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Hofmaenner DA, Furfaro D, Wild LC, Wendel-Garcia PD, Baedorf Kassis E, Pannu A, Welte T, Erlebach R, Stahl K, Grandin EW, Putensen C, Schuepbach RA, Shaefi S, David S, Seeliger B, Bode C. Reduced anticoagulation strategy is associated with a lower incidence of intracerebral hemorrhage in COVID-19 patients on extracorporeal membrane oxygenation. Intensive Care Med Exp 2023; 11:38. [PMID: 37302996 DOI: 10.1186/s40635-023-00525-3] [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: 03/03/2023] [Accepted: 05/18/2023] [Indexed: 06/13/2023] Open
Abstract
BACKGROUND Optimal anticoagulation strategies for COVID-19 patients with the acute respiratory distress syndrome (ARDS) on venovenous extracorporeal membrane oxygenation (VV ECMO) remain uncertain. A higher incidence of intracerebral hemorrhage (ICH) during VV ECMO support compared to non-COVID-19 viral ARDS patients has been reported, with increased bleeding rates in COVID-19 attributed to both intensified anticoagulation and a disease-specific endotheliopathy. We hypothesized that lower intensity of anticoagulation during VV ECMO would be associated with a lower risk of ICH. In a retrospective, multicenter study from three academic tertiary intensive care units, we included patients with confirmed COVID-19 ARDS requiring VV ECMO support from March 2020 to January 2022. Patients were grouped by anticoagulation exposure into higher intensity, targeting anti-factor Xa activity (anti-Xa) of 0.3-0.4 U/mL, versus lower intensity, targeting anti-Xa 0.15-0.3 U/mL, cohorts. Mean daily doses of unfractionated heparin (UFH) per kg bodyweight and effectively measured daily anti-factor Xa activities were compared between the groups over the first 7 days on ECMO support. The primary outcome was the rate of ICH during VV ECMO support. RESULTS 141 critically ill COVID-19 patients were included in the study. Patients with lower anticoagulation targets had consistently lower anti-Xa activity values over the first 7 ECMO days (p < 0.001). ICH incidence was lower in patients in the lower anti-Xa group: 4 (8%) vs 32 (34%) events. Accounting for death as a competing event, the adjusted subhazard ratio for the occurrence of ICH was 0.295 (97.5% CI 0.1-0.9, p = 0.044) for the lower anti-Xa compared to the higher anti-Xa group. 90-day ICU survival was higher in patients in the lower anti-Xa group, and ICH was the strongest risk factor associated with mortality (odds ratio [OR] 6.8 [CI 2.1-22.1], p = 0.001). CONCLUSIONS For COVID-19 patients on VV ECMO support anticoagulated with heparin, a lower anticoagulation target was associated with a significant reduction in ICH incidence and increased survival.
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Affiliation(s)
- Daniel A Hofmaenner
- Institute of Intensive Care Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - David Furfaro
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Lennart C Wild
- Department of Anesthesia and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Pedro David Wendel-Garcia
- Institute of Intensive Care Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Elias Baedorf Kassis
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ameeka Pannu
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Tobias Welte
- Department of Respiratory Medicine, Hannover Medical School and Member of the German Centre for Lung Research, Biomedical Research in End-Stage and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany
| | - Rolf Erlebach
- Institute of Intensive Care Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Klaus Stahl
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Edward Wilson Grandin
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Christian Putensen
- Department of Anesthesia and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Reto A Schuepbach
- Institute of Intensive Care Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Sascha David
- Institute of Intensive Care Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
| | - Benjamin Seeliger
- Department of Respiratory Medicine, Hannover Medical School and Member of the German Centre for Lung Research, Biomedical Research in End-Stage and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany
| | - Christian Bode
- Department of Anesthesia and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
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Buchtele N, Schörgenhofer C, Schwameis M, Jilma B, Schellongowski P, Herkner H, Riss K, Schmid M, Hermann A, Robak O, Nagler B, Traby L, Bojic A, Staudinger T. Add-on Prostaglandin E1 in Venovenous Extracorporeal Membrane Oxygenation: A Randomized, Double-blind, Placebo-controlled Pilot Trial. Am J Respir Crit Care Med 2022; 206:170-177. [DOI: 10.1164/rccm.202110-2359oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Nina Buchtele
- Medical University of Vienna, Department of Medicine I, Vienna, Austria
| | | | - Michael Schwameis
- Medical University of Vienna, Department of Emergency Medicine, Vienna, Austria
| | - Bernd Jilma
- Clinical Pharmacology, AKH Wien, vienna, Austria
| | | | | | | | - Monika Schmid
- Medical University of Vienna, 27271, Department of Medicine III, Wien, Austria
| | | | - Oliver Robak
- Medical University of Vienna, 1Department of Internal Medicine I, Vienna, Austria
| | - Bernhard Nagler
- Medical University of Vienna, Department of Medicine I, Vienna, Austria
| | - Ludwig Traby
- Medical University of Vienna, Department of Medicine I, Vienna, Austria
| | - Andja Bojic
- Medical University of Vienna, Vienna, Austria
| | - Thomas Staudinger
- Medical University of Vienna, Dept. of Internal Medicine I, Vienna, Austria
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Abstract
Extracorporeal membrane oxygenation (ECMO) is increasingly being used for patients with severe respiratory failure and has received particular attention during the coronavirus disease 2019 (COVID-19) pandemic. Evidence from two key randomized controlled trials, a subsequent post hoc Bayesian analysis, and meta-analyses support the interpretation of a benefit of ECMO in combination with ultra-lung-protective ventilation for select patients with very severe forms of acute respiratory distress syndrome (ARDS). During the pandemic, new evidence has emerged helping to better define the role of ECMO for patients with COVID-19. Results from large cohorts suggest outcomes during the first wave of the pandemic were similar to those in non-COVID-19 cohorts. As the pandemic continued, mortality of patients supported with ECMO has increased. However, the precise reasons for this observation are unclear. Known risk factors for mortality in COVID-19 and non-COVID-19 patients are higher patient age, concomitant extra-pulmonary organ failures or malignancies, prolonged mechanical ventilation before ECMO, less experienced treatment teams and lower ECMO caseloads in the treating center. ECMO is a high resource-dependent support option; therefore, it should be used judiciously, and its availability may need to be constrained when resources are scarce. More evidence from high-quality research is required to better define the role and limitations of ECMO in patients with severe COVID-19.
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Menon NM, Srivaths LV. Thromboembolism in children with multisystem inflammatory syndrome: a literature review. Pediatr Res 2022; 92:946-950. [PMID: 35031708 PMCID: PMC8758928 DOI: 10.1038/s41390-021-01873-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 09/13/2021] [Accepted: 11/13/2021] [Indexed: 12/22/2022]
Abstract
Multisystem inflammatory syndrome in children (MIS-C) is a hyperinflammatory response observed in children several weeks to months after acute infection with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). On review of all published cases of thromboembolism (TE) as a complication of MIS-C, 33 cases of TE were found with incidence ranging from 1.4 to 6.5%. TE occurred mostly in children aged 12 years and above. One-third of the cases were cerebral infarcts and the remaining cases included intracardiac and radial arterial thromboses, upper and lower extremity deep vein thrombosis, pulmonary embolism, and splenic infarcts. Five were asymptomatic cases and 3/33 (9%) patients (all three with cerebral infarcts) died. To conclude, TE appears to be a significant complication of MIS-C caused by SARS-CoV-2 infection, associated with morbidity and/or mortality. Patients ≥12 years are affected more often, and TE occurs despite thromboprophylaxis in some patients. Thromboprophylaxis should be considered in all cases after reviewing the concomitant bleeding risk. Prospective studies are needed to confirm the role of standard-dose thromboprophylaxis and to explore whether higher-dose thromboprophylaxis is required in certain high-risk patients with MIS-C. IMPACT: Compiles all cases of thromboembolism associated with COVID-19-related MIS-C, a report that has not been published to date.
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Affiliation(s)
- Neethu M. Menon
- grid.267308.80000 0000 9206 2401Division of Hematology, Department of Pediatrics, University of Texas Health Science Center at Houston, 7000 Fannin Street, Houston, TX 77030 USA
| | - Lakshmi V. Srivaths
- grid.267308.80000 0000 9206 2401Division of Hematology, Department of Pediatrics, University of Texas Health Science Center at Houston, 7000 Fannin Street, Houston, TX 77030 USA
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Acharya Y, Alameer A, Calpin G, Alkhattab M, Sultan S. A comprehensive review of vascular complications in COVID-19. J Thromb Thrombolysis 2021; 53:586-593. [PMID: 34724155 PMCID: PMC8558544 DOI: 10.1007/s11239-021-02593-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/13/2021] [Indexed: 02/08/2023]
Abstract
This study aims to review the available literature pertinent to vascular complications in COVID-19. A systematic search was performed using PubMed and Google Scholar to identify all relevant studies based on our study objective. Multiple studies have reported widespread systemic inflammation and procoagulant/hypercoagulable state in COVID-19, including thrombotic microangiopathy, endothelial dysfunction, bleeding disorder, and thrombosis. However, large specialised studies on vascular complications are lacking despite current evidence indicating dysfunctional coagulation pathways. Furthermore, there are no clear and definitive recommendations regarding thromboprophylaxis or full therapeutic anticoagulation in COVID-19. Several studies have reported hypercoagulability and vascular complications as important predictors of patient outcome in COVID-19. Therefore, it is important to understand the pathogenesis, epidemiology, management, and outcomes of patients who develop venous or arterial thrombosis and those with a pre-existing thrombotic disease who contract COVID-19 for risk stratification, thromboprophylaxis, optimal antithrombotic therapy during active infection and long-term anticoagulation following discharge or recovery.
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Affiliation(s)
- Yogesh Acharya
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, National University of Ireland, Newcastle Road, H91 YR71, Galway, Ireland
| | - Aqeel Alameer
- Department of Surgery, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland
| | - Gavin Calpin
- Department of General Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Maha Alkhattab
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, National University of Ireland, Newcastle Road, H91 YR71, Galway, Ireland
| | - Sherif Sultan
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, National University of Ireland, Newcastle Road, H91 YR71, Galway, Ireland. .,Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Royal College of Surgeons in Ireland and National University of Ireland Galway affiliated Hospital, Doughiska, Ireland.
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