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Liu C, Li X, Li J, Shen D, Sun Q, Zhao J, Zhao H, Fu G. Standby extracorporeal membrane oxygenation: a better strategy for high-risk percutaneous coronary intervention. Front Med (Lausanne) 2024; 11:1404479. [PMID: 38994335 PMCID: PMC11238173 DOI: 10.3389/fmed.2024.1404479] [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: 03/21/2024] [Accepted: 06/11/2024] [Indexed: 07/13/2024] Open
Abstract
Background The incidence of cardiac arrest (CA) during percutaneous coronary intervention (PCI) is relatively rare. However, when it does occur, the mortality rate is extremely high. Extracorporeal cardiopulmonary resuscitation (ECPR) has shown promising survival rates for in-hospital cardiac arrests (IHCA), with low-flow time being an independent prognostic factor for CA. However, there is no definitive answer on how to reduce low-flow time. Methods This retrospective study, conducted at a single center, included 39 patients who underwent ECPR during PCI between January 2016 and December 2022. The patients were divided into two cohorts based on whether standby extracorporeal membrane oxygenation (ECMO) was utilized during PCI: standby ECPR (SBE) (n = 13) and extemporaneous ECPR (EE) (n = 26). We compared the 30-day mortality rates between these two cohorts and investigated factors associated with survival. Results Compared to the EE cohort, the SBE cohort showed significantly lower low-flow time (P < 0.01), ECMO operation time (P < 0.01), and a lower incidence of acute kidney injury (AKI) (P = 0.017), as well as peak lactate (P < 0.01). Stand-by ECMO was associated with improved 30-day survival (p = 0.036), while prolonged low-flow time (p = 0.004) and a higher SYNTAX II score (p = 0.062) predicted death at 30 days. Conclusions Standby ECMO can provide significant benefits for patients who undergo ECPR for CA during PCI. It is a viable option for high-risk PCI cases and may enhance the overall prognosis. The low-flow time remains a critical determinant of survival.
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Affiliation(s)
- Chuang Liu
- Department of Extracorporeal Life Support Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Xingxing Li
- Department of Extracorporeal Life Support Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Jun Li
- Department of Extracorporeal Life Support Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Deliang Shen
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Qianqian Sun
- Department of Extracorporeal Life Support Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Junjie Zhao
- Department of Extracorporeal Life Support Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Hui Zhao
- Department of Extracorporeal Life Support Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Guowei Fu
- Department of Extracorporeal Life Support Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
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Taha D, Drop JG, Wildschut ED, De Hoog M, van Ommen CH, Reis Miranda DD. Evaluation of an aPTT guided versus a multimodal heparin monitoring approach in patients on extra corporeal membrane oxygenation: A retrospective cohort study. Perfusion 2024:2676591241253474. [PMID: 38739366 DOI: 10.1177/02676591241253474] [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: 05/14/2024]
Abstract
INTRODUCTION Bleeding and thrombotic complications are common in extracorporeal membrane oxygenation (ECMO) patients and are associated with increased mortality and morbidity. The optimal anticoagulation monitoring protocol in these patients is unknown. This study aims to compare the incidence of thrombotic and hemorrhagic complications before and after a protocol change. In addition, the association between hemostatic complications, coagulation tests and risk factors is evaluated. METHODS This is a retrospective single center cohort study of adult ECMO patients. We collected demographics, ECMO parameters and coagulation test results. Outcomes of the aPTT guided and multimodal protocol, including aPTT, anti-Xa assay and rotational thromboelastometry were compared and the association between coagulation tests, risk factors and hemostatic complications was determined using a logistic regression analysis for repeated measurements. RESULTS In total, 250 patients were included, 138 in the aPTT protocol and 112 in the multimodal protocol. The incidence of thrombosis (aPTT: 14%; multimodal: 12%) and bleeding (aPTT: 36%; multimodal: 40%), did not significantly differ between protocols. In the aPTT guided protocol, the aPTT was associated with thrombosis (Odds Ratio [OR] 1.015; 95% confidence interval [CI] 1.004-1.027). In both protocols, surgical interventions were risk factors for bleeding and thrombotic complications (aPTT: OR 93.2, CI 39.9-217.6; multimodal OR 17.5, CI 6.5-46.9). DISCUSSION The incidence of hemostatic complications was similar between both protocols and surgical interventions were a risk factor for hemostatic complications. Results from this study help to elucidate the role of coagulation tests and risk factors in predicting hemostatic complications in patients undergoing ECMO support.
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Affiliation(s)
- Diman Taha
- Department of Adult Intensive Care, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Joppe G Drop
- Department of Pediatric Hematology, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Enno D Wildschut
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Matthijs De Hoog
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, The Netherlands
| | - C Heleen van Ommen
- Department of Pediatric Hematology, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, The Netherlands
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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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Moussa MD, Soquet J, Robin E, Labreuche J, Rousse N, Rauch A, Loobuyck V, Leroy G, Duburcq T, Gantois G, Leroy X, Ait-Ouarab S, Lamer A, Thellier L, Lukowiak O, Schurtz G, Muller C, Juthier F, Susen S, Vincentelli A. Definitions of major bleeding for predicting mortality in critically ill adult patients who survived 24 hours while supported with peripheral veno-arterial extracorporeal membrane oxygenation for cardiogenic shock: a comparative historical cohort study. Can J Anaesth 2024; 71:523-534. [PMID: 38438682 DOI: 10.1007/s12630-024-02704-6] [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: 09/25/2022] [Revised: 10/30/2023] [Accepted: 11/01/2023] [Indexed: 03/06/2024] Open
Abstract
PURPOSE The severity of bleeding events is heterogeneously defined during peripheral veno-arterial extracorporeal membrane oxygenation (pVA-ECMO). We studied three bleeding definitions in pVA-ECMO: the Extracorporeal Life Support Organization (ELSO)-serious bleeding, the Bleeding Academic Research Consortium (BARC), and the universal definition of postoperative bleeding (UPDB) classifications. METHODS We included consecutive adult patients supported by pVA-ECMO for refractory cardiogenic shock admitted to Lille academic hospitals between January 2013 and December 2019. We assessed the association of bleeding definitions with the primary endpoint of 28-day all-cause mortality with the use of multivariate models accounting for time-dependent and competing variables. We compared models' performances using the Harrell's C-Index and the Akaike information criteria. RESULTS Twenty-eight-day mortality occurred in 128/308 (42%) 308 patients. The ELSO-serious bleeding (hazard ratio [HR], 1.67; 95% confidence interval [CI], 1.09 to 2.56) and BARC ≥ type 2 (HR, 1.55; 95% CI, 1.01 to 2.37) were associated with 28-day mortality (Harrell's C-index, 0.69; 95% CI, 0.63 to 0.74 for both). Predictors of ELSO-serious bleeding were postcardiotomy, body mass index, baseline platelets count, fibrinogen, and hemoglobin levels. CONCLUSION Extracorporeal Life Support Organization-serious bleeding and BARC ≥ type 2 are relevant definitions of major bleeding regarding their association with mortality in critically ill patients who survived the first 24 hr while supported with pVA-ECMO for cardiogenic shock. STUDY REGISTRATION CERAR (IRB 00010254-2022-050, Paris, France); first submitted on 18 April 2022.
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Affiliation(s)
- Mouhamed D Moussa
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France.
- Pôle d'Anesthésie-Réanimation, CHU Lille, Lille, France.
- Service d'Anesthésie-Réanimation Cardiovasculaire et thoracique, Institut Cœur - Poumon, CHU Lille, 2 avenue Oscar Lambret, 59 037, Lille, France.
| | - Jérôme Soquet
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France
- Department of Cardiac Surgery, CHU Lille, Lille, France
| | - Emmanuel Robin
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France
- Pôle d'Anesthésie-Réanimation, CHU Lille, Lille, France
| | | | - Natacha Rousse
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France
- Department of Cardiac Surgery, CHU Lille, Lille, France
| | - Antoine Rauch
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France
| | - Valentin Loobuyck
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France
- Department of Cardiac Surgery, CHU Lille, Lille, France
| | | | | | | | - Xavier Leroy
- Pôle d'Anesthésie-Réanimation, CHU Lille, Lille, France
| | | | - Antoine Lamer
- Pôle d'Anesthésie-Réanimation, CHU Lille, Lille, France
| | - Lise Thellier
- Pôle d'Anesthésie-Réanimation, CHU Lille, Lille, France
| | | | - Guillaume Schurtz
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France
- Department of Cardiology, CHU Lille, Lille, France
| | | | - Francis Juthier
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France
- Department of Cardiac Surgery, CHU Lille, Lille, France
| | - Sophie Susen
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France
| | - André Vincentelli
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France
- Department of Cardiac Surgery, CHU Lille, Lille, France
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Byun E, Kang PJ, Jung SH, Park SY, Lee SA, Kwon TW, Cho YP. Impact of extracorporeal membrane oxygenation-related complications on in-hospital mortality. PLoS One 2024; 19:e0300713. [PMID: 38527053 PMCID: PMC10962856 DOI: 10.1371/journal.pone.0300713] [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: 09/21/2023] [Accepted: 03/02/2024] [Indexed: 03/27/2024] Open
Abstract
INTRODUCTION Although extracorporeal membrane oxygenation (ECMO) is a well-established treatment for supporting severe cardiopulmonary failure, the morbidity and mortality of patients requiring ECMO support remain high. Evaluating and correcting potential risk factors associated with any ECMO-related complications may improve care and decrease mortality. This study aimed to assess the predictors of ECMO-related vascular and cerebrovascular complications among adult patients and to test the hypothesis that ECMO-related complications are associated with higher in-hospital mortality rates. METHODS This single-center, retrospective study included 856 ECMO runs administered via cannulation of the femoral vessels of 769 patients: venoarterial (VA) ECMO (n = 709, 82.8%) and venovenous (VV) ECMO (n = 147, 17.2%). The study outcomes included the occurrence of ECMO-related vascular and cerebrovascular complications and in-hospital death. The association of ECMO-related complications with the risk of in-hospital death was analyzed. RESULTS The incidences of ECMO-related vascular and cerebrovascular complications were 20.2% and 13.6%, respectively. The overall in-hospital mortality rate was 48.7%: 52.8% among VA ECMO runs and 29.3% among VV ECMO runs. Multivariable analysis indicated that age (P < 0.01), cardiopulmonary cerebral resuscitation (P < 0.01), continuous renal replacement therapy (P < 0.01), and initial platelet count [<50×103/μL (P = 0.02) and 50-100(×103)/μL (P < 0.01)] were associated with an increased risk of in-hospital death. ECMO-related vascular and cerebrovascular complications were not independently associated with higher in-hospital mortality rates for VA or VV ECMO runs. CONCLUSION ECMO-related vascular and cerebrovascular complications were not associated with an increased risk of in-hospital death among adult patients.
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Affiliation(s)
- Eunae Byun
- Division of Vascular Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
- Department of Surgery, Dong-A University Hospital, Busan, Republic of Korea
| | - Pil Je Kang
- Department of Thoracic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung Ho Jung
- Department of Thoracic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seo Young Park
- Department of Statistics and Data Science, Korea National Open University, Seoul, Republic of Korea
| | - Sang Ah Lee
- Division of Vascular Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Tae-Won Kwon
- Division of Vascular Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
- Department of Acute Care Surgery, Korea University Guro Hospital, Seoul, Republic of Korea
- Armed Forces Trauma Center, Bundang, Republic of Korea
| | - Yong-Pil Cho
- Division of Vascular Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Caruso V, Berthoud V, Bouchot O, Nguyen M, Bouhemad B, Guinot PG. Should the Vasoactive Inotropic Score be a Determinant for Early Initiation of VA ECMO in Postcardiotomy Cardiogenic Shock? J Cardiothorac Vasc Anesth 2024; 38:724-730. [PMID: 38182434 DOI: 10.1053/j.jvca.2023.11.040] [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: 10/13/2023] [Revised: 11/23/2023] [Accepted: 11/27/2023] [Indexed: 01/07/2024]
Abstract
OBJECTIVES The authors investigated the role of early venoarterial extracorporeal membrane oxygenation (VA ECMO) implantation in patients with postcardiotomy cardiogenic shock (PCS) on mortality and morbidity when integrating vasoactive-inotropic score (VIS) and type of catecholamine support. DESIGN A retrospective, multicenter, observational study with propensity-weight matching. SETTING Four university-affiliated intensive care units. PARTICIPANTS Patients with PCS in the operating room. INTERVENTIONS Early VA ECMO support. MEASUREMENTS AND MAIN RESULTS Of 2,742 patients screened during the study period, 424 (16%) patients were treated with inotropic drugs, and 75 (3%) patients were supported by VA ECMO in the operating room. Patients supported by VA ECMO had a higher use of vasopressor and inotropic drugs, with a higher VIS score. After propensity matching (integrating VIS and catecholamines type), mortality (56% v 20%, p < 0.001) and morbidity (cardiac, renal, transfusion) were higher in patients supported by VA ECMO than in a matched control group. CONCLUSIONS When matching integrated the pre-ECMO VIS and the type of catecholamines, VA ECMO remained associated with high mortality and morbidity, suggesting that VIS alone should not be used as a main determinant of VA ECMO implantation.
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Affiliation(s)
- Vincenza Caruso
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France
| | - Vivien Berthoud
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France; University of Burgundy and Franche-Comté, Dijon, France
| | - Olivier Bouchot
- Department of Cardiac Surgery, Dijon University Medical Centre, Dijon, France
| | - Maxime Nguyen
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France; University of Burgundy and Franche-Comté, Dijon, France
| | - Belaid Bouhemad
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France; University of Burgundy and Franche-Comté, Dijon, France
| | - Pierre-Grégoire Guinot
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France; University of Burgundy and Franche-Comté, Dijon, France.
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Isokawa S, Hifumi T, Hirano K, Watanabe Y, Horie K, Shin K, Shirasaki K, Goto M, Inoue A, Sakamoto T, Kuroda Y, Tomita S, Otani N, Group TSJIS. Risk factors for bleeding complications in patients undergoing extracorporeal cardiopulmonary resuscitation following out-of-hospital cardiac arrest: a secondary analysis of the SAVE-J II study. Ann Intensive Care 2024; 14:16. [PMID: 38280965 PMCID: PMC10821854 DOI: 10.1186/s13613-024-01253-x] [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: 05/30/2023] [Accepted: 01/18/2024] [Indexed: 01/29/2024] Open
Abstract
BACKGROUND Bleeding is the most common complication in out-of-hospital cardiac arrest (OHCA) patients receiving extracorporeal cardiopulmonary resuscitation (ECPR). No studies comprehensively described the incidence rate, timing of onset, risk factors, and treatment of bleeding complications in OHCA patients receiving ECPR in a multicenter setting with a large database. This study aimed to analyze the risk factors of bleeding during the first day of admission and to comprehensively describe details of bleeding during hospitalization in patients with OHCA receiving ECPR in the SAVE-J II study database. METHODS This study was a secondary analysis of the SAVE-J II study, which is a multicenter retrospective registry study from 36 participating institutions in Japan in 2013-2018. Adult OHCA patients who received ECPR were included. The primary outcome was the risk factor of bleeding complications during the first day of admission. The secondary outcomes were the details of bleeding complications and clinical outcomes. RESULTS A total of 1,632 patients were included. Among these, 361 patients (22.1%) had bleeding complications during hospital stay, which most commonly occurred in cannulation sites (14.3%), followed by bleeding in the retroperitoneum (2.8%), gastrointestinal tract (2.2%), upper airway (1.2%), and mediastinum (1.1%). These bleeding complications developed within two days of admission, and 21.9% of patients required interventional radiology (IVR) or/and surgical interventions for hemostasis. The survival rate at discharge of the bleeding group was 27.4%, and the rate of favorable neurological outcome at discharge was 14.1%. Multivariable logistic regression analysis showed that the platelet count (< 10 × 104/μL vs > 10 × 104/μL) was significantly associated with bleeding complications during the first day of admission (adjusted odds ratio [OR]: 1.865 [1.252-2.777], p = 0.002). CONCLUSIONS In a large ECPR registry database in Japan, up to 22.1% of patients experienced bleeding complications requiring blood transfusion, IVR, or surgical intervention for hemostasis. The initial platelet count was a significant risk factor of early bleeding complications. It is necessary to lower the occurrence of bleeding complications from ECPR, and this study provided an additional standard value for future studies to improve its safety.
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Affiliation(s)
- Shutaro Isokawa
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, 9-1 Akashicho, Chuo-Ku, Tokyo, 104-8560, Japan
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, 9-1 Akashicho, Chuo-Ku, Tokyo, 104-8560, Japan.
| | - Keita Hirano
- Department of Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yu Watanabe
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, 9-1 Akashicho, Chuo-Ku, Tokyo, 104-8560, Japan
| | - Katsuhiro Horie
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, 9-1 Akashicho, Chuo-Ku, Tokyo, 104-8560, Japan
| | - Kijong Shin
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, 9-1 Akashicho, Chuo-Ku, Tokyo, 104-8560, Japan
| | - Kasumi Shirasaki
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, 9-1 Akashicho, Chuo-Ku, Tokyo, 104-8560, Japan
| | - Masahiro Goto
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, 9-1 Akashicho, Chuo-Ku, Tokyo, 104-8560, Japan
| | - Akihiko Inoue
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Kobe, Japan
| | - Tetsuya Sakamoto
- Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Yasuhiro Kuroda
- Department of Emergency Medicine, Kagawa University School of Medicine, Kagawa, Japan
| | | | - Norio Otani
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, 9-1 Akashicho, Chuo-Ku, Tokyo, 104-8560, Japan
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8
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Cohan D, Uricchio MN, Konopka CI, Montepara CA, Verlinden NJ. Comparison of clinical outcomes with cangrelor plus aspirin versus oral dual antiplatelet therapy in patients supported with venoarterial extracorporeal membrane oxygenation. Artif Organs 2023; 47:1672-1677. [PMID: 37203212 DOI: 10.1111/aor.14590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 04/22/2023] [Accepted: 05/13/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Patients with refractory cardiogenic shock from an acute myocardial infarction may receive percutaneous coronary intervention (PCI) and require the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO). The purpose of this study was to compare bleeding and thrombotic events in patients treated with cangrelor plus aspirin versus oral dual antiplatelet therapy (DAPT) while supported with VA-ECMO. METHODS We conducted a retrospective review of patients who received PCI, were supported with VA-ECMO, and were treated with either cangrelor plus aspirin or oral DAPT from February 2016 through May 2021 at Allegheny General Hospital. The primary objective was the incidence of major bleeding, defined as Bleeding Academic Research Consortium (BARC) type 3 or greater. The incidence of thrombotic events was a secondary objective. RESULTS Thirty-seven patients were included, 19 in the cangrelor plus aspirin group, and 18 in the oral DAPT group. All the patients in the cangrelor group received a dose of 0.75 mcg/kg/min. Major bleeding occurred in 7 patients (36.8%) in the cangrelor group compared to 7 patients (38.9%) in the oral DAPT group (p = 0.90). No patient developed stent thrombosis. Two patients (10.5%) in the cangrelor group had a thrombotic event versus 3 patients (16.7%) in the oral DAPT group (p = 0.66). CONCLUSIONS Bleeding and thrombotic events were comparable between patients receiving cangrelor plus aspirin versus oral DAPT while on VA-ECMO.
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Affiliation(s)
- Dana Cohan
- Department of Pharmacy, Sentara Norfolk General Hospital, Norfolk, Virginia, USA
| | - Marissa N Uricchio
- Department of Pharmacy, Cooperman Barnabas Medical Center, Livingston, New Jersey, USA
| | - Chelsea I Konopka
- Department of Pharmacy, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Courtney A Montepara
- Department of Pharmacy, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
- Duquesne University School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Nathan J Verlinden
- Department of Pharmacy, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
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Nakatsutsumi K, Endo A, Costantini TW, Takayama W, Morishita K, Otomo Y, Inoue A, Hifumi T, Sakamoto T, Kuroda Y. Time-saving effect of real-time ultrasound-guided cannulation for extracorporeal cardiopulmonary resuscitation: A multicenter retrospective cohort study. Resuscitation 2023; 191:109927. [PMID: 37544499 DOI: 10.1016/j.resuscitation.2023.109927] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 07/25/2023] [Accepted: 07/30/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND Extracorporeal cardiopulmonary resuscitation (ECPR), a bridge to treatments for cardiac arrest patients, can be technically challenging and requires expertise. While ultrasound guidance is frequently used for vascular access, its effects on cannulation time in patients treated with ECPR are poorly defined. We hypothesized that real-time ultrasound guidance would contribute to faster and safer cannulation for ECPR. METHODS This nationwide, multicenter, retrospective study analyzed data from 36 Japanese institutions. Patients who were over age 18 years and underwent ECPR between January 1, 2013, and December 31, 2018, were included. Patients who underwent open surgical vascular access were excluded. Cannulation time and outcomes of patients who underwent real-time ultrasound-guided cannulation (i.e., ultrasound-guided group) were compared to those cannulated without the use of real-time ultrasound guidance (control group) using propensity score matching analysis. RESULTS The ultrasound-guided group comprised 510 cases, whereas the control group comprised 941 cases. Of those, 443 propensity score-matched pairs were evaluated. Cannulation time in the ultrasound-guided group was 2.5 minutes shorter than in the control group [difference, -2.5 minutes; 95% Confidence interval (CI), -3.7 to -1.3, p < 0.001]. The incidence of catheter-related complications and the incidence of the poor neurological outcomes (Cerebral Performance Category ≥3) did not differ between groups [Odds ratio (OR), 1.51; 95% CI, 0.64-3.74; OR, 1.08; 95% CI, 0.83-1.59]. CONCLUSION Real-time ultrasound-guided cannulation was associated with shorter cannulation time of ECPR.
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Affiliation(s)
- Keita Nakatsutsumi
- Trauma and Acute Critical Care Center, Tokyo Medical and Dental University Hospital, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan; Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, Department of Surgery, University of California, San Diego, CA, USA.
| | - Akira Endo
- Trauma and Acute Critical Care Center, Tokyo Medical and Dental University Hospital, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan; Department of Acute Critical Care Medicine, Tsuchiura Kyodo General Hospital, 4-1-1, Otsuno, Tsuchiura, Ibaraki, Japan
| | - Todd W Costantini
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, Department of Surgery, University of California, San Diego, CA, USA
| | - Wataru Takayama
- Trauma and Acute Critical Care Center, Tokyo Medical and Dental University Hospital, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan
| | - Koji Morishita
- Trauma and Acute Critical Care Center, Tokyo Medical and Dental University Hospital, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Tokyo Medical and Dental University Hospital, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan; National Hospital Organization Disaster Medical Center, 3256 Tachikawa-shi Midorimachi, Tokyo, Japan
| | - Akihiko Inoue
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, 1-3-1 Chuo-ku Kobe, Hyogo, Japan
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, 9-1 Chuo-ku, Tokyo, Japan
| | - Tetsuya Sakamoto
- Department of Emergency Medicine, Teikyo University School of Medicine, 2-11-1 Itabashi-ku, Tokyo, Japan
| | - Yasuhiro Kuroda
- Department of Emergency Medicine, Kagawa University School of Medicine, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa, Japan
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10
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Platelet Transfusion and In-Hospital Mortality in Veno-Arterial Extracorporeal Membrane Oxygenation Patients. ASAIO J 2022; 68:1249-1255. [PMID: 34967786 DOI: 10.1097/mat.0000000000001643] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Thrombocytopenia is common during extracorporeal membrane oxygenation (ECMO), and platelets are sometimes transfused to meet arbitrary goals. We performed a retrospective cohort study of veno-arterial (VA) ECMO patients from a single academic medical center and explored the relationship between platelet transfusion and in-hospital mortality using multivariable logistic regression. One hundred eighty-eight VA ECMO patients were included in the study. Ninety-one patients (48.4%) were transfused platelets during ECMO. Patients who received platelet transfusion had more coronary artery disease, lower platelet counts at cannulation, higher predicted mortality, lower nadir platelet counts, more ECMO days, and more red blood cell (RBC) and plasma transfusion. Mortality was 19.6% for patients who received no platelets, 40.8% for patients who received 1-3 platelets, and 78.6% for patients who received 4 or more platelets ( P < 0.001). After controlling for confounding variables including baseline severity of illness, central cannulation, postcardiotomy status, RBC and plasma transfusion, major bleeding, and total ECMO days, transfusion of 4 or more platelets remained associated with in-hospital mortality; OR = 4.68 (95% CI = 1.18-27.28), P = 0.03. Our findings highlight the need for randomized controlled trials that compare different platelet transfusion triggers, so that providers can better understand when platelet transfusion is indicated in VA ECMO patients.
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11
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Andrei S, Nguyen M, Berthoud V, Durand B, Duclos V, Morgant MC, Bouchot O, Bouhemad B, Guinot PG. Determinants of Arterial Pressure of Oxygen and Carbon Dioxide in Patients Supported by Veno-Arterial ECMO. J Clin Med 2022; 11:jcm11175228. [PMID: 36079158 PMCID: PMC9457238 DOI: 10.3390/jcm11175228] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 08/28/2022] [Accepted: 09/01/2022] [Indexed: 12/14/2022] Open
Abstract
Background: The present study aimed to assess the determinants of arterial partial pressure of oxygen (PaO2) and carbon dioxide (PaCO2) in the early phase of veno-arterial extracorporeal membrane oxygenation (VA ECMO) support. Even though the guidelines considered both the risks of hypoxemia and hyperoxemia during ECMO support, there are a lack of data concerning the patients supported by VA ECMO. Methods: This is a retrospective, monocentric, observational cohort study in a university-affiliated cardiac intensive care unit. Hemodynamic parameters, ECMO parameters, ventilator settings, and blood gas analyses were collected at several time points during the first 48 h of VA ECMO support. For each timepoint, the blood samples were drawn simultaneously from the right radial artery catheter, VA ECMO venous line (before the oxygenator), and from VA ECMO arterial line (after the oxygenator). Univariate followed by multivariate mixed-model analyses were performed for longitudinal data analyses. Results: Forty-five patients with femoro-femoral peripheral VA ECMO were included. In multivariate analysis, the patients' PaO2 was independently associated with QEC, FDO2, and time of measurement. The patients' PaCO2 was associated with the sweep rate flow and the PpreCO2. Conclusions: During acute VA ECMO support, the main determinants of patient oxygenation are determined by VA ECMO parameters.
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Affiliation(s)
- Stefan Andrei
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, F-21000 Dijon, France
- Department of Anaesthesiology and Critical Care Medicine, University of Medicine and Pharmacy “Carol Davila”, 020021 Bucharest, Romania
- Correspondence: ; Tel.: +33-38-029-3031
| | - Maxime Nguyen
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, F-21000 Dijon, France
- LNC UMR1231, University of Burgundy and Franche-Comté, F-21000 Dijon, France
| | - Vivien Berthoud
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, F-21000 Dijon, France
| | - Bastian Durand
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, F-21000 Dijon, France
| | - Valerian Duclos
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, F-21000 Dijon, France
| | | | - Olivier Bouchot
- Cardiac Surgery Department, Dijon University Hospital, F-21000 Dijon, France
| | - Belaid Bouhemad
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, F-21000 Dijon, France
- LNC UMR1231, University of Burgundy and Franche-Comté, F-21000 Dijon, France
| | - Pierre-Grégoire Guinot
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, F-21000 Dijon, France
- LNC UMR1231, University of Burgundy and Franche-Comté, F-21000 Dijon, France
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12
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Jin Y, Cui Y, Zhang Y, Zhang P, Bai L, Li Y, Gao P, Wang W, Wang X, Liu J, Hu J. Hemostatic complications and systemic heparinization in pediatric post-cardiotomy veno-arterial extracorporeal membrane oxygenation failed to wean from cardiopulmonary bypass. Transl Pediatr 2022; 11:1458-1469. [PMID: 36247891 PMCID: PMC9561514 DOI: 10.21037/tp-22-104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 07/08/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Hemostatic complications and the need for large amounts of blood products are major obstacles during veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Additionally, the occurrence of coagulopathy after cardiopulmonary bypass (CPB) affects systemic heparinization in pediatric post-cardiotomy patients. This study compares hemostatic complications in pediatric post-cardiotomy VA-ECMO patients for failure to wean from CPB with those who received post-cardiotomy VA-ECMO for other indications, while also exploring the relationship between different stages-hemostatic complications and the timing of systemic heparinization. METHODS We retrospectively analyzed 146 pediatric patients who received post-cardiotomy VA-ECMO support (CPB-ECMO, n=96 vs. non-CPB-ECMO, n=50) from January 2005 to June 2020. Patients were divided into survivors (n=46) and non-survivors (n=50) according to in-hospital mortality in the CPB-ECMO group. We compared clinical outcomes between the groups, then examined the associations between the timing of systemic heparinization after ECMO implantation and different stages-hemostatic complications, in the CPB-ECMO group. RESULTS We found that the risk of early bleeding was significantly increased in patients who failed to wean from CPB. The presence of early bleeding was accompanied by the higher demand for blood products transfusion in the CPB-ECMO group, and for treatment the patients received a longer delayed continuous heparin infusion. As a result of using delayed systemic heparinization to avoid early bleeding, early hemolysis increased in the CPB-ECMO group. A delayed systemic heparinization of 9.5 hours showed the best Youden index results and the overall greatest accuracy in predicting early hemolysis. CONCLUSIONS A direct transition from CPB to ECMO in pediatric post-cardiotomy patients significantly increases early bleeding. Delayed systemic heparinization to reduce early bleeding has good discrimination for predicting early hemolysis in the CPB-ECMO group. Coagulopathy is complex in pediatric post-cardiotomy VA-ECMO patients who failed to wean from CPB, and, as such, it is extremely important to monitor coagulation-related indicators in multiple dimensions to determine the timing of systemic heparinization.
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Affiliation(s)
- Yu Jin
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yongli Cui
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yang Zhang
- Department of Laboratory Medicine, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Peiyao Zhang
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Liting Bai
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yixuan Li
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Peng Gao
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wenting Wang
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xu Wang
- Department of Pediatric Intensive Care Unit, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jinping Liu
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jinxiao Hu
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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13
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Bleeding and thrombotic events in patients with severe COVID-19 supported with extracorporeal membrane oxygenation: a nationwide cohort study. Intensive Care Med 2022; 48:1039-1052. [PMID: 35829723 DOI: 10.1007/s00134-022-06794-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 06/01/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE To describe bleeding and thrombotic events and their risk factors in patients receiving extracorporeal membrane oxygenation (ECMO) for severe coronavirus disease 2019 (COVID-19) and to evaluate their impact on in-hospital mortality. METHODS The ECMOSARS registry included COVID-19 patients supported by ECMO in France. We analyzed all patients included up to March 31, 2022 without missing data regarding bleeding and thrombotic events. The association of bleeding and thrombotic events with in-hospital mortality and pre-ECMO variables was assessed using multivariable logistic regression models. RESULTS Among 620 patients supported by ECMO, 29% had only bleeding events, 16% only thrombotic events and 20% both bleeding and thrombosis. Cannulation site (18% of patients), ear nose and throat (12%), pulmonary bleeding (9%) and intracranial hemorrhage (8%) were the most frequent bleeding types. Device-related thrombosis and pulmonary embolism/thrombosis accounted for most of thrombotic events. In-hospital mortality was 55.7%. Bleeding events were associated with in-hospital mortality (adjusted odds ratio (adjOR) = 2.91[1.94-4.4]) but not thrombotic events (adjOR = 1.02[0.68-1.53]). Intracranial hemorrhage was strongly associated with in-hospital mortality (adjOR = 13.5[4.4-41.5]). Ventilation duration before ECMO ≥ 7 days and length of ECMO support were associated with bleeding. Thrombosis-associated factors were fibrinogen ≥ 6 g/L and length of ECMO support. CONCLUSIONS In a nationwide cohort of COVID-19 patients supported by ECMO, bleeding incidence was high and associated with mortality. Intracranial hemorrhage incidence was higher than reported for non-COVID patients and carried the highest risk of death. Thrombotic events were less frequent and not associated with mortality. Length of ECMO support was associated with a higher risk of both bleeding and thrombosis, supporting the development of strategies to minimize ECMO duration.
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14
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Teng Y, Yan S, Liu G, Lou S, Zhang Y, Ji B. An Agreement Study Between Point-of-Care and Laboratory Activated Partial Thromboplastin Time for Anticoagulation Monitoring During Extracorporeal Membrane Oxygenation. Front Med (Lausanne) 2022; 9:931863. [PMID: 35847800 PMCID: PMC9276956 DOI: 10.3389/fmed.2022.931863] [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: 04/29/2022] [Accepted: 06/07/2022] [Indexed: 11/30/2022] Open
Abstract
Background Laboratory activated partial thromboplastin time (LAB-aPTT) is a widely used laboratory assay for monitoring unfractionated heparin (UFH) therapy during extracorporeal membrane oxygenation (ECMO). But LAB-aPTT is confined to a central laboratory, and the procedure is time-consuming. In comparison, point-of-care aPTT (POC-aPTT) is a convenient and quick assay, which might be a promising method for anticoagulation monitoring in ECMO. This study was aimed to evaluate the agreement between POC-aPTT (hemochron Jr. Signature instruments) and LAB-aPTT for anticoagulation monitoring in adult ECMO patients. Methods Data of ECMO-supported adult patients anticoagulated with UFH in our institute from January 2017 to December 2020 was retrospectively reviewed. POC-aPTT and LAB-aPTT results measured simultaneously were paired and included in the analysis. The correlation between POC-aPTT and LAB-aPTT was assessed using Spearman’s correlation coefficient. Bias between POC-aPTT and LAB-aPTT were described with the Bland-Altman method. Influence factors for bias were identified using multinomial logistic regression analysis. Results A total 286 pairs of aPTT results from 63 patients were included in the analysis. POC-aPTT and LAB-aPTT correlated weakly (r = 0.385, P < 0.001). The overall bias between POC-aPTT and LAB-aPTT was 7.78 [95%CI (−32.49, 48.05)] s. The overall bias between POC-aPTT and LAB-aPTT ratio (to normal value) was 0.54 [95%CI (−0.68, 1.76)]. A higher plasma fibrinogen level [OR 1.353 (1.057, 1.733), P = 0.017] was associated with a higher chance of POC-aPTT underestimating LAB-aPTT. While a lower plasma fibrinogen level [OR 0.809 (0.679, 0.963), P = 0.017] and lower UFH rate [OR 0.928 (0.868, 0.992), P = 0.029] were associated with a higher chance of POC-aPTT overestimating LAB-aPTT. Conclusion The present study showed poor agreement between POC-aPTT and LAB-aPTT. POC-aPTT was not suitable for anticoagulation monitoring in adult ECMO patients.
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Affiliation(s)
- Yuan Teng
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Diseases, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Shujie Yan
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Diseases, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Gang Liu
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Diseases, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Song Lou
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Diseases, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yang Zhang
- Center of Laboratory Medicine, National Center for Cardiovascular Diseases, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Bingyang Ji
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Diseases, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
- *Correspondence: Bingyang Ji,
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15
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Willers A, Swol J, van Kuijk SMJ, Buscher H, McQuilten Z, Ten Cate H, Rycus PT, McKellar S, Lorusso R, Tonna JE. HEROES V-A-HEmoRrhagic cOmplications in veno-arterial Extracorporeal life Support-Development and internal validation of a multivariable prediction model in adult patients. Artif Organs 2022; 46:2266-2283. [PMID: 35712783 DOI: 10.1111/aor.14340] [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: 10/08/2021] [Revised: 05/10/2022] [Accepted: 06/11/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Risk factors for bleeding complications during extracorporeal life support (ECLS) indicated for cardiac support remain poorly investigated. The aim is to develop and internally validate a prediction model to calculate the risk for bleeding complications in adult patients receiving veno-arterial (V-A) ECLS. METHODS Data of the Extracorporeal Life Support Organization registry of adult patients undergoing V-A ECLS between 2010 and 2020 were analyzed. The primary outcome was bleeding complications recorded during V-A ECLS. Multivariable logistic regression with backward stepwise elimination was used to develop the prediction model. Performance of the model was tested by discriminative ability and calibration with receiver operator characteristic, area under the curve, and visual inspection of the calibration plot. Internal validation was performed to detect overfitting of the model. RESULTS In total 28 767 adult patients were included, of which 29.0% developed bleeding complications. Sex, body mass index, surgical cannulation, pre-ECLS respiratory and hemodynamic variables, pre-ECLS support and interventions, and different type of diagnosis were included in the prediction model. This prediction model showed a predictive capability with an AUC of 0.66. CONCLUSION The model is based on the largest cohort of V-A ECLS patients and is the best available predictive model for bleeding events given the predictors that are available in V-A ECLS compared to current literature. The model can help in identifying patients at high risk for bleeding complications and will help in developing further research and decision-making in terms of anticoagulation management. External validation is warranted to extrapolate this model in the clinical setting.
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Affiliation(s)
- Anne Willers
- ECLS Center, Cardio-Thoracic Surgery Department, Heart & Vascular Center, Maastricht University Medical Center (MUMC), Maastricht, The Netherlands
| | - Justyna Swol
- Department of Respiratory Medicine, Allergology and Sleep Medicine, Paracelsus Medical University, Nuremberg, Germany
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Center (MUMC), Maastricht, The Netherlands
| | - Hergen Buscher
- Department of Intensive Care Medicine, Center of Applied Medical Research, St Vincent's Hospital, Sydney, New South Wales, Australia.,University of New South Wales, Sydney, New South Wales, Australia
| | - Zoe McQuilten
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne Australia Clinical Haematology, Monash Health, Melbourne, Victoria, Australia
| | - Hugo Ten Cate
- Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands.,Center for Thrombosis and Hemostasis (CTH), Gutenberg University Medical Center, Mainz, Germany.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Peter T Rycus
- Extracorporeal Life Support Organization, Ann Arbor, Michigan, USA
| | - Stephen McKellar
- Division of Cardiothoracic Surgery, University of Utah Health, Salt Lake City, Utah, USA
| | - Roberto Lorusso
- ECLS Center, Cardio-Thoracic Surgery Department, Heart & Vascular Center, Maastricht University Medical Center (MUMC), Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Joseph E Tonna
- Division of Cardiothoracic Surgery, University of Utah Health, Salt Lake City, Utah, USA.,Division of Emergency Medicine, University of Utah Health, Salt Lake City, Utah, USA
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16
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Kawauchi A, Liu K, Nakamura M, Suzuki H, Fujizuka K, Nakano M. Risk Factors for Bleeding Complications during Venovenous Extracorporeal Membrane Oxygenation as a Bridge to Recovery. Artif Organs 2022; 46:1901-1911. [PMID: 35451086 PMCID: PMC9543801 DOI: 10.1111/aor.14267] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 03/17/2022] [Accepted: 04/11/2022] [Indexed: 11/29/2022]
Abstract
Background Bleeding complications during venovenous extracorporeal membrane oxygenation (V‐V ECMO) can be critical. However, there is limited information on the associated risk factors. This study investigated the risk factors for bleeding complications during V‐V ECMO as a bridge to recovery. Methods This single‐center retrospective study enrolled 59 patients (bleeding and non‐bleeding groups) who received V‐V ECMO from 2012 to 2020, to evaluate whether peak activated partial thromboplastin time (APTT) value, lowest platelet count, and mobilization to sitting on the edge of the bed during V‐V ECMO were risk factors for bleeding complications, defined according to the Extracorporeal Life Support Organization guidelines. Age, sex, body mass index, Sequential Organ Failure Assessment score, and ECMO duration before bleeding complications were covariates in the multivariate logistic regression analysis. Results Thirty‐one (53%) participants experienced 36 bleeding complications; the ECMO cannulation site, gastrointestinal tract, and nasopharyngeal region were the most common bleeding sites. The use of transfusion products and length of ECMO and intensive care unit stay were significantly and medical costs were non‐significantly increased in the bleeding group. Peak APTT (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01–1.05, p < 0.01) was significantly associated whereas the lowest platelet count (OR 0.96, 95% CI 0.82–1.13, p = 0.66) was unassociated with bleeding complications during ECMO. Achieving mobilization (OR 0.14, 95% CI 0.02–1.17, p = 0.07) decreased the trend of risk for bleeding complications. Conclusions Peak APTT might be an independent modifiable factor for bleeding complications during V‐V ECMO. The protective effect of mobilization during V‐V ECMO requires further investigation.
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Affiliation(s)
- Akira Kawauchi
- Advanced Medical Emergency Department & Critical Care Center, Japanese Red Cross Maebashi Hospital, Gunma, Japan
| | - Keibun Liu
- Critical Care Research Group, The Prince Charles hospital, Brisbane, Australia
| | - Mitsunobu Nakamura
- Advanced Medical Emergency Department & Critical Care Center, Japanese Red Cross Maebashi Hospital, Gunma, Japan
| | - Hiroyuki Suzuki
- Advanced Medical Emergency Department & Critical Care Center, Japanese Red Cross Maebashi Hospital, Gunma, Japan
| | - Kenji Fujizuka
- Advanced Medical Emergency Department & Critical Care Center, Japanese Red Cross Maebashi Hospital, Gunma, Japan
| | - Minoru Nakano
- Advanced Medical Emergency Department & Critical Care Center, Japanese Red Cross Maebashi Hospital, Gunma, Japan
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17
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Garaj M, Durila M, Vajter J, Solcova M, Marecek F, Hrachovinová I. Extracorporeal membrane oxygenation seems to induce impairment of primary hemostasis pathology as measured by a Multiplate analyzer: An observational retrospective study. Artif Organs 2021; 46:899-907. [PMID: 34904233 DOI: 10.1111/aor.14142] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 11/12/2021] [Accepted: 12/10/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) support is often associated with bleeding complications caused by secondary or primary hemostasis pathology. However, there are limited data investigating primary hemostasis using Multiplate aggregometry with specific diagnostics tests for vWF (von Willebrand factor) deficiency. AIMS The aim of this study was to find out whether short-term ECMO produces the pathology of primary hemostasis that is detected by Multiplate aggregometry and to investigate the pathology of vWF. METHODS In this study, blood samples of 20 patients undergoing lung transplantations with short-term perioperative ECMO support were analyzed. The multimeric structure, the levels of von Willebrand factor antigen (vWF), ristocetin cofactor (RCo), collagen-binding protein (CB), and the results of multiple electrode aggregometry RISTO (ristocetin), ADP (adenosine diphosphate), ASPI (Aspirin®; arachidonic acid), and TRAP (thrombin receptor activating peptide) tests were compared to the samples obtained before and after ECMO support. RESULTS The Multiplate ADP and RISTO tests showed the presence of significant pathology in primary hemostasis after surgery (p < 0.05), suggesting the presence of acquired platelet dysfunction. Although the RISTO tests suggest the presence of acquired vWF deficiency, laboratory tests for vWF antigen and RCo and CB tests showed an increase in this case. The multimeric structure of vWF did not show clinically significant deterioration. CONCLUSIONS Multiple aggregometry ADP, ASPI, and TRAP tests seem to be able to detect primary hemostasis pathology (platelets aggregation and adhesion pathology) that is present during short-term perioperative ECMO support in lung transplantation procedures. Interestingly, RISTO tests seem to be more suitable for the diagnosis of platelet dysfunction than the diagnosis of acquired vWF deficiency in this situation.
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Affiliation(s)
- Michal Garaj
- Department of Anesthesiology and Intensive Care Medicine, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, the Czech Republic
| | - Miroslav Durila
- Department of Anesthesiology and Intensive Care Medicine, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, the Czech Republic
| | - Jaromir Vajter
- Department of Anesthesiology and Intensive Care Medicine, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, the Czech Republic
| | - Michaela Solcova
- Department of Clinical Hematology, Motol University Hospital, Prague, the Czech Republic
| | - Frantisek Marecek
- Institute of Hematology and Blood Transfusion, Prague, the Czech Republic
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Zhang JC, Li T. Awake extracorporeal membrane oxygenation support for a critically ill COVID-19 patient: A case report. World J Clin Cases 2021; 9:5963-5971. [PMID: 34368315 PMCID: PMC8316967 DOI: 10.12998/wjcc.v9.i21.5963] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 03/30/2021] [Accepted: 05/15/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND A critically ill coronavirus disease 2019 (COVID-19) patient complicated by acute respiratory distress syndrome is reported. The patient survived following treatment with awake veno-venous extracorporeal membrane oxygenation (ECMO).
CASE SUMMARY A 53-year-old male patient attended our hospital following a cough for 11 d and fever for 9 d. According to his computed tomography (CT) scan and real-time reverse transcription–polymerase chain reaction assay of a throat swab, nucleic acid was positive, confirming that he had COVID-19. He was subsequently transferred to the intensive care unit due to respiratory failure. The patient received antiviral drugs, a small dose of glucocorticoid, and respiratory support, including mechanical ventilation, but the treatment effect was poor. On the 28th day after admission, veno-venous ECMO and prone position ventilation (PPV) were performed, combined with awake ECMO and other comprehensive rehabilitation measures. On the 17th day of ECMO, the patient started to improve and his chest CT and lung compliance improved. ECMO was discontinued after 27 days, and mechanical ventilation was also discontinued after 9 days. The patient was then transferred to the rehabilitation department.
CONCLUSION COVID-19 can damage lung tissues and cause evident inflammatory exudation, thus affecting oxygenation function. Awake ECMO, PPV, and comprehensive rehabilitation are effective in patients with critical COVID-19 and respiratory failure.
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Affiliation(s)
- Jing-Chen Zhang
- Department of Critical Care Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Tong Li
- Department of Critical Care Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
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Patel PA, Henderson RA, Bolliger D, Erdoes G, Mazzeffi MA. The Year in Coagulation: Selected Highlights from 2020. J Cardiothorac Vasc Anesth 2021; 35:2260-2272. [PMID: 33781668 DOI: 10.1053/j.jvca.2021.02.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 02/26/2021] [Indexed: 01/28/2023]
Abstract
This is the second annual review in the Journal of Cardiothoracic and Vascular Anesthesia to cover highlights in coagulation for cardiac surgery. The goal of this article is to provide readers with a focused summary from the literature of the prior year's most important coagulation topics. In 2020, this included a discussion covering allogeneic transfusion, antiplatelet and anticoagulant therapy, factor concentrates, coagulation testing, mechanical circulatory support, and the effects of coronavirus disease 2019.
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Affiliation(s)
- Prakash A Patel
- Department of Anesthesiology, Cardiothoracic Division, Yale University School of Medicine, New Haven, CT.
| | - Reney A Henderson
- Department of Anesthesiology, Division of Cardiothoracic Anesthesia, University of Maryland School of Medicine, Baltimore, MD
| | - Daniel Bolliger
- Department of Anesthesiology, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Gabor Erdoes
- Department of Anesthesiology and Pain Medicine, Inselspital, University Hospital of Bern, Bern, Switzerland
| | - Michael A Mazzeffi
- Department of Anesthesiology, Division of Cardiothoracic Anesthesia, University of Maryland School of Medicine, Baltimore, MD; Department of Anesthesiology, Division of Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD
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