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Wagner MS, Kranz M, Krenkel L, Pointner D, Foltan M, Lubnow M, Lehle K. Computer based visualization of clot structures in extracorporeal membrane oxygenation and histological clot investigations for understanding thrombosis in membrane lungs. Front Med (Lausanne) 2024; 11:1416319. [PMID: 38962744 PMCID: PMC11219572 DOI: 10.3389/fmed.2024.1416319] [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: 04/12/2024] [Accepted: 06/06/2024] [Indexed: 07/05/2024] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) was established as a treatment for severe cardiac or respiratory disease. Intra-device clot formation is a common risk. This is based on complex coagulation phenomena which are not yet sufficiently understood. The objective was the development and validation of a methodology to capture the key properties of clots deposed in membrane lungs (MLs), such as clot size, distribution, burden, and composition. One end-of-therapy PLS ML was examined. Clot detection was performed using multidetector computed tomography (MDCT), microcomputed tomography (μCT), and photography of fiber mats (fiber mat imaging, FMI). Histological staining was conducted for von Willebrand factor (vWF), platelets (CD42b, CD62P), fibrin, and nucleated cells (4', 6-diamidino-2-phenylindole, DAPI). The three imaging methods showed similar clot distribution inside the ML. Independent of the imaging method, clot loading was detected predominantly in the inlet chamber of the ML. The μCT had the highest accuracy. However, it was more expensive and time consuming than MDCT or FMI. The MDCT detected the clots with low scanning time. Due to its lower resolution, it only showed clotted areas but not the exact shape of clot structures. FMI represented the simplest variant, requiring little effort and resources. FMI allowed clot localization and calculation of clot volume. Histological evaluation indicated omnipresent immunological deposits throughout the ML. Visually clot-free areas were covered with leukocytes and platelets forming platelet-leukocyte aggregates (PLAs). Cells were embedded in vWF cobwebs, while vWF fibers were negligible. In conclusion, the presented methodology allowed adequate clot identification and histological classification of possible thrombosis markers such as PLAs.
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Affiliation(s)
- Maria S. Wagner
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Michael Kranz
- Department of Biofluid Mechanics, Faculty of Mechanical Engineering, Technical University of Applied Sciences (OTH) Regensburg, Regensburg, Germany
- Regensburg Center of Biomedical Engineering, Facility of University Regensburg and Technical University of Applied Sciences (OTH) Regensburg, Regensburg, Germany
| | - Lars Krenkel
- Department of Biofluid Mechanics, Faculty of Mechanical Engineering, Technical University of Applied Sciences (OTH) Regensburg, Regensburg, Germany
- Regensburg Center of Biomedical Engineering, Facility of University Regensburg and Technical University of Applied Sciences (OTH) Regensburg, Regensburg, Germany
| | - Daniel Pointner
- Department of Biofluid Mechanics, Faculty of Mechanical Engineering, Technical University of Applied Sciences (OTH) Regensburg, Regensburg, Germany
- Regensburg Center of Biomedical Engineering, Facility of University Regensburg and Technical University of Applied Sciences (OTH) Regensburg, Regensburg, Germany
| | - Maik Foltan
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Karla Lehle
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
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Penn AH, Falabella M, Sanchez A, Hernandez O, McFadden K, Hutcheson J. 25% HUMAN SERUM ALBUMIN IMPROVES HEMODYNAMICS AND PREVENTS THE NEED FOR NEARLY ALL PREHOSPITAL RESUSCITATION IN A RAT ( RATTUS NORVEGICUS ) MODEL OF TRAUMA AND HEMORRHAGE. Shock 2024; 61:869-876. [PMID: 38319752 DOI: 10.1097/shk.0000000000002313] [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: 02/08/2024]
Abstract
ABSTRACT Combat casualty care can be complicated by transport times exceeding the "golden hour," with intervention and resuscitation limited to what the medic can carry. Pharmaceutical albumin comes highly saturated with nonesterified fatty acids (NEFAs). We recently showed that treatment with 25% bovine serum albumin (BSA) loaded with oleic acid, but not NEFA-free BSA, improved survival for hours after severe hemorrhage and often eliminated the need for resuscitation in rats. However, it was unknown whether pharmaceutical albumin, derived from human sources and loaded with caprylic acid (CA), would have the same benefits. We compared adjunct treatment with oleic acid-saturated BSA, CA-saturated BSA, pharmaceutical human serum albumin, or a no-albumin control in a similar rat hemorrhagic shock model to determine whether the three NEFA-albumin groups provided the same benefits relative to control. We found almost no significant differences among the NEFA-albumin groups in any measure. Mortality in controls was too low to allow for detection of improvement in survival, but NEFA-albumin groups had significantly improved hemodynamics, lactate clearance, and greatly reduced fluid requirements compared with controls. Contrary to expectations of "dehydration," 25% albumins shifted little additional fluid into the vasculature. Rather, they restored protein to the autotransfusion fluid. Nonesterified fatty acids-albumin did not worsen lung permeability, but we observed a loss of circulating protein suggesting it may have increased overall vascular permeability. Our findings suggest that, though imperfect, 25% human serum albumin could be a solution for resuscitation in austere conditions requiring prolonged field care.
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Affiliation(s)
- Alexander H Penn
- Defense Health Agency, United States Air Force 59th Medical Wing, Surgical and Technological Advancements for Traumatic Injury in Combat (STATIC), JBSA-Lackland, Texas
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Roberts TR, Persello A, Harea GT, Vedula EM, Isenberg BC, Zang Y, Santos J, Borenstein JT, Batchinsky AI. First 24-Hour-Long Intensive Care Unit Testing of a Clinical-Scale Microfluidic Oxygenator in Swine: A Safety and Feasibility Study. ASAIO J 2024; 70:535-544. [PMID: 38165978 DOI: 10.1097/mat.0000000000002127] [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: 01/04/2024] Open
Abstract
Microfluidic membrane oxygenators are designed to mimic branching vasculature of the native lung during extracorporeal lung support. To date, scaling of such devices to achieve clinically relevant blood flow and lung support has been a limitation. We evaluated a novel multilayer microfluidic blood oxygenator (BLOx) capable of supporting 750-800 ml/min blood flow versus a standard hollow fiber membrane oxygenator (HFMO) in vivo during veno-venous extracorporeal life support for 24 hours in anesthetized, mechanically ventilated uninjured swine (n = 3/group). The objective was to assess feasibility, safety, and biocompatibility. Circuits remained patent and operated with stable pressures throughout 24 hours. No group differences in vital signs or evidence of end-organ damage occurred. No change in plasma free hemoglobin and von Willebrand factor multimer size distribution were observed. Platelet count decreased in BLOx at 6 hours (37% dec, P = 0.03), but not in HFMO; however, thrombin generation potential was elevated in HFMO (596 ± 81 nM·min) versus BLOx (323 ± 39 nM·min) at 24 hours ( P = 0.04). Other coagulation and inflammatory mediator results were unremarkable. BLOx required higher mechanical ventilator settings and showed lower gas transfer efficiency versus HFMO, but the stable device performance indicates that this technology is ready for further performance scaling and testing in lung injury models and during longer use conditions.
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Affiliation(s)
- Teryn R Roberts
- From the Autonomous Reanimation and Evacuation Research Program, The Geneva Foundation, San Antonio, Texas
| | - Antoine Persello
- From the Autonomous Reanimation and Evacuation Research Program, The Geneva Foundation, San Antonio, Texas
| | - George T Harea
- From the Autonomous Reanimation and Evacuation Research Program, The Geneva Foundation, San Antonio, Texas
| | - Else M Vedula
- Bioengineering Division, Draper, Cambridge, Massachusetts
| | | | - Yanyi Zang
- From the Autonomous Reanimation and Evacuation Research Program, The Geneva Foundation, San Antonio, Texas
| | - Jose Santos
- Bioengineering Division, Draper, Cambridge, Massachusetts
| | | | - Andriy I Batchinsky
- From the Autonomous Reanimation and Evacuation Research Program, The Geneva Foundation, San Antonio, Texas
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Roberts TR, Seekell RP, Zang Y, Harea G, Zhang Z, Batchinsky AI. In vitro hemocompatibility screening of a slippery liquid impregnated surface coating for extracorporeal organ support applications. Perfusion 2024; 39:76-84. [PMID: 35514052 DOI: 10.1177/02676591221095469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Clot formation, infection, and biofouling are unfortunate but frequent complications associated with the use of blood-contacting medical devices. The challenge of blood-foreign surface interactions is exacerbated during medical device applications involving substantial blood contact area and extended duration of use, such as extracorporeal life support (ECLS). We investigated a novel surface modification, a liquid-impregnated surface (LIS), designed to minimize protein adsorption and thrombus development on medical plastics. METHODS The hemocompatibility and efficacy of LIS was investigated first in a low-shear model with LIS applied to the lumen of blood incubation vials and exposed to human whole blood. Additionally, LIS was evaluated in a 6 h ex vivo circulation model with swine blood using full-scale ECLS circuit tubing and centrifugal pumps with clinically relevant flow rate (1.5 L/min) and shear conditions for extracorporeal carbon dioxide removal. RESULTS Under low-shear, LIS preserved fibrinogen concentration in blood relative to control polymers (+40 ± 6 mg/dL vs polyvinyl chloride, p < .0001), suggesting protein adsorption was minimized. A fibrinogen adhesion assay demonstrated a dramatic reduction in protein adsorption under low shear (87% decrease vs polyvinyl chloride, p = .01). Thrombus deposition and platelet adhesion visualized by scanning electron microscopy were drastically reduced. During the 6 h ex vivo circulation, platelets in blood exposed to LIS tubing did not become significantly activated or procoagulant, as occurred with control tubing; and again, thrombus deposition was visually reduced. CONCLUSIONS A LIS coating demonstrated potential to reduce thrombus formation on medical devices. Further testing is needed specialized to clinical setting and duration of use for specific medical target applications.
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Affiliation(s)
- Teryn R Roberts
- Autonomous Reanimation and Evacuation Research Program, The Geneva Foundation, San Antonio, TX, USA
| | | | - Yanyi Zang
- Autonomous Reanimation and Evacuation Research Program, The Geneva Foundation, San Antonio, TX, USA
| | - George Harea
- Autonomous Reanimation and Evacuation Research Program, The Geneva Foundation, San Antonio, TX, USA
| | | | - Andriy I Batchinsky
- Autonomous Reanimation and Evacuation Research Program, The Geneva Foundation, San Antonio, TX, USA
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Zhao J, Cui P, Zhou Z, Niu B, Pan C. Treatment of malignant airway stenosis with extracorporeal membrane oxygenation under low-dose anticoagulation: A case report. Heliyon 2023; 9:e23210. [PMID: 38144268 PMCID: PMC10746480 DOI: 10.1016/j.heliyon.2023.e23210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 11/24/2023] [Accepted: 11/29/2023] [Indexed: 12/26/2023] Open
Abstract
The occurrence of airway obstruction due to severe stenosis from lung cancer poses a significant risk of asphyxia. Although the placement of a metallic stent may relieve the obstruction, the procedure is associated with a high risk of asphyxia. To mitigate this risk, extracorporeal membrane pulmonary oxygenation (ECMO) has been proposed to temporarily substitute for cardiopulmonary function during the procedure. However, the use of systemic anticoagulation with heparin during ECMO may increase the likelihood of bleeding during surgery. This case report describes a successful treatment of a patient with malignant central airway obstruction through low-dose heparin veno-venous ECMO. This approach resulted in reduced intraoperative bleeding and invasive operation time, allowing for prompt postoperative withdrawal and recovery.
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Affiliation(s)
- Jingsha Zhao
- Department of Intensive Care Unit, The Third People's Hospital of Chengdu, Chengdu, Sichuan, China
- Department of Intensive Care Unit, Pujiang People's Hospital, Chengdu, Sichuan, China
| | - Peng Cui
- Department of Cardiovascular, The Third People's Hospital of Chengdu, Chengdu, Sichuan, China
| | - Ziwei Zhou
- Department of Intensive Care Unit, The Third People's Hospital of Chengdu, Chengdu, Sichuan, China
| | - Bin Niu
- Department of Respiratory, The Third People's Hospital of Chengdu, Chengdu, Sichuan, China
| | - Chuanliang Pan
- Department of Intensive Care Unit, The Third People's Hospital of Chengdu, Chengdu, Sichuan, China
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Khan SA, Shakoor A. Recent Strategies and Future Recommendations for the Fabrication of Antimicrobial, Antibiofilm, and Antibiofouling Biomaterials. Int J Nanomedicine 2023; 18:3377-3405. [PMID: 37366489 PMCID: PMC10290865 DOI: 10.2147/ijn.s406078] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 05/06/2023] [Indexed: 06/28/2023] Open
Abstract
Biomaterials and biomedical devices induced life-threatening bacterial infections and other biological adverse effects such as thrombosis and fibrosis have posed a significant threat to global healthcare. Bacterial infections and adverse biological effects are often caused by the formation of microbial biofilms and the adherence of various biomacromolecules, such as platelets, proteins, fibroblasts, and immune cells, to the surfaces of biomaterials and biomedical devices. Due to the programmed interconnected networking of bacteria in microbial biofilms, they are challenging to treat and can withstand several doses of antibiotics. Additionally, antibiotics can kill bacteria but do not prevent the adsorption of biomacromolecules from physiological fluids or implanting sites, which generates a conditioning layer that promotes bacteria's reattachment, development, and eventual biofilm formation. In these viewpoints, we highlighted the magnitude of biomaterials and biomedical device-induced infections, the role of biofilm formation, and biomacromolecule adhesion in human pathogenesis. We then discussed the solutions practiced in healthcare systems for curing biomaterials and biomedical device-induced infections and their limitations. Moreover, this review comprehensively elaborated on the recent advances in designing and fabricating biomaterials and biomedical devices with these three properties: antibacterial (bacterial killing), antibiofilm (biofilm inhibition/prevention), and antibiofouling (biofouling inhibition/prevention) against microbial species and against the adhesion of other biomacromolecules. Besides we also recommended potential directions for further investigations.
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Affiliation(s)
- Shakeel Ahmad Khan
- Department of Applied Biology and Chemical Technology, the Hong Kong Polytechnic University, Hung Hom, Kowloon, 999077, Hong Kong
| | - Adnan Shakoor
- Department of Control and Instrumentation Engineering, King Fahd University of Petroleum & Minerals, Dhahran, Saudi Arabia
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Roberts TR, Harea GT, Zang Y, Devine RP, Maffe P, Handa H, Batchinsky AI. A dual-action nitric oxide-releasing slippery surface for extracorporeal organ support: Dynamic in vitro hemocompatibility evaluation. J Biomed Mater Res B Appl Biomater 2023; 111:923-932. [PMID: 36404401 DOI: 10.1002/jbm.b.35202] [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: 08/16/2022] [Revised: 11/01/2022] [Accepted: 11/13/2022] [Indexed: 11/22/2022]
Abstract
Numerous biomaterials have been developed for application in blood-contacting medical devices to prevent thrombosis; however, few materials have been applied to full-scale devices and evaluated for hemocompatibility under clinical blood flow conditions. We applied a dual-action slippery liquid-infused (LI) nitric oxide (NO)-releasing material modification (LINO) to full-scale blood circulation tubing for extracorporeal lung support and evaluated the tubing ex vivo using swine whole blood circulated for 6 h at a clinically relevant flow. LINO tubing was compared to unmodified tubing (CTRL) and isolated LI and NO-releasing modifications (n = 9/group). The primary objective was to evaluate safety and blood compatibility of this approach, prior to progression to in vivo testing of efficacy in animal models. The secondary objective was to evaluate coagulation outcomes relevant to hemocompatibility. No untoward effects of the coating, such as elevated methemoglobin fraction, were observed. Additionally, LINO delayed platelet loss until 6 h versus the reduction in platelet count in CTRL at 3 h. At 6 h, LINO significantly reduced the concentration of platelets in an activated P-selectin expressing state versus CTRL (32 ± 1% decrease, p = .02). Blood clot deposition was significantly reduced on LINO blood pumps (p = .007) and numerically reduced on tubing versus CTRL. Following blood exposure, LINO tubing continued to produce a measurable NO-flux (0.20 ± 0.06 × 10-10 mol cm-2 min-1 ). LINO is a potential solution to reduce circuit-related bleeding and clotting during extracorporeal organ support, pending future extended testing in vivo using full-scale extracorporeal lung support devices.
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Affiliation(s)
- Teryn R Roberts
- Autonomous Reanimation and Evacuation Research Program, The Geneva Foundation, San Antonio, Texas, USA
| | - George T Harea
- Autonomous Reanimation and Evacuation Research Program, The Geneva Foundation, San Antonio, Texas, USA
| | - Yanyi Zang
- Autonomous Reanimation and Evacuation Research Program, The Geneva Foundation, San Antonio, Texas, USA
| | - Ryan P Devine
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, Athens, Georgia, USA
| | - Patrick Maffe
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, Athens, Georgia, USA
| | - Hitesh Handa
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, Athens, Georgia, USA.,Department of Pharmaceutical and Biomedical Sciences, College of Pharmacy, University of Georgia, Athens, Georgia, USA
| | - Andriy I Batchinsky
- Autonomous Reanimation and Evacuation Research Program, The Geneva Foundation, San Antonio, Texas, USA
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Gao S, Zhang Y, Peng R, Yan S, Teng Y, Qi J, Cheng G, Yu D, Liu G, Xu Q, Cai X, Zhou Z, Ji B. Hemostatic alterations during extracorporeal membrane oxygenation in ovine veno-venous and veno-arterial models. Artif Organs 2023; 47:526-536. [PMID: 36310416 DOI: 10.1111/aor.14437] [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: 04/12/2022] [Revised: 08/10/2022] [Accepted: 10/11/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) has salvaged many people's life during global pandemics. However, ECMO is associated with a high incidence of hemostatic complications. This study aims to explore the effects of the ECMO system on the coagulation system in the healthy ovine ECMO model. METHODS Ten healthy male sheep were included. Five received the veno-arterial ECMO and five received the veno-venous ECMO. Heparin was infused for systemic anticoagulation and was adjusted according to the activated clotting time. Blood routine tests, coagulation factors, anticoagulation proteins, and fibrinolysis markers were tested at the baseline and every 24 h. After weaning, the pump heads were dissected to explore thrombosis. RESULTS Platelets decreased in the first 72 h and returned to the baseline at the 120th hour. The neutrophils increased in the first 24 h and returned to the baseline at the 48th hour. Factors II, VII, and X decreased in the first 24 h and gradually increased, while factors VIII, IX, XI, and XII decreased in the first 24 h and remained at a low level. The baseline antithrombin was 73.2 ± 14.4% and reduced to 42.6 ± 9.9% at the 168th hour. Pathology showed seven sheep developed thrombus, but no clinically relevant bleeding or thrombosis events occurred. CONCLUSIONS The study explored hemostatic alterations during ECMO in healthy animal models, which eliminated the confounding under critically ill conditions. The study may provide insights into ECMO hemostatic disorders and aid the design of optimal therapeutic strategies.
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Affiliation(s)
- Sizhe Gao
- 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, Beijing, China
| | - Rui Peng
- Department of Laboratory Medicine, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Beijing, China.,Center of Clinical Laboratory, Capital Medical University Affiliated Beijing Friendship Hospital, Beijing, China
| | - Shujie Yan
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Beijing, China
| | - Yuan Teng
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Beijing, China
| | - Jiachen Qi
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Beijing, China
| | - Gaowa Cheng
- Department of Laboratory Medicine, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Beijing, China
| | - Dongze Yu
- Department of Laboratory Medicine, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Beijing, China
| | - Gang Liu
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Beijing, China
| | - Qiang Xu
- Department of Laboratory Medicine, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Beijing, China
| | - Xiaohui Cai
- Department of Laboratory Medicine, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Beijing, China
| | - Zhou Zhou
- Department of Laboratory Medicine, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Beijing, China
| | - Bingyang Ji
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Beijing, China
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Condello I. Anticoagulation in Emergency Cardiac Surgery - The Rationale for Modular Minimally Invasive Extracorporeal Circulation Use. Braz J Cardiovasc Surg 2023; 38:209-210. [PMID: 35244368 PMCID: PMC10010715 DOI: 10.21470/1678-9741-2020-0481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2023] Open
Affiliation(s)
- Ignazio Condello
- Department of Cardiac Surgery, Anthea Hospital, GVM Care & Research, Bari, Italy
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Rajsic S, Breitkopf R, Jadzic D, Popovic Krneta M, Tauber H, Treml B. Anticoagulation Strategies during Extracorporeal Membrane Oxygenation: A Narrative Review. J Clin Med 2022; 11:jcm11175147. [PMID: 36079084 PMCID: PMC9457503 DOI: 10.3390/jcm11175147] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 08/24/2022] [Accepted: 08/29/2022] [Indexed: 11/30/2022] Open
Abstract
The development of extracorporeal life support technology has added a new dimension to the care of critically ill patients who fail conventional treatment options. Extracorporeal membrane oxygenation (ECMO)—specialized temporary life support for patients with severe cardiac or pulmonary failure—plays a role in bridging the time for organ recovery, transplant, or permanent assistance. The overall patient outcome is dependent on the underlying disease, comorbidities, patient reaction to critical illness, and potential adverse events during ECMO. Moreover, the contact of the blood with the large artificial surface of an extracorporeal system circuit triggers complex inflammatory and coagulation responses. These processes may further lead to endothelial injury and disrupted microcirculation with consequent end-organ dysfunction and the development of adverse events like thromboembolism. Therefore, systemic anticoagulation is considered crucial to alleviate the risk of thrombosis and failure of ECMO circuit components. The gold standard and most used anticoagulant during extracorporeal life support is unfractionated heparin, with all its benefits and disadvantages. However, therapeutic anticoagulation of a critically ill patient carries the risk of clinically relevant bleeding with the potential for permanent injury or death. Similarly, thrombotic events may occur. Therefore, different anticoagulation strategies are employed, while the monitoring and the balance of procoagulant and anticoagulatory factors is of immense importance. This narrative review summarizes the most recent considerations on anticoagulation during ECMO support, with a special focus on anticoagulation monitoring and future directions.
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Affiliation(s)
- Sasa Rajsic
- Department of Anaesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Robert Breitkopf
- Department of Anaesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Dragana Jadzic
- Anaesthesia and Intensive Care Department, Pain Therapy Service, Cagliari University, 09042 Cagliari, Italy
| | | | - Helmuth Tauber
- Department of Anaesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Benedikt Treml
- Department of Anaesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
- Correspondence: ; Tel.: +43-50504-82231
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Melvin AC, Wick TV, Zang Y, Harea GT, Cancio LC, Reynolds MM, Batchinsky AI, Roberts TR. Development and Blood Compatibility of a Stable and Bioactive Metal-Organic Framework Composite Coating for Blood-Circulation Tubing. ACS Biomater Sci Eng 2022; 8:3438-3449. [PMID: 35776832 DOI: 10.1021/acsbiomaterials.2c00492] [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: 11/30/2022]
Abstract
Medical devices that require substantial contact between blood and a foreign surface would be dramatically safer if constructed from materials that prevent clot formation and coagulation disturbance at the blood-biomaterial interface. Nitric oxide (NO), an endogenous inhibitor of platelet activation in the vascular endothelium, could provide anticoagulation at the blood-surface interface when applied to biomaterials. We investigated an application of a copper-based metal-organic framework, H3[(Cu4Cl)3(BTTri)8-(H2O)12]·72H2O where H3BTTri = 1,3,5-tris(1H-1,2,3-triazole-5-yl)benzene] (CuBTTri), which has been shown to be an effective catalyst to generate NO from S-nitrosothiols that are endogenously present in blood. A method was developed to apply a CuBTTri composite coating to Tygon medical tubing used for extracorporeal lung support devices. The stability and activity of the coating were evaluated during 72 h dynamic saline flow testing (1.5-2.5 L/min, n = 3) with scanning electron microscopy imaging and inductively coupled mass-spectroscopy analysis. Compatibility of the coating with whole blood was assessed with a panel of hemocompatibility tests during 6 h circulation of swine donor blood in an ex vivo circulation loop constructed with CuBTTri tubing or unmodified Tygon (1.5 L/min blood flow rate, n = 8/group). Thrombus deposition and catalytic activity of the CuBTTri tubing were assessed following blood exposure. The coating remained stable during 72 h saline flow experiments at clinically relevant flow rates. No adverse effects were observed relative to controls during blood compatibility testing, to include no significant changes in platelet count (p = 0.42), platelet activation indicated by P-selectin expression (p = 0.57), coagulation panel values, or methemoglobin fraction (p = 0.18) over the 6 h circulation period. CuBTTri within the coating generated NO following blood exposure in the presence of biologically relevant concentrations of an NO donor. CuBTTri composite coating was stable and blood compatible in this pilot study and requires further investigation of efficacy using in vivo models conducted with clinically relevant blood flow rates and study duration.
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Affiliation(s)
- Alyssa C Melvin
- Colorado State University, 301 West Pitkin Street, Fort Collins, Colorado 80523, United States
| | - Tracey V Wick
- Colorado State University, 301 West Pitkin Street, Fort Collins, Colorado 80523, United States
| | - Yanyi Zang
- Autonomous Reanimation and Evacuation Research Program, The Geneva Foundation, 2509 Kennedy Circle, San Antonio, Texas 78259, United States
| | - George T Harea
- Autonomous Reanimation and Evacuation Research Program, The Geneva Foundation, 2509 Kennedy Circle, San Antonio, Texas 78259, United States
| | - Leopoldo C Cancio
- US Army Institute of Surgical Research Burn Center, 3698 Chambers Road, Fort Sam Houston, Texas 78234, United States
| | - Melissa M Reynolds
- Colorado State University, 301 West Pitkin Street, Fort Collins, Colorado 80523, United States
| | - Andriy I Batchinsky
- Autonomous Reanimation and Evacuation Research Program, The Geneva Foundation, 2509 Kennedy Circle, San Antonio, Texas 78259, United States
| | - Teryn R Roberts
- Autonomous Reanimation and Evacuation Research Program, The Geneva Foundation, 2509 Kennedy Circle, San Antonio, Texas 78259, United States
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Zhao YC, Zhao X, Fu GW, Huang MJ, Li XX, Sun QQ, Kan YB, Li J, Wang SL, Ma WT, Xu QF, Liu QL, Li HB. Heparin-free after 3000 IU heparin loaded in veno-venous ECMO supported acute respiratory failure patients with hemorrhage risk: a novel anti-coagulation strategy. Thromb J 2022; 20:36. [PMID: 35761333 PMCID: PMC9235184 DOI: 10.1186/s12959-022-00396-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 06/09/2022] [Indexed: 11/17/2022] Open
Abstract
Background The anti-coagulation protocol of patients with hemorrhage risk primary disease who need extracorporeal membrane oxygenation (ECMO) supported is controversial. This study evaluated the feasibility of a new anti-coagulation strategy, that is heparin-free after 3000 IU heparin loaded in veno-venous ECMO (VV ECMO) supported acute respiratory failure patients with hemorrhage risk. Methods A retrospective study was performed in a series of hemorrhage risk patients supported with VV ECMO at the First Affiliated Hospital of Zhengzhou University, between June 2012 to Sept 2020. A total of 70 patients received a low heparin bolus of 3000 units for cannulation but without subsequent, ongoing heparin administration. Patients were divided into survival (n = 25) and non-survival group (n = 45). Data of coagulation, hemolysis and membrane lung function were calculated and analyzed. The complications of patients were recorded. Finally, the binary Logistic regression was conducted. Results The longest heparin-free time was 216 h, and the mean heparin-free time was 102 h. Compared with survivors, the non-survivors were showed higher baseline SOFA score and lower platelet counts in 0.5 h, 24 h, 48 h and 96 h after ECMO applied. However, there was no significant differences between survivors and non-survivors in ACT, APTT, INR, D-dimer, fibrinogen, LDH, blood flow rate, Δp and Ppost-MLO2 (all p < 0.05) of all different time point. Moreover, only the baseline SOFA score was significantly associated with mortality (p < 0.001, OR(95%CI): 2.754 (1.486–5.103)) while the baseline levels of ACT, APTT, INR, platelet, D-dimer, fibrinogen and LDH have no association with mortality. The percentage of thrombosis complications was 54.3% (38/70) including 3 oxygenator changed but there was no significant difference of complications in survival and non-survival groups (p > 0.05). Conclusions The anticoagulation protocol that no heparin after a 3000 units heparin bolus in VV ECMO supported acute respiratory failure patients with hemorrhage risk is feasible.
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Affiliation(s)
- Yang-Chao Zhao
- Department of Extracorporeal Life Support Center, Department of Cardiac Surgery, The First Affiliated Hospital of Zhengzhou University, JianShe Road 1, Zhengzhou, 450052, Henan, China.
| | - Xi Zhao
- Department of Cardiology, Henan Key Laboratory of Hereditary Cardiovascular Diseases, The First Affiliated Hospital of Zhengzhou University, Cardiovascular Center, Zhengzhou, 450052, Henan, China
| | - Guo-Wei Fu
- Department of Extracorporeal Life Support Center, Department of Cardiac Surgery, The First Affiliated Hospital of Zhengzhou University, JianShe Road 1, Zhengzhou, 450052, Henan, China
| | - Ming-Jun Huang
- Department of Extracorporeal Life Support Center, Department of Cardiac Surgery, The First Affiliated Hospital of Zhengzhou University, JianShe Road 1, Zhengzhou, 450052, Henan, China
| | - Xing-Xing Li
- Department of Extracorporeal Life Support Center, Department of Cardiac Surgery, The First Affiliated Hospital of Zhengzhou University, JianShe Road 1, Zhengzhou, 450052, Henan, China
| | - Qian-Qian Sun
- Department of Extracorporeal Life Support Center, Department of Cardiac Surgery, The First Affiliated Hospital of Zhengzhou University, JianShe Road 1, Zhengzhou, 450052, Henan, China
| | - Ya-Bai Kan
- Department of Extracorporeal Life Support Center, Department of Cardiac Surgery, The First Affiliated Hospital of Zhengzhou University, JianShe Road 1, Zhengzhou, 450052, Henan, China
| | - Jun Li
- Department of Extracorporeal Life Support Center, Department of Cardiac Surgery, The First Affiliated Hospital of Zhengzhou University, JianShe Road 1, Zhengzhou, 450052, Henan, China
| | - Shi-Lei Wang
- Department of Respiration, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, China
| | - Wen-Tao Ma
- Department of Respiration, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, China
| | - Qin-Fu Xu
- Department of Respiration, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, China
| | - Qi-Long Liu
- Department of Surgery ICU, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, China
| | - Hong-Bin Li
- Department of Surgery ICU, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, China
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Hanafy NAN, El-Kemary MA. Silymarin/curcumin loaded albumin nanoparticles coated by chitosan as muco-inhalable delivery system observing anti-inflammatory and anti COVID-19 characterizations in oleic acid triggered lung injury and in vitro COVID-19 experiment. Int J Biol Macromol 2022; 198:101-110. [PMID: 34968533 PMCID: PMC8712435 DOI: 10.1016/j.ijbiomac.2021.12.073] [Citation(s) in RCA: 47] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 11/28/2021] [Accepted: 12/11/2021] [Indexed: 02/08/2023]
Abstract
Respiratory infected by COVID-19 represents a major global health problem at moment even after recovery from virus corona. Since, the lung lesions for infected patients are still sufferings from acute respiratory distress syndrome including alveolar septal edema, pneumonia, hyperplasia, and hyaline membranes Therefore, there is an urgent need to identify additional candidates having ability to overcome inflammatory process and can enhance efficacy in the treatment of COVID-19. The polypenolic extracts were integrated into moeties of bovine serum albumin (BSA) and then were coated by chitosan as a mucoadhesion polymer. The results of interleukin-6, and c-reactive protein showed significant reduction in group treated by Encap. SIL + CUR (64 ± 0.8 Pg/μL & 6 ± 0.5 μg/μL) compared to group treated by Cham. + CUR (102 ± 0.8 Pg/μL & 7 ± 0.5 μg/μL) respectively and free capsules (with no any drug inside) (148 ± 0.6 Pg/μL & 10 ± 0.6 μg/μL) respectively. Histopathology profile was improved completely. Additionally, encapsulating silymarin showed anti-viral activity in vitro COVID-19 experiment. It can be summarized that muco-inhalable delivery system (MIDS) loaded by silymarin can be used to overcome inflammation induced by oleic acid and to overcome COVID-19.
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Affiliation(s)
- Nemany A N Hanafy
- Nanomedicine group, Institute of Nanoscience and Nanotechnology, Kafrelsheikh University, 33516 Kafrelsheikh, Egypt.
| | - Maged A El-Kemary
- Nanomedicine group, Institute of Nanoscience and Nanotechnology, Kafrelsheikh University, 33516 Kafrelsheikh, Egypt.
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Santos J, Vedula EM, Lai W, Isenberg BC, Lewis DJ, Lang D, Sutherland D, Roberts TR, Harea GT, Wells C, Teece B, Karandikar P, Urban J, Risoleo T, Gimbel A, Solt D, Leazer S, Chung KK, Sukavaneshvar S, Batchinsky AI, Borenstein JT. Toward Development of a Higher Flow Rate Hemocompatible Biomimetic Microfluidic Blood Oxygenator. MICROMACHINES 2021; 12:888. [PMID: 34442512 PMCID: PMC8398684 DOI: 10.3390/mi12080888] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 07/18/2021] [Accepted: 07/24/2021] [Indexed: 01/05/2023]
Abstract
The recent emergence of microfluidic extracorporeal lung support technologies presents an opportunity to achieve high gas transfer efficiency and improved hemocompatibility relative to the current standard of care in extracorporeal membrane oxygenation (ECMO). However, a critical challenge in the field is the ability to scale these devices to clinically relevant blood flow rates, in part because the typically very low blood flow in a single layer of a microfluidic oxygenator device requires stacking of a logistically challenging number of layers. We have developed biomimetic microfluidic oxygenators for the past decade and report here on the development of a high-flow (30 mL/min) single-layer prototype, scalable to larger structures via stacking and assembly with blood distribution manifolds. Microfluidic oxygenators were designed with biomimetic in-layer blood distribution manifolds and arrays of parallel transfer channels, and were fabricated using high precision machined durable metal master molds and microreplication with silicone films, resulting in large area gas transfer devices. Oxygen transfer was evaluated by flowing 100% O2 at 100 mL/min and blood at 0-30 mL/min while monitoring increases in O2 partial pressures in the blood. This design resulted in an oxygen saturation increase from 65% to 95% at 20 mL/min and operation up to 30 mL/min in multiple devices, the highest value yet recorded in a single layer microfluidic device. In addition to evaluation of the device for blood oxygenation, a 6-h in vitro hemocompatibility test was conducted on devices (n = 5) at a 25 mL/min blood flow rate with heparinized swine donor blood against control circuits (n = 3). Initial hemocompatibility results indicate that this technology has the potential to benefit future applications in extracorporeal lung support technologies for acute lung injury.
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Affiliation(s)
- Jose Santos
- Draper, Cambridge, MA 02139, USA; (J.S.); (W.L.); (B.C.I.); (D.J.L.); (D.L.); (D.S.); (C.W.); (B.T.); (P.K.); (J.U.); (T.R.); (A.G.)
| | - Else M. Vedula
- Draper, Cambridge, MA 02139, USA; (J.S.); (W.L.); (B.C.I.); (D.J.L.); (D.L.); (D.S.); (C.W.); (B.T.); (P.K.); (J.U.); (T.R.); (A.G.)
| | - Weixuan Lai
- Draper, Cambridge, MA 02139, USA; (J.S.); (W.L.); (B.C.I.); (D.J.L.); (D.L.); (D.S.); (C.W.); (B.T.); (P.K.); (J.U.); (T.R.); (A.G.)
| | - Brett C. Isenberg
- Draper, Cambridge, MA 02139, USA; (J.S.); (W.L.); (B.C.I.); (D.J.L.); (D.L.); (D.S.); (C.W.); (B.T.); (P.K.); (J.U.); (T.R.); (A.G.)
| | - Diana J. Lewis
- Draper, Cambridge, MA 02139, USA; (J.S.); (W.L.); (B.C.I.); (D.J.L.); (D.L.); (D.S.); (C.W.); (B.T.); (P.K.); (J.U.); (T.R.); (A.G.)
| | - Dan Lang
- Draper, Cambridge, MA 02139, USA; (J.S.); (W.L.); (B.C.I.); (D.J.L.); (D.L.); (D.S.); (C.W.); (B.T.); (P.K.); (J.U.); (T.R.); (A.G.)
| | - David Sutherland
- Draper, Cambridge, MA 02139, USA; (J.S.); (W.L.); (B.C.I.); (D.J.L.); (D.L.); (D.S.); (C.W.); (B.T.); (P.K.); (J.U.); (T.R.); (A.G.)
| | - Teryn R. Roberts
- Autonomous Reanimation and Evacuation (AREVA) Research Program, The Geneva Foundation, Brooks City Base, San Antonio, TX 78006, USA; (T.R.R.); (G.T.H.); (A.I.B.)
| | - George T. Harea
- Autonomous Reanimation and Evacuation (AREVA) Research Program, The Geneva Foundation, Brooks City Base, San Antonio, TX 78006, USA; (T.R.R.); (G.T.H.); (A.I.B.)
| | - Christian Wells
- Draper, Cambridge, MA 02139, USA; (J.S.); (W.L.); (B.C.I.); (D.J.L.); (D.L.); (D.S.); (C.W.); (B.T.); (P.K.); (J.U.); (T.R.); (A.G.)
| | - Bryan Teece
- Draper, Cambridge, MA 02139, USA; (J.S.); (W.L.); (B.C.I.); (D.J.L.); (D.L.); (D.S.); (C.W.); (B.T.); (P.K.); (J.U.); (T.R.); (A.G.)
| | - Paramesh Karandikar
- Draper, Cambridge, MA 02139, USA; (J.S.); (W.L.); (B.C.I.); (D.J.L.); (D.L.); (D.S.); (C.W.); (B.T.); (P.K.); (J.U.); (T.R.); (A.G.)
| | - Joseph Urban
- Draper, Cambridge, MA 02139, USA; (J.S.); (W.L.); (B.C.I.); (D.J.L.); (D.L.); (D.S.); (C.W.); (B.T.); (P.K.); (J.U.); (T.R.); (A.G.)
| | - Thomas Risoleo
- Draper, Cambridge, MA 02139, USA; (J.S.); (W.L.); (B.C.I.); (D.J.L.); (D.L.); (D.S.); (C.W.); (B.T.); (P.K.); (J.U.); (T.R.); (A.G.)
| | - Alla Gimbel
- Draper, Cambridge, MA 02139, USA; (J.S.); (W.L.); (B.C.I.); (D.J.L.); (D.L.); (D.S.); (C.W.); (B.T.); (P.K.); (J.U.); (T.R.); (A.G.)
| | - Derek Solt
- Thrombodyne, Inc., Salt Lake City, UT 84103, USA; (D.S.); (S.S.)
| | - Sahar Leazer
- Department of Medicine, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA; (S.L.); (K.K.C.)
| | - Kevin K. Chung
- Department of Medicine, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA; (S.L.); (K.K.C.)
| | | | - Andriy I. Batchinsky
- Autonomous Reanimation and Evacuation (AREVA) Research Program, The Geneva Foundation, Brooks City Base, San Antonio, TX 78006, USA; (T.R.R.); (G.T.H.); (A.I.B.)
| | - Jeffrey T. Borenstein
- Draper, Cambridge, MA 02139, USA; (J.S.); (W.L.); (B.C.I.); (D.J.L.); (D.L.); (D.S.); (C.W.); (B.T.); (P.K.); (J.U.); (T.R.); (A.G.)
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Tethered Liquid Perfluorocarbon Coating for 72 Hour Heparin-Free Extracorporeal Life Support. ASAIO J 2021; 67:798-808. [PMID: 33534236 DOI: 10.1097/mat.0000000000001292] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Coagulopathic complications during extracorporeal life support (ECLS) result from two parallel processes: 1) foreign surface contact and shear stress during blood circulation and 2) administration of anticoagulant drugs to prevent circuit thrombosis. To address these problems, biocompatible surfaces are developed to prevent foreign surface-induced coagulopathy, reducing or eliminating the need for anticoagulants. Tethered liquid perfluorocarbon (TLP) is a nonadhesive coating that prevents adsorption of plasma proteins and thrombus deposition. We examined application of TLP to complete ECLS circuits (membranes, tubing, pumps, and catheters) during 72 hours of ECLS in healthy swine (n = 5/group). We compared TLP-coated circuits used without systemic anticoagulation to standard of care: heparin-coated circuits with continuous heparin infusion. Coagulopathic complications, device performance, and systemic effects were assessed. We hypothesized that TLP reduces circuit thrombosis and iatrogenic bleeding, without impeding gas exchange performance or causing untoward effects. No difference in bleeding or thrombotic complication rate was observed; however, circuit occlusion occurred in both groups (TLP = 2/5; CTRL = 1/5). TLP required elevated sweep gas rate to maintain normocapnia during ECLS versus CTRL (10-20 vs. 5 L/min; p = 0.047), suggesting impaired gas exchange. Thrombus deposition and protein adhesion on explanted membranes were comparable, and TLP did not preserve platelet or blood cell counts relative to controls. We conclude that neither TLP nor standard of care is an efficacious solution to prevent coagulation disturbances during ECLS. Further testing of promising biomaterials for ECLS utilizing the model outlined here is warranted.
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16
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Lv X, Deng M, Wang L, Dong Y, Chen L, Dai X. Low vs standardized dose anticoagulation regimens for extracorporeal membrane oxygenation: A meta-analysis. PLoS One 2021; 16:e0249854. [PMID: 33831104 PMCID: PMC8031334 DOI: 10.1371/journal.pone.0249854] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 03/25/2021] [Indexed: 11/18/2022] Open
Abstract
Background To compare the safety and efficacy of low-dose anticoagulation (LA) with that of standardized dose anticoagulation (SA) for patients supported with extracorporeal membrane oxygenation (ECMO). Methods PubMed, MEDLINE, the Cochrane Library, and Web of Science were screened for original articles. Screening was performed using predefined search terms to identify cohort studies reporting the comparison of LA with SA in patients supported with ECMO from Nov 1990 to Jun 2020. The effect size was determined by the odds ratio (OR) with the 95% confidence interval (CI). Results An analysis of 7 studies including a total of 553 patients was performed. LA (Low-heparin group) was administered to 255 patients, whereas the other 298 patients received SA (Full-heparin group). The incidence of gastrointestinal tract hemorrhage (OR 0.36, 95% CI 0.20–0.64) and surgical site hemorrhage (OR 0.43, 95% CI 0.20–0.94) were significantly lower in patients who underwent LA compared with that in those who underwent SA. The rates of hospital mortality (OR 0.81, 95% CI 0.42–1.56), successfully weaning off of ECMO (OR 0.80, 95% CI 0.30–2.14), pulmonary embolism (OR 0.79, 95% CI 0.24–2.65), intracardiac thrombus (OR 0.34, 95% CI 0.09–1.30), intracranial hemorrhage (OR 0.62, 95% CI 0.22–1.74), and pulmonary hemorrhage (OR 0.77, 95% CI 0.30–1.93) were similar between the two groups. Conclusions This meta-analysis confirms that LA is a feasible and safe anticoagulation strategy in patients supported by ECMO. Future studies should focus on the long-term benefits of LA compared with SA.
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Affiliation(s)
- Xiaochai Lv
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fujian, China
- Department of Fujian Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian, China
| | - Manjun Deng
- Department of Hepatopancreatobiliary Surgery, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fujian, China
| | - Lei Wang
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fujian, China
- Department of Fujian Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian, China
| | - Yi Dong
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fujian, China
- Department of Fujian Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian, China
| | - Liangwan Chen
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fujian, China
- Department of Fujian Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian, China
- * E-mail:
| | - Xiaofu Dai
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fujian, China
- Department of Fujian Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian, China
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Roberts TR, Garren M, Handa H, Batchinsky AI. Toward an artificial endothelium: Development of blood-compatible surfaces for extracorporeal life support. J Trauma Acute Care Surg 2020; 89:S59-S68. [PMID: 32251267 PMCID: PMC7398848 DOI: 10.1097/ta.0000000000002700] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
A new generation of extracorporeal artificial organ support technologies, collectively known as extracorporeal life support (ECLS) devices, is being developed for diverse applications to include acute support for trauma-induced organ failure, transitional support for bridge to organ transplant, and terminal support for chronic diseases. Across applications, one significant complication limits the use of these life-saving devices: thrombosis, bleeding, and inflammation caused by foreign surface-induced blood interactions. To address this challenge, transdisciplinary scientists and clinicians look to the vascular endothelium as inspiration for development of new biocompatible materials for ECLS. Here, we describe clinically approved and new investigational biomaterial solutions for thrombosis, such as immobilized heparin, nitric oxide-functionalized polymers, "slippery" nonadhesive coatings, and surface endothelialization. We describe how hemocompatible materials could abrogate the use of anticoagulant drugs during ECLS and by doing so radically change treatments in critical care. Additionally, we examine several special considerations for the design of biomaterials for ECLS, including: (1) preserving function of the artificial organ, (2) longevity of use, and (3) multifaceted approaches for the diversity of device functions and applications.
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Affiliation(s)
- Teryn R. Roberts
- Autonomous Reanimation and Evacuation Program, San Antonio, TX, USA
- The Geneva Foundation, Tacoma, WA, USA
- U.S. Army Institute of Surgical Research, Fort Sam Houston, TX, USA
| | - Mark Garren
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, Athens, GA, USA
| | - Hitesh Handa
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, Athens, GA, USA
| | - Andriy I. Batchinsky
- Autonomous Reanimation and Evacuation Program, San Antonio, TX, USA
- The Geneva Foundation, Tacoma, WA, USA
- U.S. Army Institute of Surgical Research, Fort Sam Houston, TX, USA
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18
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Devine R, Goudie MJ, Singha P, Schmiedt C, Douglass M, Brisbois EJ, Handa H. Mimicking the Endothelium: Dual Action Heparinized Nitric Oxide Releasing Surface. ACS APPLIED MATERIALS & INTERFACES 2020; 12:20158-20171. [PMID: 32271542 PMCID: PMC7962625 DOI: 10.1021/acsami.9b22277] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
The management of thrombosis and bacterial infection is critical to ensure the functionality of medical devices. While administration of anticoagulants is the current antithrombotic clinical practice, a variety of complications, such as uncontrolled hemorrhages or heparin-induced thrombocytopenia, can occur. Additionally, infection rates remain a costly and deadly complication associated with use of these medical devices. It has been hypothesized that if a synthetic surface could mimic the biochemical mechanisms of the endothelium of blood vessels, thrombosis could be reduced, anticoagulant use could be avoided, and infection could be prevented. Herein, the interfacial biochemical effects of the endothelium were mimicked by altering the surface of medical grade silicone rubber (SR). Surface modification was accomplished via heparin surface immobilization (Hep) and the inclusion of a nitric oxide (NO) donor into the SR polymeric matrix to achieve synergistic effects (Hep-NO-SR). An in vitro bacteria adhesion study revealed that Hep-NO-SR exhibited a 99.46 ± 0.17% reduction in viable bacteria adhesion compared to SR. An in vitro platelet study revealed Hep-NO-SR reduced platelet adhesion by 84.12 ± 6.19% compared to SR, while not generating a cytotoxic response against fibroblast cells. In a 4 h extracorporeal circuit model without systemic anticoagulation, all Hep-NO-SR samples were able to maintain baseline platelet count and device patency; whereas 66% of SR samples clotted within the first 2 h of study. Results indicate that Hep-NO-SR creates a more hemocompatible and antibacterial surface by mimicking two key biochemical functions of the native endothelium.
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Affiliation(s)
- Ryan Devine
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, Athens, GA USA
| | - Marcus J. Goudie
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, Athens, GA USA
| | - Priyadarshini Singha
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, Athens, GA USA
| | - Chad Schmiedt
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, GA USA
| | - Megan Douglass
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, Athens, GA USA
| | - Elizabeth J. Brisbois
- Department of Materials Science & Engineering, College of Engineering and Computer Science, University of Central Florida, Orlando, FL USA
| | - Hitesh Handa
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, Athens, GA USA
- Corresponding author Dr. Hitesh Handa, College of Engineering, University of Georgia, 220 Riverbend Road, Athens, GA 30602, Telephone: (706) 542-8109,
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Acute respiratory distress syndrome in the forward environment. Retrospective analysis of acute respiratory distress syndrome cases among French Army war casualties. J Trauma Acute Care Surg 2020; 89:S207-S212. [DOI: 10.1097/ta.0000000000002633] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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20
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Heparin-Free Extracorporeal Life Support Using Tethered Liquid Perfluorocarbon: A Feasibility and Efficacy Study. ASAIO J 2019; 66:809-817. [PMID: 31453831 DOI: 10.1097/mat.0000000000001055] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Coagulation management is the leading challenge during extracorporeal life support (ECLS) due to shear stress and foreign-surface-induced coagulation disturbance during circulation. A nonadhesive, liquid-infused coating called tethered liquid perfluorocarbon (TLP) was developed to prevent adhesion of blood on medical materials. We investigated the novel application of TLP to commercial ECLS circuits compared with standard heparin-coated circuits in vivo in anesthetized swine for 6 hours veno-venous ECLS (1 L/min blood flow) without systemic anticoagulation (n = 3/group). We hypothesized that TLP coating permits heparin-free circulation without untoward effects while reducing thrombus deposition compared with controls. Vital signs, respiration, gas transfer, coagulation, and histology were assessed. Scanning electron microscopy (SEM), elemental mapping, and digital imaging were used to assess thrombus deposition after circulation. There were no group differences in vitals, gas exchange, coagulation, and histology. In both groups, ECLS enabled a decrease in minute volume and end-tidal CO2, with concomitant increase in pH (p < 0.05). Scanning electron microscopy and digital imaging revealed significant thrombus on heparin-coated membranes, which was reduced or absent on TLP-coated materials. Tethered liquid perfluorocarbon permitted heparin-free ECLS without altering device performance and prevented thrombus deposition versus immobilized heparin. Pending multiday in vivo testing, TLP is a promising biomaterial solution to eliminate anticoagulation requirements during ECLS.
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Carter KT, Kutcher ME, Shake JG, Panos AL, Cochran RP, Creswell LL, Copeland H. Heparin-Sparing Anticoagulation Strategies Are Viable Options for Patients on Veno-Venous ECMO. J Surg Res 2019; 243:399-409. [PMID: 31277018 DOI: 10.1016/j.jss.2019.05.050] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Revised: 05/14/2019] [Accepted: 05/30/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO), a rescue therapy for pulmonary failure, has traditionally been limited by anticoagulation requirements. Recent practice has challenged the absolute need for anticoagulation, expanding the role of ECMO to patients with higher bleeding risk. We hypothesize that mortality, bleeding, thrombotic events, and transfusions do not differ between heparin-sparing and full therapeutic anticoagulation strategies in veno-venous (VV) ECMO management. MATERIALS AND METHODS Adult VV ECMO patients between October 2011 and May 2018 at a single center were reviewed. A heparin-sparing strategy was implemented in October 2014; we compared outcomes in an as-treated fashion. The primary end point was survival. Secondary end points included bleeding, thrombotic complications, and transfusion requirements. RESULTS Forty VV ECMO patients were included: 17 (147 circuit-days) before and 23 (214 circuit-days) after implementation of a heparin-sparing protocol. Patients treated with heparin-sparing anticoagulation had a lower body mass index (28.5 ± 7.1 versus 38.1 ± 12.4, P = 0.01), more often required inotropic support before ECMO (82 versus 50%, P = 0.05), and had a lower mean activated clotting time (167 ± 15 versus 189 ± 15 s, P < 0.01). There were no significant differences in survival to decannulation (59 versus 83%, P = 0.16) or discharge (50 versus 72%, P = 0.20), bleeding (32 versus 33%, P = 1.0), thromboembolic events (18 versus 39%, P = 0.17), or transfusion requirements (median 1.1 versus 0.9 unit per circuit-day, P = 0.48). CONCLUSIONS Survival, bleeding, thrombotic complications, and transfusion requirements did not differ between heparin-sparing and full therapeutic heparin strategies for management of VV ECMO. VV ECMO can be a safe option in patients with traditional contraindications to anticoagulation.
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Affiliation(s)
- Kristen T Carter
- Department of Surgery, University of Mississippi Medical Center, Jackson, Mississippi
| | - Matthew E Kutcher
- Division of Trauma, Critical Care, and Acute Care Surgery, University of Mississippi Medical Center, Jackson, Mississippi
| | - Jay G Shake
- Division of Cardiothoracic Surgery, University of Mississippi Medical Center, Jackson, Mississippi
| | - Anthony L Panos
- Division of Cardiothoracic Surgery, University of Mississippi Medical Center, Jackson, Mississippi
| | - Richard P Cochran
- Division of Cardiothoracic Surgery, University of Mississippi Medical Center, Jackson, Mississippi
| | - Lawrence L Creswell
- Division of Cardiothoracic Surgery, University of Mississippi Medical Center, Jackson, Mississippi
| | - Hannah Copeland
- Division of Cardiothoracic Surgery, University of Mississippi Medical Center, Jackson, Mississippi.
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22
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Roberts TR, Leslie DC, Cap AP, Cancio LC, Batchinsky AI. Tethered-liquid omniphobic surface coating reduces surface thrombogenicity, delays clot formation and decreases clot strength ex vivo. J Biomed Mater Res B Appl Biomater 2019; 108:496-502. [PMID: 31069955 DOI: 10.1002/jbm.b.34406] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 03/12/2019] [Accepted: 04/25/2019] [Indexed: 12/16/2022]
Abstract
Hemocompatible materials for extracorporeal life support (ECLS) technology are investigated to mitigate thrombotic complications associated with this therapy. A promising solution is an omniphobic bilayer coating, tethered liquid perfluorocarbon (TLP), which utilizes an immobilized tether to anchor a mobile, liquid surface lubricant that prevents adhesion of blood components to the substrate. In this study, we investigated the effects of TLP on real-time clot formation using thromboelastography (TEG). TLP was applied to TEG cups, utilizing perfluorodecalin (PFD) or FluorLube63 as the liquid layer, and compared to uncoated cups. Human blood (n = 10) was added to cups; and TEG parameters (R, K, α-angle, MA, LY30, LY60) and adherent thrombus weight were assessed. TLP decreased clot amplification (α-angle), clot strength (MA), and adherent clot weight (p < .0001). These effects were greater with FluorLube63 versus PFD (α-angle p < .0001; MA p = .0019; clot weight p < .0001). Reaction time (R) was longer in TLP-coated cups versus control cups with liquid lubricant added (p = .0377). Percent fibrinolysis (LY30 and LY60) was greater in the TLP versus controls at LY30 (p < .0001), and in FluoroLube63 versus controls at LY60 (p = .0021). TLP significantly altered clot formation, exerting antithrombogenic effects. This reduction in surface thrombogenicity supports TLP as a candidate for improved biocompatibility of ECLS materials, pending further validation with exposure to shear stress.
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Affiliation(s)
- Teryn R Roberts
- Multi-Organ Support Technology, U.S. Army Institute of Surgical Research, San Antonio, Texas.,The Geneva Foundation, Tacoma, Washington.,Morsani College of Medicine, University of South Florida, Tampa, Florida
| | | | - Andrew P Cap
- Multi-Organ Support Technology, U.S. Army Institute of Surgical Research, San Antonio, Texas
| | - Leopoldo C Cancio
- Multi-Organ Support Technology, U.S. Army Institute of Surgical Research, San Antonio, Texas
| | - Andriy I Batchinsky
- Multi-Organ Support Technology, U.S. Army Institute of Surgical Research, San Antonio, Texas.,The Geneva Foundation, Tacoma, Washington.,Morsani College of Medicine, University of South Florida, Tampa, Florida.,Department of Translational Medicine, University of the Incarnate Word, San Antonio, Texas
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23
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Raman J, Alimohamed M, Dobrilovic N, Lateef O, Aziz S. A comparison of low and standard anti-coagulation regimens in extracorporeal membrane oxygenation. J Heart Lung Transplant 2019; 38:433-439. [DOI: 10.1016/j.healun.2019.01.1313] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 01/22/2019] [Accepted: 01/28/2019] [Indexed: 11/24/2022] Open
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24
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Kamuf J, Garcia-Bardon A, Ziebart A, Thomas R, Rümmler R, Möllmann C, Hartmann EK. Oleic Acid-Injection in Pigs As a Model for Acute Respiratory Distress Syndrome. J Vis Exp 2018:57783. [PMID: 30417861 PMCID: PMC6235613 DOI: 10.3791/57783] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
The acute respiratory distress syndrome is a relevant intensive care disease with an incidence ranging between 2.2% and 19% of intensive care unit patients. Despite treatment advances over the last decades, ARDS patients still suffer mortality rates between 35 and 40%. There is still a need for further research to improve the outcome of patients suffering from ARDS. One problem is that no single animal model can mimic the complex pathomechanism of the acute respiratory distress syndrome, but several models exist to study different parts of it. Oleic acid injection (OAI)-induced lung injury is a well-established model for studying ventilation strategies, lung mechanics and ventilation/perfusion distribution in animals. OAI leads to severely impaired gas exchange, deterioration of lung mechanics and disruption of the alveolo-capillary barrier. The disadvantage of this model is the controversial mechanistic relevance of this model and the necessity for central venous access, which is challenging especially in smaller animal models. In summary, OAI-induced lung injury leads to reproducible results in small and large animals and hence represents a well-suited model for studying ARDS. Nevertheless, further research is necessary to find a model that mimics all parts of ARDS and lacks the problems associated with the different models existing today.
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Affiliation(s)
- Jens Kamuf
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University;
| | - Andreas Garcia-Bardon
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University
| | - Alexander Ziebart
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University
| | - Rainer Thomas
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University
| | - Robert Rümmler
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University
| | - Christian Möllmann
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University
| | - Erik K Hartmann
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University
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25
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Mazzeffi MA, Tanaka K, Roberts A, Rector R, Menaker J, Kon Z, Deatrick KB, Kaczorowski D, Griffith B, Herr D. Bleeding, Thrombosis, and Transfusion With Two Heparin Anticoagulation Protocols in Venoarterial ECMO Patients. J Cardiothorac Vasc Anesth 2018; 33:1216-1220. [PMID: 30181084 DOI: 10.1053/j.jvca.2018.07.045] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To compare the incidence of bleeding and thrombosis between adult venoarterial (VA) extracorporeal membrane oxygenation (ECMO) patients managed with an activated clotting time (ACT)-guided heparin anticoagulation protocol and activated partial thromboplastin time (aPTT) protocol. DESIGN Retrospective cohort study. SETTING Tertiary care, academic medical center. PARTICIPANTS Consecutive adult VA ECMO patients during a 6-year period. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Demographic, medical, transfusion, and ECMO data were collected for all patients. Primary study outcomes were bleeding and thrombosis. Secondary outcomes were stroke and in-hospital mortality. One hundred twenty-one patients were included in the cohort. Fifty patients had ACT monitoring, and 71 had aPTT monitoring. There was no difference in the incidence of bleeding or thrombosis between the 2 groups (78.0% v 67.6% for bleeding [p = 0.21] and 16.0% v 19.7% for thrombosis [p = 1.0]). After adjusting for age and total ECMO days, patients managed with ACT received approximately 30% more red blood cell, fresh frozen plasma, and platelet transfusion (all p < 0.05). CONCLUSION There is no apparent difference in the incidence rate of bleeding or thrombosis between VA ECMO patients managed with an ACT- or aPTT-guided heparin anticoagulation protocol. Patients managed with an ACT-guided protocol received more blood transfusion, which could reflect greater total bleeding. Future randomized controlled trials would help to elucidate optimal anticoagulation strategies for VA ECMO patients.
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Affiliation(s)
- Michael A Mazzeffi
- University of Maryland School of Medicine, Department of Anesthesiology, Baltimore, MD.
| | - Kenichi Tanaka
- University of Maryland School of Medicine, Department of Anesthesiology, Baltimore, MD
| | - Alia Roberts
- University of Maryland School of Medicine, Department of Anesthesiology, Baltimore, MD
| | - Raymond Rector
- University of Maryland School of Medicine, Department of Surgery, Division of Cardiothoracic Surgery, Baltimore, MD
| | - Jay Menaker
- University of Maryland School of Medicine, Department of Surgery Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD
| | - Zachary Kon
- New York University, Langone Health, New York, NY
| | - Kristopher B Deatrick
- University of Maryland School of Medicine, Department of Surgery, Division of Cardiothoracic Surgery, Baltimore, MD
| | - David Kaczorowski
- University of Maryland School of Medicine, Department of Surgery, Division of Cardiothoracic Surgery, Baltimore, MD
| | - Bartley Griffith
- University of Maryland School of Medicine, Department of Surgery, Division of Cardiothoracic Surgery, Baltimore, MD
| | - Daniel Herr
- University of Maryland School of Medicine, Department of Surgery Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD
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26
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Alpha7 Nicotine Acetylcholine Receptor Agonist PNU-282987 Attenuates Acute Lung Injury in a Cardiopulmonary Bypass Model in Rats. Shock 2018; 47:474-479. [PMID: 27661000 DOI: 10.1097/shk.0000000000000744] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Cardiopulmonary bypass (CPB) carries a risk of lung ischemia-reperfusion, leading to acute lung injury (ALI). Alpha7 nicotinic acetylcholine receptor (alpha7nAChR) has been implicated in the release of high mobility group box1 (HMGB1), which promotes systemic inflammation in response to ischemia-reperfusion injury. However, the specific role of alpha7nAChR in CPB is poorly understood. This study employed the alpha7nAChR agonist PNU-282987 and a rat model of CPB to determine whether alpha7nAChR was associated with CPB-induced lung damage. METHODS Thirty Sprague-Dawley rats were randomly divided into five groups as follows: normal group, sham group, CPB group, PNU-282987 plus CPB group, and PNU-282987 plus sham group. Rats were subjected to CPB under anesthesia for 60 min. PNU-282987 (4.8 mg/kg) was administered via arterial inflow. Two hours post-CPB, samples of blood, bronchoalveolar lavage fluid (BALF), and lung tissues were processed for investigations. RESULTS In CPB rats, structural damage in the lung was marked. Density of alpha7nAChR of the lung in the CPB group was significantly less than all other groups, while lung edema, inflammatory markers in serum and lung, protein concentrations in BALF were significantly higher. In the PNU-282987 plus CPB group, by all the above measures the CPB-associated effects were significantly ameliorated but were not identical to the control groups. CONCLUSION Our results suggest that PNU-282987 affords protective effect against CPB-induced ALI, and inhibits HMGB1 release.
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27
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Kreyer S, Muders T, Theuerkauf N, Spitzhüttl J, Schellhaas T, Schewe JC, Guenther U, Wrigge H, Putensen C. Hemorrhage under veno-venous extracorporeal membrane oxygenation in acute respiratory distress syndrome patients: a retrospective data analysis. J Thorac Dis 2017; 9:5017-5029. [PMID: 29312706 DOI: 10.21037/jtd.2017.11.05] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background Despite being still invasive and challenging, technical improvement has resulted in broader and more frequent application of extracorporeal membrane oxygenation (ECMO), to prevent hypoxemia and to reduce invasiveness of mechanical ventilation (MV). Heparin-coated ECMO-circuits are currently standard of care, in addition to heparin based anticoagulation (AC) regimen guided by activated clotting time (ACT) or activated partial thromboplastin time (aPTT). Despite these advances, a reliable prediction of hemorrhage is difficult and the risk of hemorrhagic complication remains unfortunately high. We hypothesized, that there are coagulation parameters that are indices for a higher risk of hemorrhage under veno-venous (VV)-ECMO therapy. Methods Data from 36 patients with severe respiratory failure treated with VV-ECMO at a University Hospital intensive care unit (ICU) were analyzed retrospectively. Patients were separated into two groups based on severity of hemorrhagic complications and transfusion requirements. The following data were collected: demographics, hemodynamic data, coagulation samples, transfusion requirements, change of ECMO-circuit during treatment and adverse effects, including hemorrhage and thrombosis. Results In this study 74 hemorrhagic events were observed, one third of which were severe. Patients suffering from severe hemorrhage had a lower survival rate on VV-ECMO (43% vs. 91%; P=0.002) and in ICU (36% vs. 86%; P=0.002). SAPS II, factor VII and X were different between mild and severe hemorrhage group. Conclusions Severe hemorrhage under VV-ECMO is associated with higher mortality. Only factor VII and X differed between groups. Further clinical studies are required to determine the timing of initiation and targets for AC therapies during VV-ECMO.
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Affiliation(s)
- Stefan Kreyer
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Thomas Muders
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Nils Theuerkauf
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Juliane Spitzhüttl
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Torsten Schellhaas
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Jens-Christian Schewe
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Ulf Guenther
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Hermann Wrigge
- Department of Anesthesiology and Intensive Care Medicine, University of Leipzig, Leipzig, Germany
| | - Christian Putensen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
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28
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Electron Microscopy as a Tool for Assessment of Anticoagulation Strategies During Extracorporeal Life Support: The Proof Is on the Membrane. ASAIO J 2017; 62:525-32. [PMID: 27258220 DOI: 10.1097/mat.0000000000000394] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Extracorporeal life support (ECLS) is fast becoming more common place for use in adult patients failing mechanical ventilation. Management of coagulation and thrombosis has long been a major complication in the use of ECLS therapies. Scanning electron microscopy (SEM) of membrane oxygenators (MOs) after use in ECLS circuits can offer novel insight into any thrombotic material deposition on the MO. In this pilot study, we analyzed five explanted MOs immediately after use in a sheep model of different acute respiratory distress syndrome (ARDS). We describe our methods of MO dissection, sample preparation, image capture, and results. Of the five MOs analyzed, those that received continuous heparin infusion showed very little thrombosis formation or other clot material, whereas those that were used with only initial heparin bolus showed readily apparent thrombotic material.
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29
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Platelet and coagulation function before and after burn and smoke inhalation injury in sheep. J Trauma Acute Care Surg 2017; 83:S59-S65. [PMID: 28452873 DOI: 10.1097/ta.0000000000001472] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Smoke inhalation and burn injury remain a major source of morbidity and mortality. There is known dysregulation of hemostasis in burn patients, but either hypercoagulation or hypocoagulation states are reported. Sheep are an established animal model for studying burn pathology and provide robust data on hemostatic function at baseline and after injury. METHODS After an IACUC-approved protocol, 15 sheep were anesthetized and subjected to a 40% full thickness burn with smoke inhalation. Blood was sampled at baseline, 1 day postinjury (early effects) and days 2, 3, and 4 (late effects) after injury. Assays at each timepoint assessed: hemostatic function by thromboelastography (TEG), platelet counts and function by flow cytometry and aggregometry, coagulation protein levels, and free hemoglobin. Data were analyzed by the Wilcoxon paired test (nonparametric) with significance set at less than 0.05. RESULTS By 24 hours postinjury, platelet counts had dropped, whereas the percent activated platelets increased. Absolute platelet functional response to the agonist adenosine diphosphate (ADP) decreased, whereas response to collagen showed no significant difference. On a per platelet basis, ADP response was unchanged, whereas the collagen response was elevated. Prothrombin time and activated partial thromboplastin time were prolonged. TEG parameters decreased significantly from baseline. Fibrinogen and factor V were trending up; coagulation proteins ATIII, factors IX and X were decreased.Late effects were followed in six animals. At day 4, platelet counts remained depressed compared with baseline with a nadir at day 2; responses to agonist on a per platelet basis remained the same for ADP and stayed elevated for collagen. Platelets continued to have elevated activation levels. Fibrinogen and factor V remained significantly elevated, whereas TEG parameters and prothrombin time, factors IX and X returned to near baseline levels. CONCLUSION Coagulation parameters and hemostasis are dysregulated in sheep after smoke inhalation and burn. By 24 hours, sheep were hypocoagulable and subsequently became hypercoagulable by day 4. These results suggest a three-stage coagulopathy in burn injuries with a known early consumptive hypercoagulable state which is followed by a relatively hypocoagulable state with increased bleeding risk and then a return to a relatively unknown hypercoagulability with increased susceptibility to thrombotic disorders.
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30
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Krueger K, Schmutz A, Zieger B, Kalbhenn J. Venovenous Extracorporeal Membrane Oxygenation With Prophylactic Subcutaneous Anticoagulation Only: An Observational Study in More Than 60 Patients. Artif Organs 2016; 41:186-192. [DOI: 10.1111/aor.12737] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Revised: 01/16/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Kirsten Krueger
- Department of Anaesthesiology and Critical Care Medicine; Freiburg University Medical Center; Freiburg Germany
| | - Axel Schmutz
- Department of Anaesthesiology and Critical Care Medicine; Freiburg University Medical Center; Freiburg Germany
| | - Barbara Zieger
- Department of Paediatrics and Adolescent Medicine, Laboratory for Haemostaseology; Freiburg University Medical Center; Freiburg Germany
| | - Johannes Kalbhenn
- Department of Anaesthesiology and Critical Care Medicine; Freiburg University Medical Center; Freiburg Germany
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31
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Ion-Exchange Resin Anticoagulation (I-ERA): A Novel Extracorporeal Technique for Regional Anticoagulation. Shock 2016; 46:304-11. [PMID: 26939038 DOI: 10.1097/shk.0000000000000597] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Extracorporeal treatments always require blood anticoagulation. We tested feasibility and efficacy of a novel technique for regional extracorporeal blood anticoagulation based on calcium removal by ion-exchange resins (i-ER), called ion-exchange resin anticoagulation (i-ERA). METHODS Eight swine were connected to a veno-venous extracorporeal circuit comprising a hemodiafilter and an i-ER. Blood flow was 150 mL/min. Hemodiafiltrate was generated at 975 mL/min and passed through the i-ER. A fraction of the calcium-free hemodiafiltrate was returned to the hemodiafilter (675 mL/min), while the remaining was recirculated prior the hemodiafilter (300 mL/min) to dilute blood entering the hemodiafilter. A calcium replacement solution was continuously infused. Two hours after i-ERA start, blood was sampled from inlet, before the hemodiafilter (prehemodiafilter blood) and from outlet of the extracorporeal circuit for ionized calcium (iCa) concentration and thromboelastography (TEG). Arterial blood was collected for blood gas analyses, electrolytes concentrations, and plasma free hemoglobin. Hemodynamics and ventilation were monitored. RESULTS i-ERA reduced iCa from 1.28 ± 0.05 mmol/L (inlet) to 0.47 ± 0.03 mmol/L (prehemodiafilter blood) and 0.25 ± 0.03 mmol/L (outlet). Prehemodiafilter blood and outlet samples showed no sign of clot formation (reaction time (R) >60 min; maximal amplitude (MA) = 0 (0-0) mm), while blood-inlet had normal coagulation (R = 8.5 (5.8-10.2) min; MA = 65.2 (63.2-68.7) mm). Arterial gas analyses and electrolytes concentrations, hemodynamics, and ventilation were unchanged. No hemolysis was recorded. CONCLUSIONS In a swine model, i-ERA proved feasible and effective in reducing iCa and preventing clot formation with TEG analyses. Further studies are warranted to evaluate the long-term efficacy and safety of i-ERA. LEVEL OF EVIDENCE V-therapeutic animal experiment.
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