA-ECMO.
Collapse
Affiliation(s)
- Yuan Li
- Qilu Hospital, Shandong University, Jinan, China
| | - Lin Wang
- Qilu Hospital, Shandong University, Jinan, China
| | | | - Hui Han
- Qilu Hospital, Shandong University, Jinan, China
| | - Han Liu
- Qilu Hospital, Shandong University, Jinan, China
| | - Chaoyang Li
- Qilu Hospital, Shandong University, Jinan, China
| | - Haipeng Guo
- Qilu Hospital, Shandong University, Jinan, China
| | - Yuguo Chen
- Qilu Hospital, Shandong University, Jinan, China
| | - Xiaomei Chen
- Qilu Hospital, Shandong University, Jinan, China
| |
Collapse
|
63
|
Hékimian G, Masi P, Lejeune M, Lebreton G, Chommeloux J, Desnos C, Pineton De Chambrun M, Martin-Toutain I, Nieszkowska A, Bréchot N, Schmidt M, Leprince P, Luyt CE, Combes A, Frere C. Extracorporeal Membrane Oxygenation Induces Early Alterations in Coagulation and Fibrinolysis Profiles in COVID-19 Patients with Acute Respiratory Distress Syndrome. Thromb Haemost 2021; 121:1031-1042. [PMID: 34130315 DOI: 10.1055/a-1529-2257] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hemostatic changes induced by extracorporeal membrane oxygenation (ECMO) support have been yet poorly documented in coronavirus-19 (COVID-19) patients who have a baseline complex hypercoagulable state. In this prospective monocentric study of patients with severe acute respiratory distress syndrome (ARDS) rescued by ECMO, we performed longitudinal measurements of coagulation and fibrinolysis markers throughout the course of ECMO support in 20 COVID-19 and 10 non-COVID-19 patients. Blood was sampled before and then 24 hours, 7, and 14 days after ECMO implantation. Clinical outcomes were prospectively assessed until discharge from the intensive care unit or death. The median age of participants was 47 (35-56) years, with a median body mass index of 30 (27-35) kg/m2, and a Sepsis-related Organ Failure Assessment score of 12 (8-16). Baseline levels of von Willebrand factor, fibrinogen, factor VIII, prothrombin F1 + 2, thrombin-antithrombin, D-dimer, and plasminogen activator inhibitor-1 (PAI-1) were elevated in both COVID-19 and non-COVID-19 ARDS patients, indicating that endothelial activation, endogenous thrombin generation, and fibrinolysis shutdown occur in all ARDS patients before ECMO implantation. From baseline to day 7, thrombin generation (prothrombin F1 + 2, p < 0.01) and fibrin formation markers (fibrin monomers, p < 0.001) significantly increased, further resulting in significant decreases in platelet count (p < 0.0001) and fibrinogen level (p < 0.001). PAI-1 levels significantly decreased from baseline to day 7 (p < 0.0001) in all ARDS patients. These changes were more marked in COVID-19 patients, resulting in 14 nonfatal and 3 fatal bleeding. Additional studies are warranted to determine whether monitoring of thrombin generation and fibrinolysis markers might help to early predict bleeding complications in COVID-19 patients supported by ECMO.
Collapse
Affiliation(s)
- Guillaume Hékimian
- Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France.,Sorbonne Université, INSERM UMRS_1166, Institute of Cardiometabolism And Nutrition, Paris, France
| | - Paul Masi
- Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France
| | - Manon Lejeune
- Sorbonne Université, INSERM UMRS_1166, Institute of Cardiometabolism And Nutrition, Paris, France.,Department of Hematology, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France
| | - Guillaume Lebreton
- Sorbonne Université, INSERM UMRS_1166, Institute of Cardiometabolism And Nutrition, Paris, France.,Department of Cardiothoracic Surgery, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France
| | - Juliette Chommeloux
- Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France
| | - Cyrielle Desnos
- Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France
| | - Marc Pineton De Chambrun
- Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France
| | - Isabelle Martin-Toutain
- Department of Hematology, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France
| | - Ania Nieszkowska
- Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France
| | - Nicolas Bréchot
- Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France
| | - Matthieu Schmidt
- Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France.,Sorbonne Université, INSERM UMRS_1166, Institute of Cardiometabolism And Nutrition, Paris, France
| | - Pascal Leprince
- Sorbonne Université, INSERM UMRS_1166, Institute of Cardiometabolism And Nutrition, Paris, France.,Department of Cardiothoracic Surgery, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France
| | - Charles-Edouard Luyt
- Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France.,Sorbonne Université, INSERM UMRS_1166, Institute of Cardiometabolism And Nutrition, Paris, France
| | - Alain Combes
- Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France.,Sorbonne Université, INSERM UMRS_1166, Institute of Cardiometabolism And Nutrition, Paris, France
| | - Corinne Frere
- Sorbonne Université, INSERM UMRS_1166, Institute of Cardiometabolism And Nutrition, Paris, France.,Department of Hematology, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France
| |
Collapse
|
64
|
Qiu C, Li T, Wei G, Xu J, Yu W, Wu Z, Li D, He Y, Chen T, Zhang J, He X, Hu J, Fang J, Zhang H. Hemorrhage and venous thromboembolism in critically ill patients with COVID-19. SAGE Open Med 2021; 9:20503121211020167. [PMID: 34104439 PMCID: PMC8170290 DOI: 10.1177/20503121211020167] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 05/03/2021] [Indexed: 12/28/2022] Open
Abstract
Objective: The majority of patients with COVID-19 showed mild symptoms. However,
approximately 5% of them were critically ill and require intensive care unit
admission for advanced life supports. Patients in the intensive care unit
were high risk for venous thromboembolism and hemorrhage due to the
immobility and anticoagulants used during advanced life supports. The aim of
the study was to report the incidence and treatments of the two
complications in such patients. Method: Patients with COVID-19 (Group 1) and patients with community-acquired
pneumonia (Group 2) that required intensive care unit admission were
enrolled in this retrospective study. Their demographics, laboratory
results, ultrasound findings and complications such as venous
thromboembolism and hemorrhage were collected and compared. Results: Thirty-four patients with COVID-19 and 51 patients with community-acquired
pneumonia were included. The mean ages were 66 and 63 years in Groups 1 and
2, respectively. Venous thromboembolism was detected in 6 (18%) patients
with COVID-19 and 18 (35%) patients with community-acquired pneumonia
(P = 0.09). The major type was distal deep venous thrombosis. Twenty-one
bleeding events occurred in 12 (35%) patients with COVID-19 and 5 bleeding
events occurred in 5 (10%) patients with community-acquired pneumonia,
respectively (P = 0.01). Gastrointestinal system was the most common source
of bleeding. With the exception of one death due to intracranial bleeding,
blood transfusion with or without surgical/endoscopic treatments was able to
manage the bleeding in the remaining patients. Multivariable logistic
regression showed increasing odds of hemorrhage with extracorporeal membrane
oxygenation (odds ratio: 13.9, 95% confidence interval: 4.0–48.1) and
COVID-19 (odds ratio: 4.7, 95% confidence interval: 1.2–17.9). Conclusion: Venous thromboembolism and hemorrhage were common in both groups. The
predominant type of venous thromboembolism was distal deep venous
thrombosis, which presented a low risk of progression. COVID-19 and
extracorporeal membrane oxygenation were risk factors for hemorrhage. Blood
transfusion with or without surgical/endoscopic treatments was able to
manage it in most cases.
Collapse
Affiliation(s)
- Chenyang Qiu
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Tong Li
- Department of Emergency, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Guoqing Wei
- Department of Hematology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jun Xu
- Intensive Care Unit, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Wenqiao Yu
- Intensive Care Unit, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Ziheng Wu
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Donglin Li
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yangyan He
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Tianchi Chen
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jingchen Zhang
- Department of Emergency, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xujian He
- Department of Emergency, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jia Hu
- Department of Emergency, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Junjun Fang
- Intensive Care Unit, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Hongkun Zhang
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| |
Collapse
|
65
|
Kannapadi NV, Jami M, Premraj L, Etchill EW, Giuliano K, Bush EL, Kim BS, Seal S, Whitman G, Cho SM. Neurologic Injury in Patients With COVID-19 Who Receive VV-ECMO Therapy: A Cohort Study. J Cardiothorac Vasc Anesth 2021; 35:3456-3461. [PMID: 34119413 PMCID: PMC8117479 DOI: 10.1053/j.jvca.2021.05.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 05/03/2021] [Accepted: 05/06/2021] [Indexed: 01/13/2023]
Affiliation(s)
- Nivedha V Kannapadi
- Division of Neurosciences Critical Care, Department of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Meghana Jami
- Division of Neurosciences Critical Care, Department of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Eric W Etchill
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Katherine Giuliano
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Errol L Bush
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Bo Soo Kim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Stella Seal
- Department of Hospital, Health, and Community Services, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Glenn Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sung-Min Cho
- Division of Neurosciences Critical Care, Department of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| |
Collapse
|
66
|
Jiritano F, Fina D, Lorusso R, Ten Cate H, Kowalewski M, Matteucci M, Serra R, Mastroroberto P, Serraino GF. Systematic review and meta-analysis of the clinical effectiveness of point-of-care testing for anticoagulation management during ECMO. J Clin Anesth 2021; 73:110330. [PMID: 33962338 DOI: 10.1016/j.jclinane.2021.110330] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 04/17/2021] [Accepted: 04/20/2021] [Indexed: 12/26/2022]
Abstract
STUDY OBJECTIVE Viscoelastic point-of-care (POC) tests are commonly used to provide prompt diagnosis of coagulopathy and allow targeted treatments in bleeding patients on ECMO. We evaluated the clinical effectiveness of point-of-care (POC) testing for anticoagulation management in patients on extracorporeal membrane oxygenation (ECMO). DESIGN Systematic review and meta-analysis. Eligible studies evaluating the use of thromboelastography- or thromboelastometry-guided algorithms, anti-factor Xa and platelet function testing were selected after screening the literature from July 1975 to January 2020. SETTING Patients on ECMO support. PATIENTS Anticoagulation management on ECMO patients. INTERVENTIONS Rotational thromboelastometry, thromboelastography, alone or combined with platelet function testing. Trials monitoring the anticoagulation effects during ECMO using an anti-factor Xa assay were included in the systematic review. MEASUREMENTS The primary outcomes were bleeding events, surgical revisions, thrombosis events and ECMO circuit change/failure. Secondary outcomes were blood-product transfusions, cerebrovascular accidents, mortality on ECMO, ECMO duration, intensive care unit and hospital discharge rates, and in-hospital mortality. MAIN RESULTS Thirty-one trials enrolling 1684 participants were included in the systematic review. Four trials enrolling 547 subjects were included in the meta-analysis. The use of a POC testing device resulted in improved detection of surgical bleeding (RR: 0.68, 95% CI 0.49 to 0.94, I2 = 0%; χ2 test for heterogeneity, P = 0.02). The use of POC-guided algorithms did not affect bleeding (RR:0.78, 95% CI 0.58 to 1.04, I2 = 47%; χ2 test for heterogeneity, P = 0.09), thrombosis events (RR:1.35, 95% CI 0.86 to 2.12, I2 = 37%; χ2 test for heterogeneity, P = 0.19), or ECMO circuit/change (RR:0.90, 95% CI 0.48 to 1.71, I2 = 28%; χ2 test for heterogeneity, P = 0.75). CONCLUSION Routine use of POC tests did not improve the main clinical outcomes beyond suggesting a diagnosis of surgical bleeding in ECMO patients.
Collapse
Affiliation(s)
- Federica Jiritano
- Cardiac Surgery Unit, Dept. Experimental and Clinical Medicine, University "Magna Graecia" of Catanzaro, Catanzaro, Italy; Cardio-Thoracic Surgery Dept., Heart & Vascular Centre, Maastricht University Medical Centre (MUMC), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands.
| | - Dario Fina
- Cardio-Thoracic Surgery Dept., Heart & Vascular Centre, Maastricht University Medical Centre (MUMC), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands; Città di Lecce Hospital, GVM Care and Research, Lecce, Italy
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Dept., Heart & Vascular Centre, Maastricht University Medical Centre (MUMC), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | - Hugo Ten Cate
- Laboratory for Clinical Thrombosis and Haemostasis, Department of Internal Medicine, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Mariusz Kowalewski
- Cardio-Thoracic Surgery Dept., Heart & Vascular Centre, Maastricht University Medical Centre (MUMC), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands; Clinical Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior and Administration, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Matteo Matteucci
- Cardio-Thoracic Surgery Dept., Heart & Vascular Centre, Maastricht University Medical Centre (MUMC), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands; Department of Cardiac Surgery, Circolo Hospital, University of Insubria, Varese, Italy
| | - Raffaele Serra
- Department of Medical and Surgical Sciences, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - Pasquale Mastroroberto
- Cardiac Surgery Unit, Dept. Experimental and Clinical Medicine, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - Giuseppe Filiberto Serraino
- Cardiac Surgery Unit, Dept. Experimental and Clinical Medicine, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| |
Collapse
|
67
|
Klaeske K, Dieterlen MT, Eifert S, Scholz U, Garbade J, Jawad K, Sieg F, Borger MA, Meyer AL. Device-induced platelet dysfunction in patients after left ventricular assist device implantation. J Thromb Haemost 2021; 19:1331-1341. [PMID: 33636040 DOI: 10.1111/jth.15279] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 01/26/2021] [Accepted: 02/22/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Non-surgical bleeding (NSB) is a major complication after left ventricular assist device (LVAD) implantation. It has been reported that non-physiological shear stress caused by LVADs could alter platelet receptor expression, which leads to bleeding disorders caused by coagulation dysfunctions. OBJECTIVES Because bleeding diathesis could be multifactorial, we focused on the combined characterization of platelet receptor expression patterns and oxidative stress to compare patients with NSB and patients without coagulation disorder in a monocentric, prospective study. METHODS Blood samples were obtained from LVAD patients with NSB (bleeder group, n = 19) and without NSB (non-bleeder group, n = 20). The platelet receptors platelet endothelial cell adhesion molecule-1 (PECAM-1), glycoprotein (GP)Ibα, P-selectin, CD63, and GPIIb/IIIa, as well as the production of intraplatelet reactive oxygen species (ROS) were quantified by flow cytometry. Aggregation capacity was evaluated by aggregometry. RESULTS The surface expression level of P-selectin and GPIbα on platelets was decreased in bleeders (P-selectin: 465 ± 72 U; GPIbα: 435 ± 41 U) compared to non-bleeders (P-selectin: 859 ± 115 U, P < .01; GPIbα: 570 ± 49 U, p = .04). Additionally, the mean fluorescence intensity of ADP-stimulated P-selectin and PECAM-1 expressing platelets were reduced in bleeders (P-selectin: 944 ± 84 U; PECAM-1: 6722 ± 419 U) compared to non-bleeders (P-selectin: 1269 ± 130 U, P = .04; PECAM-1: 8542 ± 665 U, P = .03). Bleeders showed a higher amount of ROS formation in platelets (88.0 ± 2.6%) than non-bleeders (81.5 ± 2.1%, P = .05). CONCLUSIONS These findings suggested that changes of three platelet receptors (GPIbα, P-selectin, and PECAM-1) and elevated oxidative stress may play a role in patients with bleeding complications following LVAD implantation. These results might help to explain the high incidence of spontaneous hemorrhage during LVAD support through an altered platelet function.
Collapse
Affiliation(s)
- Kristin Klaeske
- University Department for Cardiac Surgery, Leipzig Heart Center, Helios Clinic, Leipzig, Germany
| | - Maja-Theresa Dieterlen
- University Department for Cardiac Surgery, Leipzig Heart Center, Helios Clinic, Leipzig, Germany
| | - Sandra Eifert
- University Department for Cardiac Surgery, Leipzig Heart Center, Helios Clinic, Leipzig, Germany
| | - Ute Scholz
- MVZ Labor Dr. Reising-Ackermann und Kollegen, Center of Hemostasis, Leipzig, Germany
| | - Jens Garbade
- University Department for Cardiac Surgery, Leipzig Heart Center, Helios Clinic, Leipzig, Germany
| | - Khalil Jawad
- University Department for Cardiac Surgery, Leipzig Heart Center, Helios Clinic, Leipzig, Germany
| | - Franz Sieg
- University Department for Cardiac Surgery, Leipzig Heart Center, Helios Clinic, Leipzig, Germany
| | - Michael A Borger
- University Department for Cardiac Surgery, Leipzig Heart Center, Helios Clinic, Leipzig, Germany
| | - Anna L Meyer
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| |
Collapse
|
68
|
Hemostasis, coagulation and thrombin in venoarterial and venovenous extracorporeal membrane oxygenation: the HECTIC study. Sci Rep 2021; 11:7975. [PMID: 33846433 PMCID: PMC8042030 DOI: 10.1038/s41598-021-87026-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 03/23/2021] [Indexed: 02/06/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) support has a high incidence of both bleeding and thrombotic complications. Despite clear differences in patient characteristics and pathologies between veno-venous (VV) and veno-arterial (VA) ECMO support, anticoagulation practices are often the same across modalities. Moreover, there is very little data on their respective coagulation profiles and comparisons of thrombin generation in these patients. This study compares the coagulation profile and thrombin generation between patients supported with either VV and VA ECMO. A prospective cohort study of patients undergoing VA and VV ECMO at an Intensive care department of a university hospital and ECMO referral centre. In addition to routine coagulation testing and heparin monitoring per unit protocol, thromboelastography (TEG), multiplate aggregometry (MEA), calibrated automated thrombinography (CAT) and von-Willebrand’s activity (antigen and activity ratio) were sampled second-daily for 1 week, then weekly thereafter. VA patients had significantly lower platelets counts, fibrinogen, anti-thrombin and clot strength with higher d-dimer levels than VV patients, consistent with a more pronounced consumptive coagulopathy. Thrombin generation was higher in VA than VV patients, and the heparin dose required to suppress thrombin generation was lower in VA patients. There were no significant differences in total bleeding or thrombotic event rates between VV and VA patients when adjusted for days on extracorporeal support. VA patients received a lower median daily heparin dose 8500 IU [IQR 2500–24000] versus VV 28,800 IU [IQR 17,300–40,800.00]; < 0.001. Twenty-eight patients (72%) survived to hospital discharge; comprising 53% of VA patients and 77% of VV patients. Significant differences between the coagulation profiles of VA and VV patients exist, and anticoagulation strategies for patients of these modalities should be different. Further research into the development of tailored anticoagulation strategies that include the mode of ECMO support need to be completed.
Collapse
|
69
|
Mazzeffi MA, Chow JH, Tanaka K. COVID-19 Associated Hypercoagulability: Manifestations, Mechanisms, and Management. Shock 2021; 55:465-471. [PMID: 32890309 PMCID: PMC7959868 DOI: 10.1097/shk.0000000000001660] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 07/17/2020] [Accepted: 08/24/2020] [Indexed: 12/15/2022]
Abstract
ABSTRACT Patients with severe coronavirus disease-2019 (COVID-19) frequently have hypercoagulability caused by the immune response to the severe acute respiratory syndrome coronavirus-2 infection. The pathophysiology of COVID-19 associated hypercoagulability is not fully understood, but characteristic changes include: increased fibrinogen concentration, increased Factor VIII activity, increased circulating von Willebrand factor, and exhausted fibrinolysis. Anticoagulant therapy improves outcomes in mechanically ventilated patients with COVID-19 and viscoelastic coagulation testing offers an opportunity to tailor anticoagulant therapy based on an individual patient's coagulation status. In this narrative review, we summarize clinical manifestations of COVID-19, mechanisms, monitoring considerations, and anticoagulant therapy. We also review unique considerations for COVID-19 patients who are on extracorporeal membrane oxygenation.
Collapse
Affiliation(s)
- Michael A Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | | | | |
Collapse
|
70
|
Desai M, Osborn E, King C, Shlobin OA, Psotka M, Ryan L, Javid Akhtar S, Singh R. Extracorporeal life support for cardiogenic shock during pregnancy and postpartum: a single center experience. Perfusion 2021; 37:493-498. [PMID: 33765891 DOI: 10.1177/02676591211004369] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The use of veno-arterial extracorporeal membrane oxygenation (VA ECMO) for cardiogenic shock in pregnant and postpartum patients remains limited by concerns of bleeding, hemolysis, and fetal risks. This case series examines the underlying characteristics and management strategies for this high-risk population. METHODS All pregnant and post-partum patients who underwent VA ECMO in the cardiovascular intensive care unit between January 1, 2016 and November 1, 2019, were included in this retrospective study. Management of maternal and fetal O2 delivery, left ventricular (LV) unloading, anticoagulation, and ECMO circuit characteristics were evaluated. RESULTS Five patients required veno-arterial ECMO for restoration of systemic perfusion. Three patients developed peripartum cardiomyopathy, one septic cardiomyopathy, and one acute right ventricular (RV) failure. The median age was 30.6 years, with median gestational age in pregnant patients of 31 weeks. Maternal and fetal survival to discharge was 80%. Bleeding was the primary complication, with two patients requiring blood transfusions; one requiring interventional radiology (IR) embolization and the other requiring surgical intervention to control bleeding. One patient was successfully delivered on VA ECMO. No fetal complications were directly attributed to VA ECMO. CONCLUSIONS VA ECMO can be employed successfully in obstetric patients with cardiogenic shock with appropriate patient selection. Further research is needed to determine if VA ECMO provides a survival advantage over traditional management strategies in this vulnerable population.
Collapse
Affiliation(s)
- Mehul Desai
- Medical Critical Care Service, Department of Medicine, INOVA Fairfax Hospital, Falls Church, VA, USA
| | - Erik Osborn
- Medical Critical Care Service, Department of Medicine, INOVA Fairfax Hospital, Falls Church, VA, USA
| | - Christopher King
- Advanced Lung Disease, INOVA Fairfax Hospital, Falls Church, VA, USA
| | - Oksana A Shlobin
- Advanced Lung Disease, INOVA Fairfax Hospital, Falls Church, VA, USA
| | - Mitchell Psotka
- Advanced Heart Failure, INOVA Fairfax Hospital, Falls Church, VA, USA
| | - Liam Ryan
- INOVA Cardiac and Thoracic Surgery, INOVA Fairfax Hospital, Falls Church, VA, USA
| | - Saba Javid Akhtar
- INOVA Cardiac and Thoracic Surgery, INOVA Fairfax Hospital, Falls Church, VA, USA
| | - Ramesh Singh
- INOVA Cardiac and Thoracic Surgery, INOVA Fairfax Hospital, Falls Church, VA, USA
| |
Collapse
|
71
|
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
|
72
|
Factor XIII Activity Might Already Be Impaired before Veno-Venous ECMO in ARDS Patients: A Prospective, Observational Single-Center Cohort Study. J Clin Med 2021; 10:jcm10061203. [PMID: 33799338 PMCID: PMC7999955 DOI: 10.3390/jcm10061203] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 03/05/2021] [Accepted: 03/09/2021] [Indexed: 12/16/2022] Open
Abstract
Direct complications in patients receiving extracorporeal (veno-venous) membrane oxygenation (vvECMO) are mainly either due to bleeding or thromboembolism. We aimed to evaluate the course of routine coagulation parameters and the activity of different coagulation factors—with special focus on factor XIII (F XIII)—before, during and after vvECMO in acute respiratory distress syndrome (ARDS) patients. The activity of coagulation factors and rotational thrombelastometry were analyzed in 20 ECMO patients before (T-1) and 6 h (T0), one (T1), three (T3) and seven days (T7) after the implantation, as well as one and three days after the termination of ECMO. F XIII activity was already severely decreased to 37% (30/49) before ECMO. F XIII activity was the only coagulation factor continuously declining during vvECMO, being significantly decreased at T3 (31% (26/45) vs. 24% (18/42), p = 0.0079) and T7 (31% (26/45) vs. 23% (17/37), p = 0.0037) compared to T0. Three days after termination of vvECMO, platelet count and fibrinogen nearly doubled and factors II, V, XI and XIII showed spontaneous significant increases. Severe ARDS patients showed a considerably diminished factor XIII activity before vvECMO initiation and its activity continuously declined later on. Thus, incorporation of F XIII monitoring into the regular hemostaseologic routine during vvECMO therapy seems advisable. Due to the potential development of a hypercoagulatory state after the termination of vvECMO, tight hemostasiologic monitoring should persist in the initial phase after ECMO termination.
Collapse
|
73
|
Patel PA, Henderson RA, Bolliger D, Erdoes G, Mazzeffi MA. The Year in Coagulation: Selected Highlights from 2020. J Cardiothorac Vasc Anesth 2021; 35:2260-2272. [PMID: 33781668 DOI: 10.1053/j.jvca.2021.02.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 02/26/2021] [Indexed: 01/28/2023]
Abstract
This is the second annual review in the Journal of Cardiothoracic and Vascular Anesthesia to cover highlights in coagulation for cardiac surgery. The goal of this article is to provide readers with a focused summary from the literature of the prior year's most important coagulation topics. In 2020, this included a discussion covering allogeneic transfusion, antiplatelet and anticoagulant therapy, factor concentrates, coagulation testing, mechanical circulatory support, and the effects of coronavirus disease 2019.
Collapse
Affiliation(s)
- Prakash A Patel
- Department of Anesthesiology, Cardiothoracic Division, Yale University School of Medicine, New Haven, CT.
| | - Reney A Henderson
- Department of Anesthesiology, Division of Cardiothoracic Anesthesia, University of Maryland School of Medicine, Baltimore, MD
| | - Daniel Bolliger
- Department of Anesthesiology, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Gabor Erdoes
- Department of Anesthesiology and Pain Medicine, Inselspital, University Hospital of Bern, Bern, Switzerland
| | - Michael A Mazzeffi
- Department of Anesthesiology, Division of Cardiothoracic Anesthesia, University of Maryland School of Medicine, Baltimore, MD; Department of Anesthesiology, Division of Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD
| |
Collapse
|
74
|
Olson SR, Murphree CR, Zonies D, Meyer AD, McCarty OJ, DeLoughery TG, Shatzel JJ. Thrombosis and Bleeding in Extracorporeal Membrane Oxygenation (ECMO) Without Anticoagulation: A Systematic Review. ASAIO J 2021; 67:290-296. [PMID: 33627603 PMCID: PMC8623470 DOI: 10.1097/mat.0000000000001230] [Citation(s) in RCA: 118] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) causes both thrombosis and bleeding. Major society guidelines recommend continuous, systemic anticoagulation to prevent thrombosis of the ECMO circuit, though this may be undesirable in those with active, or high risk of, bleeding. We aimed to systematically review thrombosis and bleeding outcomes in published cases of adults treated with ECMO without continuous systemic anticoagulation. Ovid MEDLINE, Cochrane CENTRAL and CDSR, and hand search via SCOPUS were queried. Eligible studies were independently reviewed by two blinded authors if they reported adults (≥18 years) treated with either VV- or VA-ECMO without continuous systemic anticoagulation for ≥24 hours. Patient demographics, clinical data, and specifics of ECMO technology and treatment parameters were collected. Primary outcomes of interest included incidence of bleeding, thrombosis of the ECMO circuit requiring equipment exchange, patient venous or arterial thrombosis, ability to wean off of ECMO, and mortality. Of the 443 total publications identified, 34 describing 201 patients met our inclusion criteria. Most patients were treated for either acute respiratory distress syndrome or cardiogenic shock. The median duration of anticoagulant-free ECMO was 4.75 days. ECMO circuity thrombosis and patient thrombosis occurred in 27 (13.4%) and 19 (9.5%) patients, respectively. Any bleeding and major or "severe" bleeding was reported in 66 (32.8%) and 56 (27.9%) patients, respectively. Forty patients (19%) died. While limited by primarily retrospective data and inconsistent reporting of outcomes, our systematic review of anticoagulant-free ECMO reveals an incidence of circuity and patient thrombosis comparable to patients receiving continuous systemic anticoagulation while on ECMO.
Collapse
Affiliation(s)
- Sven R. Olson
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland OR
| | - Catherine R. Murphree
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland OR
| | - David Zonies
- Division of Trauma & Critical Care, Department of Surgery, Oregon Health and Science University, Portland OR
| | - Andrew D. Meyer
- Division of Pediatric Critical Care, Department of Pediatrics, University of Texas Health, San Antonio TX
| | - Owen J.T. McCarty
- Department of Biomedical Engineering, Oregon Health & Science University, Portland OR
| | - Thomas G. DeLoughery
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland OR
| | - Joseph J. Shatzel
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland OR
- Department of Biomedical Engineering, Oregon Health & Science University, Portland OR
| |
Collapse
|
75
|
Wang S, Griffith BP, Wu ZJ. Device-Induced Hemostatic Disorders in Mechanically Assisted Circulation. Clin Appl Thromb Hemost 2021; 27:1076029620982374. [PMID: 33571008 PMCID: PMC7883139 DOI: 10.1177/1076029620982374] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Mechanically assisted circulation (MAC) sustains the blood circulation in the body of a patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) or on ventricular assistance with a ventricular assist device (VAD) or on extracorporeal membrane oxygenation (ECMO) with a pump-oxygenator system. While MAC provides short-term (days to weeks) support and long-term (months to years) for the heart and/or lungs, the blood is inevitably exposed to non-physiological shear stress (NPSS) due to mechanical pumping action and in contact with artificial surfaces. NPSS is well known to cause blood damage and functional alterations of blood cells. In this review, we discussed shear-induced platelet adhesion, platelet aggregation, platelet receptor shedding, and platelet apoptosis, shear-induced acquired von Willebrand syndrome (AVWS), shear-induced hemolysis and microparticle formation during MAC. These alterations are associated with perioperative bleeding and thrombotic events, morbidity and mortality, and quality of life in MCS patients. Understanding the mechanism of shear-induce hemostatic disorders will help us develop low-shear-stress devices and select more effective treatments for better clinical outcomes.
Collapse
Affiliation(s)
- Shigang Wang
- Department of Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Bartley P Griffith
- Department of Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Zhongjun J Wu
- Department of Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA.,Fischell Department of Bioengineering, A. James Clark School of Engineering, University of Maryland, College Park, MD, USA
| |
Collapse
|
76
|
Mazzeffi M, Judd M, Rabin J, Tabatabai A, Menaker J, Menne A, Chow J, Shah A, Henderson R, Herr D, Tanaka K. Tissue Factor Pathway Inhibitor Levels During Veno-Arterial Extracorporeal Membrane Oxygenation in Adults. ASAIO J 2021; 67:878-883. [PMID: 33606392 DOI: 10.1097/mat.0000000000001322] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Tissue factor pathway inhibitor (TFPI) has multiple anticoagulant properties. To our knowledge, no studies have measured TFPI levels in adult veno-arterial (VA) extracorporeal membrane oxygenation patients. We hypothesized that adult VA ECMO patients would have increased TFPI levels and slowed tissue factor triggered thrombin generation. Twenty VA ECMO patients had TFPI levels and thrombin generation lag time measured on ECMO day 1 or 2, day 3, and day 5. TFPI levels and thrombin generation lag time were compared against healthy control plasma samples. Mean TFPI levels were significantly higher in ECMO patients on ECMO day 1 or 2 = 81,877 ± 19,481 pg/mL, day 3 = 73,907 ± 26,690 pg/mL, and day 5 = 77,812 ± 23,484 pg/mL compared with control plasma = 38,958 ± 9,225 pg/mL (P < 0.001 for all comparisons). Median thrombin generation lag time was significantly longer in ECMO patients on ECMO day 1 or 2 = 10.0 minutes [7.5, 13.8], day 3 = 9.0 minutes [6.8, 12.1], and day 5 = 10.7 minutes [8.3, 15.2] compared with control plasma = 3.6 minutes [2.9, 4.2] (P < 0.001 for all comparisons). TFPI is increased in VA ECMO patients and tissue factor triggered thrombin generation is slowed. Increased TFPI levels could contribute to the multifactorial coagulopathy that occurs during ECMO.
Collapse
Affiliation(s)
| | | | - Joseph Rabin
- Department of Surgery, Program in Trauma, R Adams Cowley Shock Trauma Center
| | - Ali Tabatabai
- Department of Medicine, Program in Trauma, R Adams Cowley Shock Trauma Center
| | - Jay Menaker
- Department of Surgery, Program in Trauma, R Adams Cowley Shock Trauma Center
| | - Ashley Menne
- Department of Emergency Medicine, Program in Trauma, R Adams Cowley Shock Trauma Center
| | | | - Aakash Shah
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland School of Medicine, Baltimore, MD
| | | | - Daniel Herr
- Department of Medicine, Program in Trauma, R Adams Cowley Shock Trauma Center
| | | |
Collapse
|
77
|
Squiccimarro E, Jiritano F, Serraino GF, ten Cate H, Paparella D, Lorusso R. Quantitative and Qualitative Platelet Derangements in Cardiac Surgery and Extracorporeal Life Support. J Clin Med 2021; 10:jcm10040615. [PMID: 33561947 PMCID: PMC7914426 DOI: 10.3390/jcm10040615] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 01/30/2021] [Accepted: 02/03/2021] [Indexed: 01/19/2023] Open
Abstract
Thrombocytopenia and impaired platelet function are known as intrinsic drawbacks of cardiac surgery and extracorporeal life supports (ECLS). A number of different factors influence platelet count and function including the inflammatory response to a cardiopulmonary bypass (CPB) or to ECLS, hemodilution, hypothermia, mechanical damage and preoperative treatment with platelet-inhibiting agents. Moreover, although underestimated, heparin-induced thrombocytopenia is still a hiccup in the perioperative management of cardiac surgical and, above all, ECLS patients. Moreover, recent investigations have highlighted how platelet disorders also affect patients undergoing biological prosthesis implantation. Though many hypotheses have been suggested, the mechanism underlying thrombocytopenia and platelet disorders is still to be cleared. This narrative review aims to offer clinicians a summary of their major causes in the cardiac surgery setting.
Collapse
Affiliation(s)
- Enrico Squiccimarro
- Department of Cardiac Surgery, Mater Dei Hospital, 70125 Bari, Italy;
- Department of Emergency and Organ Transplant (DETO), University of Bari, 70125 Bari, Italy
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre (MUMC), 6229HX Maastricht, The Netherlands;
| | - Federica Jiritano
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre (MUMC), 6229HX Maastricht, The Netherlands;
- Cardiac Surgery Unit, Department of Experimental and Clinical Medicine, University “Magna Graecia” of Catanzaro, 88100 Catanzaro, Italy;
- Correspondence:
| | - Giuseppe Filiberto Serraino
- Cardiac Surgery Unit, Department of Experimental and Clinical Medicine, University “Magna Graecia” of Catanzaro, 88100 Catanzaro, Italy;
| | - Hugo ten Cate
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, D-55131 Mainz, Germany;
- Thrombosis Center Maastricht, Maastricht University Medical Center (MUMC), 6229HX Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), 6229HX Maastricht, The Netherlands
| | - Domenico Paparella
- Division of Cardiac Surgery, Santa Maria Hospital, GVM Care & Research, 70125 Bari, Italy;
- Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre (MUMC), 6229HX Maastricht, The Netherlands;
- Cardiovascular Research Institute Maastricht (CARIM), 6229HX Maastricht, The Netherlands
| |
Collapse
|
78
|
Klompas AM, Boswell MR, Plack DL, Smith MM. Thrombocytopenia: Perioperative Considerations for Patients Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth 2021; 36:893-905. [PMID: 33707107 DOI: 10.1053/j.jvca.2021.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 02/01/2021] [Indexed: 11/11/2022]
Abstract
The etiologies of thrombocytopenia in patients presenting for cardiac surgery are extensive, but clinically relevant conditions generally can be categorized by those related to decreased platelet production or increased platelet destruction. Many causes require mere acknowledgment and availability of allogeneic platelet transfusion; others have unique considerations for which providers should be familiar. The purpose of this review is to provide an overview of the common causes of thrombocytopenia, summarize the literature, and discuss perioperative considerations for patients undergoing cardiac surgery.
Collapse
Affiliation(s)
- Allan M Klompas
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, 200 First St SW, Rochester, MN
| | - Michael R Boswell
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, 200 First St SW, Rochester, MN
| | - Daniel L Plack
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, 200 First St SW, Rochester, MN
| | - Mark M Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, 200 First St SW, Rochester, MN.
| |
Collapse
|
79
|
Abstract
Patients receiving extracorporeal membrane oxygenation (ECMO) often require prolonged mechanical ventilation. Providers may be reluctant to perform tracheostomies on patients during ECMO due to their tenuous clinical status and systemic anticoagulation. We report our experience with performing open and percutaneous tracheostomies on patients supported on ECMO from August 2009 to December 2017. Of the 127 patients who underwent tracheostomy during ECMO support, the median age was 42 years (interquartile range [IQR], 29-54), 99 (78%) patients had venovenous (VV) cannulation, 22 (17%) patients had venoarterial (VA) cannulation, and six (5%) patients had hybrid configurations. Percutaneous tracheostomy was performed in 110 (87%) patients. Median-activated partial thromboplastin time (aPTT) at the time of tracheostomy was 47.5 seconds (IQR, 41-57.6 seconds). The median time from ECMO initiation to tracheostomy was 7 days (IQR, 4-11 days). A total of 55 patients (43%) received packed red blood cell (pRBC) transfusions within 48 hours after tracheostomy with a median transfusion of 2 units (IQR, 1-3). There was no procedural mortality. Overall, 88 (69%) patients survived to decannulation and 74 (58%) survived to hospital discharge. Our experience with the largest published series of tracheostomies during ECMO demonstrates that excellent outcomes can be achieved without significant morbidity.
Collapse
|
80
|
Cho SM, Canner J, Caturegli G, Choi CW, Etchill E, Giuliano K, Chiarini G, Calligy K, Rycus P, Lorusso R, Kim BS, Sussman M, Suarez JI, Geocadin R, Bush EL, Ziai W, Whitman G. Risk Factors of Ischemic and Hemorrhagic Strokes During Venovenous Extracorporeal Membrane Oxygenation: Analysis of Data From the Extracorporeal Life Support Organization Registry. Crit Care Med 2021; 49:91-101. [PMID: 33148951 PMCID: PMC9513801 DOI: 10.1097/ccm.0000000000004707] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES Stroke is commonly reported in patients receiving venovenous extracorporeal membrane oxygenation, but risk factors are not well described. We sought to determine preextracorporeal membrane oxygenation and on-extracorporeal membrane oxygenation risk factors for both ischemic and hemorrhagic strokes in patients with venovenous extracorporeal membrane oxygenation support. DESIGN Retrospective analysis. SETTING Data reported to the Extracorporeal Life Support Organization by 366 extracorporeal membrane oxygenation centers from 2013 to 2019. PATIENTS Patients older than 18 years supported with a single run of venovenous extracorporeal membrane oxygenation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 15,872 venovenous extracorporeal membrane oxygenation patients, 812 (5.1%) had at least one type of acute brain injury, defined as ischemic stroke, hemorrhagic stroke, or brain death. Overall, 215 (1.4%) experienced ischemic stroke and 484 (3.1%) experienced hemorrhagic stroke. Overall inhospital mortality was 36%, but rates were higher in those with ischemic or hemorrhagic stroke (68% and 73%, respectively). In multivariable analysis, preextracorporeal membrane oxygenation pH (adjusted odds ratio = 0.10; 95% CI, 0.03-0.35; p < 0.001), hemolysis (adjusted odds ratio = 2.27; 95% CI, 1.22-4.24; p = 0.010), gastrointestinal hemorrhage (adjusted odds ratio = 2.01; 95% CI 1.12-3.59; p = 0.019), and disseminated intravascular coagulation (adjusted odds ratio = 3.61; 95% CI, 1.51-8.66; p = 0.004) were independently associated with ischemic stroke. Pre-extracorporeal membrane oxygenation pH (adjusted odds ratio = 0.28; 95% CI, 0.12-0.65; p = 0.003), preextracorporeal membrane oxygenation Po2 (adjusted odds ratio = 0.96; 95% CI, 0.93-0.99; p = 0.021), gastrointestinal hemorrhage (adjusted odds ratio = 1.70; 95% CI, 1.15-2.51; p = 0.008), and renal replacement therapy (adjusted odds ratio=1.57; 95% CI, 1.22-2.02; p < 0.001) were independently associated with hemorrhagic stroke. CONCLUSIONS Among venovenous extracorporeal membrane oxygenation patients in the Extracorporeal Life Support Organization registry, approximately 5% had acute brain injury. Mortality rates increased two-fold when ischemic or hemorrhagic strokes occurred. Risk factors such as lower pH and hypoxemia during the pericannulation period and markers of coagulation disturbances were associated with acute brain injury. Further research on understanding preextracorporeal membrane oxygenation and on-extracorporeal membrane oxygenation risk factors and the timing of acute brain injury is necessary to develop appropriate prevention and management strategies.
Collapse
Affiliation(s)
- Sung-Min Cho
- Division of Neuroscience Critical Care, Departments of Neurology and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joe Canner
- Division of Cardiac Surgery, Cardiovascular Surgical Intensive Care, Department of Surgery, Heart and Vascular Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Giorgio Caturegli
- Division of Neuroscience Critical Care, Departments of Neurology and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Chun Woo Choi
- Division of Cardiac Surgery, Cardiovascular Surgical Intensive Care, Department of Surgery, Heart and Vascular Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Eric Etchill
- Division of Cardiac Surgery, Cardiovascular Surgical Intensive Care, Department of Surgery, Heart and Vascular Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Katherine Giuliano
- Division of Cardiac Surgery, Cardiovascular Surgical Intensive Care, Department of Surgery, Heart and Vascular Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Giovanni Chiarini
- Cardio-Thoracic Surgery Department, Maastricht University Medical Centre (MUMC), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands
- Division of Anesthesiology, Intensive Care and Emergency Medicine, Spedali Civili University, Affiliated Hospital of Brescia, Brescia, Italy
| | - Kate Calligy
- Division of Cardiac Surgery, Cardiovascular Surgical Intensive Care, Department of Surgery, Heart and Vascular Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Peter Rycus
- Extracorporeal Life Support Organization (ELSO), Ann Arbor, Michigan
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Maastricht University Medical Centre (MUMC), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands
| | - Bo Soo Kim
- Division of Cardiac Surgery, Cardiovascular Surgical Intensive Care, Department of Surgery, Heart and Vascular Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Marc Sussman
- Division of Cardiac Surgery, Cardiovascular Surgical Intensive Care, Department of Surgery, Heart and Vascular Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jose I. Suarez
- Division of Neuroscience Critical Care, Departments of Neurology and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Romergryko Geocadin
- Division of Neuroscience Critical Care, Departments of Neurology and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Errol L. Bush
- Division of Thoracic Surgery, Department of Surgery, Heart and Vascular Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Wendy Ziai
- Division of Neuroscience Critical Care, Departments of Neurology and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Glenn Whitman
- Division of Cardiac Surgery, Cardiovascular Surgical Intensive Care, Department of Surgery, Heart and Vascular Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| |
Collapse
|
81
|
Acquired von Willebrand syndrome in ECMO patients: A 3-year cohort study. Blood Cells Mol Dis 2020; 87:102526. [PMID: 33338698 DOI: 10.1016/j.bcmd.2020.102526] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 11/25/2020] [Accepted: 11/25/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Bleeding is a common but possibly underreported side effect of Extracorporeal Membrane Oxygenation (ECMO). Impairment of primary hemostasis by acquired von Willebrand syndrome (aVWS) and platelet dysfunction as well as activation and consumption of plasmatic coagulation factors contribute to hemorrhage. The aim of the present cohort study of consecutively enrolled patients admitted to our ECMO center was to collect demographic, medical and laboratory data possibly associated with i) development of clinically relevant bleeding and/or ii) death during a 12-months follow-up. RESULTS Within a 3-year period 338 white patients aged 18-89 years (median: 60; male 64.5%) were enrolled. 78 of 338 patients (23%) presented with clinical relevant bleeding symptoms. The overall death rate was 74.6% within a median time of 9 days (1-229) post intervention. Logistic-regression analysis adjusted for age and gender revealed that i) the presence of blood group O versus non-O (Odds ratio (OR)/95%CI: 1.9/1.007-3.41), ECMO duration per day (1.1/1.06-1.14), veno-venous versus veno-arterial ECMO cannulation (2.33/1.2-4.5) and the overall need for blood product administered per unit (1.02/1.016-1.028) was independenly associated with bleeding in patients suffering from aVWS. ii) Older age (increase per year) at ECMO start (1.015/1.012-1.029) and an increasing amount of blood product units were significantly related with death (1.007/1.001-1.013). Patients with veno-venous versus veno-arterial cannulation survived longer (0.48/0.24-0.94). CONCLUSION In the present cohort study we found a clinical relevant bleeding rate of 23% in subjects with aVWS associated with blood group O, a longer ECMO duration and veno-venous cannulation.
Collapse
|
82
|
Mazzeffi M, Tanaka K, Wu YF, Zhang A, Kareddy N, Tadjou Tito E, Rock P, Michelson AD, Frelinger AL. Platelet surface GPIbα, activated GPIIb-IIIa, and P-selectin levels in adult veno-arterial extracorporeal membrane oxygenation patients. Platelets 2020; 33:116-122. [DOI: 10.1080/09537104.2020.1856360] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Michael Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kenichi Tanaka
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Yi-Feng Wu
- Center for Platelet Research Studies, Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
- Department of Hematology and Oncology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation & College of Medicine, Tzu-Chi University, Hualien, Taiwan
| | - Aijun Zhang
- Center for Platelet Research Studies, Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | - Niharika Kareddy
- Center for Platelet Research Studies, Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | - Emmanuel Tadjou Tito
- Department of Anesthesiology, Rutgers University School of Medicine, Newark, NJ, USA
| | - Peter Rock
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Alan D. Michelson
- Center for Platelet Research Studies, Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | - Andrew L. Frelinger
- Center for Platelet Research Studies, Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
83
|
Quach ME, Li R. Structure-function of platelet glycoprotein Ib-IX. J Thromb Haemost 2020; 18:3131-3141. [PMID: 32735697 PMCID: PMC7854888 DOI: 10.1111/jth.15035] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/13/2020] [Accepted: 07/17/2020] [Indexed: 12/20/2022]
Abstract
The glycoprotein (GP)Ib-IX receptor complex plays a critical role in platelet physiology and pathology. Its interaction with von Willebrand factor (VWF) on the subendothelial matrix instigates platelet arrest at the site of vascular injury and is vital to primary hemostasis. Its reception to other ligands and counter-receptors in the bloodstream also contribute to various processes of platelet biology that are still being discovered. While its basic composition and its link to congenital bleeding disorders were well documented and firmly established more than 25 years ago, recent years have witnessed critical advances in the organization, dynamics, activation, regulation, and functions of the GPIb-IX complex. This review summarizes important findings and identifies questions that remain about this unique platelet mechanoreceptor complex.
Collapse
Affiliation(s)
- M Edward Quach
- Aflac Cancer and Blood Disorders Center, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Renhao Li
- Aflac Cancer and Blood Disorders Center, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| |
Collapse
|
84
|
Mondal S, Hollander KN, Ibekwe SO, Williams B, Tanaka K. Heyde Syndrome-Pathophysiology and Perioperative Implications. J Cardiothorac Vasc Anesth 2020; 35:3331-3339. [PMID: 33132021 DOI: 10.1053/j.jvca.2020.10.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 10/02/2020] [Accepted: 10/04/2020] [Indexed: 11/11/2022]
Abstract
Gastrointestinal (GI) bleeding in patients with calcific aortic valve stenosis (AVS), termed Heyde syndrome, was first described by Edward C. Heyde. The strong association between valvular replacement and the eradication of clinically significant GI bleeding confirmed an underlying pathophysiologic relationship. The rheologic stress created by AVS increases proteolysis of von Willebrand factor (VWF), resulting in loss of predominantly high-molecular-weight VWF (Hmw VWF). Angiodysplastic vessels present in patients with AVS, coupled with the lack of functioning Hmw VWF, increase the risk for GI bleeds. Aortic valve replacement, both surgical and transcatheter-based, is often a definitive treatment for GI bleeding, leading to recovery of Hmw VWF multimers. Perioperative management of patients involves monitoring their coagulation profiles with relevant laboratory tests and instituting appropriate management. Management can be directed in the following two ways: by improving internal release of VWF or by administration of external therapeutics containing VWF. It is important for perioperative physicians to obtain an understanding of the pathophysiology of this disease process and closely monitor the bleeding pattern so that targeted therapies can be initiated.
Collapse
Affiliation(s)
- Samhati Mondal
- Department of Anesthesiology, Cardiac Anesthesia Division, University of Maryland School of Medicine, Baltimore, MD.
| | - Kimberly N Hollander
- Department of Anesthesiology, Cardiac Anesthesia Division, University of Maryland School of Medicine, Baltimore, MD
| | - Stephanie O Ibekwe
- Department of Anesthesiology, Cardiovascular Division, BTGH, Baylor College of Medicine, Houston, TX
| | - Brittney Williams
- Department of Anesthesiology, Cardiac Anesthesia Division, University of Maryland School of Medicine, Baltimore, MD
| | - Kenichi Tanaka
- Department of Anesthesiology, Cardiac Anesthesia Division, University of Maryland School of Medicine, Baltimore, MD
| |
Collapse
|
85
|
Schlagenhauf A, Zieger B, Muntean W. Contact activation and acquired von Willebrand syndrome during neonatal extracorporeal circulation. J Thromb Haemost 2020; 18:3119-3121. [PMID: 33463037 DOI: 10.1111/jth.15058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 06/25/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Axel Schlagenhauf
- Division of General Pediatrics, Department of Pediatrics and Adolescent Medicine, Medical University Graz, Graz, Austria
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Barbara Zieger
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Wolfgang Muntean
- Division of General Pediatrics, Department of Pediatrics and Adolescent Medicine, Medical University Graz, Graz, Austria
| |
Collapse
|
86
|
Usman AA, Han J, Acker A, Olia SE, Bermudez C, Cucchiara B, Mikkelsen ME, Wald J, Mackay E, Szeto W, Vernick WJ, Gutsche JT. A Case Series of Devastating Intracranial Hemorrhage During Venovenous Extracorporeal Membrane Oxygenation for COVID-19. J Cardiothorac Vasc Anesth 2020; 34:3006-3012. [PMID: 32828653 PMCID: PMC7385062 DOI: 10.1053/j.jvca.2020.07.063] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 07/18/2020] [Accepted: 07/20/2020] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Anticoagulation may be a challenge in coronavirus disease 2019 (COVID-19) extracorporeal membrane oxygenation due to endothelial injury and dysregulation of coagulation, which may increase the risk of thrombotic and bleeding complications. This report was created to describe the authors' single institutional experience, with emphasis on the high rate of intracranial hemorrhage for the first 10 patients with COVID-19 placed on venovenous extracorporeal membrane oxygenation (VV ECMO). DESIGN Case series, retrospective analysis. SETTING Single institution. PARTICIPANTS Ten patients. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patient characteristics, mortality, stroke rate, and length of stay data were collected in all patients. In addition, laboratory values of D-dimer and C-reactive protein and standard measurements of prothrombin and activated partial thromboplastin time were collected on all patients. Ten patients, each confirmed with COVID-19 via reverse transcription-polymerase chain reaction, were supported on VV ECMO for acute respiratory distress syndrome (ARDS) for a mean duration of 9.4 ± 7 days. Four of 10 patients had hemorrhagic strokes, 3 of which resulted in death. At 30 days after initiation of VV ECMO, a total of 7 survivors included 6 patients discharged from the hospital and 1 patient who remained in the intensive care unit. CONCLUSIONS In this small study of 10 patients, intracranial hemorrhage was a common complication, resulting in a high rate of death. The authors urge caution in the anticoagulation management of VV ECMO for patients with severe ARDS and COVID-19 patients. Close monitoring of all hematologic parameters is recommended during ECMO support while awaiting larger, multicenter studies to examine the best practice.
Collapse
Affiliation(s)
- Asad Ali Usman
- Department of Anesthesia and Critical Care, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA
| | - Jason Han
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA
| | - Andrew Acker
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA
| | - Salim E Olia
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA
| | - Christian Bermudez
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA
| | - Brett Cucchiara
- Department of Neurology, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA
| | - Mark E Mikkelsen
- Division of Pulmonary, Allergy, and Critical Care, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA
| | - Joyce Wald
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA
| | - Emily Mackay
- Department of Anesthesia and Critical Care, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA
| | - Wilson Szeto
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA
| | - William J Vernick
- Department of Anesthesia and Critical Care, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA
| | - Jacob T Gutsche
- Department of Anesthesia and Critical Care, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA.
| |
Collapse
|
87
|
Hayakawa M, Takano K, Kayashima M, Kasahara K, Fukushima H, Matsumoto M. Management of a COVID-19 Patient during ECMO: Paying Attention to Acquired von Willebrand Syndrome. J Atheroscler Thromb 2020; 28:396-401. [PMID: 33116032 PMCID: PMC8147570 DOI: 10.5551/jat.58362] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Patients with severe COVID-19 often experience complications including coagulopathy and fatal thrombosis. COVID-19 pneumonia sometimes leads to acute respiratory distress syndrome, requiring extracorporeal membrane oxygenation (ECMO), during which thrombosis and bleeding are major causes of death. Anticoagulation such as heparin is essential for COVID-19 patients on ECMO; however, bleeding might be caused by not only heparin, but also acquired von Willebrand syndrome (AVWS). To date, no study has examined ECMO-related bleeding and AVWS in COVID-19 patients. We report a COVID-19 patient who experienced bleeding from AVWS in addition to disseminated intravascular coagulation (DIC) during ECMO. The level of high–molecular weight VWF multimers decreased during ECMO therapy, and these findings promptly improved after discontinuation of ECMO. Plasma levels of VWF antigen were extremely high, probably due to endothelial cell damage caused by COVID-19. On the other hand, plasma levels of ADAMTS13 activity were moderately reduced, to 20–30% of normal. The patient was successfully treated with cryoprecipitate in bleeding during ECMO without a reduction in heparin, which might have induced thromboembolism. Bleeding found in this patient might be caused by AVWS and DIC. Severe COVID-19 patients are in a thrombotic state and need to receive anticoagulant therapy. However, once they receive ECMO therapy, bleeding symptoms could be observed. In such cases, physicians should think of AVWS in addition to the side effect of heparin and DIC.
Collapse
Affiliation(s)
- Masaki Hayakawa
- Department of Blood Transfusion Medicine, Nara Medical University
| | - Keisuke Takano
- Department of Emergency and Critical Care Medicine, Nara Medical University
| | | | - Kei Kasahara
- Center for Infectious Diseases, Nara Medical University
| | - Hidetada Fukushima
- Department of Emergency and Critical Care Medicine, Nara Medical University
| | | |
Collapse
|
88
|
Chan CHH, Inoue M, Ki KK, Murashige T, Fraser JF, Simmonds MJ, Tansley GD, Watanabe N. Shear-dependent platelet aggregation size. Artif Organs 2020; 44:1286-1295. [PMID: 32735693 PMCID: PMC7818454 DOI: 10.1111/aor.13783] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 07/13/2020] [Accepted: 07/14/2020] [Indexed: 12/17/2022]
Abstract
Nonsurgical bleeding is the most frequent complication of left ventricular assist device (LVAD) support. Supraphysiologic shear rates generated in LVAD causes impaired platelet aggregation, which increases the risk of bleeding. The effect of shear rate on the formation size of platelet aggregates has never been reported experimentally, although platelet aggregation size can be considered to be directly relevant to bleeding complications. Therefore, this study investigated the impact of shear rate and exposure time on the formation size of platelet aggregates, which is vital in predicting bleeding in patients with an LVAD. Human platelet‐poor plasma (containing von Willebrand factor, vWF) and fluorochrome‐labeled platelets were subjected to a range of shear rates (0‐10 000 s−1) for 0, 5, 10, and 15 minutes using a custom‐built blood‐shearing device. Formed sizes of platelet aggregates under a range of shear‐controlled environment were visualized and measured using microscopy. The loss of high molecular weight (HMW) vWF multimers was quantified using gel electrophoresis and immunoblotting. An inhibition study was also performed to investigate the reduction in platelet aggregation size and HMW vWF multimers caused by either mechanical shear or enzymatic (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13—ADAMTS13, the von Willebrand factor protease) mechanism under low and high shear conditions (360 and 10 000 s−1). We found that the average size of platelet aggregates formed under physiological shear rates of 360‐3000 s−1 (200‐300 μm2) was significantly larger compared to those sheared at >6000 s−1 (50‐100 μm2). Furthermore, HMW vWF multimers were reduced with increased shear rates. The inhibition study revealed that the reduction in platelet aggregation size and HWM vWF multimers were mainly associated with ADAMTS13. In conclusion, the threshold of shear rate must not exceed >6000 s−1 in order to maintain the optimal size of platelet aggregates to “plug off” the injury site and stop bleeding.
Collapse
Affiliation(s)
- Chris Hoi Houng Chan
- School of Engineering and Built Environment, Griffith University, Gold Coast, QLD, Australia.,Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Masataka Inoue
- School of Engineering and Built Environment, Griffith University, Gold Coast, QLD, Australia.,Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Department of Life Sciences, Systems Engineering and Science, Graduate School of Engineering and Science, Shibaura Institute of Technology, Saitama, Japan
| | - Katrina K Ki
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Tomotaka Murashige
- School of Engineering and Built Environment, Griffith University, Gold Coast, QLD, Australia.,School of Engineering, Tokyo Institute of Technology, Tokyo, Japan
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia.,School of Medicine, Griffith University, Gold Coast, QLD, Australia
| | - Michael J Simmonds
- Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia
| | - Geoff D Tansley
- School of Engineering and Built Environment, Griffith University, Gold Coast, QLD, Australia.,Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia
| | - Nobuo Watanabe
- Department of Life Sciences, Systems Engineering and Science, Graduate School of Engineering and Science, Shibaura Institute of Technology, Saitama, Japan
| |
Collapse
|
89
|
Mansour A, Roussel M, Gaussem P, Nédelec-Gac F, Pontis A, Flécher E, Bachelot-Loza C, Gouin-Thibault I. Platelet Functions During Extracorporeal Membrane Oxygenation. Platelet-Leukocyte Aggregates Analyzed by Flow Cytometry as a Promising Tool to Monitor Platelet Activation. J Clin Med 2020; 9:jcm9082361. [PMID: 32718096 PMCID: PMC7464627 DOI: 10.3390/jcm9082361] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 07/17/2020] [Accepted: 07/21/2020] [Indexed: 02/07/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is an extracorporeal circulation used to manage patients with severe circulatory or respiratory failure. It is associated with both high bleeding and thrombosis risks, mainly as a result of biomaterial/blood interface phenomena, high shear stress, and complex inflammatory response involving the activation of coagulation and complement systems, endothelial cells, leukocytes, and platelets. Besides their critical role in hemostasis, platelets are important players in inflammatory reactions, especially due to their ability to bind and activate leukocytes. Hence, we reviewed studies on platelet function of ECMO patients. Moreover, we addressed the issue of platelet–leukocyte aggregates (PLAs), which is a key step in both platelet and leukocyte activation, and deserves to be investigated in these patients. A reduced expression of GPIb and GPVI was found under ECMO therapy, due to the shedding processes. However, defective platelet aggregation is inconsistently reported and is still not clearly defined. Due to the high susceptibility of PLAs to pre-analytical conditions, defining and strictly adhering to a rigorous laboratory methodology is essential for reliable and reproducible results, especially in the setting of complex inflammatory situations like ECMO. We provide results on sample preparation and flow cytometric whole blood evaluation of circulating PLAs.
Collapse
Affiliation(s)
- Alexandre Mansour
- Department of Anesthesiology Critical Care Medicine and Perioperative Medicine, Rennes University Hospital, F-35000 Rennes, France;
- Rennes University Hospital, INSERM-CIC 1414, F-35000 Rennes, France
- Innovative Therapies in Haemostasis, Paris University, INSERM U1140, F-75006 Paris, France; (P.G.); (C.B.-L.)
| | - Mikael Roussel
- Department of Biological Hematology, Rennes University Hospital, F-35000 Rennes, France; (M.R.); (F.N.-G.); (A.P.)
- Microenvironment, Cell Differentiation, Immunology and Cancer, Rennes University, INSERM U1236, F-35000 Rennes, France
- Cytometrie Hematologique Francophone Association (CytHem), F-75013 Paris, France
| | - Pascale Gaussem
- Innovative Therapies in Haemostasis, Paris University, INSERM U1140, F-75006 Paris, France; (P.G.); (C.B.-L.)
- Department of Biological Hematology, AH-HP, Georges Pompidou European University Hospital, F-75015 Paris, France
| | - Fabienne Nédelec-Gac
- Department of Biological Hematology, Rennes University Hospital, F-35000 Rennes, France; (M.R.); (F.N.-G.); (A.P.)
| | - Adeline Pontis
- Department of Biological Hematology, Rennes University Hospital, F-35000 Rennes, France; (M.R.); (F.N.-G.); (A.P.)
| | - Erwan Flécher
- Cardio-Thoracic Surgery, Rennes University Hospital, INSERM U1099, F-35000 Rennes, France;
| | - Christilla Bachelot-Loza
- Innovative Therapies in Haemostasis, Paris University, INSERM U1140, F-75006 Paris, France; (P.G.); (C.B.-L.)
| | - Isabelle Gouin-Thibault
- Rennes University Hospital, INSERM-CIC 1414, F-35000 Rennes, France
- Department of Biological Hematology, Rennes University Hospital, F-35000 Rennes, France; (M.R.); (F.N.-G.); (A.P.)
- Correspondence:
| |
Collapse
|
90
|
The authors reply. Crit Care Med 2020; 48:e733. [PMID: 32697518 DOI: 10.1097/ccm.0000000000004420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
91
|
Mazzeffi M, Bathula A, Tabatabai A, Menaker J, Kaczorowski D, Madathil R, Galvagno S, Pasrija C, Rector R, Tanaka K, Herr D. Von Willebrand Factor Concentrate Administration for Acquired Von Willebrand Syndrome- Related Bleeding During Adult Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2020; 35:882-887. [PMID: 32758410 DOI: 10.1053/j.jvca.2020.06.083] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 06/26/2020] [Accepted: 06/27/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To review the use of Von Willebrand Factor (VWF) concentrate for treatment of acquired Von Willebrand syndrome (VWS)-related bleeding in adult extracorporeal membrane oxygenation (ECMO) patients and determine if it was associated with improved VWF laboratory parameters. DESIGN Retrospective observational cohort study. SETTING Tertiary care academic medical center. PARTICIPANTS Adult ECMO patients who received VWF concentrate for treatment of acquired VWS- related bleeding. INTERVENTIONS None, observational study. MEASUREMENTS AND MAIN RESULTS Ten adult ECMO patients received VWF concentrate for treatment of bleeding with evidence of acquired VWS over a 15-month period. Six patients were on veno-arterial ECMO and 4 were on veno-venous ECMO. The most common site of bleeding was airway or tracheal bleeding. The mean dose of VWF concentrate was 41 IU/kg. Mean VWF antigen was 263 ± 93 IU/dL before treatment and 394 ± 54 after treatment. Mean ristocetin cofactor activity was 127 ± 47 IU/dL before treatment and 240 ± 33 after treatment. The mean VWF ristocetin cofactor activity antigen ratio increased from 0.52 ± 0.14 before treatment to 0.62 ± 0.04 after treatment. Four of 10 patients had complete resolution of their bleeding within 24 hours, and 6 of 10 had complete resolution of their bleeding within 2- to- 4 days. There were 3 patients who had thrombotic events potentially related to VWF concentrate administration. No patient had an arterial thrombosis, stroke, or myocardial infarction. CONCLUSIONS VWF concentrate administration increases VWF function in adult ECMO patients, but also may be associated with increased thrombotic risk. Larger studies are needed to determine VWF concentrate's safety, efficacy, and optimal dosing in adult ECMO patients.
Collapse
Affiliation(s)
- Michael Mazzeffi
- University of Maryland School of Medicine, Department of Anesthesiology, Baltimore, MD.
| | - Allison Bathula
- University of Maryland Medical Center, Department of Pharmacy, Baltimore, MD
| | - Ali Tabatabai
- University of Maryland School of Medicine, Department of Medicine, Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD
| | - Jay Menaker
- University of Maryland School of Medicine, Department of Surgery, Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD
| | - David Kaczorowski
- University of Maryland School of Medicine, Department of Surgery, Division of Cardiothoracic Surgery, Baltimore, MD
| | - Ronson Madathil
- University of Maryland School of Medicine, Department of Surgery, Division of Cardiothoracic Surgery, Baltimore, MD
| | - Samuel Galvagno
- University of Maryland School of Medicine, Department of Anesthesiology, Baltimore, MD
| | - Chetan Pasrija
- University of Maryland School of Medicine, Department of Surgery, Division of Cardiothoracic Surgery, Baltimore, MD
| | - Raymond Rector
- University of Maryland School of Medicine, Department of Surgery, Division of Cardiothoracic Surgery, Baltimore, MD
| | - Kenichi Tanaka
- University of Maryland School of Medicine, Department of Anesthesiology, Baltimore, MD
| | - Daniel Herr
- University of Maryland School of Medicine, Department of Medicine, Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD
| |
Collapse
|
92
|
Mazzeffi MA, Patel PA, Bolliger D, Erdoes G, Tanaka K. The Year in Coagulation: Selected Highlights From 2019. J Cardiothorac Vasc Anesth 2020; 34:1745-1754. [DOI: 10.1053/j.jvca.2020.01.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 01/27/2020] [Indexed: 12/26/2022]
|
93
|
Durila M, Vajter J, Garaj M, Smetak T, Hedvicak P, Berousek J, Vymazal T. Acquired primary hemostasis pathology detected by platelet function analyzer 200 seen during extracorporeal membrane oxygenation is sufficient to prevent circuit thrombosis: A pilot study. J Heart Lung Transplant 2020; 39:980-982. [PMID: 32591313 DOI: 10.1016/j.healun.2020.05.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 05/01/2020] [Accepted: 05/31/2020] [Indexed: 10/24/2022] Open
Affiliation(s)
| | - Jaromir Vajter
- Departments of Anesthesiology and Intensive Care Medicine
| | - Michal Garaj
- Departments of Anesthesiology and Intensive Care Medicine
| | - Tomas Smetak
- Cardiovascular Surgery, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Pavel Hedvicak
- Cardiovascular Surgery, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Jan Berousek
- Departments of Anesthesiology and Intensive Care Medicine
| | - Tomas Vymazal
- Departments of Anesthesiology and Intensive Care Medicine
| |
Collapse
|
94
|
Broman LM, Westlund CJ, Gilbers M, Perry da Câmara L, Prahl Wittberg L, Taccone FS, Malfertheiner MV, Di Nardo M, Swol J, Vercaemst L, Barrett NA, Pappalardo F, Belohlavek J, Belliato M, Lorusso R. Pressure and flow properties of dual-lumen cannulae for extracorporeal membrane oxygenation. Perfusion 2020; 35:736-744. [PMID: 32500818 DOI: 10.1177/0267659120926009] [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: 11/15/2022]
Abstract
INTRODUCTION In the last decade, dual-lumen cannulae have been increasingly applied in patients undergoing extracorporeal life support. Well-performing vascular access is crucial for efficient extracorporeal membrane oxygenation support; thus, guidance for proper cannulae size is required. Pressure-flow charts provided by manufacturers are often based on tests performed using water, rarely blood. However, blood is a shear-thinning and viscoelastic fluid characterized by different flow properties than water. METHODS We performed a study evaluating pressure-flow curves during standardized conditions using human whole blood in two commonly available dual-lumen cannulae used in neonates, pediatric, and adult patients. Results were merged and compared with the manufacturer's corresponding curves obtained from the public domain. RESULTS The results showed that using blood as compared with water predominantly influenced drainage flow. A 10-80% higher pressure-drop was needed to obtain same drainage flow (hematocrit of 26%) compared with manufacturer's water charts in 13-31 Fr bi-caval dual-lumen cannulae. The same net difference was found in cavo-atrial cannulae (16-32 Fr), where a lower drainage pressure was required (Hct of 26%) compared with the manufacturer's test using blood with an Hct of 33%. Return pressure-flow data were similar, independent whether pumping blood or water, to the data reported by manufacturers. CONCLUSION Non-standardized testing of pressure-flow properties of extracorporeal membrane oxygenation dual-lumen cannulae prevents an adequate prediction of pressure-flow results when these cannulae are used in patients. Properties of dual-lumen cannulae may vary between sizes within same cannula family, in particular concerning the drainage flow.
Collapse
Affiliation(s)
- Lars Mikael Broman
- Workgroup on Innovation and Technology in ECLS, EuroELSO, Newcastle upon Tyne, UK
- ECMO Centre Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - C Jerker Westlund
- ECMO Centre Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Martijn Gilbers
- Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Hospital, Maastricht, The Netherlands
- Department of Physiology, Maastricht University, Maastricht, The Netherlands
| | | | - Lisa Prahl Wittberg
- The Linné Flow Centre and BioMEx Centre, Department of Mechanics, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Fabio Silvio Taccone
- Workgroup on Innovation and Technology in ECLS, EuroELSO, Newcastle upon Tyne, UK
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Maximilian V Malfertheiner
- Workgroup on Innovation and Technology in ECLS, EuroELSO, Newcastle upon Tyne, UK
- Department of Internal Medicine II, Cardiology and Pneumology, University Medical Center Regensburg, Regensburg, Germany
| | - Matteo Di Nardo
- Workgroup on Innovation and Technology in ECLS, EuroELSO, Newcastle upon Tyne, UK
- Pediatric Intensive Care Unit, Children's Hospital Bambino Gesù, IRCCS, Rome, Italy
| | - Justyna Swol
- Workgroup on Innovation and Technology in ECLS, EuroELSO, Newcastle upon Tyne, UK
- Department of Respiratory Medicine, Allergology and Sleep Medicine, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Leen Vercaemst
- Workgroup on Innovation and Technology in ECLS, EuroELSO, Newcastle upon Tyne, UK
- Department of Perfusion, University Hospital Gasthuisberg, Louvain, Belgium
| | - Nicholas A Barrett
- Workgroup on Innovation and Technology in ECLS, EuroELSO, Newcastle upon Tyne, UK
- Department of Critical Care, Guy's and St. Thomas' NHS Foundation Trust, London, UK
- Centre for Human & Applied Physiological Sciences (CHAPS), School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College, London, UK
| | - Federico Pappalardo
- Workgroup on Innovation and Technology in ECLS, EuroELSO, Newcastle upon Tyne, UK
- Department of Cardiothoracic Anesthesia and Intensive Care, San Raffaele Hospital, Milan, Italy
| | - Jan Belohlavek
- Workgroup on Innovation and Technology in ECLS, EuroELSO, Newcastle upon Tyne, UK
- 2nd Department of Medicine, Cardiovascular Medicine, General University Hospital in Prague, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Mirko Belliato
- Workgroup on Innovation and Technology in ECLS, EuroELSO, Newcastle upon Tyne, UK
- U.O.C. Anestesia e Rianimazione 1, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Roberto Lorusso
- Workgroup on Innovation and Technology in ECLS, EuroELSO, Newcastle upon Tyne, UK
- Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Hospital, Maastricht, The Netherlands
| |
Collapse
|
95
|
Tiede A, Zieger B, Lisman T. Acquired bleeding disorders. Haemophilia 2020; 27 Suppl 3:5-13. [PMID: 32476241 DOI: 10.1111/hae.14033] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 04/23/2020] [Indexed: 12/19/2022]
Abstract
Acquired bleeding disorders can accompany hematological, neoplastic, autoimmune, cardiovascular or liver diseases, but can sometimes also arise spontaneously. They can manifest as single factor deficiencies or as complex hemostatic abnormalities. This review addresses (a) acquired hemophilia A, an autoimmune disorder characterized by inhibitory autoantibodies against coagulation factor VIII; (b) acquired von Willebrand syndrome in patients with cardiovascular disorders, where shear stress abnormalities result in destruction of von Willebrand factor; and (c) liver function disorders that comprise complex changes in pro- and anti-hemostatic factors, whose clinical implications are often difficult to predict. The article provides an overview on the pathophysiology, diagnostic tests and state-of-the-art treatment strategies.
Collapse
Affiliation(s)
- Andreas Tiede
- Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Barbara Zieger
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ton Lisman
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| |
Collapse
|
96
|
Jiritano F, Serraino GF, Ten Cate H, Fina D, Matteucci M, Mastroroberto P, Lorusso R. Platelets and extra-corporeal membrane oxygenation in adult patients: a systematic review and meta-analysis. Intensive Care Med 2020; 46:1154-1169. [PMID: 32328725 PMCID: PMC7292815 DOI: 10.1007/s00134-020-06031-4] [Citation(s) in RCA: 82] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 03/28/2020] [Indexed: 12/24/2022]
Abstract
Despite increasing improvement in extracorporeal membrane oxygenation (ECMO) technology and knowledge, thrombocytopenia and impaired platelet function are usual findings in ECMO patients and the underlying mechanisms are only partially elucidated. The purpose of this meta-analysis and systematic review was to thoroughly summarize and discuss the existing knowledge of platelet profile in adult ECMO population. All studies meeting the inclusion criteria (detailed data about platelet count and function) were selected, after screening literature from July 1975 to August 2019. Twenty-one studies from 1.742 abstracts were selected. The pooled prevalence of thrombocytopenia in ECMO patients was 21% (95% CI 12.9-29.0; 14 studies). Thrombocytopenia prevalence was 25.4% (95% CI 10.6-61.4; 4 studies) in veno-venous ECMO, whereas it was 23.2% (95% CI 11.8-34.5; 6 studies) in veno-arterial ECMO. Heparin-induced thrombocytopenia prevalence was 3.7% (95% CI 1.8-5.5; 12 studies). Meta-regression revealed no significant association between ECMO duration and thrombocytopenia. Platelet function impairment was described in 7 studies. Impaired aggregation was shown in 5 studies, whereas loss of platelet receptors was found in one trial, and platelet activation was described in 2 studies. Platelet transfusions were needed in up to 50% of the patients. Red blood cell transfusions were administered from 46 to 100% of the ECMO patients. Bleeding events varied from 16.6 to 50.7%, although the cause and type of haemorrhage was not consistently reported. Thrombocytopenia and platelet dysfunction are common in ECMO patients, regardless the type of ECMO mode. The underlying mechanisms are multifactorial, and understanding and management are still limited. Further research to design appropriate strategies and protocols for its monitoring, management, or prevention should be matter of thorough investigations.
Collapse
Affiliation(s)
- Federica Jiritano
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC), P. Debeylaan, 26, 6220 AZ, Maastricht, The Netherlands.
- Cardiac Surgery Unit, Department of Experimental and Clinical Medicine, University "Magna Graecia" of Catanzaro, Catanzaro, Italy.
| | - Giuseppe Filiberto Serraino
- Cardiac Surgery Unit, Department of Experimental and Clinical Medicine, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - Hugo Ten Cate
- Laboratory for Clinical Thrombosis and Hemostasis, Department of Internal Medicine, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Dario Fina
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC), P. Debeylaan, 26, 6220 AZ, Maastricht, The Netherlands
- IRCCS San Donato, University of Milan, Milan, Italy
| | - Matteo Matteucci
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC), P. Debeylaan, 26, 6220 AZ, Maastricht, The Netherlands
- Department of Cardiac Surgery, Circolo Hospital, University of Insubria, Varese, Italy
| | - Pasquale Mastroroberto
- Cardiac Surgery Unit, Department of Experimental and Clinical Medicine, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC), P. Debeylaan, 26, 6220 AZ, Maastricht, The Netherlands
| |
Collapse
|
97
|
Oran I. Flow-diverting stent and delayed intracranial bleeding: the case for discussing acquired von Willebrand disease. Platelets 2020; 32:432-435. [PMID: 32406779 DOI: 10.1080/09537104.2020.1754379] [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: 10/24/2022]
Abstract
A unique feature of the flow-diverting stent (FDS) has rendered it useful in the endovascular treatment of selected intracranial aneurysms for the last decade. Delayed aneurysmal rupture and intracranial parenchymal bleeding are two leading hemorrhagic complications after FDS. It has recently been shown for the first time that there is a relationship between FDS and reduced level of vWF activity in patients undergoing endovascular cerebral aneurysm treatment. Here, the current literature is reviewed in the context of this novel finding to propose an illustrative scenario that conceptually links implantation of FDS to delayed intracranial bleeding, through the mechanism of shear-induced activation of vWF. In this scenario, after FDS implantation, sustained release of activated vWF in association with platelets plays a pivotal role in the mechanisms of delayed intracranial hemorrhages.
Collapse
Affiliation(s)
- Ismail Oran
- Section of Interventional Radiology, KENT Hospital, Izmir, Turkey
| |
Collapse
|
98
|
Multi-Modal Characterization of the Coagulopathy Associated With Extracorporeal Membrane Oxygenation. Crit Care Med 2020; 48:e400-e408. [DOI: 10.1097/ccm.0000000000004286] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
|
99
|
Freund A, Jobs A, Lurz P, Feistritzer HJ, de Waha-Thiele S, Meyer-Saraei R, Montalescot G, Huber K, Noc M, Windecker S, Zeymer U, Ouarrak T, Schneider S, Thiele H, Desch S. Frequency and Impact of Bleeding on Outcome in Patients With Cardiogenic Shock. JACC Cardiovasc Interv 2020; 13:1182-1193. [DOI: 10.1016/j.jcin.2020.02.042] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 02/04/2020] [Accepted: 02/27/2020] [Indexed: 01/17/2023]
|
100
|
Lansink-Hartgring AO, Hoffmann R, van den Bergh W, de Vries A. Changes in Red Blood Cell Properties and Platelet Function during Extracorporeal Membrane Oxygenation. J Clin Med 2020; 9:jcm9041168. [PMID: 32325803 PMCID: PMC7230459 DOI: 10.3390/jcm9041168] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 04/14/2020] [Accepted: 04/17/2020] [Indexed: 11/16/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is associated with frequent hemorrhagic and thromboembolic complications. The multiple effects of ECMO include inflammatory response on contact with the circuit; hemolysis acquired von Willebrand syndrome likely affects the function of red blood cells (RBC) and platelets. The aim of this prospective observational study was to analyze RBC aggregation and elongation (deformability) and platelet aggregation in the first week of ECMO. Sixteen patients were included. Blood samples were taken prior to initiation of ECMO and on days 1, 2, 3, 5, and 7. RBC aggregation and elongation were analyzed using the laser-assisted optical rotational red cell analyzer (Lorrca). Upstroke, top, and amplitude as indices of aggregation showed significant time effects. RBC elongation was not affected at low shear stress. At high shear stress there was an increase in the elongation index at day 2 (p = 0.004), followed by a decrease. Platelet function was analyzed using multiple electrode aggregometry (Multiplate®). In pairwise comparison in the days 1–7 to the value prior to ECMO there was no significant difference in platelet aggregation by any of the three agonists (ADP p = 0.61; TRAP p = 0.77; Ristocetin p = 0.25). This implies that the rheology of RBCs seemed to be more affected by ECMO than platelets. Especially the red blood cell deformability continues to decline at higher shear stress.
Collapse
Affiliation(s)
- Annemieke Oude Lansink-Hartgring
- Department of Critical Care, University of Groningen, University Medical Center Groningen, 9700 RB Groningen, The Netherlands;
- Correspondence:
| | - Roland Hoffmann
- Department of Cardiothoracic Surgery, University Medical Center Groningen, 9700 RB Groningen, The Netherlands;
| | - Walter van den Bergh
- Department of Critical Care, University of Groningen, University Medical Center Groningen, 9700 RB Groningen, The Netherlands;
| | - Adrianus de Vries
- Department of Anesthesiology, University Medical Center Groningen, 9700 RB Groningen, The Netherlands;
| |
Collapse
|