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Davies MG, Hart JP. Extracorporal Membrane Oxygenation in Massive Pulmonary Embolism. Ann Vasc Surg 2024; 105:287-306. [PMID: 38588954 DOI: 10.1016/j.avsg.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 02/09/2024] [Accepted: 02/10/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Massive pulmonary embolism (MPE) carries significant 30-day mortality risk, and a change in societal guidelines has promoted the increasing use of extracorporeal membrane oxygenation (ECMO) in the immediate management of MPE-associated cardiovascular shock. This narrative review examines the current status of ECMO in MPE. METHODS A literature review was performed from 1982 to 2022 searching for the terms "Pulmonary embolism" and "ECMO," and the search was refined by examining those publications that covered MPE. RESULTS In the patient with MPE, veno-arterial ECMO is now recommended as a bridge to interventional therapy. It can reliably decrease right ventricular overload, improve RV function, and allow hemodynamic stability and restoration of tissue oxygenation. The use of ECMO in MPE has been associated with lower mortality in registry reviews, but there has been no significant difference in outcomes between patients treated with and without ECMO in meta-analyses. Applying ECMO is also associated with substantial multisystem morbidity due to systemic inflammatory response, bleeding with coagulopathy, hemorrhagic stroke, renal dysfunction, and acute limb ischemia, which must be factored into the outcomes. CONCLUSIONS The application of ECMO in MPE should be combined with an aggressive interventional pulmonary interventional program and should strictly adhere to the current selection criteria.
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Affiliation(s)
- Mark G Davies
- Center for Quality, Effectiveness, and Outcomes in Cardiovascular Diseases, Houston, TX; Department of Vascular and Endovascular Surgery, Ascension Health, Waco, TX.
| | - Joseph P Hart
- Division of Vascular Surgery, Medical College of Wisconsin, Milwaukee, WI
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Masi P, Gendreau S, Moyon Q, Leguyader M, Lebreton G, Ropers J, Dangers L, Sitruk S, Bréchot N, Pineton de Chambrun M, Chommeloux J, Schmidt M, Luyt CE, Leprince P, Combes A, Frere C, Hékimian G. Bleeding complications, coagulation disorders, and their management in acute myocardial infarction-related cardiogenic shock rescued by veno-arterial ECMO: A retrospective cohort study. J Crit Care 2024; 82:154771. [PMID: 38471248 DOI: 10.1016/j.jcrc.2024.154771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 02/21/2024] [Accepted: 03/05/2024] [Indexed: 03/14/2024]
Abstract
PURPOSE Management of dual antiplatelet therapy (DAPT) in patients on venoarterial-extracorporeal membrane (VA-ECMO) after acute myocardial infarction (AMI) is challenging. Our objective was to describe the frequency, management and outcomes of severe bleeding complications and determine their occurrence risk factors. MATERIAL AND METHODS We conducted a retrospective observational cohort study including post-AMI cardiogenic shock patients requiring VA-ECMO. Severe bleeding was defined based on the Bleeding Academic Research Consortium classification. We calculated multivariable Fine-Gray models to assess factors associated with risk of severe bleeding. RESULTS From January 2015 to July 2019, 176 patients received VA-ECMO after AMI and 132 patients were included. Sixty-five (49%) patients died. Severe bleeding occurred in 39% of cases. Severe thrombocytopenia (< 50 G/L) and hypofibrinogenemia (<1,5 g/L) occurred in respectively 31% and 19% of patients. DAPT was stopped in 32% of patients with a 6% rate of stent thrombosis. Anticoagulation was stopped in 39% of patients. Using a multivariate competing risk model, female sex, time on ECMO, troponin at admission and Impella® implantation were independently associated with severe bleeding. CONCLUSIONS Bleeding complications and coagulation disorders were frequent and severe in patients on VA-ECMO after AMI, leading of antiplatelet therapy withdrawal in one third of patients.
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Affiliation(s)
- Paul Masi
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive Réanimation, Paris, France; AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, F-94010 Créteil, France.
| | - Ségolène Gendreau
- AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, F-94010 Créteil, France
| | - Quentin Moyon
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive Réanimation, Paris, France; Sorbonne Université, Inserm, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Paris, France
| | - Maxence Leguyader
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive Réanimation, Paris, France
| | - Guillaume Lebreton
- Sorbonne Université, Inserm, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Paris, France; Cardiothoracic surgery department, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, F-75013 Paris, France
| | - Jacques Ropers
- Assistance Publique Hôpitaux de Paris, Unité de Recherche Clinique des Hôpitaux Universitaires Pitié Salpêtrière -Hôpitaux Universitaires Pitié Salpêtrière - Charles Foix, Paris, France
| | - Laurence Dangers
- Réanimation Polyvalente, Centre Hospitalier Universitaire Félix Guyon, Saint-Denis, France
| | - Samuel Sitruk
- Assistance Publique Hôpitaux de Paris, Unité de Recherche Clinique des Hôpitaux Universitaires Pitié Salpêtrière -Hôpitaux Universitaires Pitié Salpêtrière - Charles Foix, Paris, France
| | - Nicolas Bréchot
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive Réanimation, Paris, France; Sorbonne Université, Inserm, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Paris, France
| | - Marc Pineton de Chambrun
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive Réanimation, Paris, France; Sorbonne Université, Inserm, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Paris, France
| | - Juliette Chommeloux
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive Réanimation, Paris, France; Sorbonne Université, Inserm, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Paris, France
| | - Matthieu Schmidt
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive Réanimation, Paris, France; Sorbonne Université, Inserm, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Paris, France
| | - Charles Edouard Luyt
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive Réanimation, Paris, France; Sorbonne Université, Inserm, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Paris, France
| | - Pascal Leprince
- Sorbonne Université, Inserm, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Paris, France; Cardiothoracic surgery department, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, F-75013 Paris, France
| | - Alain Combes
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive Réanimation, Paris, France; Sorbonne Université, Inserm, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Paris, France
| | - Corinne Frere
- Sorbonne Université, Inserm, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Paris, France; Department of Hematology, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, F-75013 Paris, France
| | - Guillaume Hékimian
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive Réanimation, Paris, France; Sorbonne Université, Inserm, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Paris, France
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3
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Crochemore T, Görlinger K, Lance MD. In Response. Anesth Analg 2024; 139:e14-e15. [PMID: 39008873 DOI: 10.1213/ane.0000000000007072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/17/2024]
Affiliation(s)
- Tomaz Crochemore
- Department of Critical Care, Hospital Moriah, São Paulo, Brazil, Werfen LATAM, São Paulo, Brazil,
| | - Klaus Görlinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, Essen, Germany, TEM Innovations GmbH/Werfen PBM , Munich, Germany
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Masi P, Gouriet L, Radu C, Folliguet T, Fiore A, Gallet R, Bagate F, Mekontso Dessap A, De Prost N. Immediate Clinical Complications Occurring During Membrane Change in Patients on Veno-Venous Extracorporeal Membrane Oxygenation. ASAIO J 2024:00002480-990000000-00530. [PMID: 39052935 DOI: 10.1097/mat.0000000000002270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024] Open
Abstract
The clinical tolerance of extracorporeal membrane oxygenation (ECMO) membrane changes in acute respiratory distress syndrome (ARDS) patients under veno-venous ECMO (VV-ECMO) has not been reported. The aim of this study was to describe the tolerance of membrane change. Patients requiring VV-ECMO were retrospectively included between March 2020 and May 2022. In case of membrane dysfunction or an increase in hemolysis markers or an alteration in gas exchange, a membrane change was performed. The primary outcome was a composite measure defined as the occurrence of at least one of the following events within 1 hour of membrane change: severe hypoxemia, hemodynamic collapse, bradycardia, arrhythmia, cardiac arrest, and death. During the study period, 70 patients required a VV-ECMO, 29 (41%) of whom died. Thirty-two patients required a membrane change for a total of 56 changes. The primary outcome occurred for 33 (59%) changes. Arterial desaturation <80% occurred for all complicated membrane changes and cardiac arrest concerned nine changes (16%). Low tidal volume (VT), respiratory system compliance (Crs), PaO2, and high ECMO blood flow (QECMO) were associated with poor tolerance of membrane change. Threshold values of 130 ml for VT, 9.3 cm H2O for Crs, 72 mm Hg for PaO2, and 3.65 L/minute for QECMO best determined the risk of poor tolerance of membrane change.
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Affiliation(s)
- Paul Masi
- From the Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, Créteil, France
- Univ Paris Est Créteil, Cardiovascular and Respiratory Manifestations of Acute lung injury and Sepsis (CARMAS), Créteil, France
| | - Loic Gouriet
- From the Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, Créteil, France
- Univ Paris Est Créteil, Cardiovascular and Respiratory Manifestations of Acute lung injury and Sepsis (CARMAS), Créteil, France
| | - Costin Radu
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Service de chirurgie cardiaque, Departement Medico-Universitaire (DMU) CARE, Créteil, France
- Faculté de Santé, Université Paris Est Créteil, Créteil, France; and
| | - Thierry Folliguet
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Service de chirurgie cardiaque, Departement Medico-Universitaire (DMU) CARE, Créteil, France
- Faculté de Santé, Université Paris Est Créteil, Créteil, France; and
| | - Antonio Fiore
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Service de chirurgie cardiaque, Departement Medico-Universitaire (DMU) CARE, Créteil, France
- Faculté de Santé, Université Paris Est Créteil, Créteil, France; and
| | - Romain Gallet
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Service de cardiologie, Créteil, France
| | - François Bagate
- From the Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, Créteil, France
- Univ Paris Est Créteil, Cardiovascular and Respiratory Manifestations of Acute lung injury and Sepsis (CARMAS), Créteil, France
| | - Armand Mekontso Dessap
- From the Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, Créteil, France
- Univ Paris Est Créteil, Cardiovascular and Respiratory Manifestations of Acute lung injury and Sepsis (CARMAS), Créteil, France
| | - Nicolas De Prost
- From the Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, Créteil, France
- Univ Paris Est Créteil, Cardiovascular and Respiratory Manifestations of Acute lung injury and Sepsis (CARMAS), Créteil, France
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Ulloa-Morrison R, Pavez N, Parra E, Lopez R, Mondaca R, Fernandez P, Kraunik D, Sanhueza C, Bravo S, Cornu MG, Kattan E. Critical care management of hantavirus cardiopulmonary syndrome. A narrative review. J Crit Care 2024; 84:154867. [PMID: 39024823 DOI: 10.1016/j.jcrc.2024.154867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 05/28/2024] [Accepted: 05/29/2024] [Indexed: 07/20/2024]
Abstract
Hantaviruses, members of the Bunyaviridae family, can cause two patterns of disease in humans, hantavirus hemorrhagic fever with renal syndrome (HFRS) and cardiopulmonary syndrome (HCPS), being the latter hegemonic on the American continent. Andesvirus is one of the strains that can cause HCPS and is endemic in Chile. Its transmission occurs through direct or indirect contact with infected rodents' urine, saliva, or feces and inhalation of aerosol particles containing the virus. HCPS rapidly evolves into acute but reversible multiorgan dysfunction. The hemodynamic pattern of HCPS is not identical to that of cardiogenic or septic shock, being characterized by hypovolemia, systolic dysfunction, and pulmonary edema secondary to increased permeability. Given the lack of specific effective therapies to treat this viral infection, the focus of treatment lies in the timely provision of intensive care, specifically hemodynamic and respiratory support, which often requires veno-arterial extracorporeal membrane oxygenation (VA-ECMO). This narrative review aims to provide insights into specific ICU management of HCPS based on the available evidence and gathered experience in Chile and South America including perspectives of pathophysiology, organ dysfunction kinetics, timely life support provision, safe patient transportation, and key challenges for the future.
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Affiliation(s)
| | - Nicolas Pavez
- Unidad de Cuidados Intensivos, Hospital Guillermo Grant Benavente, Concepción, Chile; Departamento de Medicina Interna, Universidad de Concepción, Concepción, Chile
| | - Esteban Parra
- Unidad de Cuidados Intensivos, Hospital Las Higueras, Talcahuano, Chile
| | - Rene Lopez
- Departamento de Paciente Crítico, Clínica Alemana de Santiago, Santiago, Chile; Grupo Intensivo, ICIM, Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Roberto Mondaca
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Paula Fernandez
- Unidad de Cuidados Intensivos, Hospital Guillermo Grant Benavente, Concepción, Chile; Departamento de Medicina Interna, Universidad de Concepción, Concepción, Chile
| | - David Kraunik
- Unidad de Cuidados Intensivos, Hospital Las Higueras, Talcahuano, Chile; Departamento de Medicina Interna, Universidad de Concepción, Concepción, Chile
| | - Claudia Sanhueza
- Unidad de Cuidados Intensivos, Hospital Las Higueras, Talcahuano, Chile
| | - Sebastian Bravo
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Eduardo Kattan
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.
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van Wijk XMR, Sanchez Oviol Z, Winter WE, Harris NS, Marin MJ. An Introduction to the Complete Blood Count for Clinical Chemists: Platelets. J Appl Lab Med 2024; 9:833-847. [PMID: 38549553 DOI: 10.1093/jalm/jfae023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 02/12/2024] [Indexed: 07/02/2024]
Abstract
BACKGROUND The most ordered laboratory test worldwide is the complete blood count (CBC). CONTENT In this primer, an introduction to platelet testing in the context of the CBC is provided with a discussion of the laboratory evaluation of platelet abnormalities including thrombocytopenia and thrombocytosis. SUMMARY As clinical chemists continue to be tasked to direct laboratories outside of the traditional clinical chemistry sections such as hematology, expertise must be developed. This primer is dedicated to that effort.
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Affiliation(s)
| | - Zaraith Sanchez Oviol
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, FL, United States
| | - William E Winter
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, FL, United States
| | - Neil S Harris
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, FL, United States
| | - Maximo J Marin
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, FL, United States
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Lüsebrink E, Lanz H, Binzenhöfer L, Hoffmann S, Höpler J, Kraft M, Gade N, Gmeiner J, Roden D, Saleh I, Hagl C, Nickenig G, Massberg S, Zimmer S, Jamin RN, Scherer C. Heparin-Induced Thrombocytopenia in Patients Suffering Cardiogenic Shock. Crit Care Explor 2024; 6:e1117. [PMID: 39042702 PMCID: PMC11265775 DOI: 10.1097/cce.0000000000001117] [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: 07/25/2024] Open
Abstract
OBJECTIVES Cardiogenic shock (CS) is associated with high mortality. Patients treated for CS mostly require heparin therapy, which may be associated with complications such as heparin-induced thrombocytopenia (HIT). HIT represents a serious condition associated with platelet decline and increased hypercoagulability and remains a poorly researched field in intensive care medicine. Primary purpose of this study was to: 1) determine HIT prevalence in CS, 2) assess the performance of common diagnostic tests for the workup of HIT, and 3) compare outcomes in CS patients with excluded and confirmed HIT. DESIGN Retrospective dual-center study including adult patients 18 years old or older with diagnosed CS and suspected HIT from January 2010 to November 2022. SETTING Cardiac ICU at the Ludwig-Maximilians University hospital in Munich and the university hospital of Bonn. PATIENTS AND INTERVENTIONS In this retrospective analysis, adult patients with diagnosed CS and suspected HIT were included. Differences in baseline characteristics, mortality, neurologic and safety outcomes between patients with excluded and confirmed HIT were evaluated. MEASUREMENTS AND MAIN RESULTS In cases of suspected HIT, positive screening antibodies were detected in 159 of 2808 patients (5.7%). HIT was confirmed via positive functional assay in 57 of 2808 patients, corresponding to a prevalence rate of 2.0%. The positive predictive value for anti-platelet factor 4/heparin screening antibodies was 35.8%. Total in-hospital mortality (58.8% vs. 57.9%; p > 0.999), 1-month mortality (47.1% vs. 43.9%; p = 0.781), and 12-month mortality (58.8% vs. 59.6%; p > 0.999) were similar between patients with excluded and confirmed HIT, respectively. Furthermore, no significant difference in neurologic outcome among survivors was found between groups (Cerebral Performance Category [CPC] score 1: 8.8% vs. 8.8%; p > 0.999 and CPC 2: 7.8% vs. 12.3%; p = 0.485). CONCLUSIONS HIT was a rare complication in CS patients treated with unfractionated heparin and was not associated with increased mortality. Also, HIT confirmation was not associated with worse neurologic outcome in survivors. Future studies should aim at developing more precise, standardized, and cost-effective strategies to diagnose HIT and prevent complications.
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Affiliation(s)
- Enzo Lüsebrink
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Hugo Lanz
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Leonhard Binzenhöfer
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Sabine Hoffmann
- Institute for Medical Information Processing, Biometry, and Epidemiology, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Julia Höpler
- Institute for Medical Information Processing, Biometry, and Epidemiology, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Marie Kraft
- Institute for Medical Information Processing, Biometry, and Epidemiology, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Nils Gade
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Jonas Gmeiner
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Daniel Roden
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Inas Saleh
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Christian Hagl
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
- Herzchirurgische Klinik und Poliklinik, Klinikum der Universität München, Munich, Germany
| | - Georg Nickenig
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Bonn, Bonn, Germany
| | - Steffen Massberg
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Sebastian Zimmer
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Bonn, Bonn, Germany
| | - Raúl Nicolás Jamin
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Bonn, Bonn, Germany
| | - Clemens Scherer
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
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Song D, Jin Y, Zhang Y, Zhou Z. Heparin-induced thrombocytopenia in extracorporeal membrane oxygenation-supported patients: a systematic review and meta-analysis. Thromb J 2024; 22:55. [PMID: 38937784 PMCID: PMC11212165 DOI: 10.1186/s12959-024-00624-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 06/17/2024] [Indexed: 06/29/2024] Open
Abstract
BACKGROUND In recent years, extracorporeal membrane oxygenation (ECMO) has been increasingly used in critically ill patients with respiratory or cardiac failure. Heparin is usually used as anticoagulation therapy during ECMO support. However, heparin-induced thrombocytopenia (HIT) in ECMO-supported patients, which results in considerable morbidity and mortality, has not yet been well described. This meta-analysis and systematic review aimed to thoroughly report the incidence of HIT on ECMO, as well as the characteristics and outcomes of HIT patients. METHODS We searched the PubMed, Embase, Cochrane Library, and Scopus databases for studies investigating HIT in adult patients supported by ECMO. All studies conforming to the inclusion criteria were screened from 1975 to August 2023. Nineteen studies from a total of 1,625 abstracts were selected. The primary outcomes were the incidence of HIT and suspected HIT. RESULTS The pooled incidence of HIT in ECMO-supported patients was 4.2% (95% CI: 2.7-5.6; 18 studies). A total of 15.9% (95% CI: 9.0-22.8; 12 studies) of patients on ECMO were suspected of having HIT. Enzyme-linked immunosorbent assay (ELISA) is the most commonly used immunoassay. The median optical density (OD) of the ELISA in HIT-confirmed patients ranged from 1.08 to 2.10. In most studies, the serotonin release assay (SRA) was performed as a HIT-confirming test. According to the subgroup analysis, the pooled incidence of HIT in ECMO patients was 2.7% in studies whose diagnostic mode was functional assays, which is significantly lower than the incidence in studies in which the patients were diagnosed by immunoassay (14.5%). Argatroban was most commonly used as an alternative anticoagulation agent after the withdrawal of heparin. Among confirmed HIT patients, 45.5% (95% CI: 28.8-62.6) experienced thrombotic events, while 50.1% (95% CI: 24.9-75.4) experienced bleeding events. Overall, 46.6% (95% CI: 30.4-63.1) of patients on ECMO with HIT died. CONCLUSION According to our study, the pooled incidence of HIT in ECMO-supported patients is 4.2%, and it contributes to adverse outcomes. Inappropriate diagnostic methods can easily lead to misdiagnosis of HIT. Further research and development of diagnostic algorithms and laboratory assays are warranted.
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Affiliation(s)
- Danyu Song
- Department of Laboratory Medicine, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Fuwai Hospital, No. 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Yu Jin
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Beijing, China
| | - Yang Zhang
- Department of Laboratory Medicine, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Fuwai Hospital, No. 167 Beilishi Road, Xicheng District, Beijing, 100037, China.
| | - Zhou Zhou
- Department of Laboratory Medicine, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Fuwai Hospital, No. 167 Beilishi Road, Xicheng District, Beijing, 100037, China.
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Brodska H, Smalcova J, Kavalkova P, Lavage DR, Dusik M, Belohlavek J, Drabek T. Biomarkers for neuroprognostication after standard versus extracorporeal cardiopulmonary resuscitation - A sub-analysis of Prague-OHCA study. Resuscitation 2024; 199:110219. [PMID: 38649087 DOI: 10.1016/j.resuscitation.2024.110219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 04/09/2024] [Accepted: 04/14/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Limited evidence exists for prognostic performance of biomarkers in patients resuscitated from out-of-hospital cardiac arrest (OHCA) with extracorporeal CPR (ECPR). We hypothesized that (1) the time course and (2) prognostic performance of biomarkers might differ between CPR and ECPR in a sub-analysis of Prague-OHCA study. METHODS Patients received either CPR (n = 164) or ECPR (n = 92). The primary outcome was favorable neurologic survival at 180 days [cerebral performance category (CPC) 1-2]. Secondary outcomes included biomarkers of neurologic injury, inflammation and hemocoagulation. RESULTS Favorable neurologic outcome was not different between groups: CPR 29.3% vs. ECPR 21.7%; p = 0.191. Biomarkers exhibited similar trajectories in both groups, with better values in patients with CPC 1-2. Procalcitonin (PCT) was higher in ECPR group at 24-72 h (all p < 0.01). Neuron-specific enolase (NSE), C-reactive protein and neutrophil-to-lymphocyte ratio did not differ between groups. Platelets, D-dimers and fibrinogen were lower in ECPR vs. CPR groups at 24-72 h (all p < 0.001). ROC analysis (24-48-72 h) showed the best performance of NSE in both CPR and ECPR groups (AUC 0.89 vs. 0.78; 0.9 vs. 0.9; 0.91 vs. 0.9). PCT showed good performance specifically in ECPR (0.72 vs. 0.84; 0.73 vs. 0.87; 0.73 vs. 0.86). Optimal cutoff points of NSE and PCT were higher in ECPR vs. CPR. CONCLUSIONS Biomarkers exhibited similar trajectories although absolute values tended to be higher in ECPR. NSE had superior performance in both groups. PCT showed a good performance specifically in ECPR. Additional biomarkers may have modest incremental value. Prognostication algorithms should reflect the resuscitation method.
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Affiliation(s)
- Helena Brodska
- Institute of Medical Biochemistry and Laboratory Diagnostics, First Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 499/2, 128 08 Prague, Czech Republic
| | - Jana Smalcova
- First Faculty of Medicine, Charles University and General University Hospital in Prague, Katerinska 32, Prague, Czech Republic; Emergency Medical Service in Prague, Korunni 98, Prague, Czech Republic
| | - Petra Kavalkova
- 2nd Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, U Nemocnice 499/2, 128 08 Prague, Czech Republic
| | - Danielle R Lavage
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine and UPMC, 200 Lothrop St, Pittsburgh PA 15213, United States
| | - Milan Dusik
- 2nd Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, U Nemocnice 499/2, 128 08 Prague, Czech Republic
| | - Jan Belohlavek
- 2nd Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, U Nemocnice 499/2, 128 08 Prague, Czech Republic
| | - Tomas Drabek
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine and UPMC, 200 Lothrop St, Pittsburgh PA 15213, United States; Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, John G. Rangos Research Center, 4401 Penn Avenue, Pittsburgh, PA 15224, United States.
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Kim J, Yeo HJ, Cho WH, Lee HJ. Predictors of mortality and transfusion requirements in venoarterial extracorporeal membrane oxygenation patients. Lab Med 2024; 55:347-354. [PMID: 37706544 DOI: 10.1093/labmed/lmad089] [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: 09/15/2023] Open
Abstract
OBJECTIVE The aim of this study was to evaluate the prognostic impact of variables, including thrombocytopenia and the amount of platelet transfusion, for predicting survival in venoarterial extracorporeal membrane oxygenation (ECMO) recipients. Additionally, we aimed to identify the predictors of increased transfusion requirement during venoarterial ECMO support. METHODS All patients who received venoarterial ECMO between December 2008 and March 2020 were retrospectively analyzed. Univariate and multivariate Cox regressions were used to evaluate in-hospital mortality according to variables including thrombocytopenia and daily average of platelet concentrate transfusion. Stepwise multiple linear regression analysis was used to identify independent predictors for transfusion requirements. RESULTS Analysis of 218 patients demonstrated severe thrombocytopenia as an independent predictor of in-hospital mortality (hazard ratio = 2.840, 95% CI: 1.593-5.063, P < .001), along with age, pre-ECMO cardiac arrest, and pH. In contrast, the amount of platelet transfusion was not associated with in-hospital mortality. Multiple variables, including the type of indication for ECMO were associated with transfusion requirements. CONCLUSION Our findings identified severe thrombocytopenia as an independent prognostic factor of in-hospital mortality. However, daily average platelet transfusion was not associated with survival outcomes. Additionally, our study identified predictive variables of increased transfusion requirements.
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Affiliation(s)
- Jongmin Kim
- Department of Laboratory Medicine, Pusan National University Hospital, Busan, Korea
| | - Hye Ju Yeo
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Korea
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Woo Hyun Cho
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Korea
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Hyun-Ji Lee
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
- Department of Laboratory Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
- Department of Laboratory Medicine, Pusan National University School of Medicine, Yangsan, Korea
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11
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Lüsebrink E, Binzenhöfer L, Hering D, Villegas Sierra L, Schrage B, Scherer C, Speidl WS, Uribarri A, Sabate M, Noc M, Sandoval E, Erglis A, Pappalardo F, De Roeck F, Tavazzi G, Riera J, Roncon-Albuquerque R, Meder B, Luedike P, Rassaf T, Hausleiter J, Hagl C, Zimmer S, Westermann D, Combes A, Zeymer U, Massberg S, Schäfer A, Orban M, Thiele H. Scrutinizing the Role of Venoarterial Extracorporeal Membrane Oxygenation: Has Clinical Practice Outpaced the Evidence? Circulation 2024; 149:1033-1052. [PMID: 38527130 DOI: 10.1161/circulationaha.123.067087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) for temporary mechanical circulatory support in various clinical scenarios has been increasing consistently, despite the lack of sufficient evidence regarding its benefit and safety from adequately powered randomized controlled trials. Although the ARREST trial (Advanced Reperfusion Strategies for Patients with Out-of-Hospital Cardiac Arrest and Refractory Ventricular Fibrillation) and a secondary analysis of the PRAGUE OHCA trial (Prague Out-of-Hospital Cardiac Arrest) provided some evidence in favor of VA-ECMO in the setting of out-of-hospital cardiac arrest, the INCEPTION trial (Early Initiation of Extracorporeal Life Support in Refractory Out-of-Hospital Cardiac Arrest) has not found a relevant improvement of short-term mortality with extracorporeal cardiopulmonary resuscitation. In addition, the results of the recently published ECLS-SHOCK trial (Extracorporeal Life Support in Cardiogenic Shock) and ECMO-CS trial (Extracorporeal Membrane Oxygenation in the Therapy of Cardiogenic Shock) discourage the routine use of VA-ECMO in patients with infarct-related cardiogenic shock. Ongoing clinical trials (ANCHOR [Assessment of ECMO in Acute Myocardial Infarction Cardiogenic Shock, NCT04184635], REVERSE [Impella CP With VA ECMO for Cardiogenic Shock, NCT03431467], UNLOAD ECMO [Left Ventricular Unloading to Improve Outcome in Cardiogenic Shock Patients on VA-ECMO, NCT05577195], PIONEER [Hemodynamic Support With ECMO and IABP in Elective Complex High-risk PCI, NCT04045873]) may clarify the usefulness of VA-ECMO in specific patient subpopulations and the efficacy of combined mechanical circulatory support strategies. Pending further data to refine patient selection and management recommendations for VA-ECMO, it remains uncertain whether the present usage of this device improves outcomes.
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Affiliation(s)
- Enzo Lüsebrink
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Leonhard Binzenhöfer
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Daniel Hering
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Laura Villegas Sierra
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Benedikt Schrage
- Department of Cardiology, University Heart and Vascular Center Hamburg, Germany and DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Germany (B.S.)
| | - Clemens Scherer
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Walter S Speidl
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria (W.S.S.)
| | - Aitor Uribarri
- Cardiology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain. CIBER-CV (A.U.)
| | - Manel Sabate
- Interventional Cardiology Department, Hospital Clinic, Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain (M.S.)
| | - Marko Noc
- Center for Intensive Internal Medicine, University Medical Center, Ljubljana, Slovenia (M.N.)
| | - Elena Sandoval
- Department of Cardiovascular Surgery, Hospital Clínic, Barcelona, Spain (E.S.)
| | - Andrejs Erglis
- Latvian Centre of Cardiology, Paul Stradins Clinical University Hospital, Riga, Latvia (A.E.)
| | - Federico Pappalardo
- Cardiothoracic and Vascular Anesthesia and Intensive Care Unit, AO SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy (F.P.)
| | - Frederic De Roeck
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium (F.D.R.)
| | - Guido Tavazzi
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia Intensive Care, Fondazione IRCCS Policlinico San Matteo, Italy (G.T.)
| | - Jordi Riera
- Intensive Care Department, Vall d'Hebron University Hospital, and SODIR, Vall d'Hebron Research Institute, Barcelona, Spain (J.R.)
| | - Roberto Roncon-Albuquerque
- Department of Intensive Care Medicine, São João University Hospital Center, UnIC@RISE and Department of Surgery and Physiology, Faculty of Medicine of Porto, Portugal (R.R.-A.)
| | - Benjamin Meder
- Department of Cardiology, Angiology, and Pneumology, University Hospital Heidelberg, Germany (B.M.)
| | - Peter Luedike
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen (P.L., T.R.)
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen (P.L., T.R.)
| | - Jörg Hausleiter
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Christian Hagl
- Department of Cardiac Surgery, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Germany (C.H.)
| | - Sebastian Zimmer
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, Germany (S.Z.)
| | - Dirk Westermann
- Department of Cardiology and Angiology, Medical Center, University of Freiburg, Germany (D.W.)
| | - Alain Combes
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France, and Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France (A.C.)
| | - Uwe Zeymer
- Klinikum der Stadt Ludwigshafen and Institut für Herzinfarktforschung, Ludwigshafen am Rhein, Germany (U.Z.)
| | - Steffen Massberg
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Andreas Schäfer
- Department of Cardiology and Angiology, Hannover Medical School, Germany (A.S.)
| | - Martin Orban
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig, Department of Internal Medicine/Cardiology and Leipzig Heart Science, Germany (H.T.)
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12
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Moyon Q, Triboulet F, Reuter J, Lebreton G, Dorget A, Para M, Chommeloux J, Stern J, Pineton de Chambrun M, Hékimian G, Luyt CE, Combes A, Sonneville R, Schmidt M. Venoarterial extracorporeal membrane oxygenation in immunocompromised patients with cardiogenic shock: a cohort study and propensity-weighted analysis. Intensive Care Med 2024; 50:406-417. [PMID: 38436727 DOI: 10.1007/s00134-024-07354-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 02/11/2024] [Indexed: 03/05/2024]
Abstract
PURPOSE The outcomes of immunocompromised patients with cardiogenic shock treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO) are seldom documented, making ECMO candidacy decisions challenging. This study aims (1) to report outcomes of immunocompromised patients treated with VA-ECMO, (2) to identify pre-ECMO predictors of 90-day mortality, (3) to assess the impact of immunodepression on 90-day mortality, and (4) to describe the main ECMO-related complications. METHODS This is a retrospective, propensity-weighted study conducted in two French experienced ECMO centers. RESULTS From January 2006 to January 2022, 177 critically ill immunocompromised patients (median (interquartile range, IQR) age 49 (32-60) years) received VA-ECMO. The main causes of immunosuppression were long-term corticosteroids/immunosuppressant treatment (29%), hematological malignancy (26%), solid organ transplant (20%), and solid tumor (13%). Overall 90-day and 1-year mortality were 70% (95% confidence interval (CI) 63-77%) and 75% (95% CI 65-79%), respectively. Older age and higher pre-ECMO lactate were independently associated with 90-day mortality. Across immunodepression causes, 1-year mortality ranged from 58% for patients with infection by human immunodeficiency virus (HIV) or asplenia, to 89% for solid organ transplant recipients. Hemorrhagic and infectious complications affected 39% and 54% of patients, while more than half the stay in intensive care unit (ICU) was spent on antibiotics. In a propensity score-weighted model comparing the 177 patients with 942 non-immunocompromised patients experiencing cardiogenic shock on VA-ECMO, immunocompromised status was independently associated with a higher 90-day mortality (odds ratio 2.53, 95% CI 1.72-3.79). CONCLUSION Immunocompromised patients undergoing VA-ECMO treatment face an unfavorable prognosis, with higher 90-day mortality compared to non-immunocompromised patients. This underscores the necessity for thorough evaluation and careful selection of ECMO candidates within this frail population.
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Affiliation(s)
- Quentin Moyon
- Assistance Publique des Hopitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | - Félicien Triboulet
- Assistance Publique des Hopitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | - Jean Reuter
- Assistance Publique des Hopitaux de Paris, Medical and Infectious Diseases Intensive Care Unit, Bichat Hospital, Paris Diderot University, Sorbonne Paris Cité, INSERM/Paris Diderot University, Paris, France
| | - Guillaume Lebreton
- Assistance Publique des Hopitaux de Paris, Service de Chirurgie Cardiaque, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 75013, Paris, France
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, 75013, Paris, France
| | - Amandine Dorget
- Assistance Publique des Hopitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | - Marylou Para
- Assistance Publique Des Hopitaux de Paris, Bichat Hospital, Service de Chirurgie Cardiaque, Paris Diderot University, Sorbonne Paris Cité, INSERM/Paris Diderot University, Paris, France
| | - Juliette Chommeloux
- Assistance Publique des Hopitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | - Jules Stern
- Assistance Publique Des Hopitaux de Paris, Department of Anesthesiology and Critical Care Medicine, Bichat Hospital, Paris Diderot University, Sorbonne Paris Cité, INSERM/Paris Diderot University, Paris, France
| | - Marc Pineton de Chambrun
- Assistance Publique des Hopitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 75013, Paris, France
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, 75013, Paris, France
| | - Guillaume Hékimian
- Assistance Publique des Hopitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | - Charles-Edouard Luyt
- Assistance Publique des Hopitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 75013, Paris, France
- Sorbonne Université, GRC 30, RESPIRE, Paris, France
| | - Alain Combes
- Assistance Publique des Hopitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 75013, Paris, France
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, 75013, Paris, France
- Sorbonne Université, GRC 30, RESPIRE, Paris, France
| | - Romain Sonneville
- Assistance Publique des Hopitaux de Paris, Medical and Infectious Diseases Intensive Care Unit, Bichat Hospital, Paris Diderot University, Sorbonne Paris Cité, INSERM/Paris Diderot University, Paris, France
| | - Matthieu Schmidt
- Assistance Publique des Hopitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 75013, Paris, France.
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, 75013, Paris, France.
- Sorbonne Université, GRC 30, RESPIRE, Paris, France.
- Service de Médecine Intensive-Réanimation Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition 47, Boulevard de L'Hôpital, 75013, Paris, France.
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13
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Walker LR, Hollinger LE, Southgate WM, Selewski DT, Korte JE, Gregoski M, Steflik HJ. Neonatal Extracorporeal Membrane Oxygenation: Associations between Continuous Renal Replacement Therapy, Thrombocytopenia, and Outcomes. Blood Purif 2024; 53:665-675. [PMID: 38432196 DOI: 10.1159/000538010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 02/20/2024] [Indexed: 03/05/2024]
Abstract
INTRODUCTION The incidence of thrombocytopenia in neonates receiving extracorporeal membrane oxygenation (ECMO) with and without concurrent continuous renal replacement therapy (CRRT) and associated complications have not been well described. The primary aims of the current study were to (1) characterize thrombocytopenia in neonates receiving ECMO (including those treated concurrently with CRRT) and (2) evaluate risk factors (including CRRT utilization) associated with severe thrombocytopenia. In a planned exploratory secondary aim, we explored the association of severe thrombocytopenia with outcomes in neonates receiving ECMO. METHODS We conducted a retrospective single-center chart review of neonates who received ECMO 07/01/14-03/01/20 and evaluated associations between CRRT, severe thrombocytopenia (platelet count <50,000/mm3), and outcomes (ECMO duration, length of stay, and survival). RESULTS Fifty-two neonates received ECMO; 35 (67%) received concurrent CRRT. Severe thrombocytopenia occurred in 27 (52%) neonates overall and in 21 (60%) neonates who received concurrent CRRT. Underlying diagnosis, ECMO mode, care unit, and moderate/severe hemolysis differed between those who did and did not receive CRRT. CRRT receivers experienced shorter hospital stays than CRRT non-receivers, but ECMO duration, length of intensive care unit (ICU) stay, and survival did not differ between groups. CRRT receipt was associated with severe thrombocytopenia. Exploratory classification and regression tree (CART) analysis suggests CRRT use, birthweight, and ICU location are all predictors of interest for severe thrombocytopenia. CONCLUSIONS In our cohort, CRRT use during ECMO was associated with severe thrombocytopenia, and patients who received ECMO with CRRT experienced shorter hospital stays than those who did not receive CRRT. Exploratory CART analysis suggests CRRT use, birthweight, and ICU location are all predictors for severe thrombocytopenia and warrant further investigations in larger studies.
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Affiliation(s)
- Lauren R Walker
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Laura E Hollinger
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
| | - W Michael Southgate
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
| | - David T Selewski
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jeffrey E Korte
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Mathew Gregoski
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Heidi J Steflik
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
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14
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Basílio C, Anders M, Rycus P, Paiva JA, Roncon-Albuquerque R. Cardiac Tamponade Complicating Extracorporeal Membrane Oxygenation: An Extracorporeal Life Support Organization Registry Analysis. J Cardiothorac Vasc Anesth 2024; 38:731-738. [PMID: 38233245 DOI: 10.1053/j.jvca.2023.12.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 12/01/2023] [Accepted: 12/18/2023] [Indexed: 01/19/2024]
Abstract
OBJECTIVES Cardiac tamponade is a potentially life-threatening complication during extracorporeal membrane oxygenation (ECMO). In this study, the authors assessed the incidence, patient characteristics, and risk factors for mortality of cardiac tamponade during ECMO. DESIGN The authors queried the Extracorporeal Life Support Organization (ELSO) Registry from 1997 to 2021 for all adults with cardiac tamponade as a reported complication during ECMO. PARTICIPANTS Cardiac tamponade was reported in 2,176 (64% men; 53.8 ± 0.33 years) of 84,430 adults (2.6%). MEASUREMENTS AND MAIN RESULTS Venoarterial ECMO was the main configuration (78%), followed by venovenous ECMO (VV ECMO) (18%), for cardiac (67%), pulmonary (21%) support, and extracorporeal cardiopulmonary resuscitation (ECPR) (12%). Percutaneous cannulation was performed in 51%, with the femoral vein and femoral artery as the most common sites for drainage and return cannulae, with dual-lumen cannulae in 39% of VV ECMO. Hospital survival was lower (35% v 49%; p < 0.01) when compared with that of all adults from the ELSO Registry. In multivariate analysis, age, aortic dissection and/or rupture, COVID-19, ECPR, pre-ECMO renal-replacement therapy, and prone position are associated with hospital mortality, whereas ECMO for pulmonary support is associated with hospital survival. Similarly, renal, cardiovascular, metabolic, neurologic, and pulmonary complications occurred more frequently in nonsurvivors. CONCLUSIONS Cardiac tamponade is a rare complication during ECMO that, despite being potentially reversible, is associated with high hospital mortality. Venoarterial ECMO is the most common configuration. ECMO for pulmonary support was associated with higher survival, and ECPR was associated with higher mortality. In these patients, other ECMO-related complications were frequently reported and associated with hospital mortality.
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Affiliation(s)
- Carla Basílio
- Department of Emergency and Intensive Care Medicine, São João University Hospital Centre, Porto, Portugal.
| | - Marc Anders
- Extracorporeal Life Support Organization, Ann Arbor, MI; Department of Pediatrics (Critical Care), Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Peter Rycus
- Extracorporeal Life Support Organization, Ann Arbor, MI
| | - José Artur Paiva
- Department of Emergency and Intensive Care Medicine, São João University Hospital Centre, Porto, Portugal; Department of Medicine, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Roberto Roncon-Albuquerque
- Department of Emergency and Intensive Care Medicine, São João University Hospital Centre, Porto, Portugal; Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
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15
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Tagaya M, Okano S, Murataka T, Handa H, Ichikawa S, Takahashi S. Platelet volume indices and von Willebrand factor levels in blood exposed to polymer- or heparin-coated membrane oxygenators. Int J Artif Organs 2024; 47:198-204. [PMID: 38326931 DOI: 10.1177/03913988231223360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
INTRODUCTION To understand the behavior of platelet volume indices and the von Willebrand factor (VWF), in vitro experiments using whole human blood were performed with extracorporeal circulation (ECC) circuits, including membrane oxygenators coated with acrylate copolymer (ACP) or immobilized heparin (IHP). METHODS Heparinized blood was circulated through two distinct experimental circuits: an ACP-coated reservoir and tubes, as well as membranes coated with either ACP or IHP (comprising five pieces of each type). The platelet distribution width, mean platelet volume (MPV), platelet large cell ratio (P-LCR), VWF quantity (VWFQ), and VWF activity (VWFA) were measured at 0, 8, 16, 24, and 32 h in each experiment. A two-way analysis of variance (ANOVA) was performed to determine whether the coating type or circulation duration affected the transition of each measurement. RESULTS Two-way ANOVA indicated that the transitions of MPV, P-LCR, and VWFA were significantly affected by the circulation duration (p = 0.030, 0.001, and <0.001, respectively) and that the transitions of VWFQ and VWFA were significantly affected by the coating type (p = 0.022 and 0.006, respectively). Factor interactions between the coating type and circulation duration were not observed for each transition (p > 0.05). CONCLUSIONS Our findings suggest that P-LCR is a good index for platelet activation in blood-circulating ECC and that VWFA and VWFQ are significantly attenuated in blood-circulating ECC with ACP-coated membranes, indicating the advantage of IHP coating regarding platelet activation.
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Affiliation(s)
- Masashi Tagaya
- Department of Medical Engineering, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Shinya Okano
- Department of Medical Engineering, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Takuo Murataka
- Department of Medical Engineering, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Hiroki Handa
- Department of Medical Engineering, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Shunsuke Ichikawa
- Department of Medical Engineering, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Shunsuke Takahashi
- Department of Nephrology, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
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Martucci G, Giani M, Schmidt M, Tanaka K, Tabatabai A, Tuzzolino F, Agerstrand C, Riera J, Ramanan R, Grasselli G, Ait Hssain A, Gannon WD, Buabbas S, Gorjup V, Trethowan B, Rizzo M, Fanelli V, Jeon K, De Pascale G, Combes A, Ranieri MV, Duburcq T, Foti G, Chico JI, Balik M, Broman LM, Schellongowski P, Buscher H, Lorusso R, Brodie D, Arcadipane A. Anticoagulation and Bleeding during Veno-Venous Extracorporeal Membrane Oxygenation: Insights from the PROTECMO Study. Am J Respir Crit Care Med 2024; 209:417-426. [PMID: 37943110 DOI: 10.1164/rccm.202305-0896oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 11/08/2023] [Indexed: 11/10/2023] Open
Abstract
Rationale: Definitive guidelines for anticoagulation management during veno-venous extracorporeal membrane oxygenation (VV ECMO) are lacking, whereas bleeding complications continue to pose major challenges. Objectives: To describe anticoagulation modalities and bleeding events in adults receiving VV ECMO. Methods: This was an international prospective observational study in 41 centers, from December 2018 to February 2021. Anticoagulation was recorded daily in terms of type, dosage, and monitoring strategy. Bleeding events were reported according to site, severity, and impact on mortality. Measurements and Main Results: The study cohort included 652 patients, and 8,471 days on ECMO were analyzed. Unfractionated heparin was the initial anticoagulant in 77% of patients, and the most frequently used anticoagulant during the ECMO course (6,221 d; 73%). Activated partial thromboplastin time (aPTT) was the most common test for monitoring coagulation (86% of days): the median value was 52 seconds (interquartile range, 39 to 61 s) but dropped by 5.3 seconds after the first bleeding event (95% confidence interval, -7.4 to -3.2; P < 0.01). Bleeding occurred on 1,202 days (16.5%). Overall, 342 patients (52.5%) experienced at least one bleeding event (one episode every 215 h on ECMO), of which 10 (1.6%) were fatal. In a multiple penalized Cox proportional hazard model, higher aPTT was a potentially modifiable risk factor for the first episode of bleeding (for 20-s increase; hazard ratio, 1.07). Conclusions: Anticoagulation during VV ECMO was a dynamic process, with frequent stopping in cases of bleeding and restart according to the clinical picture. Future studies might explore lower aPTT targets to reduce the risk of bleeding.
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Affiliation(s)
| | - Marco Giani
- Fondazione IRCCS San Gerardo dei Tintori, Università degli Studi di Milano Bicocca, Monza, Italy
| | - Matthieu Schmidt
- Sorbonne University, Institute of Cardiometabolism and Nutrition, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Paris, France
| | - Kenichi Tanaka
- The University of Oklahoma Health Sciences Center, University of Oklahoma, Oklahoma City, Oklahoma
| | - Ali Tabatabai
- University of Maryland St. Joseph Medical Center, Towson, Maryland
| | - Fabio Tuzzolino
- Statistics and Data Management Services, Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (IRCCS-ISMETT), Palermo, Italy
| | - Cara Agerstrand
- Department of Medicine and Center for Acute Respiratory Failure, Irving Medical Center, Columbia University, New York, New York
| | - Jordi Riera
- Critical Care Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Shock Organ Dysfunction and Resuscitation (SODIR), Vall d'Hebron Institut de Recerca, Barcelona, Spain
- Centro de Investigacion en Red de Enfermedades Respiratorias (CIBERES) Instituto de Salud Carlos III, Barcelona, Spain
| | - Raj Ramanan
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Giacomo Grasselli
- Department of Anesthesia, Intensive Care, and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | | | - Whitney D Gannon
- Department of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sara Buabbas
- Kuwait Extracorporeal Life Support Program, Jaber Al-Ahmad Alsabah Hospital, Kuwait City, Kuwait
| | | | - Brian Trethowan
- Meijer Heart Center, Butterworth Hospital, Spectrum Health, Grand Rapids, Michigan
| | - Monica Rizzo
- Statistics and Data Management Services, Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (IRCCS-ISMETT), Palermo, Italy
| | - Vito Fanelli
- Department of Surgical Sciences and
- Department of Anesthesia, Critical Care, and Emergency, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Kyeongman Jeon
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Gennaro De Pascale
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alain Combes
- Sorbonne University, Institute of Cardiometabolism and Nutrition, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Paris, France
| | | | - Thibault Duburcq
- Centre Hospitalier Regional Universitaire (CHRU) Lille, Hôpital Roger Salengro, Lille, France
| | - Giuseppe Foti
- Fondazione IRCCS San Gerardo dei Tintori, Università degli Studi di Milano Bicocca, Monza, Italy
| | - Juan I Chico
- Critical Care Department, Alvaro Cunqueiro University Hospital, Vigo, Spain
| | - Martin Balik
- First Medical Faculty, General University Hospital, Prague, Czech Republic
| | - Lars Mikael Broman
- ECMO Centre Karolinska, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Peter Schellongowski
- Department of Medicine I, Intensive Care Unit 13i2, Center of Excellence in Medical Intensive Care, Medical University of Vienna, Vienna, Austria
| | - Hergen Buscher
- St. Vincent's Hospital Sydney, University of New South Wales, Sydney, New South Wales, Australia
| | - Roberto Lorusso
- Cardiothoracic Surgery Department, Maastricht University Medical Center, and
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands; and
| | - Daniel Brodie
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
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Bartlett R, Arachichilage DJ, Chitlur M, Hui SKR, Neunert C, Doyle A, Retter A, Hunt BJ, Lim HS, Saini A, Renné T, Kostousov V, Teruya J. The History of Extracorporeal Membrane Oxygenation and the Development of Extracorporeal Membrane Oxygenation Anticoagulation. Semin Thromb Hemost 2024; 50:81-90. [PMID: 36750217 DOI: 10.1055/s-0043-1761488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) was first started for humans in early 1970s by Robert Bartlett. Since its inception, there have been numerous challenges with extracorporeal circulation, such as coagulation and platelet activation, followed by consumption of coagulation factors and platelets, and biocompatibility of tubing, pump, and oxygenator. Unfractionated heparin (heparin hereafter) has historically been the defacto anticoagulant until recently. Also, coagulation monitoring was mainly based on bedside activated clotting time and activated partial thromboplastin time. In the past 50 years, the technology of ECMO has advanced tremendously, and thus, the survival rate has improved significantly. The indication for ECMO has also expanded. Among these are clinical conditions such as postcardiopulmonary bypass, sepsis, ECMO cardiopulmonary resuscitation, and even severe coronavirus disease 2019 (COVID-19). Not surprisingly, the number of ECMO cases has increased according to the Extracorporeal Life Support Organization Registry and prolonged ECMO support has become more prevalent. It is not uncommon for patients with COVID-19 to be on ECMO support for more than 1 year until recovery or lung transplant. With that being said, complications of bleeding, thrombosis, clot formation in the circuit, and intravascular hemolysis still remain and continue to be major challenges. Here, several clinical ECMO experts, including the "Father of ECMO"-Dr. Robert Bartlett, describe the history and advances of ECMO.
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Affiliation(s)
- Robert Bartlett
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Deepa J Arachichilage
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
- Department of Haematology, Imperial College, Healthcare NHS Trust, London, United Kingdom
| | - Meera Chitlur
- Division of Hematology/Oncology, Central Michigan University School of Medicine, Children's Hospital of Michigan, Michigan
| | - Shiu-Ki Rocky Hui
- Department of Pathology & Immunology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Cindy Neunert
- Columbia University Irving Medical Center, New York, New York
| | | | | | | | - Hoong Sern Lim
- University Hospitals Birmingham NHS Foundation Trust, United Kingdom
| | - Arun Saini
- Department of Pathology & Immunology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Thomas Renné
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
- Center for Thrombosis and Hemostasis (CTH), Johannes Gutenberg University Medical Center, Mainz, Germany
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Vadim Kostousov
- Department of Pathology & Immunology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Jun Teruya
- Department of Pathology & Immunology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
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18
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Yao Y, Kang H, Cheng Y, Su X, Wang B. Inflammatory Progression in Patients Undergoing Extracorporeal Membrane Oxygenation. Curr Mol Med 2024; 24:844-855. [PMID: 37340745 DOI: 10.2174/1566524023666230619102723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 04/24/2023] [Accepted: 05/04/2023] [Indexed: 06/22/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) is identified as a novel therapeutic strategy that offers short-term support to the metabolism of the heart and lungs in humans. Recently, the clinical centers, which provide ECMO has increased rapidly worldwide. The indications for the use of ECMO in daily clinical practice were broadened dynamically. However, even with the widespread adoption of ECMO, it still remains significant morbidity and mortality, and the underlying mechanisms are still not elucidated. Notably, one of the vital complications during ECMO was proposed as the inflammatory progression within the extracorporeal circulation. via the development of inflammatory response, patients with ECMO may further suffer from systemic inflammatory response syndrome (SIRS), posing serious risks to human health. Recently, growing evidence confirmed that through exposure of blood into the ECMO circuit could lead to the stimulation of the immune system which also facilitated the inflammatory response and systemic impaired. In the current review, the pathological development of inflammatory progression in patients with ECMO is well-listed. Furthermore, the relationship between immune-related activation and the development of inflammation is also summarized, which may further help us to decide the therapeutic strategies in daily clinical practice.
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Affiliation(s)
- Yan'er Yao
- Department of Cardiology, the Xiamen Cardiovascular Hospital of Xiamen University, Xiamen, Fujian, China
| | - Huiyuan Kang
- Department of Cardiology, the Xiamen Cardiovascular Hospital of Xiamen University, Xiamen, Fujian, China
| | - Ye Cheng
- Department of Cardiology, the Xiamen Cardiovascular Hospital of Xiamen University, Xiamen, Fujian, China
| | - Xin Su
- Department of Cardiology, the Xiamen Cardiovascular Hospital of Xiamen University, Xiamen, Fujian, China
| | - Bin Wang
- Department of Cardiology, the Xiamen Cardiovascular Hospital of Xiamen University, Xiamen, Fujian, China
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19
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Spencer BL, Johnson MD, Wilhelm SK, Lautner-Csorba OD, Matich H, Lautner G, Fallon BP, Dann T, Gudex L, Langley M, Meyerhoff M, Potkay J, Bartlett R, Rojas-Pena A, Hirschl RB. A Pumpless Pediatric Artificial Lung Maintains Function for 72 h Without Systemic Anticoagulation Using the Nitric Oxide Surface Anticoagulation System. J Pediatr Surg 2024; 59:103-108. [PMID: 37858393 PMCID: PMC10843264 DOI: 10.1016/j.jpedsurg.2023.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 09/06/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Children with end-stage lung disease are commonly managed with extracorporeal life support (ECLS) as a bridge to lung transplantation. A pumpless artificial lung (MLung) is a portable alternative to ECLS and it allows for ambulation. Both ECLS and pumpless artificial lungs require systemic anticoagulation which is associated with hemorrhagic complications. We tested the MLung with a novel Nitric Oxide (NO) Surface Anticoagulation (NOSA) system, to provide local anticoagulation for 72 h of support in a pediatric-size ovine model. METHODS Four mini sheep underwent thoracotomy and cannulation of the pulmonary artery (inflow) and left atrium (outflow), recovered and were monitored for 72hr. The circuit tubing and connectors were coated with the combination of an NO donor (diazeniumdiolated dibutylhexanediamine; DBHD-N2O2) and argatroban. The animals were connected to the MLung and 100 ppm of NO was added to the sweep gas. Systemic hemodynamics, blood chemistry, blood gases, and methemoglobin were collected. RESULTS Mean device flow was 836 ± 121 mL/min. Device outlet saturation was 97 ± 4%. Pressure drop across the lung was 3.5 ± 1.5 mmHg and resistance was 4.3 ± 1.7 mmHg/L/min. Activated clotting time averaged 170 ± 45s. Methemoglobin was 2.9 ± 0.8%. Platelets declined from 590 ± 101 at baseline to 160 ± 90 at 72 h. NO flux (x10-10 mol/min/cm2) of the NOSA circuit averaged 2.8 ± 0.6 (before study) and 1.9 ± 0.1 (72 h) and across the MLung 18 ± 3 NO flux was delivered. CONCLUSION The MLung is a more portable form of ECLS that demonstrates effective gas exchange for 72 h without hemodynamic changes. Additionally, the NOSA system successfully maintained local anticoagulation without evidence of systemic effects.
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Affiliation(s)
- Brianna L Spencer
- Extracorporeal Life Support Laboratory, Department of Surgery, University of Michigan, 1150 West Medical Center Dr. MSRB II, Ann Arbor, MI 48109, United States.
| | - Matthew D Johnson
- Extracorporeal Life Support Laboratory, Department of Surgery, University of Michigan, 1150 West Medical Center Dr. MSRB II, Ann Arbor, MI 48109, United States
| | - Spencer K Wilhelm
- Extracorporeal Life Support Laboratory, Department of Surgery, University of Michigan, 1150 West Medical Center Dr. MSRB II, Ann Arbor, MI 48109, United States
| | - Orsolya D Lautner-Csorba
- Extracorporeal Life Support Laboratory, Department of Surgery, University of Michigan, 1150 West Medical Center Dr. MSRB II, Ann Arbor, MI 48109, United States
| | - Hannah Matich
- Extracorporeal Life Support Laboratory, Department of Surgery, University of Michigan, 1150 West Medical Center Dr. MSRB II, Ann Arbor, MI 48109, United States
| | - Gergely Lautner
- Extracorporeal Life Support Laboratory, Department of Surgery, University of Michigan, 1150 West Medical Center Dr. MSRB II, Ann Arbor, MI 48109, United States
| | - Brian P Fallon
- Extracorporeal Life Support Laboratory, Department of Surgery, University of Michigan, 1150 West Medical Center Dr. MSRB II, Ann Arbor, MI 48109, United States
| | - Tyler Dann
- Extracorporeal Life Support Laboratory, Department of Surgery, University of Michigan, 1150 West Medical Center Dr. MSRB II, Ann Arbor, MI 48109, United States
| | - Leah Gudex
- Extracorporeal Life Support Laboratory, Department of Surgery, University of Michigan, 1150 West Medical Center Dr. MSRB II, Ann Arbor, MI 48109, United States
| | - Mark Langley
- Extracorporeal Life Support Laboratory, Department of Surgery, University of Michigan, 1150 West Medical Center Dr. MSRB II, Ann Arbor, MI 48109, United States
| | - Mark Meyerhoff
- Department of Chemistry, University of Michigan, Ann Arbor, MI 48109, United States
| | - Joseph Potkay
- Extracorporeal Life Support Laboratory, Department of Surgery, University of Michigan, 1150 West Medical Center Dr. MSRB II, Ann Arbor, MI 48109, United States; VA Ann Arbor Healthcare System, Ann Arbor, MI, United States
| | - Robert Bartlett
- Extracorporeal Life Support Laboratory, Department of Surgery, University of Michigan, 1150 West Medical Center Dr. MSRB II, Ann Arbor, MI 48109, United States
| | - Alvaro Rojas-Pena
- Extracorporeal Life Support Laboratory, Department of Surgery, University of Michigan, 1150 West Medical Center Dr. MSRB II, Ann Arbor, MI 48109, United States
| | - Ronald B Hirschl
- Extracorporeal Life Support Laboratory, Department of Surgery, University of Michigan, 1150 West Medical Center Dr. MSRB II, Ann Arbor, MI 48109, United States; Section of Pediatric Surgery, Department of Surgery, University of Michigan Medical School, C.S. Mott Children's Hospital, 1540 E Hospital Dr, Ann Arbor, MI 48109, United States
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Ou CY, Tsai MT, Wang YC, Roan JN, Kan CD, Hu YN. Predictors and Outcomes of Acute Brain Injury in Patients on Venoarterial Extracorporeal Membrane Oxygenation after Cardiopulmonary Resuscitation. ACTA CARDIOLOGICA SINICA 2024; 40:111-122. [PMID: 38264077 PMCID: PMC10801429 DOI: 10.6515/acs.202401_40(1).20230817b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 08/17/2023] [Indexed: 01/25/2024]
Abstract
Background Venoarterial (V-A) extracorporeal membrane oxygenation (ECMO) after cardiac arrest often predisposes patients to acute brain injury (ABI), which affects survival and neurological performance. The investigation of the predictors of ABI will be beneficial for further management. Objectives To explore the predictors and outcomes of ABI and intracerebral hemorrhage (ICH) in patients experiencing cardiac arrest and cardiopulmonary resuscitation (CPR) with V-A ECMO support. Methods We retrospectively analyzed 150 patients who successfully weaned from V-A ECMO support after pre-ECMO CPR at our institution from January 2009 to December 2021. Short-term and long-term outcomes were evaluated. Characteristics before and during ECMO were analyzed for determining the predictors of ABI and ICH. Results Of the 150 patients, 66 (44.0%) had ABI. ABI was associated with higher in-hospital mortality (62.1% vs. 21.4%, p < 0.0001) and poorer long-term survival after discharge (p = 0.002). Patients who survived to discharge with ABI had significantly more severe neurological deficits at discharge (84.0% vs. 42.4%, p < 0.0001) and improved little at one year after discharge (33.3% vs. 11.4%, p = 0.027). We found that CPR duration [odds ratio (OR) = 1.04, p = 0.003] was the independent risk factor for ABI, whereas lower platelet counts was the independent risk factor for ICH (OR = 0.96, p = 0.019). Conclusions After CPR, development of ABI during V-A ECMO support impacted survival and further neurological outcome. Longer CPR duration before ECMO set up significantly increases the occurrence of ABI. Besides, severe thrombocytopenia during ECMO support increases the possibility of ICH.
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Affiliation(s)
- Chia-Yu Ou
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Meng-Ta Tsai
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yi-Chen Wang
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Jun-Neng Roan
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chung-Dann Kan
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yu-Ning Hu
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Krasivskyi I, Großmann C, Aswadi W, Ivanov B, Gerfer S, Gaisendrees C, Elderia A, Mihaylova M, Eghbalzadeh K, Deppe AC, Sabashnikov A, Rahmanian PB, Mader N, Wahlers T, Djordjevic I. Impact of thrombocytopenia on short-term outcomes in patients undergoing mobile extracorporeal membrane oxygenation support. Perfusion 2023:2676591231224635. [PMID: 38146253 DOI: 10.1177/02676591231224635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2023]
Abstract
INTRODUCTION The prolonged use of extracorporeal membrane oxygenation (ECMO) support is associated with increased consumption of platelets and hemolysis. The prognostic impact of thrombocytopenia prior to and during ECMO support on patient's short-, mid- and long-term outcomes has been critically evaluated and discussed over the last years. However, only few data have been published on thrombocytopenia caused by mobile ECMO support. The aim of this study was to evaluate the impact of thrombocytopenia on short-term outcomes and predictors of in-hospital mortality in patients supported by mobile ECMO for transportation and subsequent weaning in a tertiary centre. METHODS This retrospective single-centre study analyzed a total of 117 patients requiring mobile veno-arterial (va) ECMO support and subsequent transportation from referral hospitals to our department from January 2015 until December 2021. A total of 15 patients had to be excluded from the analysis for missing data regarding baseline platelet count. Patients were divided into two groups: thrombocytopenia group (<130 × 109/L, n = 44) and non-thrombocytopenia group (≥130 × 109/L, n = 58). The primary outcome was in-hospital mortality. Secondary outcomes were successful ECMO-weaning, and the incidence of associated complications (bleeding, acute hepatic failure, acute renal failure, dialysis, and septic shock). RESULTS The dialysis rate before ECMO initiation was significantly higher (p = .041) in the thrombocytopenia group compared to the non-thrombocytopenia group. The rates of bleeding complications (p = .032) and limb ischemia (p = .003) were significantly higher in patients with low platelet count. Moreover, complication rates of acute hepatic failure (p < .001), acute renal failure (p < .001) and dialysis (p = .033) were significantly higher in the thrombocytopenia group. Also, in-hospital mortality was significantly higher (p = .002) in patients with low platelet count before initiation of ECMO support. CONCLUSION Based on the results of the present study, patients with thrombocytopenia prior to mobile vaECMO support may be at significantly higher risk for associated complications and short-term mortality.
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Affiliation(s)
- Ihor Krasivskyi
- Department of Cardiac Surgery, Intensive Care Medicine and Thoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Clara Großmann
- Department of Cardiac Surgery, Intensive Care Medicine and Thoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Wasil Aswadi
- Department of Cardiac Surgery, Intensive Care Medicine and Thoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Borko Ivanov
- Department of Cardiothoracic Surgery, Helios Hospital Siegburg, Siegburg, Germany
| | - Stephen Gerfer
- Department of Cardiac Surgery, Intensive Care Medicine and Thoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Christopher Gaisendrees
- Department of Cardiac Surgery, Intensive Care Medicine and Thoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Ahmed Elderia
- Department of Cardiac Surgery, Intensive Care Medicine and Thoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Mariya Mihaylova
- Department of Cardiac Surgery, Intensive Care Medicine and Thoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Kaveh Eghbalzadeh
- Department of Cardiac Surgery, Intensive Care Medicine and Thoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Antje-Christin Deppe
- Department of Cardiac Surgery, Intensive Care Medicine and Thoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Anton Sabashnikov
- Department of Cardiac Surgery, Intensive Care Medicine and Thoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Parwis Baradaran Rahmanian
- Department of Cardiac Surgery, Intensive Care Medicine and Thoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Navid Mader
- Department of Cardiac Surgery, Intensive Care Medicine and Thoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Thorsten Wahlers
- Department of Cardiac Surgery, Intensive Care Medicine and Thoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Ilija Djordjevic
- Department of Cardiac Surgery, Intensive Care Medicine and Thoracic Surgery, University Hospital Cologne, Cologne, Germany
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Shu HT, Covarrubias O, Shah MM, Muquit ST, Yang VB, Zhao X, Kagabo W, Shou BL, Kalra A, Whitman G, Kim BS, Cho SM, LaPorte DM, Shafiq B. What Factors Are Associated With Arterial Line-Related Limb Ischemia in Patients on Extracorporeal Membrane Oxygenation? A Single-Center Retrospective Cohort Study. J Cardiothorac Vasc Anesth 2023; 37:2489-2498. [PMID: 37735020 DOI: 10.1053/j.jvca.2023.08.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 06/27/2023] [Accepted: 08/14/2023] [Indexed: 09/23/2023]
Abstract
OBJECTIVES The primary purpose of this study was to identify factors associated with the development of arterial line-related limb ischemia in patients on extracorporeal membrane oxygenation (ECMO). The authors also sought to characterize and report the outcomes of patients who developed arterial line-related limb ischemia. DESIGN Retrospective cohort study. SETTING A single academic tertiary referral ECMO center. PARTICIPANTS Consecutive patients who were treated with ECMO over 6 years. INTERVENTIONS Use of arterial line. MEASUREMENTS AND MAIN RESULTS A total of 278 consecutive ECMO patients were included, with 19 (7%) patients developing arterial line-related limb ischemia during the ECMO run. Postcannulation Sequential Organ Failure Assessment (SOFA) (adjusted odds ratio [aOR] 1.20, 95% CI 1.08-1.32), Acute Physiology and Chronic Health Evaluation-II (aOR 0.84, 95% CI 0.74-0.95), and adjusted Vasopressor Dose Equivalence (aOR 1.03, 95% CI 1.01-1.05) scores were independently associated with the development of arterial line-associated limb ischemia. A SOFA score of ≥17 at the time of ECMO cannulation had an 80% sensitivity and 87% specificity for predicting arterial line-related limb ischemia. CONCLUSIONS Arterial line-related limb ischemia is much more common in ECMO patients than in the typical intensive care unit setting. The SOFA score may be useful in identifying which patients may be at risk for arterial line-related limb ischemia. As this was a single-center retrospective study, these results are inherently exploratory, and prospective multicenter studies are necessary to validate these results.
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Affiliation(s)
- Henry T Shu
- Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Oscar Covarrubias
- Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Manuj M Shah
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Siam T Muquit
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Victor B Yang
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Xiyu Zhao
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Whitney Kagabo
- Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Benjamin L Shou
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Andrew Kalra
- Division of Cardiac Surgery, Department of Surgery, 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
| | - Bo Soo Kim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sung-Min Cho
- Division of Neuroscience Critical Care, Departments of Neurology and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dawn M LaPorte
- Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Babar Shafiq
- Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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Yan C, Tian D, Zhang C, Zhang Q, Sun Y. Evaluation of blood cellular and biochemical parameters in rats under a chronic hypoxic environment at high altitude. Ann Med 2023; 55:898-907. [PMID: 36896573 PMCID: PMC10796155 DOI: 10.1080/07853890.2023.2184859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 02/21/2023] [Indexed: 03/11/2023] Open
Abstract
BACKGROUND The purpose of this study was to explore the changes in blood cellular and biochemical parameters of rats in a natural environment of low pressure and low oxygen on the plateau. METHODS Male Sprague-Dawley rats in two groups were raised in different environments from 4 weeks of age for a period of 24 weeks. They were raised to 28 weeks of age and then transported to the plateau medical laboratory of Qinghai University. Blood cellular and biochemical parameters were measured and the data of the two groups were statistically analyzed. RESULTS 1. RBC in the HA group was higher than that in the Control group, but there was no significant difference between the two groups (p > 0.05), Compared with the Control group, HGB, MCV, MCH, MCHC and RDW in the HA group were significantly higher (p < 0.05). 2. Compared with the Control group, WBC, LYMP, EO, LYMP% and EO% in the HA group decreased significantly (p < 0.05), and ANC% increased significantly (p < 0.05). 3. In the platelet index, compared with the Control group, PLT in the HA group was significantly reduced (p < 0.05), PDW, MRV, P-LCR were significantly increased (p < 0.05). 4. In blood biochemical indicators, compared with the Control group, AST, TBIL, IBIL, LDH in the HA group decreased significantly (p < 0.05), CK in the HA group increased significantly (p < 0.05). CONCLUSIONS 1. The indexes related to red blood cells, white blood cells, platelets and some biochemical indexes in the blood of rats at high altitude have changed. 2. Under the high altitude environment, the oxygen carrying capacity of SD rats is improved, the resistance to disease may be reduced, the coagulation and hemostasis functions may be affected, and there is a risk of bleeding. The liver function, renal function, heart function and skeletal muscle energy metabolism may be affected. 3. This study can provide an experimental basis for the research on the pathogenesis of high-altitude diseases from the perspective of blood.KEY MESSAGESIn this study, red blood cells, white blood cells, platelets and blood biochemical indicators were included in the real plateau environment to comprehensively analyze the changes of blood cellular and biochemical parameters in rats under the chronic plateau hypobaric hypoxia environment.From the perspective of blood, this study can provide an experimental basis for research on the pathogenesis of high-altitude diseases.Explore the data support of oxygen-carrying capacity, disease resistance and energy metabolism of the body in the natural environment at high altitude.
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Affiliation(s)
- Chunlong Yan
- Suzhou Medical College of Soochow University, suzhou, China
- Department of Radiology, Jining No.1 People’s Hospital, Jining, China
- Department of Radiology, Qinghai Provincial People’s Hospital, Xining, China
| | - Dengfeng Tian
- Department of Radiology, Qinghai Provincial People’s Hospital, Xining, China
| | - Chenhong Zhang
- Department of Radiology, Qinghai Provincial People’s Hospital, Xining, China
| | - Qiang Zhang
- Department of Neurosurgery, Qinghai Provincial People's Hospital, Xining, China
| | - Yanqiu Sun
- Department of Radiology, Qinghai Provincial People’s Hospital, Xining, China
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Wolny M, Dittrich M, Knabbe C, Birschmann I. Immature platelets in COVID-19. Platelets 2023; 34:2184183. [PMID: 36883692 DOI: 10.1080/09537104.2023.2184183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
Platelets play a critical role in immune response. Coronavirus disease 2019 (COVID-19) patients with a severe course often show pathological coagulation parameters including thrombocytopenia, and at the same time the proportion of immature platelets increases. In this study, the platelet count and the immature platelet fraction (IPF) of hospitalized patients with different oxygenation requirements was investigated daily over a course of 40 days. In addition, the platelet function of COVID-19 patients was analyzed. It was found that the number of platelets in patients with the most severe course (intubation and extracorporeal membrane oxygenation (ECMO)) was significantly lower (111.5 ∙ 106 /mL) than in the other groups (mild (no intubation, no ECMO): 203.5 ∙ 106 /mL, p < .0001, moderate (intubation, no ECMO): 208.0 ∙ 106 /mL, p < .0001). IPF tended to be elevated (10.9%). Platelet function was reduced. Differentiation by outcome revealed that the deceased patients had a highly significant lower platelet count and higher IPF (97.3 ∙ 106 /mL, p < .0001, 12.2%, p = .0003).
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Affiliation(s)
- Monika Wolny
- Institut für Laboratoriums- und Transfusionsmedizin, Herz- und Diabeteszentrum NRW, Universitätsklinik der Ruhr-Universität Bochum, Bad Oeynhausen, Deutschland
| | - Marcus Dittrich
- Institut für Humangenetik und Bioinformatik, Universität Würzburg, Würzburg, Deutschland
| | - Cornelius Knabbe
- Institut für Laboratoriums- und Transfusionsmedizin, Herz- und Diabeteszentrum NRW, Universitätsklinik der Ruhr-Universität Bochum, Bad Oeynhausen, Deutschland
| | - Ingvild Birschmann
- Institut für Laboratoriums- und Transfusionsmedizin, Herz- und Diabeteszentrum NRW, Universitätsklinik der Ruhr-Universität Bochum, Bad Oeynhausen, Deutschland
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25
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Pluenneke JC, Mohamed AM, Hayes CH, Berry TP, Thomas EL, Zhurav L, Kozinn JB, Haines MM, Welge JA. Evaluation of Cangrelor Use After Percutaneous Coronary Intervention in Patients With Mechanical Circulatory Support. J Cardiothorac Vasc Anesth 2023; 37:2511-2516. [PMID: 37775345 DOI: 10.1053/j.jvca.2023.08.153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 08/28/2023] [Accepted: 08/31/2023] [Indexed: 10/01/2023]
Abstract
OBJECTIVES To describe cangrelor use in patients on concurrent mechanical circulatory support who underwent postpercutaneous coronary intervention. DESIGN A single-center, retrospective, cohort study. SETTING At a quaternary teaching hospital. PARTICIPANTS Included patients were ≥18 years old, admitted to the intensive care unit, underwent percutaneous coronary intervention with stent placement, initiated on mechanical circulatory support, and received cangrelor in the postpercutaneous coronary intervention period. INTERVENTIONS Retrospectively analyzed cangrelor use in patients on mechanical circulatory support. MEASUREMENTS AND MAIN RESULTS The primary outcome was the incidence of thrombosis and bleeding events during cangrelor administration. Additional outcomes included initial cangrelor dose, number of cangrelor dose adjustments per patient, survival from mechanical circulatory support, and mortality within 30 days. Overall, 19 patients were included in this study. In total, 14 patients (74%) experienced a bleeding event; however, 93% were classified as a minor bleed. There was 1 major bleeding event. There were no thrombotic events observed during cangrelor administration. The median initial cangrelor dose was 0.5 µg/kg/min. There were 10 patients who underwent dose adjustment, with the majority being dose reductions based on antiplatelet monitoring (VerifyNow assay). Survival from mechanical circulatory support occurred in 17 patients (89%), and 30-day mortality occurred in 8 patients (42%). CONCLUSIONS For patients receiving cangrelor as a bridge to oral P2Y12 inhibitor therapy on mechanical circulatory support, the authors observed a low rate of major bleeding and no episodes of thrombosis. Lower starting doses appear feasible with no observed increased risk of thrombotic complications. Future studies are needed to confirm these observations.
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Affiliation(s)
- Jack C Pluenneke
- Department of Pharmacy, Saint Luke's Hospital of Kansas City, Kansas City, MO; Saint Luke's Mid America Heart Institute, Kansas City, MO.
| | - Adham M Mohamed
- Department of Pharmacy, Saint Luke's Hospital of Kansas City, Kansas City, MO; Saint Luke's Mid America Heart Institute, Kansas City, MO
| | - Charles H Hayes
- Department of Pharmacy, Saint Luke's Hospital of Kansas City, Kansas City, MO; Saint Luke's Mid America Heart Institute, Kansas City, MO
| | - Timothy P Berry
- Department of Pharmacy, Saint Luke's Hospital of Kansas City, Kansas City, MO; Saint Luke's Mid America Heart Institute, Kansas City, MO
| | - Elizabeth L Thomas
- Department of Pharmacy, Saint Luke's Hospital of Kansas City, Kansas City, MO; Saint Luke's Mid America Heart Institute, Kansas City, MO
| | - Larisa Zhurav
- Saint Luke's Mid America Heart Institute, Kansas City, MO; University of Missouri-Kansas City, School of Medicine, Kansas City, MO
| | - Jonathan B Kozinn
- Saint Luke's Mid America Heart Institute, Kansas City, MO; University of Missouri-Kansas City, School of Medicine, Kansas City, MO
| | - Michelle M Haines
- Saint Luke's Mid America Heart Institute, Kansas City, MO; University of Missouri-Kansas City, School of Medicine, Kansas City, MO
| | - Julie A Welge
- Department of Pharmacy, Saint Luke's Hospital of Kansas City, Kansas City, MO; Saint Luke's Mid America Heart Institute, Kansas City, MO
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26
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Ma JW, Hu SY, Hsieh MS, Lee YC, Huang SC, Chen KJ, Chang YZ, Tsai YC. PEAL Score to Predict the Mortality Risk of Cardiogenic Shock in the Emergency Department: An Observational Study. J Pers Med 2023; 13:1614. [PMID: 38003929 PMCID: PMC10672116 DOI: 10.3390/jpm13111614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 11/12/2023] [Accepted: 11/14/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND The in-hospital mortality of cardiogenic shock (CS) remains high (28% to 45%). As a result, several studies developed prediction models to assess the mortality risk and provide guidance on treatment, including CardShock and IABP-SHOCK II scores, which performed modestly in external validation studies, reflecting the heterogeneity of the CS populations. Few articles established predictive scores of CS based on Asian people with a higher burden of comorbidities than Caucasians. We aimed to describe the clinical characteristics of a contemporary Asian population with CS, identify risk factors, and develop a predictive scoring model. METHODS A retrospective observational study was conducted between 2014 and 2019 to collect the patients who presented with all-cause CS in the emergency department of a single medical center in Taiwan. We divided patients into subgroups of CS related to acute myocardial infarction (AMI-CS) or heart failure (HF-CS). The outcome was all-cause 30-day mortality. We built the prediction model based on the hazard ratio of significant variables, and the cutoff point of each predictor was determined using the Youden index. We also assessed the discrimination ability of the risk score using the area under a receiver operating characteristic curve. RESULTS We enrolled 225 patients with CS. One hundred and seven patients (47.6%) were due to AMI-CS, and ninety-eight patients among them received reperfusion therapy. Forty-nine patients (21.8%) eventually died within 30 days. Fifty-three patients (23.55%) presented with platelet counts < 155 × 103/μL, which were negatively associated with a 30-day mortality of CS in the restrictive cubic spline plot, even within the normal range of platelet counts. We identified four predictors: platelet counts < 200 × 103/μL (HR 2.574, 95% CI 1.379-4.805, p = 0.003), left ventricular ejection fraction (LVEF) < 40% (HR 2.613, 95% CI 1.020-6.692, p = 0.045), age > 71 years (HR 2.452, 95% CI 1.327-4.531, p = 0.004), and lactate > 2.7 mmol/L (HR 1.967, 95% CI 1.069-3.620, p = 0.030). The risk score ended with a maximum of 5 points and showed an AUC (95% CI) of 0.774 (0.705-0.843) for all patients, 0.781 (0.678-0.883), and 0.759 (0.662-0.855) for AMI-CS and HF-CS sub-groups, respectively, all p < 0.001. CONCLUSIONS Based on four parameters, platelet counts, LVEF, age, and lactate (PEAL), this model showed a good predictive performance for all-cause mortality at 30 days in the all patients, AMI-CS, and HF-CS subgroups. The restrictive cubic spline plot showed a significantly negative correlation between initial platelet counts and 30-day mortality risk in the AMI-CS and HF-CS subgroups.
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Affiliation(s)
- Jen-Wen Ma
- Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung 407219, Taiwan; (J.-W.M.); (K.-J.C.); (Y.-C.T.)
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung 402, Taiwan
- Institute of Medicine, School of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan;
| | - Sung-Yuan Hu
- Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung 407219, Taiwan; (J.-W.M.); (K.-J.C.); (Y.-C.T.)
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung 402, Taiwan
- Institute of Medicine, School of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan;
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 11217, Taiwan;
| | - Ming-Shun Hsieh
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 11217, Taiwan;
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taoyuan Branch, Taoyuan 330, Taiwan
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan;
| | - Yi-Chen Lee
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan;
| | - Shih-Che Huang
- School of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan;
- Department of Emergency Medicine, Chung Shan Medical University Hospital, Taichung 40201, Taiwan
- Lung Cancer Research Center, Chung Shan Medical University Hospital, Taichung 40201, Taiwan
| | - Kuan-Ju Chen
- Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung 407219, Taiwan; (J.-W.M.); (K.-J.C.); (Y.-C.T.)
- Center for Cardiovascular Medicine, Taichung Veterans General Hospital, Taichung 407219, Taiwan
| | - Yan-Zin Chang
- Institute of Medicine, School of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan
- Department of Clinical Laboratory, Drug Testing Center, Chung Shan Medical University Hospital, Taichung 40201, Taiwan
| | - Yi-Chun Tsai
- Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung 407219, Taiwan; (J.-W.M.); (K.-J.C.); (Y.-C.T.)
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Wiest C, Müller T, Lubnow M, Fisser C, Philipp A, Foltan M, Schneckenpointner R, Malfertheiner MV. Intracranial hemorrhage in a large cohort of patients supported with veno-venous ECMO. A retrospective single-center analysis. Perfusion 2023:2676591231213514. [PMID: 37948845 DOI: 10.1177/02676591231213514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
BACKGROUND Intracranial bleeding (ICB) is a serious complication during veno-venous extracorporeal membrane oxygenation (V-V ECMO), with potentially fatal consequences. PURPOSE This study aimed to evaluate the incidence, time of detection of ICB among patients treated with V-V ECMO and potential risk factors for developing ICB during V-V ECMO. METHODS Five hundred fifty six patients were included in this retrospective single center analysis. RESULTS Median time on V-V ECMO was 9 (IQR 6-15) days. Intracranial bleeding during V-V ECMO was detected in 10.9% of all patients (61 patients with ICB). Only 17 patients with ICB presented obvious clinical symptoms. Intracranial bleeding was detected on cerebral imaging in median after 5 days (IQR 1-14) after starting V-V ECMO. Overall survival to hospital discharge was 63.7% (ICB: 29.5%). Risk factors of ICB before starting V-V ECMO in univariable analysis were platelets <100/nl (OR: 3.82), creatinine >1.5mg/dl (OR: 1.98), norepinephrine >2.5mg/h (OR: 2.5), ASAT >80U/L (OR: 1.86), blood-urea >100mg/dl (OR: 1.81) and LDH >550u/L (OR: 2.07). Factors associated with cannulation were rapid decrease in paCO2 >35mmHg (OR: 2.56) and rapid decrease in norepinephrine >1mg/h (OR: 2.53). Multivariable analysis revealed low platelets, high paCO2 before ECMO, and rapid drop in paCO2 after V-V ECMO initiation as significant risk factors for ICB. CONCLUSION The results emphasize that ICB is a frequent complication during V-V ECMO. Many bleedings were incidental findings, therefore screening for ICB is advisable. The univariate risk factors reflect the underlying disease severity, coagulation disorders and peri-cannulation factors, and may help to identify patients at risk.
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Affiliation(s)
- Clemens Wiest
- Clinic and Policlinic of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Thomas Müller
- Clinic and Policlinic of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Matthias Lubnow
- Clinic and Policlinic of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Christoph Fisser
- Clinic and Policlinic of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Alois Philipp
- Clinic of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Maik Foltan
- Clinic of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Roland Schneckenpointner
- Clinic and Policlinic of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Maximilian V Malfertheiner
- Clinic and Policlinic of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
- Clinic of Pneumonology Donaustauf, Donaustauf, Germany
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Tasoudis P, Lobo LJ, Coakley RD, Agala CB, Egan TM, Haithcock BE, Mody GN, Long JM. Outcomes Following Lung Transplant for COVID-19-Related Complications in the US. JAMA Surg 2023; 158:1159-1166. [PMID: 37585215 PMCID: PMC10433141 DOI: 10.1001/jamasurg.2023.3489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 05/25/2023] [Indexed: 08/17/2023]
Abstract
Importance The COVID-19 pandemic led to the use of lung transplant as a lifesaving therapy for patients with irreversible lung injury. Limited information is currently available regarding the outcomes associated with this treatment modality. Objective To describe the outcomes following lung transplant for COVID-19-related acute respiratory distress syndrome or pulmonary fibrosis. Design, Setting, and Participants In this cohort study, lung transplant recipient and donor characteristics and outcomes following lung transplant for COVID-19-related acute respiratory distress syndrome or pulmonary fibrosis were extracted from the US United Network for Organ Sharing database from March 2020 to August 2022 with a median (IQR) follow-up period of 186 (64-359) days in the acute respiratory distress syndrome group and 181 (40-350) days in the pulmonary fibrosis group. Overall survival was calculated using the Kaplan-Meier method. Cox proportional regression models were used to examine the association of certain variables with overall survival. Exposures Lung transplant following COVID-19-related acute respiratory distress syndrome or pulmonary fibrosis. Main Outcomes and Measures Overall survival and graft failure rates. Results Among 385 included patients undergoing lung transplant, 195 had COVID-19-related acute respiratory distress syndrome (142 male [72.8%]; median [IQR] age, 46 [38-54] years; median [IQR] allocation score, 88.3 [80.5-91.1]) and 190 had COVID-19-related pulmonary fibrosis (150 male [78.9%]; median [IQR] age, 54 [45-62]; median [IQR] allocation score, 78.5 [47.7-88.3]). There were 16 instances of acute rejection (8.7%) in the acute respiratory distress syndrome group and 15 (8.6%) in the pulmonary fibrosis group. The 1-, 6-, and 12- month overall survival rates were 0.99 (95% CI, 0.96-0.99), 0.95 (95% CI, 0.91-0.98), and 0.88 (95% CI, 0.80-0.94) for the acute respiratory distress syndrome cohort and 0.96 (95% CI, 0.92-0.98), 0.92 (95% CI, 0.86-0.96), and 0.84 (95% CI, 0.74-0.90) for the pulmonary fibrosis cohort. Freedom from graft failure rates were 0.98 (95% CI, 0.96-0.99), 0.95 (95% CI, 0.90-0.97), and 0.88 (95% CI, 0.79-0.93) in the 1-, 6-, and 12-month follow-up periods in the acute respiratory distress cohort and 0.96 (95% CI, 0.92-0.98), 0.93 (95% CI, 0.87-0.96), and 0.85 (95% CI, 0.74-0.91) in the pulmonary fibrosis cohort, respectively. Receiving a graft from a donor with a heavy and prolonged history of smoking was associated with worse overall survival in the acute respiratory distress syndrome cohort, whereas the characteristics associated with worse overall survival in the pulmonary fibrosis cohort included female recipient, male donor, and high recipient body mass index. Conclusions and Relevance In this study, outcomes following lung transplant were similar in patients with irreversible respiratory failure due to COVID-19 and those with other pretransplant etiologies.
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Affiliation(s)
- Panagiotis Tasoudis
- Department of Surgery, Division of Cardiothoracic Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill
| | - Leonard J. Lobo
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill
| | - Raymond D. Coakley
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill
| | - Chris B. Agala
- Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill
| | - Thomas M. Egan
- Department of Surgery, Division of Cardiothoracic Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill
| | - Benjamin E. Haithcock
- Department of Surgery, Division of Cardiothoracic Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill
| | - Gita N. Mody
- Department of Surgery, Division of Cardiothoracic Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill
| | - Jason M. Long
- Department of Surgery, Division of Cardiothoracic Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill
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Powell EK, Lankford AS, Ghneim M, Rabin J, Haase DJ, Dahi S, Deatrick KB, Krause E, Bittle G, Galvagno SM, Scalea T, Tabatabai A. Decreased PRESET-Score corresponds with improved survival in COVID-19 veno-venous extracorporeal membrane oxygenation. Perfusion 2023; 38:1623-1630. [PMID: 36114156 PMCID: PMC9482881 DOI: 10.1177/02676591221128237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The PREdiction of Survival on ECMO Therapy Score (PRESET-Score) predicts mortality while on veno-venous extracorporeal membrane oxygenation (VV ECMO) for acute respiratory distress syndrome. The aim of our study was to assess the association between PRESET-Score and survival in a large COVID-19 VV ECMO cohort. METHODS This was a single-center retrospective study of COVID-19 VV ECMO patients from 15 March 2020, to 30 November 2021. Univariable and Multivariable analyses were performed to assess patient survival and score differences. RESULTS A total of 105 patients were included in our analysis with a mean PRESET-Score of 6.74. Overall survival was 65.71%. The mean PRESET-Score was significantly lower in the survivor group (6.03 vs 8.11, p < 0.001). Patients with a PRESET-Score less than or equal to six had improved survival compared to those with a PRESET-Score greater than or equal to 8 (97.7% vs. 32.5%, p < 0.001). In a multivariable logistic regression, a lower PRESET-Score was also predictive of survival (OR 2.84, 95% CI 1.75, 4.63, p < 0.001). CONCLUSION We demonstrate that lower PRESET scores are associated with improved survival. The utilization of this validated, quantifiable, and objective scoring system to help identify COVID-19 patients with the greatest potential to benefit from VV-ECMO appears feasible. The incorporation of the PRESET-Score into institutional ECMO candidacy guidelines can help insure and improve access of this limited healthcare resource to all critically ill patients.
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Affiliation(s)
- Elizabeth K Powell
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Allison S Lankford
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Obstetrics Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Mira Ghneim
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Joseph Rabin
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Daniel J Haase
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Siamak Dahi
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kristopher B Deatrick
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Eric Krause
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Gregory Bittle
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Samuel M Galvagno
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Thomas Scalea
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ali Tabatabai
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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30
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Rauch A, Dupont A, Rosa M, Desvages M, Le Tanno C, Abdoul J, Didelot M, Ung A, Ruez R, Jeanpierre E, Daniel M, Corseaux D, Spillemaeker H, Labreuche J, Pradines B, Rousse N, Lenting PJ, Moussa MD, Vincentelli A, Bordet JC, Staels B, Vincent F, Denis CV, Van Belle E, Casari C, Susen S. Shear Forces Induced Platelet Clearance Is a New Mechanism of Thrombocytopenia. Circ Res 2023; 133:826-841. [PMID: 37883587 DOI: 10.1161/circresaha.123.322752] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 09/26/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND Thrombocytopenia has been consistently described in patients with extracorporeal membrane oxygenation (ECMO) and associated with poor outcome. However, the prevalence and underlying mechanisms remain largely unknown, and a device-related role of ECMO in thrombocytopenia has been hypothesized. This study aims to investigate the mechanisms underlying thrombocytopenia in ECMO patients. METHODS In a prospective cohort of 107 ECMO patients, we investigated platelet count, functions, and glycoprotein shedding. In an ex vivo mock circulatory ECMO loop, we assessed platelet responses and VWF (von Willebrand factor)-GP Ibα (glycoprotein Ibα) interactions at low- and high-flow rates, in the presence or absence of red blood cells. The clearance of human platelets subjected or not to ex vivo perfusion was studied using an in vivo transfusion model in NOD/SCID (nonobese diabetic/severe combined Immunodeficient) mice. RESULTS In ECMO patients, we observed a time-dependent decrease in platelet count starting 1 hour after device onset, with a mean drop of 7%, 35%, and 41% at 1, 24, and 48 hours post-ECMO initiation (P=0.00013, P<0.0001, and P<0.0001, respectively), regardless of the type of ECMO. This drop in platelet count was associated with a decrease in platelet GP Ibα expression (before: 47.8±9.1 versus 24 hours post-ECMO: 42.3±8.9 mean fluorescence intensity; P=0.002) and an increase in soluble GP Ibα plasma levels (before: 5.6±3.3 versus 24 hours post-ECMO: 10.8±4.1 µg/mL; P<0.0001). GP Ibα shedding was also observed ex vivo and was unaffected by (1) red blood cells, (2) the coagulation potential, (3) an antibody blocking VWF-GP Ibα interaction, (4) an antibody limiting VWF degradation, and (5) supraphysiological VWF plasma concentrations. In contrast, GP Ibα shedding was dependent on rheological conditions, with a 2.8-fold increase at high- versus low-flow rates. Platelets perfused at high-flow rates before being transfused to immunodeficient mice were eliminated faster in vivo with an accelerated clearance of GP Ibα-negative versus GP Ibα-positive platelets. CONCLUSIONS ECMO-associated shear forces induce GP Ibα shedding and thrombocytopenia due to faster clearance of GP Ibα-negative platelets. Inhibiting GP Ibα shedding could represent an approach to reduce thrombocytopenia during ECMO.
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Affiliation(s)
- Antoine Rauch
- Inserm, Institut Pasteur de Lille, France (A.R., A.D., M.R., M. Desvages, C.L.T., J.A., M. Didelot, A.U., R.R., E.J., M. Daniel, D.C., H.S., B.P., N.R., M.D.M., A.V., B.S., F.V., E.V.B., S.S.), CHU Lille, University Lille, France
- Department of Hematology and Transfusion, UFR3S-Université de Lille (A.R., A.D., M.D., E..J., M.D., S.S.)
| | - Annabelle Dupont
- Inserm, Institut Pasteur de Lille, France (A.R., A.D., M.R., M. Desvages, C.L.T., J.A., M. Didelot, A.U., R.R., E.J., M. Daniel, D.C., H.S., B.P., N.R., M.D.M., A.V., B.S., F.V., E.V.B., S.S.), CHU Lille, University Lille, France
- Department of Hematology and Transfusion, UFR3S-Université de Lille (A.R., A.D., M.D., E..J., M.D., S.S.)
| | - Mickael Rosa
- Inserm, Institut Pasteur de Lille, France (A.R., A.D., M.R., M. Desvages, C.L.T., J.A., M. Didelot, A.U., R.R., E.J., M. Daniel, D.C., H.S., B.P., N.R., M.D.M., A.V., B.S., F.V., E.V.B., S.S.), CHU Lille, University Lille, France
- Department of Hematology and Transfusion, UFR3S-Université de Lille (A.R., A.D., M.D., E..J., M.D., S.S.)
| | - Maximilien Desvages
- Inserm, Institut Pasteur de Lille, France (A.R., A.D., M.R., M. Desvages, C.L.T., J.A., M. Didelot, A.U., R.R., E.J., M. Daniel, D.C., H.S., B.P., N.R., M.D.M., A.V., B.S., F.V., E.V.B., S.S.), CHU Lille, University Lille, France
| | - Christina Le Tanno
- Inserm, Institut Pasteur de Lille, France (A.R., A.D., M.R., M. Desvages, C.L.T., J.A., M. Didelot, A.U., R.R., E.J., M. Daniel, D.C., H.S., B.P., N.R., M.D.M., A.V., B.S., F.V., E.V.B., S.S.), CHU Lille, University Lille, France
| | - Johan Abdoul
- Inserm, Institut Pasteur de Lille, France (A.R., A.D., M.R., M. Desvages, C.L.T., J.A., M. Didelot, A.U., R.R., E.J., M. Daniel, D.C., H.S., B.P., N.R., M.D.M., A.V., B.S., F.V., E.V.B., S.S.), CHU Lille, University Lille, France
| | - Mélusine Didelot
- Inserm, Institut Pasteur de Lille, France (A.R., A.D., M.R., M. Desvages, C.L.T., J.A., M. Didelot, A.U., R.R., E.J., M. Daniel, D.C., H.S., B.P., N.R., M.D.M., A.V., B.S., F.V., E.V.B., S.S.), CHU Lille, University Lille, France
| | - Alexandre Ung
- Inserm, Institut Pasteur de Lille, France (A.R., A.D., M.R., M. Desvages, C.L.T., J.A., M. Didelot, A.U., R.R., E.J., M. Daniel, D.C., H.S., B.P., N.R., M.D.M., A.V., B.S., F.V., E.V.B., S.S.), CHU Lille, University Lille, France
| | - Richard Ruez
- Inserm, Institut Pasteur de Lille, France (A.R., A.D., M.R., M. Desvages, C.L.T., J.A., M. Didelot, A.U., R.R., E.J., M. Daniel, D.C., H.S., B.P., N.R., M.D.M., A.V., B.S., F.V., E.V.B., S.S.), CHU Lille, University Lille, France
| | - Emmanuelle Jeanpierre
- Inserm, Institut Pasteur de Lille, France (A.R., A.D., M.R., M. Desvages, C.L.T., J.A., M. Didelot, A.U., R.R., E.J., M. Daniel, D.C., H.S., B.P., N.R., M.D.M., A.V., B.S., F.V., E.V.B., S.S.), CHU Lille, University Lille, France
- Department of Hematology and Transfusion, UFR3S-Université de Lille (A.R., A.D., M.D., E..J., M.D., S.S.)
| | - Mélanie Daniel
- Inserm, Institut Pasteur de Lille, France (A.R., A.D., M.R., M. Desvages, C.L.T., J.A., M. Didelot, A.U., R.R., E.J., M. Daniel, D.C., H.S., B.P., N.R., M.D.M., A.V., B.S., F.V., E.V.B., S.S.), CHU Lille, University Lille, France
- Department of Hematology and Transfusion, UFR3S-Université de Lille (A.R., A.D., M.D., E..J., M.D., S.S.)
| | - Delphine Corseaux
- Inserm, Institut Pasteur de Lille, France (A.R., A.D., M.R., M. Desvages, C.L.T., J.A., M. Didelot, A.U., R.R., E.J., M. Daniel, D.C., H.S., B.P., N.R., M.D.M., A.V., B.S., F.V., E.V.B., S.S.), CHU Lille, University Lille, France
| | - Hugues Spillemaeker
- Inserm, Institut Pasteur de Lille, France (A.R., A.D., M.R., M. Desvages, C.L.T., J.A., M. Didelot, A.U., R.R., E.J., M. Daniel, D.C., H.S., B.P., N.R., M.D.M., A.V., B.S., F.V., E.V.B., S.S.), CHU Lille, University Lille, France
- Department of Cardiology, UFR3S-Université de Lille (H.S., F.V., E.V.B.)
| | - Julien Labreuche
- ULR 2694-METRICS: Évaluation des technologies de santé et des pratiques médicales (J.L.), CHU Lille, University Lille, France
| | - Bénédicte Pradines
- Inserm, Institut Pasteur de Lille, France (A.R., A.D., M.R., M. Desvages, C.L.T., J.A., M. Didelot, A.U., R.R., E.J., M. Daniel, D.C., H.S., B.P., N.R., M.D.M., A.V., B.S., F.V., E.V.B., S.S.), CHU Lille, University Lille, France
| | - Natacha Rousse
- Inserm, Institut Pasteur de Lille, France (A.R., A.D., M.R., M. Desvages, C.L.T., J.A., M. Didelot, A.U., R.R., E.J., M. Daniel, D.C., H.S., B.P., N.R., M.D.M., A.V., B.S., F.V., E.V.B., S.S.), CHU Lille, University Lille, France
- Department of Cardiac Surgery, UFR3S-Université de Lille (N.R., A.V.)
| | - Peter J Lenting
- INSERM, UMR-S 1176, Université Paris-Saclay, Le Kremlin Bicêtre, France (P.J.L., C.V.D., C.C.)
| | - Mouhamed D Moussa
- Inserm, Institut Pasteur de Lille, France (A.R., A.D., M.R., M. Desvages, C.L.T., J.A., M. Didelot, A.U., R.R., E.J., M. Daniel, D.C., H.S., B.P., N.R., M.D.M., A.V., B.S., F.V., E.V.B., S.S.), CHU Lille, University Lille, France
| | - André Vincentelli
- Inserm, Institut Pasteur de Lille, France (A.R., A.D., M.R., M. Desvages, C.L.T., J.A., M. Didelot, A.U., R.R., E.J., M. Daniel, D.C., H.S., B.P., N.R., M.D.M., A.V., B.S., F.V., E.V.B., S.S.), CHU Lille, University Lille, France
- Department of Cardiac Surgery, UFR3S-Université de Lille (N.R., A.V.)
| | | | - Bart Staels
- Inserm, Institut Pasteur de Lille, France (A.R., A.D., M.R., M. Desvages, C.L.T., J.A., M. Didelot, A.U., R.R., E.J., M. Daniel, D.C., H.S., B.P., N.R., M.D.M., A.V., B.S., F.V., E.V.B., S.S.), CHU Lille, University Lille, France
| | - Flavien Vincent
- Inserm, Institut Pasteur de Lille, France (A.R., A.D., M.R., M. Desvages, C.L.T., J.A., M. Didelot, A.U., R.R., E.J., M. Daniel, D.C., H.S., B.P., N.R., M.D.M., A.V., B.S., F.V., E.V.B., S.S.), CHU Lille, University Lille, France
- Department of Cardiology, UFR3S-Université de Lille (H.S., F.V., E.V.B.)
| | - Cécile V Denis
- INSERM, UMR-S 1176, Université Paris-Saclay, Le Kremlin Bicêtre, France (P.J.L., C.V.D., C.C.)
| | - Eric Van Belle
- Inserm, Institut Pasteur de Lille, France (A.R., A.D., M.R., M. Desvages, C.L.T., J.A., M. Didelot, A.U., R.R., E.J., M. Daniel, D.C., H.S., B.P., N.R., M.D.M., A.V., B.S., F.V., E.V.B., S.S.), CHU Lille, University Lille, France
- Department of Cardiology, UFR3S-Université de Lille (H.S., F.V., E.V.B.)
| | - Caterina Casari
- INSERM, UMR-S 1176, Université Paris-Saclay, Le Kremlin Bicêtre, France (P.J.L., C.V.D., C.C.)
| | - Sophie Susen
- Inserm, Institut Pasteur de Lille, France (A.R., A.D., M.R., M. Desvages, C.L.T., J.A., M. Didelot, A.U., R.R., E.J., M. Daniel, D.C., H.S., B.P., N.R., M.D.M., A.V., B.S., F.V., E.V.B., S.S.), CHU Lille, University Lille, France
- Department of Hematology and Transfusion, UFR3S-Université de Lille (A.R., A.D., M.D., E..J., M.D., S.S.)
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31
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Broman LM, Dubrovskaja O, Balik M. Extracorporeal Membrane Oxygenation for Septic Shock in Adults and Children: A Narrative Review. J Clin Med 2023; 12:6661. [PMID: 37892799 PMCID: PMC10607553 DOI: 10.3390/jcm12206661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 10/09/2023] [Accepted: 10/14/2023] [Indexed: 10/29/2023] Open
Abstract
Refractory septic shock is associated with a high risk of death. Circulatory support in the form of veno-arterial extracorporeal membrane oxygenation (VA ECMO) may function as a bridge to recovery, allowing for the treatment of the source of the sepsis. Whilst VA ECMO has been accepted as the means of hemodynamic support for children, in adults, single center observational studies show survival rates of only 70-90% for hypodynamic septic shock. The use of VA ECMO for circulatory support in hyperdynamic septic shock with preserved cardiac output or when applied late during cardio-pulmonary resuscitation is not recommended. With unresolving septic shock and a loss of ventriculo-arterial coupling, stress cardiomyopathy often develops. If the cardiac index (CI) approaches subnormal levels (CI < 2.5 L/min m-2) that do not match low systemic vascular resistance with a resulting loss of vital systemic perfusion pressure, VA ECMO support should be considered. A further decrease to the level of cardiogenic shock (CI < 1.8 L/min m-2) should be regarded as an indication for VA ECMO insertion. For patients who maintain a normal-to-high CI as part of their refractory vasoparalysis, VA ECMO support is justified in children and possibly in patients with a low body mass index. Extracorporeal support for septic shock should be limited to high-volume ECMO centers.
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Affiliation(s)
- Lars Mikael Broman
- ECMO Centre Karolinska, Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, 17176 Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, 17177 Stockholm, Sweden
| | - Olga Dubrovskaja
- Intensive Care Department II, North Estonia Medical Centre, 13419 Tallinn, Estonia;
| | - Martin Balik
- Department of Anesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, 12808 Prague, Czech Republic;
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32
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Šoltés J, Skribuckij M, Říha H, Lipš M, Michálek P, Balík M, Pořízka M. Update on Anticoagulation Strategies in Patients with ECMO-A Narrative Review. J Clin Med 2023; 12:6067. [PMID: 37763010 PMCID: PMC10532142 DOI: 10.3390/jcm12186067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 09/14/2023] [Accepted: 09/18/2023] [Indexed: 09/29/2023] Open
Abstract
The use of extracorporeal membrane oxygenation (ECMO) has recently increased exponentially. ECMO has become the preferred mode of organ support in refractory respiratory or circulatory failure. The fragile balance of haemostasis physiology is massively altered by the patient's critical condition and specifically the aetiology of the underlying disease. Furthermore, an application of ECMO conveys another disturbance of haemostasis due to blood-circuit interaction and the presence of an oxygenator. The purpose of this review is to summarise current knowledge on the anticoagulation management in patients undergoing ECMO therapy. The unfractionated heparin modality with monitoring of activated partial thromboplastin tests is considered to be a gold standard for anticoagulation in this specific subgroup of intensive care patients. However, alternative modalities with other agents are comprehensively discussed. Furthermore, other ways of monitoring can represent the actual state of coagulation in a more complex fashion, such as thromboelastometric/graphic methods, and might become more frequent. In conclusion, the coagulation system of patients with ECMO is altered by multiple variables, and there is a significant lack of evidence in this area. Therefore, a highly individualised approach is the best solution today.
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Affiliation(s)
- Ján Šoltés
- Department of Anaesthesiology and Intensive Care Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, 12808 Prague, Czech Republic; (J.Š.); (H.Ř.); (M.L.); (P.M.); (M.B.)
- Emergency Service of Central Bohemia, Vančurova 1544, 27201 Kladno, Czech Republic
| | - Michal Skribuckij
- Department of Anaesthesia, Golden Jubilee University National Hospital, Clydebank G81 4DY, UK;
| | - Hynek Říha
- Department of Anaesthesiology and Intensive Care Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, 12808 Prague, Czech Republic; (J.Š.); (H.Ř.); (M.L.); (P.M.); (M.B.)
- Department of Anaesthesiology and Intensive Care Medicine, Institute for Clinical and Experimental Medicine, 14021 Prague, Czech Republic
| | - Michal Lipš
- Department of Anaesthesiology and Intensive Care Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, 12808 Prague, Czech Republic; (J.Š.); (H.Ř.); (M.L.); (P.M.); (M.B.)
| | - Pavel Michálek
- Department of Anaesthesiology and Intensive Care Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, 12808 Prague, Czech Republic; (J.Š.); (H.Ř.); (M.L.); (P.M.); (M.B.)
- Department of Anaesthesia, Antrim Area Hospital, Antrim BT41 2RL, UK
| | - Martin Balík
- Department of Anaesthesiology and Intensive Care Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, 12808 Prague, Czech Republic; (J.Š.); (H.Ř.); (M.L.); (P.M.); (M.B.)
| | - Michal Pořízka
- Department of Anaesthesiology and Intensive Care Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, 12808 Prague, Czech Republic; (J.Š.); (H.Ř.); (M.L.); (P.M.); (M.B.)
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33
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Hvas CL, Christensen S, Balle CM, Munk-Andersen H, Jeppesen AN, Hvas AM. Bleeding patients on extracorporeal membrane oxygenation have reduced platelet aggregation and plasma fibrinogen: a longitudinal observational study. Sci Rep 2023; 13:14557. [PMID: 37666949 PMCID: PMC10477285 DOI: 10.1038/s41598-023-41773-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 08/31/2023] [Indexed: 09/06/2023] Open
Abstract
This study investigated changes in coagulation and associations with occurrence of bleeding and thrombosis during extracorporeal membrane oxygenation (ECMO) therapy. The study included 100 adult ECMO-patients. Standard coagulation parameters, platelet aggregation and thromboelastometry (ROTEM®) were compared with healthy controls. Data on bleeding and thrombosis were collected until recovery or death. Mortality data were collected 30 days after weaning from ECMO. During ECMO therapy, 53 patients experienced at least one moderate or major bleed. Among these, 42 (79%) patients experienced the first bleeding on day 1 or 2. Platelet aggregation and ROTEM® revealed a hypocoagulable state in ECMO patients when compared with healthy controls. Patients bleeding on day 1 or 2, had lower platelet count (p = 0.04), poorer platelet aggregation and lower levels of fibrinogen (p < 0.01) than patients not bleeding on day 1 or 2. Further, ROTEM® clot propagation was reduced in bleeding patients (p < 0.001). Mortality was higher among bleeding patients than patients not bleeding on day 1 or 2 (67% versus 34%, p < 0.01). Congruity existed between ROTEM® measurements and standard coagulation assays, but plasma fibrinogen had a stronger association with bleeding than ROTEM® measurements. The present study does not support ROTEM® analysis as a routine part of coagulation monitoring during ECMO therapy.
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Affiliation(s)
- Christine Lodberg Hvas
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark.
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - Steffen Christensen
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Camilla Mains Balle
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Heidi Munk-Andersen
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Anni Nørgaard Jeppesen
- Department of Cardiothoracic- and Vascular Surgery, Anaesthesia Section, Aarhus University Hospital, Aarhus, Denmark
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34
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Raasveld SJ, van den Oord C, Schenk J, van den Bergh WM, Oude Lansink-Hartgring A, van der Velde F, Maas JJ, van de Berg P, Lorusso R, Delnoij TSR, Dos Reis Miranda D, Scholten E, Taccone FS, Dauwe DF, De Troy E, Hermans G, Pappalardo F, Fominskiy E, Ivancan V, Bojčić R, de Metz J, van den Bogaard B, Donker DW, Meuwese CL, De Bakker M, Reddi B, Henriques JPS, Broman LM, Dongelmans DA, Vlaar APJ. The interaction of thrombocytopenia, hemorrhage, and platelet transfusion in venoarterial extracorporeal membrane oxygenation: a multicenter observational study. Crit Care 2023; 27:321. [PMID: 37605277 PMCID: PMC10441744 DOI: 10.1186/s13054-023-04612-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 08/14/2023] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND Thrombocytopenia, hemorrhage and platelet transfusion are common in patients supported with venoarterial extracorporeal membrane oxygenation (VA ECMO). However, current literature is limited to small single-center experiences with high degrees of heterogeneity. Therefore, we aimed to ascertain in a multicenter study the course and occurrence rate of thrombocytopenia, and to assess the association between thrombocytopenia, hemorrhage and platelet transfusion during VA ECMO. METHODS This was a sub-study of a multicenter (N = 16) study on transfusion practices in patients on VA ECMO, in which a retrospective cohort (Jan-2018-Jul-2019) focusing on platelets was selected. The primary outcome was thrombocytopenia during VA ECMO, defined as mild (100-150·109/L), moderate (50-100·109/L) and severe (< 50·109/L). Secondary outcomes included the occurrence rate of platelet transfusion, and the association between thrombocytopenia, hemorrhage and platelet transfusion, assessed through mixed-effect models. RESULTS Of the 419 patients included, median platelet count at admission was 179·109/L. During VA ECMO, almost all (N = 398, 95%) patients developed a thrombocytopenia, of which a significant part severe (N = 179, 45%). One or more platelet transfusions were administered in 226 patients (54%), whereas 207 patients (49%) suffered a hemorrhagic event during VA ECMO. In non-bleeding patients, still one in three patients received a platelet transfusion. The strongest association to receive a platelet transfusion was found in the presence of severe thrombocytopenia (adjusted OR 31.8, 95% CI 17.9-56.5). After including an interaction term of hemorrhage and thrombocytopenia, this even increased up to an OR of 110 (95% CI 34-360). CONCLUSIONS Thrombocytopenia has a higher occurrence than is currently recognized. Severe thrombocytopenia is strongly associated with platelet transfusion. Future studies should focus on the etiology of severe thrombocytopenia during ECMO, as well as identifying indications and platelet thresholds for transfusion in the absence of bleeding. TRIAL REGISTRATION This study was registered at the Netherlands Trial Registry at February 26th, 2020 with number NL8413 and can currently be found at https://trialsearch.who.int/Trial2.aspx?TrialID=NL8413.
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Affiliation(s)
- Senta Jorinde Raasveld
- Department of Critical Care, Amsterdam University Medical Centers, Location Academic Medical Centers, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Claudia van den Oord
- Department of Critical Care, Amsterdam University Medical Centers, Location Academic Medical Centers, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Jimmy Schenk
- Department of Critical Care, Amsterdam University Medical Centers, Location Academic Medical Centers, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Department of Epidemiology and Data Science, Amsterdam University Medical Centre, Amsterdam Public Health, University of Amsterdam, Location AMC, Amsterdam, The Netherlands
| | - Walter M van den Bergh
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | | | - Jacinta J Maas
- Adult Intensive Care Unit, Leiden University Medical Center, Leiden, The Netherlands
| | - Pablo van de Berg
- Adult Intensive Care Unit, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Roberto Lorusso
- Cardiothoracic Surgery Department, Heart and Vascular Center, Maastricht University Medical Center, and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Thijs S R Delnoij
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Intensive Care, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Dinis Dos Reis Miranda
- Adult Intensive Care Unit, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Erik Scholten
- Department of Intensive Care, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Fabio Silvio Taccone
- Department of Intensive Care, Université Libre de Bruxelles, Hôpital Erasme Bruxelles, Brussels, Belgium
| | - Dieter F Dauwe
- Surgical Intensive Care Unit, Department of Intensive Care Medicine, University Hospital Leuven, Leuven, Belgium
| | - Erwin De Troy
- Surgical Intensive Care Unit, Department of Intensive Care Medicine, University Hospital Leuven, Leuven, Belgium
| | - Greet Hermans
- Medical Intensive Care Unit, Department of General Internal Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Federico Pappalardo
- Department of CardioThoracic and Vascular Anesthesia and Intensive Care, AO SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Evgeny Fominskiy
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Višnja Ivancan
- Department of Anesthesia and Intensive Care, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Robert Bojčić
- Department of Anesthesia and Intensive Care, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Jesse de Metz
- Department of Intensive Care, OLVG, Amsterdam, The Netherlands
| | | | - Dirk W Donker
- Intensive Care Center, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
- Cardiovascular and Respiratory Physiology, TechMed Centre, University of Twente, Enschede, The Netherlands
| | - Christiaan L Meuwese
- Adult Intensive Care Unit, Erasmus University Medical Center, Rotterdam, The Netherlands
- Intensive Care Center, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
| | - Martin De Bakker
- Department of Critical Care, Royal Adelaide Hospital, Adelaide, Australia
| | - Benjamin Reddi
- Department of Critical Care, Royal Adelaide Hospital, Adelaide, Australia
| | - José P S Henriques
- Department of Cardiology, Amsterdam University Medical Centers, Location Academic Medical Centers, Amsterdam, The Netherlands
| | - Lars Mikael Broman
- ECMO Center Karolinska, Karolinska University Hospital, Stockholm, Sweden
| | - Dave A Dongelmans
- Department of Critical Care, Amsterdam University Medical Centers, Location Academic Medical Centers, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Alexander P J Vlaar
- Department of Critical Care, Amsterdam University Medical Centers, Location Academic Medical Centers, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Battista J, De Luca D, Eleni Dit Trolli S, Allard L, Bacchetta J, Bouhamri N, Enoch C, Faudeux C, Guichoux J, Javouhey E, Kolev K, Regiroli G, Ranchin B, Bernardor J. CARPEDIEM® for continuous kidney replacement therapy in neonates and small infants: a French multicenter retrospective study. Pediatr Nephrol 2023; 38:2827-2837. [PMID: 36625933 DOI: 10.1007/s00467-022-05871-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 12/19/2022] [Accepted: 12/19/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND The Cardio-Renal Pediatric Dialysis Emergency Machine (CA.R.P.E.D.I.E.M.®) device is a continuous kidney replacement therapy (CKRT) equipment dedicated to neonates and small infants. This study aimed to assess the effectiveness, feasibility, outcomes, and technical considerations relating to CARPEDIEM® use. METHODS This retrospective multicenter study included 19 newborns and six infants receiving CARPEDIEM® in five French pediatric and neonatal intensive care units. Laboratory parameters were collected at the initiation and end of the first CARPEDIEM® session. Results are presented as median [IQR] (range). RESULTS At initiation, age was 4 days [2-13] (1-1134) with a body weight of 3.3 kg [2.5-4] (1.3-11.1). Overall, 131 sessions and 2125 h of treatment were performed. Treatment duration per patient was 42 h [24-91] (8-557). Continuous veno-venous hemofiltration (CVVH) was performed in 20 children. Blood flow rate was 8 mL/kg/min [6-9] (3-16). The effluent flow rate for CVVH was 74 mL/kg/h [43-99] (28-125) and net ultrafiltration (UF) 6 mL/kg/h [2-8] (1-12). In the five children treated by hemodialysis, the blood and dialysate flow rates were 6 mL/kg/min [5-7] (4-7) and 600 mL/h [300-600] (120-600), respectively, while session duration was 8 h [6-12] (2-24). Most infants required a catheter between 4.5 and 6.5 French. Hemodynamic instability with a need for volume replacement occurred in 31 sessions (23%). Thrombocytopenia was observed in 29 sessions (22%). No hemorrhage occurred; all the patients survived the sessions, but only eight patients (32%) were alive at hospital discharge. CONCLUSIONS These data confirm that the use of CARPEDIEM® is safe and effective in critically ill neonates and infants. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Jennifer Battista
- Department of Pediatric Nephrology, Archet 2, CHU de Nice, Hôpital Archet, 151 Route Saint-Antoine de Ginestière, 06200, Nice, France
| | - Daniele De Luca
- Division of Pediatrics and Neonatal Critical Care, "A. Béclère" Medical Centre, Paris Saclay University Hospitals, APHP, and the Physiopathology and Therapeutic Innovation Unit-INSERM U999, Paris Saclay University, Paris, France
| | - Sergio Eleni Dit Trolli
- Department of Intensive Care and Neonatal Medecine, CHU de Nice, Hôpital Archet, Nice, France
| | - Lise Allard
- Pediatric Nephrology Unit, Reference Center for Rare Renal Diseases, SORARE, Bordeaux University Hospital, Bordeaux, France
| | - Justine Bacchetta
- Reference Center for Rare Renal Diseases, Pediatric Nephrology-Rheumatology-Dermatology Unit and INSERM 1033 Unit, Hospices Civils de Lyon, Femme Mere Enfant Hospital, Lyon 1 University, Bron, France
| | - Nourredine Bouhamri
- Pediatric Intensive Care Unit, Hôpital Louis Pradel, Lyon 1 University, Lyon, France
| | - Carole Enoch
- Pediatric Nephrology, Internal Medicine and Rheumatology, Southwest Renal Rare Diseases Centre (SORARE), University Children's Hospital, Toulouse, France
| | - Camille Faudeux
- Department of Pediatric Nephrology, Archet 2, CHU de Nice, Hôpital Archet, 151 Route Saint-Antoine de Ginestière, 06200, Nice, France
| | - Julie Guichoux
- Pediatric Intensive Care Unit, Bordeaux University Hospital, Bordeaux, France
| | - Etienne Javouhey
- Paediatric Intensive Care Unit, Mother and Children University Hospital, Hospices Civils de Lyon, Bron, France
| | - Karine Kolev
- Paediatric Intensive Care Unit, Mother and Children University Hospital, Hospices Civils de Lyon, Bron, France
| | - Giulia Regiroli
- Division of Pediatrics and Neonatal Critical Care, "A. Béclère" Medical Centre, Paris Saclay University Hospitals, APHP, and the Physiopathology and Therapeutic Innovation Unit-INSERM U999, Paris Saclay University, Paris, France
| | - Bruno Ranchin
- Reference Center for Rare Renal Diseases, Pediatric Nephrology-Rheumatology-Dermatology Unit and INSERM 1033 Unit, Hospices Civils de Lyon, Femme Mere Enfant Hospital, Lyon 1 University, Bron, France
| | - Julie Bernardor
- Department of Pediatric Nephrology, Archet 2, CHU de Nice, Hôpital Archet, 151 Route Saint-Antoine de Ginestière, 06200, Nice, France.
- Reference Center for Rare Renal Diseases, Pediatric Nephrology-Rheumatology-Dermatology Unit and INSERM 1033 Unit, Hospices Civils de Lyon, Femme Mere Enfant Hospital, Lyon 1 University, Bron, France.
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Tagaya M, Murataka T, Okano S, Handa H, Takahashi S. Comparison of complement consumption and platelet accumulation between membrane oxygenators coated with a polymer or heparin. Perfusion 2023:2676591231177912. [PMID: 37216953 DOI: 10.1177/02676591231177912] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
INTRODUCTION The membrane oxygenator in extracorporeal circulation circuits is coated with acrylate-copolymer (ACP) or immobilized heparin (IHP) to enhance hemocompatibility. To evaluate the relative features of both coatings, we compared blood components circulated in the circuits with ACP-and IHP-coated membranes in vitro using whole human blood. METHODS Whole human blood was heparinized and circulated in two experimental circuits with an ACP-coated reservoir, tubes, and an ACP- or IHP-coated membrane. Platelet (PLT) counts and the amount of total protein (TP), complement component 3 (C3), and complement component 4 (C4) were measured at 0, 8, 16, 24, and 32 h in each experiment (n = 5). RESULTS The PLT count at 0-h circulation was lower in the IHP-coated than in the ACP-coated circuits (p = 0.034); however, no significant difference was observed at other time points. Reduction in TP at 8-h and 16-h circulation and in C3 at 32-h circulation was lesser in the ACP-coated than in the IHP-coated circuits (p = 0.004, 0.034, and 0.027, respectively); reduction in TP and C3 at other time points and C4 at each time point was not significantly different. There were significant interactions between coating type and circulation duration in the PLT, TP, and C3 transitions (p = 0.008, 0.020, and 0.043, respectively). CONCLUSIONS Our findings suggest that ACP-coated membranes can prevent the initial drop in PLT count and C3 consumption over 32 h, whereas IHP-coated membranes could not prevent this drop in extracorporeal circulation. Therefore, ACP-coated membranes are suitable for short- and long-term extracorporeal life support.
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Affiliation(s)
- Masashi Tagaya
- Department of Medical Engineering, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Takuo Murataka
- Department of Medical Engineering, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Shinya Okano
- Department of Medical Engineering, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Hiroki Handa
- Department of Medical Engineering, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Shunsuke Takahashi
- Department of Nephrology, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
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Tagaya M, Murataka T, Okano S, Handa H, Tanaka Y, Takahashi S. Activity of anticoagulant proteins on the polymer-coated and heparin-coated membranes in an extracorporeal circulation circuit. Perfusion 2023; 38:600-608. [PMID: 35098806 DOI: 10.1177/02676591211073769] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION We performed in vitro experiments using whole human blood without anticoagulants to clarify the activity of anticoagulant proteins on membranes coated with acrylate-copolymer (ACP) with a hydrophilic blood-contacting layer compared to those coated by immobilizing heparin (IHP) in extracorporeal circulation. METHODS Whole human blood from healthy volunteers was recirculated in two types of experimental circuits with an ACP-coated reservoir and tubes and an ACP-coated or IHP-coated membrane. To compare the fluctuation of anticoagulant proteins, the circuit pressure at the inlet and outlet of the membrane was measured every 5 min; antithrombin antigen (ATQ), antithrombin activity, protein-C quantitation (PCQ), protein-C activity, protein-S free antigen (PSQ), and protein-S activity were measured at 0, 30, 60, 120, and 180 min in each experiment (n = 5). RESULTS The time taken to achieve high circuit pressure (> 300 mmHg) at the inlet of the membrane was significantly shorter in the ACP-coated membrane circuit (28 ± 2.7 min) than in the IHP-coated membrane circuit (54 ± 24 min); however, the ATQ, PCQ, and PSQ at 180 min of recirculation were significantly higher in the former than in the latter (all p < .05). CONCLUSIONS ACP-coated membranes can prevent the consumption of anticoagulant proteins but cannot delay circuit thrombogenicity compared to IHP-coated membranes. Considering patient care during the post-extracorporeal circulation period, the use of ACP coating, which can preserve anticoagulant protein, is better in extracorporeal circulation circuits.
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Affiliation(s)
- Masashi Tagaya
- Department of Medical Engineering, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Takuo Murataka
- Department of Medical Engineering, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Shinya Okano
- Department of Medical Engineering, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Hiroki Handa
- Department of Medical Engineering, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Yuri Tanaka
- Department of Clinical Laboratory, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Shunsuke Takahashi
- Department of Nephrology, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
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Tong Y, Rouzhahong J, Zhou W, Wang R, Wang Y, Ren Y, Guo J, Li Y, Wang Z, Song Y. Comparison of bivalirudin versus heparin in adult extracorporeal membrane oxygenation anticoagulant therapy: A retrospective case-control study. Int J Artif Organs 2023; 46:162-170. [PMID: 36600413 DOI: 10.1177/03913988221148763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION There were controversial opinions on the use of bivalirudin versus heparin for anticoagulant therapy in extracorporeal membrane oxygenation. The aim of our present study is to evaluate the efficacy and safety of bivalirudin versus heparin for the maintenance of systemic anticoagulation during adult veno-venous extracorporeal membrane oxygenation (V-V ECMO). METHODS Adult patients who received V-V ECMO support in our center between February 2018and February 2022 were retrospectively recruited. We analyzed their ECMO support time, platelet count, coagulation indicators, blood product infusion volume, the incidence of thrombosis and bleeding, probability of successful weaning of ECMO, and in-hospital mortality. RESULTS A total of 58 patients received V-V ECMO support. Thirty-four patients were finally included according to the exclusion and inclusion criteria, 14 and 20 accepted bivalirudin and heparin for anticoagulant therapy, respectively. The Minimum platelet value (98.50 × 109/L (85.50, 123.75) vs 49.50 × 109/L (31.25, 83.00), p = 0.002) and mean platelet value (149.90 × 109/L (127.40, 164.80) vs 74.55 × 109/L (62.45, 131.60), p = 0.03) and the ratio of successful weaning of ECMO (92.8% vs 60.0%, p = 0.033) in bivalirudin group were significantly higher than those in heparin group. The red blood cell infusion volume (7.00 U (3.00, 13.25) vs 13.75 U (7.25, 22.63), p = 0.039), platelet infusion volume (0.00 mL (0.00, 75.00) vs 300 mL (0.00, 825.00), p = 0.027), and the incidence of major bleeding (0.00% vs 30%, p = 0.024) in bivalirudin group were significantly lower than those in heparin group. CONCLUSIONS In V-V ECMO-supported adult patients, systemic anticoagulation with bivalirudin has achieved the same anticoagulation targets as heparin with less frequency of major bleeding events and lower requirement for blood products without significantly increased risk of thrombosis. Bivalirudin most likely is a safe and effective anticoagulation method for adult patients supported by V-V ECMO.
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Affiliation(s)
- Yaowei Tong
- Department of Intensive Care Unit, The First Affiliated Hospital of Xinjiang Medical University, Urumchi, China
| | - Julaiti Rouzhahong
- Department of Intensive Care Unit, The First Affiliated Hospital of Xinjiang Medical University, Urumchi, China
| | - Wangtao Zhou
- Department of Intensive Care Unit, The First Affiliated Hospital of Xinjiang Medical University, Urumchi, China
| | - Rui Wang
- Department of Intensive Care Unit, The First Affiliated Hospital of Xinjiang Medical University, Urumchi, China
| | - Yuqiang Wang
- Department of Intensive Care Unit, The First Affiliated Hospital of Xinjiang Medical University, Urumchi, China
| | - Yucheng Ren
- Department of Intensive Care Unit, The First Affiliated Hospital of Xinjiang Medical University, Urumchi, China
| | - Ju Guo
- Department of Intensive Care Unit, The First Affiliated Hospital of Xinjiang Medical University, Urumchi, China
| | - Ying Li
- Department of Intensive Care Unit, The First Affiliated Hospital of Xinjiang Medical University, Urumchi, China
| | - Zhengkai Wang
- Department of Intensive Care Unit, The First Affiliated Hospital of Xinjiang Medical University, Urumchi, China
| | - Yunlin Song
- Department of Intensive Care Unit, The First Affiliated Hospital of Xinjiang Medical University, Urumchi, China
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Dwaah H, Jain N, Kapur NK, Ortoleva JP, Chweich H, Couper GS, Kawabori M. The impact of temporary mechanical circulatory support strategies on thrombocytopenia. J Crit Care 2023; 73:154216. [PMID: 36434833 DOI: 10.1016/j.jcrc.2022.154216] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 08/06/2022] [Accepted: 10/29/2022] [Indexed: 11/24/2022]
Abstract
One common but not well-understood phenomenon of temporary mechanical circulatory support (MCS) use is thrombocytopenia. This clinical issue increases the risk of bleeding and the need for platelet transfusion. Additionally, heparin-induced thrombocytopenia must be considered as part of the differential diagnosis, which complicates patient management. In what follows, we analyze the degree and relative rate of platelet count drop with various temporary MCS strategies - Impella 5.5; Veno-venous Extracorporeal Membrane Oxygenation (VV ECMO); Veno-arterial ECMO (VA ECMO); Intra-aortic Balloon Pump (IABP) and Centrimag Biventricular Assist Device (BIVAD). A total of 337 cohort was investigated. 77 was included for analysis after strict exclusion criteria were utilized (platelet transfusions, bleeding complications, etc.). Repeated measure mixed effect and linear regression models were used to assess the percent platelet drop on implantation of MCS and recovery after explantation of MCS. A statistically significant mean percent drop occurred in MCS types - VA ECMO(-69.6%, p < 0.001), VV ECMO(-40.9%, p < 0.001), Impella 5.5(-20.9%, p = 0.01) and IABP(-28.3%, p = 0.01), except Centrimag BIVAD(-6.5%, p = 0.61). Platelet recovery to or above baseline occurred in VA ECMO(+107.0%, p = 0.42), Impella 5.5(+117.2%, p = 0.28), IABP(+108.3%, p = 0.37), VV-ECMO(163.3%, p = 0.01*) and Centrimag BIVAD(+100.1%, p = 0.99). These results show that the degree of thrombocytopenia depends on MCS device type and is reversible.
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Affiliation(s)
- Henry Dwaah
- Tufts University School of Medicine, Boston, MA 02111, USA
| | - Nupur Jain
- Tufts University School of Medicine, Boston, MA 02111, USA
| | - Navin K Kapur
- The CardioVascular Center, Tufts Medical Center, Boston, MA 02111, USA
| | - Jamel P Ortoleva
- The CardioVascular Center, Tufts Medical Center, Boston, MA 02111, USA
| | - Haval Chweich
- The CardioVascular Center, Tufts Medical Center, Boston, MA 02111, USA
| | - Gregory S Couper
- The CardioVascular Center, Tufts Medical Center, Boston, MA 02111, USA
| | - Masashi Kawabori
- The CardioVascular Center, Tufts Medical Center, Boston, MA 02111, USA.
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Helms J, Frere C, Thiele T, Tanaka KA, Neal MD, Steiner ME, Connors JM, Levy JH. Anticoagulation in adult patients supported with extracorporeal membrane oxygenation: guidance from the Scientific and Standardization Committees on Perioperative and Critical Care Haemostasis and Thrombosis of the International Society on Thrombosis and Haemostasis. J Thromb Haemost 2023; 21:373-396. [PMID: 36700496 DOI: 10.1016/j.jtha.2022.11.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 11/08/2022] [Accepted: 11/09/2022] [Indexed: 01/26/2023]
Abstract
Anticoagulation of patients supported by extracorporeal membrane oxygenation is challenging because of a high risk of both bleeding and thrombotic complications, and often empirical. Practice in anticoagulation management is therefore highly variable. The scope of this guidance document is to provide clinicians with practical advice on the choice of an anticoagulant agent, dosing, and the optimal anticoagulant monitoring strategy during extracorporeal membrane oxygenation support in adult patients.
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Affiliation(s)
- Julie Helms
- Strasbourg University (UNISTRA), Strasbourg University Hospital, Medical Intensive Care Unit - NHC, INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Strasbourg, France.
| | - Corinne Frere
- Sorbonne Université, UMRS 1166, AP-HP. Sorbonne Université, Pitié-Salpêtrière Hospital, Paris, France
| | - Thomas Thiele
- Institut für Transfusionsmedizin, Universitätsmedizin Rostock, Schillingallee 36, Rostock, Germany
| | - Kenichi A Tanaka
- Department of Anesthesiology, Universit of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Matthew D Neal
- Department of Surgery, Trauma and Transfusion Medicine Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Marie E Steiner
- Division of Hematology/Oncology and Division of Critical Care, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - Jean M Connors
- Hematology Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC, USA
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Kieninger B, Kilger M, Foltan M, Gruber M, Lunz D, Dienemann T, Schmid S, Graf B, Wiest C, Lubnow M, Müller T, Salzberger B, Schneider-Brachert W, Kieninger M. Prognostic factors for favorable outcomes after veno-venous extracorporeal membrane oxygenation in critical care patients with COVID-19. PLoS One 2023; 18:e0280502. [PMID: 36662898 PMCID: PMC9858373 DOI: 10.1371/journal.pone.0280502] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 01/03/2023] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Patients with COVID-19 and severe acute respiratory failure may require veno-venous extracorporeal membrane oxygenation (VV ECMO). Yet, this procedure is resource-intensive and high mortality rates have been reported. Thus, predictors for identifying patients who will benefit from VV ECMO would be helpful. METHODS This retrospective study included 129 patients with COVID-19 and severe acute respiratory failure, who had received VV ECMO at the University Medical Center Regensburg, Germany, between 1 March 2020 and 31 December 2021. Patient-specific factors and relevant intensive-care parameters at the time of the decision to start VV ECMO were investigated regarding their value as predictors of patient survival. In addition, the intensive-care course of the first 10 days of VV ECMO was compared between survivors and patients who had died in the intensive care unit. RESULTS The most important parameters for predicting outcome were patient age and platelet count, which differed significantly between survivors and non-survivors (age: 52.6±8.1 vs. 57.4±10.1 years, p<0.001; platelet count before VV ECMO: 321.3±132.2 vs. 262.0±121.0 /nL, p = 0.006; average on day 10: 199.2±88.0 vs. 147.1±57.9 /nL, p = 0.002). A linear regression model derived from parameters collected before the start of VV ECMO only included age and platelet count. Patients were divided into two groups by using receiver operating characteristics (ROC) analysis: group 1: 78% of patients, mortality 26%; group 2: 22% of patients, mortality 75%. A second linear regression model included average blood pH, minimum paO2, and average pump flow on day 10 of VV ECMO in addition to age and platelet count. The ROC curve resulted in two cut-off values and thus in three groups: group 1: 25% of patients, mortality 93%; group 2: 45% of patients, mortality 31%; group 3: 30% of patients, mortality 0%.
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Affiliation(s)
- Bärbel Kieninger
- Department of Infection Prevention and Infectious Diseases, University Medical Center Regensburg, Regensburg, Germany
| | - Magdalena Kilger
- Department of Anesthesiology, University Medical Center Regensburg, Regensburg, Germany
| | - Maik Foltan
- Department of Cardiac, Thoracic and Cardiovascular Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Michael Gruber
- Department of Anesthesiology, University Medical Center Regensburg, Regensburg, Germany
| | - Dirk Lunz
- Department of Anesthesiology, University Medical Center Regensburg, Regensburg, Germany
| | - Thomas Dienemann
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Stephan Schmid
- Department of Internal Medicine I, University Medical Center Regensburg, Regensburg, Germany
| | - Bernhard Graf
- Department of Anesthesiology, University Medical Center Regensburg, Regensburg, Germany
| | - Clemens Wiest
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Thomas Müller
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Bernd Salzberger
- Department of Infection Prevention and Infectious Diseases, University Medical Center Regensburg, Regensburg, Germany
| | - Wulf Schneider-Brachert
- Department of Infection Prevention and Infectious Diseases, University Medical Center Regensburg, Regensburg, Germany
| | - Martin Kieninger
- Department of Anesthesiology, University Medical Center Regensburg, Regensburg, Germany
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Lüsebrink E, Scherer C, Binzenhöfer L, Hoffmann S, Höpler J, Kellnar A, Thienel M, Joskowiak D, Peterß S, Petzold T, Deseive S, Hein R, Brunner S, Kääb S, Braun D, Theiss H, Hausleiter J, Hagl C, Massberg S, Orban M. Heparin-Induced Thrombocytopenia in Patients Undergoing Venoarterial Extracorporeal Membrane Oxygenation. J Clin Med 2023; 12:jcm12010362. [PMID: 36615162 PMCID: PMC9821297 DOI: 10.3390/jcm12010362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 12/17/2022] [Accepted: 12/27/2022] [Indexed: 01/04/2023] Open
Abstract
Background: Heparin-induced thrombocytopenia (HIT) is a serious, immune-mediated adverse drug reaction to unfractionated heparin (UFH) affecting also patients undergoing venoarterial extracorporeal membrane oxygenation (VA-ECMO). Although the association between VA-ECMO support and the development of thrombocytopenia has long been known and discussed, HIT as one underlying cause is still insufficiently understood. Therefore, the purpose of this study was to further investigate the epidemiology, mortality, diagnosis, and clinical management of HIT occurring in VA-ECMO patients treated with UFH. Methods: We conducted a retrospective single-center study including adult patients (≥18 years) with VA-ECMO support in the cardiac intensive care unit (ICU) of the University Hospital of Munich (LMU) between January 2013 and May 2022, excluding patients with a known history of HIT upon admission. Differences in baseline characteristics and clinical outcome between excluded HIT (positive anti-platelet factor 4 (PF4)/heparin antibody test but negative functional assay) and confirmed HIT (positive anti-PF4/heparin antibody test and positive functional assay) VA-ECMO patients as well as diagnosis and clinical management of HIT were analysed. Results: Among the 373 patients included, anti-PF4/heparin antibodies were detected in 53/373 (14.2%) patients. Functional HIT testing confirmed HIT in 13 cases (3.5%) and excluded HIT in 40 cases (10.7%), corresponding to a prevalence of confirmed HIT of 13/373 (3.5%) [1.6, 5.3] and a positive predictive value (PPV) of 24.5% for the antibody screening test. The platelet course including platelet recovery following argatroban initiation was similar between all groups. One-month mortality in patients with excluded HIT was 14/40 (35%) and 3-month mortality 17/40 (43%), compared to 5/13 (38%) (p > 0.999), and 6/13 (46%) (p > 0.999) in patients with confirmed HIT. Neurological outcome in both groups measured by the cerebral performance category of survivors on hospital discharge was similar, as well as adverse events during VA-ECMO therapy. Conclusions: With a prevalence of 3.5%, HIT is a non-frequent complication in patients on VA-ECMO and was not associated with a higher mortality rate. HIT was ultimately excluded by functional essay in 75% of VA-ECMO patients with clinical suspicion of HIT and positive anti-PF4/heparin antibody test. Argatroban seems to be an appropriate and safe therapeutic option for confirmed HIT-positive patients on VA-ECMO support.
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Affiliation(s)
- Enzo Lüsebrink
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
- Correspondence:
| | - Clemens Scherer
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Leonhard Binzenhöfer
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Sabine Hoffmann
- Institut für Medizinische Informationsverarbeitung Biometrie und Epidemiologie, Klinikum der Universität München, 81377 Munich, Germany
| | - Julia Höpler
- Institut für Medizinische Informationsverarbeitung Biometrie und Epidemiologie, Klinikum der Universität München, 81377 Munich, Germany
| | - Antonia Kellnar
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Manuela Thienel
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Dominik Joskowiak
- Herzchirurgische Klinik und Poliklinik, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Sven Peterß
- Herzchirurgische Klinik und Poliklinik, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Tobias Petzold
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Simon Deseive
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Ralph Hein
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Stefan Brunner
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Stefan Kääb
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Daniel Braun
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Hans Theiss
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Jörg Hausleiter
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Christian Hagl
- Herzchirurgische Klinik und Poliklinik, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Steffen Massberg
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Martin Orban
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
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Rychlíčková J, Šrámek V, Suk P. Use of fondaparinux in patients with heparin-induced thrombocytopenia on veno-venous extracorporeal membrane oxygenation: A three-patient case series report. Front Med (Lausanne) 2023; 10:1112770. [PMID: 36910487 PMCID: PMC9996216 DOI: 10.3389/fmed.2023.1112770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/06/2023] [Indexed: 02/25/2023] Open
Abstract
Heparin-induced thrombocytopenia is a life-threatening immune-mediated complication of unfractionated heparin therapy. Fondaparinux is a therapeutic alternative, but it has limited evidence for its use in patients on extracorporeal membrane oxygenation (ECMO). We present a series of three adult patients with COVID-19 on ECMO who were diagnosed with heparin-induced thrombocytopenia after 7-12 days of unfractionated heparin treatment and were switched to fondaparinux. Fondaparinux was initiated with an intravenous loading dose of 5 mg, followed by a dose of 2.5 mg subcutaneously every 8-12 h. Dosage was adjusted according to daily measured anti-Xa concentration with a target range of 0.4-0.7 mg/L. The total duration of treatment with fondaparinux and ECMO ranged from 13 to 26 days. One major bleeding episode unrelated to fondaparinux therapy was observed, and the transfusions requirement was also low in all patients. The ECMO circuit was changed once in each patient. This series provides a deep insight into the use of fondaparinux over an extended period of time in patients on ECMO. Based on the presented data, fondaparinux can be considered a reasonable and affordable anticoagulant in patients without a high risk of bleeding.
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Affiliation(s)
- Jitka Rychlíčková
- International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czechia.,Department of Anesthesiology and Intensive Care, Faculty of Medicine, Masaryk University, St. Anne's University Hospital Brno, Brno, Czechia.,Department of Pharmacology, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Vladimír Šrámek
- International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czechia.,Department of Anesthesiology and Intensive Care, Faculty of Medicine, Masaryk University, St. Anne's University Hospital Brno, Brno, Czechia
| | - Pavel Suk
- International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czechia.,Department of Anesthesiology and Intensive Care, Faculty of Medicine, Masaryk University, St. Anne's University Hospital Brno, Brno, Czechia
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Li Y, Wang H, Xi Y, Sun A, Deng X, Chen Z, Fan Y. Impact of volute design features on hemodynamic performance and hemocompatibility of centrifugal blood pumps used in ECMO. Artif Organs 2023; 47:88-104. [PMID: 35962603 DOI: 10.1111/aor.14384] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/28/2022] [Accepted: 08/09/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND The centrifugal blood pump volute has a significant impact on its hemodynamic performance hemocompatibility. Previous studies about the effect of volute design features on the performance of blood pumps are relatively few. METHODS In the present study, the computational fluid dynamics (CFD) method was utilized to evaluate the impact of volute design factors, including spiral start position, volute tongue radius, inlet height, size, shape and diffuser pipe angle on the hemolysis index and thrombogenic potential of the centrifugal blood pump. RESULTS Correlation analysis shows that flow losses affect the hemocompatibility of the blood pump by influencing shear stress and residence time. The closer the spiral start position of the volute, the better the hydraulic performance and hemocompatibility of the blood pump. Too large or too small volute inlet heights can worsen hydraulic performance and hemolysis, and higher volute inlet height can increase the thrombogenic potential. Small volute sizes exacerbate hemolysis and large volute sizes increase the thrombogenic risk, but volute size does not affect hydraulic performance. When the diffuser pipe is tangent to the base circle of the volute, the best hydraulic performance and hemolysis performance of the blood pump is achieved, but the thrombogenic potential is increased. The trapezoid volute has poor hydraulic performance and hemocompatibility. The round volute has the best hydraulic and hemolysis performance, but the thrombogenic potential is higher than that of the rectangle volute. CONCLUSION This study found that the hemolysis index shows a significant correlation with spiral start position, volute size, and diffuser pipe angle. Thrombogenic potential exhibits a good correlation with all the studied volute design features. The flow losses affect the hemocompatibility of the blood pump by influencing shear stress and residence time. The finding of this study can be used to guide the optimization of blood pump for improving the hemodynamic performance and hemocompatibility.
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Affiliation(s)
- Yuan Li
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Hongyu Wang
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Yifeng Xi
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Anqiang Sun
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Xiaoyan Deng
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Zengsheng Chen
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Yubo Fan
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
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Major Bleeding and Thromboembolic Events in Veno-Venous Extracorporeal Membrane Oxygenation-Patients With Isolated Respiratory Failure. ASAIO J 2022; 68:1529-1535. [PMID: 36469449 DOI: 10.1097/mat.0000000000001698] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Bleeding and thromboembolic events are common during veno-venous extracorporeal membrane oxygenation (vvECMO). It is unknown whether these complications are driven by the ECMO system itself, multiorgan-failure, or both. The aim of this study was to assess the prevalence of bleeding and thromboembolic events in patients with isolated respiratory failure. Patients with vvECMO were retrospectively included from March 2009 to October 2017. Exclusion included any organ failure other than respiratory. Major bleeding was defined as a decrease in hemoglobin ≥2 g/dl per 24 hours, the requirement for transfusion of ≥2 packed red blood cell concentrates per 24 hours, any retroperitoneal, pulmonary, central nervous system bleeding, or bleeding requiring surgery. Thromboembolic events were assessed by duplex sonography or CT scan. Of 601 patients, 123 patients with a mean age of 49 ± 15 years and a median Sepsis-related Organ Failure Assessment score of 8 (7-9) were eligible for the analysis. Major bleeding was observed in 73%; 35% of all bleedings occurred on the day of or after ECMO initiation. A more pronounced decrease of PaCO2 after ECMO initiation was seen in patients with intracranial bleeding (ICB) compared with those without. Thromboembolic events were noted in 30%. The levels of activated prothrombin time, fibrinogen, platelet count, or D-dimers affected neither bleeding nor the prevalence of thromboembolic events.
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Complications Associated With Venovenous Extracorporeal Membrane Oxygenation-What Can Go Wrong? Crit Care Med 2022; 50:1809-1818. [PMID: 36094523 DOI: 10.1097/ccm.0000000000005673] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES Despite increasing use and promising outcomes, venovenous extracorporeal membrane oxygenation (V-V ECMO) introduces the risk of a number of complications across the spectrum of ECMO care. This narrative review describes the variety of short- and long-term complications that can occur during treatment with ECMO and how patient selection and management decisions may influence the risk of these complications. DATA SOURCES English language articles were identified in PubMed using phrases related to V-V ECMO, acute respiratory distress syndrome, severe respiratory failure, and complications. STUDY SELECTION Original research, review articles, commentaries, and published guidelines from the Extracorporeal Life support Organization were considered. DATA EXTRACTION Data from relevant literature were identified, reviewed, and integrated into a concise narrative review. DATA SYNTHESIS Selecting patients for V-V ECMO exposes the patient to a number of complications. Adequate knowledge of these risks is needed to weigh them against the anticipated benefit of treatment. Timing of ECMO initiation and transfer to centers capable of providing ECMO affect patient outcomes. Choosing a configuration that insufficiently addresses the patient's physiologic deficit leads to consequences of inadequate physiologic support. Suboptimal mechanical ventilator management during ECMO may lead to worsening lung injury, delayed lung recovery, or ventilator-associated pneumonia. Premature decannulation from ECMO as lungs recover can lead to clinical worsening, and delayed decannulation can prolong exposure to complications unnecessarily. Short-term complications include bleeding, thrombosis, and hemolysis, renal and neurologic injury, concomitant infections, and technical and mechanical problems. Long-term complications reflect the physical, functional, and neurologic sequelae of critical illness. ECMO can introduce ethical and emotional challenges, particularly when bridging strategies fail. CONCLUSIONS V-V ECMO is associated with a number of complications. ECMO selection, timing of initiation, and management decisions impact the presence and severity of these potential harms.
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Li Y, Wang H, Xi Y, Sun A, Deng X, Chen Z, Fan Y. Multi-indicator analysis of mechanical blood damage with five clinical ventricular assist devices. Comput Biol Med 2022; 151:106271. [PMID: 36347061 DOI: 10.1016/j.compbiomed.2022.106271] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/29/2022] [Accepted: 10/30/2022] [Indexed: 11/07/2022]
Abstract
PURPOSE Device-induced blood damage contributes the hemolysis, thrombosis and bleeding complications in patients supported with ventricular assist device (VAD). This study aims to use a multi-indicator method to understand how devices causes blood damage and identify the "hot spots" of blood trauma within VADs. METHODS Computational fluid dynamics (CFD) methods were chosen to investigate the hemodynamic features of five clinical VADs (Impella 5.0, UltraMag, CHVAD, HVAD, and HeartMate II) under the same clinical support condition (flow rate of 4.5L/min, pressure head around 75 mmHg). A comprehensive multi-indicator evaluation method including hemodynamic parameters, hemolysis model, thrombotic potential model and bleeding probability model was used to analyze blood damage and assess the hemodynamic performance and hemocompatibility of these VADs. RESULTS Simulation results show that shear stress from 50 Pa to 100 Pa plays a major role in blood damage in Impella 5.0, UltraMag and CHVAD, while blood damage in HVAD and HeartMate II is mainly caused by shear stress greater than 100 Pa. Residence time was not the main factor for blood damage in Impella 5.0, and also makes a limited contribution to blood trauma in UltraMag and CHVAD, while it takes a critical role in elevating thrombotic potential in HVAD and HeartMate II. The distribution of regions of high hemolysis risk and high bleeding probability was similar for all these VADs and partially overlapped for high thrombotic potential regions. For Impella 5.0, regions with high hemolysis and bleeding risk were found mainly in the blade tip clearance and diffuser domains, high thrombotic potential regions were almost absent. For UltraMag, regions with high hemolysis, bleeding and thrombosis potential were found in two corners of the inlet pipe, the secondary flow passage, and the impeller eye. For CHVAD, the high-risk regions for hemolysis, bleeding and thrombosis are mainly in the inner side of the secondary flow passage and the middle region of the impeller passage. The narrow hydrodynamic clearance and impeller passage had a high risk of hemolysis and bleeding, and the clearance between the rotor and guide cone and the hydrodynamic clearance had high thrombotic potential. For HeartMate II, regions of high hemolysis risk and bleeding probability were found in the near-wall region of the straightener, the blade tip clearance and the diffuser domain. The corners of the inlet and outlet pipe and the straightener and diffuser regions had high thrombotic potential. CONCLUSION The risk of hemolysis, bleeding and thrombosis for these five VADs, in increasing order, was Impella 5.0, UltraMag, CHVAD, HVAD, and HeartMate II. Flow losses caused by the rotor mechanical movement, chaotic flow and narrow clearances increase the blood damage for all these VADs. The multi-indicator analysis can comprehensively evaluate the VAD performance with improved assessment accuracy of CFD.
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Affiliation(s)
- Yuan Li
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, 100083, China
| | - Hongyu Wang
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, 100083, China
| | - Yifeng Xi
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, 100083, China
| | - Anqiang Sun
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, 100083, China
| | - Xiaoyan Deng
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, 100083, China
| | - Zengsheng Chen
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, 100083, China.
| | - Yubo Fan
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, 100083, China.
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Raasveld SJ, Volleman C, Combes A, Broman LM, Taccone FS, Peters E, Ten Berg S, van den Brom CE, Thiele H, Lorusso R, Henriques JPS, Vlaar APJ. Knowledge gaps and research priorities in adult veno-arterial extracorporeal membrane oxygenation: a scoping review. Intensive Care Med Exp 2022; 10:50. [PMID: 36424482 PMCID: PMC9691798 DOI: 10.1186/s40635-022-00478-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 11/14/2022] [Indexed: 11/27/2022] Open
Abstract
PURPOSE This scoping review aims to identify and describe knowledge gaps and research priorities in veno-arterial extracorporeal membrane oxygenation (VA-ECMO). METHODS An expert panel was recruited consisting of eight international experts from different backgrounds. First, a list of priority topics was made. Second, the panel developed structured questions using population, intervention, comparison and outcomes (PICO) format. All PICOs were scored and prioritized. For every selected PICO, a structured literature search was performed. RESULTS After an initial list of 49 topics, eight were scored as high-priority. For most of these selected topics, current literature is limited to observational studies, mainly consisting of retrospective cohorts. Only for ECPR and anticoagulation, randomized controlled trials (RCTs) have been performed or are ongoing. Per topic, a summary of the literature is stated including recommendations for further research. CONCLUSIONS This scoping review identifies and presents an overview of knowledge gaps and research priorities in VA-ECMO. Current literature is mostly limited to observational studies, although with increasing attention for this patient population, more RCTs are finishing or ongoing. Translational research, from preclinical trials to high-quality or randomized controlled trials, is important to improve the standard practices in this critically ill patient population. Take-home message This scoping review identifies and presents an overview of research gaps and priorities in VA-ECMO. Translational research, from preclinical trials to high-quality or randomized controlled trials, is important to improve the standard practices in this critically ill patient population.
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Affiliation(s)
- Senta Jorinde Raasveld
- Department of Critical Care, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, The Netherlands
| | - Carolien Volleman
- Department of Critical Care, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Alain Combes
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS1166-ICAN, Paris, France
- Service de Médicine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Hospital Pitié-Salpêtrière, Paris, France
| | - Lars Mikael Broman
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Fabio Silvio Taccone
- Department of Intensive Care, Université Libre de Bruxelles, Hôpital Universitaire de Bruxelles (HUB), Brussels, Belgium
| | - Elma Peters
- Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Sanne Ten Berg
- Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Charissa E van den Brom
- Department of Critical Care, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Anesthesiology, Amsterdam UMC, VU University, Amsterdam, The Netherlands
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Science GmbH, Leipzig, Germany
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - José P S Henriques
- Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Alexander P J Vlaar
- Department of Critical Care, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, The Netherlands.
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TEMPORAL TRENDS IN THE USE AND OUTCOMES OF TEMPORARY MECHANICAL CIRCULATORY SUPPORT AS A BRIDGE TO CARDIAC TRANSPLANTATION IN SPAIN. FINAL REPORT OF THE ASIS-TC STUDY. J Heart Lung Transplant 2022; 42:488-502. [PMID: 36470772 DOI: 10.1016/j.healun.2022.10.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 09/12/2022] [Accepted: 10/23/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND We aimed to describe recent trends in the use and outcomes of temporary mechanical circulatory support (MCS) as a bridge to heart transplantation (HTx) in Spain. METHODS Retrospective case-by-case analysis of 1,036 patients listed for emergency HTx while on temporary MCS in 16 Spanish institutions from January 1st, 2010 to December 31st, 2020. Patients were classified in 3 eras according to changes in donor allocation criteria (Era 1: January 2010/May 2014; Era 2: June 2014/May 2017; Era 3: June 2017/December 2020). RESULTS Over time, the proportion of candidates listed with intra-aortic balloon pumps decreased (Era 1 = 55.9%, Era 2 = 32%, Era 3 = 0.9%; p < 0.001), while the proportion of candidates listed with surgical continuous-flow temporary VADs (Era 1 = 10.6%, Era 2 = 32%, Era 3 = 49.1%; p < 0.001) and percutaneous VADs (Era 1 = 0.3%, Era 2 = 6.3%; Era 3 = 17.2%; p < 0.001) increased. Rates of HTx increased from Era 1 (79.4%) to Era 2 (87.8%), and Era 3 (87%) (p = 0.004), while rates of death before HTx decreased (Era 1 = 17.7%; Era 2 = 11%, Era 3 = 12.4%; p = 0.037) Median time from listing to HTx increased in patients supported with intra-aortic balloon pumps (Era 1 = 8 days, Era 2 = 15 days; p < 0.001) but remained stable in other candidates (Era 1 = 6 days; Era 2 = 5 days; Era 3 = 6 days; p = 0.134). One-year post-transplant survival was 71.4% in Era 1, 79.3% in Era 2, and 76.5% in Era 3 (p = 0.112). Preoperative bridging with ECMO was associated with increased 1-year post-transplant mortality (adjusted HR=1.71; 95% CI 1.15-2.53; p = 0.008). CONCLUSIONS During the period 2010 to 2020, successive changes in the Spanish organ allocation protocol were followed by a significant increase of the rate of HTx and a significant reduction of waiting list mortality in candidates supported with temporary MCS. One-year post-transplant survival rates remained acceptable.
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Krasivskyi I, Ivanov B, Vehrenberg J, Eghbalzadeh K, Gerfer S, Gaisendrees C, Kuhn E, Sabashnikov A, Mader N, Djordjevic I, Wahlers T. Sex-Related Differences in Short-Term Outcomes after Mobile VA-ECMO Implantation: Five-Year Experience of an ECMO Retrieval Program. Life (Basel) 2022; 12:life12111746. [PMID: 36362901 PMCID: PMC9695761 DOI: 10.3390/life12111746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 10/20/2022] [Accepted: 10/21/2022] [Indexed: 11/06/2022] Open
Abstract
Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) represents an increasingly used method for circulatory support. Despite the ongoing research, survival following VA-ECMO therapy remains low. Sex-related differences might impact the outcome of therapeutic measures. We aimed to compare all-cause mortality among female and male patients who underwent VA-ECMO as a bridge to recovery investigating sex-related differences. From January 2015 until August 2020, 87 patients were supported by VA-ECMO as a part of our out-of-center mobile ECMO program. In order to analyze sex-associated differences in early clinical outcomes, patients were divided into two sex categories: men (n = 62) and women (n = 25). All relevant data (in-hospital mortality, ICU and hospital stay, renal failure requiring dialysis, lung failure, bleeding, stroke and septic shock) were analyzed retrospectively after the extraction from our institutional database. Mean age of the study population was 53 ± 14 years. Mean EuroSCORE II predicted mortality was 6.5 ± 3.7. In-hospital mortality rate was not significantly lower in the female group (58.3%) vs. the male group (71.2%), p = 0.190. The mean length of ICU and hospital stay was 9 ± 11 in the male group vs. 10 ± 13 in the female group, p = 0.901, and 10 ± 12 (male group) vs. 11 ± 13 (female group), p = 0.909, respectively. Renal failure requiring hemodialysis (36.2% (males) vs. 28.6% (females), p = 0.187) was comparable between both groups. Respiratory failure was diagnosed in 31 (56.4%) male vs. 8 (34.8%) female patients, p = 0.068, while 16 (28.6%) male vs. 3 (13.0%) female patients (p = 0.118) suffered from septic shock. Based on our data, there were no sex-specific outcome discrepancies in patients treated with mobile VA-ECMO implantation.
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Affiliation(s)
- Ihor Krasivskyi
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
- Correspondence: ; Tel.: +49-176-353-88-719
| | - Borko Ivanov
- Department of Cardiothoracic Surgery, Helios Hospital Siegburg, 53721 Siegburg, Germany
| | - Johannes Vehrenberg
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Kaveh Eghbalzadeh
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Stephen Gerfer
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | | | - Elmar Kuhn
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Anton Sabashnikov
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Navid Mader
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Ilija Djordjevic
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
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