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Santiago MJ, Gómez C, Magaña I, Muñoz V, Saiz P, Sánchez A, López-Herce J. Hematological complications in children subjected to extracorporeal membrane oxygenation. Med Intensiva 2018; 43:281-289. [PMID: 29605581 DOI: 10.1016/j.medin.2018.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 01/27/2018] [Accepted: 02/01/2018] [Indexed: 01/12/2023]
Abstract
OBJECTIVES To analyze the hematological complications and need for transfusions in children receiving extracorporeal life support (ECLS). DESIGN A retrospective study was carried out. SETTING A pediatric intensive care unit. PATIENTS Children under 18 years of age subjected to ECLS between September 2006 and November 2015. INTERVENTIONS None. VARIABLES OF INTEREST Patient and ECLS characteristics, anticoagulation, hematological and coagulation parameters, transfusions and clinical course. RESULTS A total of 100 patients (94 with heart disease) with a median age of 11 months were studied. Seventy-six patients presented bleeding. The most frequent bleeding point was the mediastinum and 39 patients required revision surgery. In the first 3days, 97% of the patients required blood transfusion (34.4ml/kg per day), 94% platelets (21.1ml/kg per day) and 90% plasma (26.6ml/kg per day). Patients who were in the postoperative period, those who were bleeding at the start of ECLS, those requiring revision surgery, those who could not suspend extracorporeal circulation, and those subjected to transthoracic cannulation required a greater volume of transfusions than the rest of the patients. Thromboembolism occurred in 14 patients and hemolysis in 33 patients. Mortality among the children who were bleeding at the start of ECLS (57.6%) was significantly higher than in the rest of the patients (37.5%) (P=.048). CONCLUSIONS Children subjected to ECLS present high blood product needs. The main factors related to transfusions were the postoperative period, bleeding at the start of ECLS, revision surgery, transthoracic cannulation, and the impossibility of suspending extracorporeal circulation. Children with bleeding suffered greater mortality than the rest of the patients.
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Affiliation(s)
- M J Santiago
- Servicio de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Madrid, España; Instituto de Investigación Sanitaria, Hospital Gregorio Marañón, Madrid, España; Red de Salud Maternoinfantil y del Desarrollo (Red SAMID) RD16/0022/0007, Madrid RETICS financiada por el PN I+D+I 2008-2011, ISCIII, Subdirección General de Evaluación y Fomento de la Investigación y el Fondo Europeo de Desarrollo Regional (FEDER), ef. RD16/0022/0007
| | - C Gómez
- Departamento de Pediatría, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, España
| | - I Magaña
- Departamento de Pediatría, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, España
| | - V Muñoz
- Departamento de Pediatría, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, España
| | - P Saiz
- Departamento de Pediatría, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, España
| | - A Sánchez
- Servicio de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Madrid, España; Instituto de Investigación Sanitaria, Hospital Gregorio Marañón, Madrid, España; Red de Salud Maternoinfantil y del Desarrollo (Red SAMID) RD16/0022/0007, Madrid RETICS financiada por el PN I+D+I 2008-2011, ISCIII, Subdirección General de Evaluación y Fomento de la Investigación y el Fondo Europeo de Desarrollo Regional (FEDER), ef. RD16/0022/0007
| | - J López-Herce
- Servicio de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Madrid, España; Departamento de Pediatría, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, España; Instituto de Investigación Sanitaria, Hospital Gregorio Marañón, Madrid, España; Red de Salud Maternoinfantil y del Desarrollo (Red SAMID) RD16/0022/0007, Madrid RETICS financiada por el PN I+D+I 2008-2011, ISCIII, Subdirección General de Evaluación y Fomento de la Investigación y el Fondo Europeo de Desarrollo Regional (FEDER), ef. RD16/0022/0007.
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Kalbhenn J, Schlagenhauf A, Rosenfelder S, Schmutz A, Zieger B. Acquired von Willebrand syndrome and impaired platelet function during venovenous extracorporeal membrane oxygenation: Rapid onset and fast recovery. J Heart Lung Transplant 2018; 37:985-991. [PMID: 29650295 DOI: 10.1016/j.healun.2018.03.013] [Citation(s) in RCA: 106] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Revised: 02/18/2018] [Accepted: 03/14/2018] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Bleeding contributes to the high mortality of venovenous extracorporeal membrane oxygenation (vvECMO). The development of acquired von Willebrand syndrome (AVWS) has been identified as relevant pathology during ECMO. This study was performed to determine the onset of AVWS after implantation and the recovery of von Willebrand factor (VWF) parameters after explantation of ECMO in a large cohort of patients. METHODS VWF parameters of 59 patients treated with vvECMO at a university ECMO center were obtained before ECMO implantation, during therapy, and after explantation. In a subgroup of patients, light transmission aggregometry of platelets and flow-cytometric quantification of platelet granule secretion were performed. RESULTS All patients developed severe AVWS hours after implantation of vvECMO. After explantation, AVWS recovered within 3 hours in 60%, within 6 hours in 86%, and in all patients within 1 day. Aggregometry showed hypoaggregability of platelets after stimulation with ADP, ristocetin, collagen, and epinephrine. Flow-cytometric platelet analyses revealed severely reduced expression of CD62 and CD63. CONCLUSIONS All patients during vvECMO support rapidly develop AVWS and platelet dysfunction, resulting in severe impairment of coagulation. After explantation, AVWS overwhelmingly recovers within hours, resulting in a hypercoagulative state. These findings augment the need for novel extracorporeal technologies with reduced shear stress, and shift the emphasis for intense anti-coagulation during ECMO instead to a time-point after explantation.
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Affiliation(s)
- Johannes Kalbhenn
- Department of Anesthesiology and Critical Care, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Axel Schlagenhauf
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Simone Rosenfelder
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Axel Schmutz
- Department of Anesthesiology and Critical Care, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Barbara Zieger
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Hellmann C, Schmutz A, Kalbhenn J. Bleeding during veno-venous ECMO cannot reliably be predicted by rotational thrombelastometry (ROTEM™). Perfusion 2017; 33:289-296. [DOI: 10.1177/0267659117746231] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction: Veno-venous extracorporeal membrane oxygenation (vvECMO) used for respiratory support is associated with clinical bleeding in at least one third of patients. Mechanisms promoting bleeding, like acquired von Willebrand syndrome, cannot be identified by routine coagulation tests. This study was performed to evaluate rotational Thrombelastography (ROTEM™) for specific results predicting bleeding events during vvECMO. Methods: Five hundred and thirty-four ROTEM™ analyses of 57 patients over 574 days have been evaluated. Patients were graded into three groups according to the severity of bleeding, following the Freiburg ECMO bleeding assessment. ROTEM™ results and basic as well as comprehensive laboratory coagulation tests have been compared among the three groups and overall between defined time points. Results: Fourteen patients (25 %) presented without bleeding, 22 patients (39 %) showed mild bleeding and 21 patients (36 %) became evident with relevant clinical bleeding. No bleeding shock and no fatal bleeding event occurred. No case of hyperfibrinolysis was observed. Neither a statistical difference for ECMO blood flow nor duration of therapy among the groups could be shown. The only significant difference was clotting time (CT) in the InTEM analysis, with a median (IQR) of 175 (37.5) seconds in Group 1, 190 (54.5) seconds in Group 2 and 204 (90) seconds in Group 3. When comparing overall ROTEM™ analyses between defined time points, continuous worsening of CT can be found in ExTEM, FibTEM and ApTEM. Reduced A10, A20 and congruently maximum clot firmness, especially, developed in ExTEM and ApTEM and with a minor characteristic in InTEM, but not in FibTEM. ROTEM™ and coagulation-parameter results before 19 clinical relevant bleeding episodes compared to all other results only showed differences in FibTEM. Conclusion: ROTEM™ as a functional viscoelastic analysis does not provide additional information to basic and comprehensive laboratory tests during vvECMO. Bleeding events cannot be predicted by the means of specific ROTEM™ results.
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Affiliation(s)
- Christina Hellmann
- Department of Anesthesiology and Critical Care, Medical Center – Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Axel Schmutz
- Department of Anesthesiology and Critical Care, Medical Center – Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Johannes Kalbhenn
- Department of Anesthesiology and Critical Care, Medical Center – Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Xie A, Lo P, Yan TD, Forrest P. Neurologic Complications of Extracorporeal Membrane Oxygenation: A Review. J Cardiothorac Vasc Anesth 2017. [DOI: 10.1053/j.jvca.2017.03.001] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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55
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Lorusso R. Extracorporeal life support and neurologic complications: still a long way to go. J Thorac Dis 2017; 9:E954-E956. [PMID: 29266103 DOI: 10.21037/jtd.2017.09.30] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
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Is Extracorporeal CO2 Removal Really “Safe” and “Less” Invasive? Observation of Blood Injury and Coagulation Impairment during ECCO2R. ASAIO J 2017; 63:666-671. [DOI: 10.1097/mat.0000000000000544] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
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Neurologic Injury in Adults Supported With Veno-Venous Extracorporeal Membrane Oxygenation for Respiratory Failure. Crit Care Med 2017; 45:1389-1397. [DOI: 10.1097/ccm.0000000000002502] [Citation(s) in RCA: 125] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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58
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Wallinder A, Pellegrino V, Fraser JF, McGiffin DC. ECMO as a bridge to non-transplant cardiac surgery. J Card Surg 2017; 32:514-521. [DOI: 10.1111/jocs.13172] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Andreas Wallinder
- Department of Cardiothoracic Surgery; Sahlgrenska University Hospital; Gothenburg Sweden
| | - Vincent Pellegrino
- Intensive Care Unit; Alfred Hospital; Melbourne Victoria Australia
- Department of Epidemiology and Preventive Medicine; School of Public Health and Preventive Medicine; Monash University; Melbourne Victoria Australia
| | - John F. Fraser
- Critical Care Research Group; The Prince Charles Hospital; University of Queensland and Adult Intensive Care Service; Brisbane Queensland Australia
| | - David C. McGiffin
- Department of Cardiothoracic Surgery; Alfred Hospital and Monash University; Melbourne Victoria Australia
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Braune S, Sieweke A, Jarczak D, Kluge S. [Extracorporeal lung support]. Med Klin Intensivmed Notfmed 2017; 112:426-436. [PMID: 28555443 DOI: 10.1007/s00063-017-0304-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 04/18/2017] [Indexed: 01/28/2023]
Abstract
Systems for extracorporeal lung support have recently undergone significant technological improvements leading to more effective and safe treatment. Despite limited scientific evidence these systems are increasingly used in the intensive care unit for treatment of different types of acute respiratory failure. In general two types of systems can be differentiated: devices for extracorporeal carbon dioxide removal (ECCO2R) for ventilatory insufficiency and devices for extracorporeal membrane oxygenation (ECMO) for severe hypoxemic failure. Despite of all technological developments extracorporeal lung support remains an invasive and a potentially dangerous form of treatment with bleeding and vascular injury being the two main complications. For this reason indications and contraindications should always be critically considered and extracorporeal lung support should only be carried out in centers with appropriate experience and expertise.
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Affiliation(s)
- S Braune
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
- IV. Medizinische Klinik, Internistische Intensivmedizin und Notaufnahme, St. Franziskus-Hospital, 48145, Münster, Deutschland
| | - A Sieweke
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - D Jarczak
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - S Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.
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60
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Francischetti IMB, Szymanski J, Rodriguez D, Heo M, Wolgast LR. Laboratory and clinical predictors of 30-day survival for patients on Extracorporeal Membrane Oxygenation (ECMO): 8-Year experience at Albert Einstein College of Medicine, Montefiore Medical Center. J Crit Care 2017; 40:136-144. [PMID: 28399414 DOI: 10.1016/j.jcrc.2017.03.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 03/21/2017] [Accepted: 03/29/2017] [Indexed: 12/12/2022]
Abstract
PURPOSE Survival of patients on ECMO has remained stable in every population. Laboratory values predictors of survival are required to improve patient care. MATERIALS AND METHODS Clinical Looking Glass software was used to assess Electronic Medical Records (EMRs) of patients at Albert Einstein College of Medicine, Montefiore Medical Center (2007-2014). RESULTS Our population comprises of 166 adults and was divided in survivors and non-survivors, within 30days. Indications for ECMO were cardiac (65%), respiratory (25%) and infectious diseases (<10%). Eighty six patients (51.8%) survived the procedure. Gender, body weight, ejection fraction, diastolic blood pressure, and socio-economic status did not differ among survivors and non-survivors. In contrast, younger patients (45yo vs 55yo, p=0.0001) and higher systolic blood pressure (115mmHg vs 103mmHg, p=0.025) have favorable outcome. Univariate analysis shows that pre-cannulation values for creatinine (p=0.0003), chloride (p=0.009), bicarbonate (p=0.015) and pH (p=0.03) have prognostic value. Post-cannulation aPTT, pH, platelet and lymphocyte counts also have discriminative power. Notably, multiple logistic regressions for Multivariate Analysis identified chloride (OR 1.07; 95% CI 1.02-1.13; p=0.004), pH (OR 3.35; 95% CI 1.89-5.9; p<0.0001) and aPTT (OR 0.98; 95% CI 0.976-0.998; p=0.024) as independent risk factors for 30-day mortality. These results imply that pre-existing renal conditions and hemostatic dysregulation contribute to poor outcome. Finally, patients on VV-ECMO have increase odds of survival (OR 1.88; 95% CI 1.06-3.34; p=0.029). CONCLUSIONS Laboratory markers identified herein may guide the management of patients on ECMO.
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Affiliation(s)
- Ivo M B Francischetti
- Department of Pathology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, United States.
| | - James Szymanski
- Department of Pathology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, United States
| | - Daniel Rodriguez
- Pediatric Perfusion Service, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, United States
| | - Moonseong Heo
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, United States
| | - Lucia R Wolgast
- Department of Pathology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, United States
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Aubron C, DePuydt J, Belon F, Bailey M, Schmidt M, Sheldrake J, Murphy D, Scheinkestel C, Cooper DJ, Capellier G, Pellegrino V, Pilcher D, McQuilten Z. Predictive factors of bleeding events in adults undergoing extracorporeal membrane oxygenation. Ann Intensive Care 2016; 6:97. [PMID: 27714705 PMCID: PMC5053950 DOI: 10.1186/s13613-016-0196-7] [Citation(s) in RCA: 160] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 09/18/2016] [Indexed: 12/12/2022] Open
Abstract
Background Bleeding is the most frequent complication associated with extracorporeal membrane oxygenation (ECMO) support in critically ill patients. Nonetheless, risk factors for bleeding have been poorly described especially those associated with coagulation anomalies and anticoagulant therapy during ECMO support. The aim of this study is to describe bleeding complications in critically ill patients undergoing ECMO and to identify risk factors for bleeding events. Methods We retrospectively analysed ICU charts of adults who received either veno-venous (VV) or veno-arterial (VA) ECMO support in two participating ICUs between 2010 and 2013. Characteristics of patients with and without bleeding complications, as per the Extracorporeal Life Support Organisation (ELSO) definition, were compared, and the impact of bleeding complications on patient outcomes was assessed using survival analysis. Variables that were independently associated with bleeding, including daily clinical and biological variables during ECMO courses, were modelled. Results Of the 149 ECMO episodes (111 VA ECMO and 38 VV ECMO) performed in 147 adults, 89 episodes (60 %) were complicated by at least one bleeding event. The most common bleeding sources were: ECMO cannula (37 %), haemothorax or cardiac tamponade (17 %) and ear–nose and throat (16 %). Intra-cranial haemorrhage occurred in five (2.2 %) patients. Bleeding complications were independently associated with worse survival [adjusted hazard ratio (HR) 2.17, 95 % confidence interval (CI) 1.07–4.41, P = 0.03]. Higher activated partial thromboplastin time (aPTT) [adjusted odds ratio (OR) 3.00, 95 % CI 1.64–5.47, P < 0.01], APACHE III score [adjusted OR 1.01, 95 % CI 1.01–1.02, P = 0.01] and ECMO following surgery [adjusted OR 3.04, 95 % CI 1.62–5.69, P < 0.01] were independently associated with greater risk of bleeding occurrence. A similar association between bleeding and higher aPTT was found when non-post-surgical VA ECMO was considered separately. Conclusions Bleeding events based on the ELSO bleeding definition occurred in more than 60 % of ECMO episodes and were associated with hospital mortality. We identified higher aPTT prior bleeding as an independent risk factor for bleeding event, suggesting that better control of the aPTT (through a better control of either coagulopathy or anticoagulation) may improve patients’ outcome.
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Affiliation(s)
- Cécile Aubron
- The Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia. .,The Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia. .,Medical Intensive Care Unit, Centre Hospitalier Régional et Universitaire de Brest, site La Cavale Blanche, Bvd Tanguy Prigent, 29609, Brest Cedex, France. .,LUBEM, EA 3882 - Université de Bretagne Occidentale, 29 200 Brest, France.
| | - Joris DePuydt
- The Intensive Care Unit, The Alfred Hospital, Melbourne, Australia.,University Hospital of Antwerp, 2000, Antwerp, Belgium
| | - François Belon
- The Intensive Care Unit, Jean Minjoz Hospital, 25030, Besançon, France
| | - Michael Bailey
- The Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Matthieu Schmidt
- The Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.,Medical Intensive Care Unit, iCAN, Institute of Cardiometabolism and Nutrition, Hôpital de la Pitié-Salpetrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Jayne Sheldrake
- The Intensive Care Unit, The Alfred Hospital, Melbourne, Australia
| | - Deirdre Murphy
- The Intensive Care Unit, The Alfred Hospital, Melbourne, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Carlos Scheinkestel
- The Intensive Care Unit, The Alfred Hospital, Melbourne, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - D Jamie Cooper
- The Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.,The Intensive Care Unit, The Alfred Hospital, Melbourne, Australia
| | - Gilles Capellier
- The Intensive Care Unit, Jean Minjoz Hospital, 25030, Besançon, France
| | - Vincent Pellegrino
- The Intensive Care Unit, The Alfred Hospital, Melbourne, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - David Pilcher
- The Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.,The Intensive Care Unit, The Alfred Hospital, Melbourne, Australia
| | - Zoe McQuilten
- The Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.,The Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
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Staudacher DL, Biever PM, Benk C, Ahrens I, Bode C, Wengenmayer T. Dual Antiplatelet Therapy (DAPT) versus No Antiplatelet Therapy and Incidence of Major Bleeding in Patients on Venoarterial Extracorporeal Membrane Oxygenation. PLoS One 2016; 11:e0159973. [PMID: 27467697 PMCID: PMC4965019 DOI: 10.1371/journal.pone.0159973] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 07/11/2016] [Indexed: 11/26/2022] Open
Abstract
Aims Bleeding is a frequent complication in patients on venoarterial extracorporeal membrane oxygenation (VA-ECMO). An indication for dual antiplatelet therapy due to coronary stent implantation is present in a considerable number of these patients. The objective of this retrospective study was to evaluate if dual antiplatelet therapy (DAPT) significantly increases the high intrinsic bleeding risk in patients on VA-ECMO. Methods and Results A total of 93 patients were treated with VA-ECMO between October 2010 and October 2013. Average time on VA-ECMO was 58.9 ± 1.7 hours. Dual antiplatelet therapy was given to 51.6% of all patients. Any bleeding was recorded in 60.2% of all patients. There was no difference in bleeding incidence in patients on DAPT when compared to those without any antiplatelet therapy including any bleeding (66.7% vs. 57.1%, p = 0.35), BARC3 bleeding (43.8% vs. 33.3%, p = 0.31) or pulmonary bleeding (16.7% vs. 19.0%, p = 0.77). This holds true after adjustment for confounders. Rate of transfusion of red blood cells were similar in patients with or without DAPT (35.4% vs. 28.6%, p = 0.488). Conclusions Bleeding on VA-ECMO is frequent. This registry recorded no statistical difference in bleeding in patients on dual antiplatelet therapy when compared to no antiplatelet therapy. When indicated, DAPT should not be withheld from VA ECMO patients.
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Affiliation(s)
- Dawid L. Staudacher
- Heart Center Freiburg University, Department of Cardiology and Angiology I, Freiburg, Germany
- * E-mail:
| | - Paul M. Biever
- Heart Center Freiburg University, Department of Cardiology and Angiology I, Freiburg, Germany
| | - Christoph Benk
- Heart Center Freiburg University, Department of Cardiovascular Surgery, Freiburg, Germany
| | - Ingo Ahrens
- Heart Center Freiburg University, Department of Cardiology and Angiology I, Freiburg, Germany
| | - Christoph Bode
- Heart Center Freiburg University, Department of Cardiology and Angiology I, Freiburg, Germany
| | - Tobias Wengenmayer
- Heart Center Freiburg University, Department of Cardiology and Angiology I, Freiburg, Germany
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Braune S, Sieweke A, Brettner F, Staudinger T, Joannidis M, Verbrugge S, Frings D, Nierhaus A, Wegscheider K, Kluge S. The feasibility and safety of extracorporeal carbon dioxide removal to avoid intubation in patients with COPD unresponsive to noninvasive ventilation for acute hypercapnic respiratory failure (ECLAIR study): multicentre case–control study. Intensive Care Med 2016; 42:1437-44. [DOI: 10.1007/s00134-016-4452-y] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 07/11/2016] [Indexed: 10/21/2022]
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64
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Laine A, Niemi T, Suojaranta-Ylinen R, Raivio P, Soininen L, Lemström K, Hämmäinen P, Schramko A. Decreased maximum clot firmness in rotational thromboelastometry (ROTEM®) is associated with bleeding during extracorporeal mechanical circulatory support. Perfusion 2016; 31:625-633. [PMID: 27125829 DOI: 10.1177/0267659116647473] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND: We aimed to characterize the coagulation disturbances which may increase the risk of bleeding, thrombosis or death shortly after implantation of an extracorporeal membrane oxygenation (ECMO) or ventricular assist (VAD) device. METHODS: Antithrombotic treatment was started in 23 VAD and 24 ECMO patients according to the hospital protocol. Additionally, conventional laboratory testing, rotational thromboelastometry (ROTEM®) and platelet function analysis (Multiplate®) were performed at predetermined intervals. RESULTS: Four out of twenty-four (16.7%) of ECMO patients and 6/23 (26.1%) of VAD patients had severe bleeding after the procedure. When all the patients were analyzed together, low maximum clot firmness (MCF) in ExTEM and FibTEM analyses was associated with severe bleeding (p<0.05) and low MCF in FibTEM with 30-day mortality. Low platelet count and hematocrit levels were also associated with severe bleeding. When VAD and ECMO patients were separated into different groups, the association between ROTEM® parameters, bleeding and survival was found only in limited time points. Four patients with VAD had cerebral ischemia indicative of thromboembolism. However, this had no significant correlation with ROTEM® or Multiplate® parameters. CONCLUSION: Hypocoagulation shown by ROTEM® was associated with bleeding complications in patients with mechanical circulatory support. In contrast, hypercoagulation did not correlate with clinical thrombosis.
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Affiliation(s)
- Antti Laine
- 1 Division of Anaesthesiology, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Tomi Niemi
- 1 Division of Anaesthesiology, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Raili Suojaranta-Ylinen
- 2 Division of Intensive Care, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Peter Raivio
- 3 Heart and Lung Center, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Leena Soininen
- 2 Division of Intensive Care, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Karl Lemström
- 3 Heart and Lung Center, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Pekka Hämmäinen
- 3 Heart and Lung Center, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Alexey Schramko
- 1 Division of Anaesthesiology, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki, Helsinki University Hospital, Helsinki, Finland.,2 Division of Intensive Care, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
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A Retrospective Observational Case Series of Low-Flow Venovenous Extracorporeal Carbon Dioxide Removal Use in Patients with Respiratory Failure. ASAIO J 2016; 62:458-62. [DOI: 10.1097/mat.0000000000000386] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
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Patroniti N, Scaravilli V. Hemostatic changes during extracorporeal membrane oxygenation: a commentary. ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:140. [PMID: 27162790 DOI: 10.21037/atm.2016.03.32] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Nicolò Patroniti
- 1 School of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza 20900 (MB), Italy ; 2 Department of Emergency and Intensive Care, San Gerardo Hospital, Via Pergolesi 33, Monza 20900 (MB), Italy
| | - Vittorio Scaravilli
- 1 School of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza 20900 (MB), Italy ; 2 Department of Emergency and Intensive Care, San Gerardo Hospital, Via Pergolesi 33, Monza 20900 (MB), Italy
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