1
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Zhou P, Guo QQ, Wang FX, Zhou L, Hu HF, Deng Z. Nonlinear relationship between platelet count and 30-day in-hospital mortality in ICU acute respiratory failure patients: a multicenter retrospective cohort study. Eur J Med Res 2024; 29:312. [PMID: 38849948 PMCID: PMC11161993 DOI: 10.1186/s40001-024-01909-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 05/29/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND Limited evidence exists regarding the link between platelet count and 30-day in-hospital mortality in acute respiratory failure (ARF) patients. Thus, this study aims to investigate this association among ICU patients experiencing acute respiratory failure. METHODS We conducted a retrospective cohort study across multiple centers, utilizing data from the US eICU-CRD v2.0 database covering 22,262 patients with ARF in the ICU from 2014 to 2015. Our aim was to investigate the correlation between platelet count and 30-day in-hospital mortality using binary logistic regression, subgroup analyses, and smooth curve fitting. RESULTS The 30-day in-hospital mortality rate was 19.73% (4393 out of 22,262), with a median platelet count of 213 × 109/L. After adjusting for covariates, our analysis revealed an inverse association between platelet count and 30-day in-hospital mortality (OR = 0.99, 95% CI 0.99, 0.99). Subgroup analyses supported the robustness of these findings. Furthermore, a nonlinear relationship was identified between platelet count and 30-day in-hospital mortality, with the inflection point at 120 × 109/L. Below the inflection point, the effect size (OR) was 0.89 (0.87, 0.91), indicating a significant association. However, beyond this point, the relationship was not statistically significant. CONCLUSION This study establishes a clear negative association between platelet count and 30-day in-hospital mortality among ICU patients with ARF. Furthermore, we have identified a nonlinear relationship with saturation effects, indicating that among ICU patients with acute respiratory failure, the lowest 30-day in-hospital mortality rate occurs when the baseline platelet count is approximately 120 × 109/L.
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Affiliation(s)
- Pan Zhou
- Department of Emergency Medicine, Shenzhen Second People's Hospital/The First Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen, 518035, China
| | - Qin-Qin Guo
- Department of Emergency Medicine, Shenzhen Second People's Hospital/The First Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen, 518035, China
| | - Fang-Xi Wang
- Department of Emergency Medicine, Shenzhen Second People's Hospital/The First Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen, 518035, China
| | - Li Zhou
- Department of Emergency Medicine, Shenzhen Second People's Hospital/The First Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen, 518035, China
| | - Hao-Fei Hu
- Department of Nephrology, Shenzhen Second People's Hospital/The First Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen, 518035, China.
| | - Zhe Deng
- Department of Emergency Medicine, Shenzhen Second People's Hospital/The First Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen, 518035, China.
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2
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Wendel-Garcia PD, Seeliger B, Hofmaenner D, Bode C, Stahl K, David S. Low-Dose Anticoagulation to Prevent Intracranial Hemorrhage in COVID-19 Patients under Extracorporeal Membrane Oxygenation Support. Am J Respir Crit Care Med 2024; 209:894-895. [PMID: 38306654 PMCID: PMC10995580 DOI: 10.1164/rccm.202311-2090le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 02/01/2024] [Indexed: 02/04/2024] Open
Affiliation(s)
| | - Benjamin Seeliger
- Department of Respiratory Medicine
- Biomedical Research in End-Stage and Obstructive Lung Disease Hannover
- German Center for Lung Research, Hannover, Germany; and
| | - Daniel Hofmaenner
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Christian Bode
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Klaus Stahl
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology
| | - Sascha David
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
- Department of Nephrology, Hannover Medical School, Hannover, Germany
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3
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Hla TTW, Christou S, Sanderson B, Hanks F, Cameron L, Camporota L, Doyle AJ, Retter A. Anti-Xa Assay Monitoring Improves the Precision of Anticoagulation in Venovenous Extracorporeal Membrane Oxygenation. ASAIO J 2024; 70:313-320. [PMID: 38039550 DOI: 10.1097/mat.0000000000002100] [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: 12/03/2023] Open
Abstract
Unfractionated heparin (UFH) is the most used anticoagulant in patients receiving veno-venous extracorporeal membrane oxygenation (VV-ECMO). Its therapeutic levels are monitored using activated partial thromboplastin time ratio (aPTTr) or antifactor Xa (anti-Xa) assay. This was a retrospective, single-center, cohort study where all adult patients with viral etiology respiratory failure requiring VV-ECMO from January 2, 2015 to January 31, 2022 were included. Anticoagulation was monitored using aPTTr (until November 1, 2019) or anti-Xa assay (after November 1, 2019). We compared the accuracy and precision of anticoagulation monitoring tests using time in therapeutic range (TTR) and variance growth rate (VGR), respectively, and their impact on bleeding and thrombotic events (BTEs). A total of 254 patients, 74 in aPTTr and 180 in anti-Xa monitoring groups, were included with a total of 4,992 ECMO-person days. Accuracy was comparable: mean TTR of 47% in aPTTr and 51% in anti-Xa groups ( p = 0.28). Antifactor Xa monitoring group demonstrated improved precision with a lower variance (median VGR 0.21 vs. 1.61 in aPTTr, p < 0.05). Secondary outcome of less heparin prescription changes (adjusted rate ratio [RR] = 1.01, p = 0.01), fewer blood transfusions (adjusted RR = 0.78, p < 0.05), and ECMO circuit changes (adjusted RR = 0.68, p < 0.05) were seen with anti-Xa monitoring.
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Affiliation(s)
- Teddy Tun Win Hla
- From the Department of Critical Care, St Thomas' Hospital, London, UK
- University College London Institute of Health Informatics, University College London, London, UK
| | - Silvana Christou
- From the Department of Critical Care, St Thomas' Hospital, London, UK
| | - Barnaby Sanderson
- From the Department of Critical Care, St Thomas' Hospital, London, UK
| | - Fraser Hanks
- Pharmacy Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Lynda Cameron
- Pharmacy Department, Institute of Pharmaceutical Science, King's College London, London, UK
| | - Luigi Camporota
- From the Department of Critical Care, St Thomas' Hospital, London, UK
| | - Andrew J Doyle
- Centre for Thrombosis and Haemostasis, St Thomas' Hospital, London, UK
| | - Andrew Retter
- From the Department of Critical Care, St Thomas' Hospital, London, UK
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4
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Gao W, Shen H, Chang Y, Tang Q, Li T, Sun D. Bivalirudin-hydrogel coatings of polyvinyl chloride on extracorporeal membrane oxygenation for anticoagulation. Front Cardiovasc Med 2023; 10:1301507. [PMID: 38162136 PMCID: PMC10754995 DOI: 10.3389/fcvm.2023.1301507] [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: 09/25/2023] [Accepted: 11/29/2023] [Indexed: 01/03/2024] Open
Abstract
Introduction Thromboembolic events associated with extracorporeal membrane oxygenation (ECMO) in clinical treatment are typical. Heparin coating has been widely employed as a surface modification strategy for ECMO tubes. However, its clinical application is often accompanied by unavoidable complications due to its mechanism of action. As a direct thrombin inhibitor with a single target, Bivalirudin (BV) has exhibited a lower incidence of adverse events and superior pharmacokinetic performance compared to heparin. Methods A gelatin methacrylate hydrogel (GelMA) coating layer with BV was successfully synthesized on polyvinyl chloride, and the drug release ratio was close to complete release within 7 days. Results and discussion Simulated extracorporeal circulation experiments using roller pumps in vitro and jugular arteriovenous bypass experiments in rabbits demonstrated its outstanding anticoagulant efficacy. The systemic anticoagulant assay proved that BV hydrogel coating does not affect the coagulation level, and reduces the risk of complications such as systemic bleeding compared to intravenous injection. BV-Coating GelMA hydrogel tube has exhibited good biocompatibility and significantly improved anticoagulant performance, making it an optimal choice for surface materials used in blood-contacting medical devices.
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Affiliation(s)
- Wenqing Gao
- Department of Cardiac Center, Tianjin Third Central Hospital, Tianjin, China
- Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, China
- School of Medicine, Nankai University, Tianjin, China
- Tianjin ECMO Treatment and Training Base, Tianjin, China
| | - Hechen Shen
- Department of Cardiac Center, Tianjin Third Central Hospital, Tianjin, China
- Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, China
- Tianjin ECMO Treatment and Training Base, Tianjin, China
- The Third Central Clinical College of Tianjin Medical University, Tianjin, China
| | - Yun Chang
- Department of Cardiac Center, Tianjin Third Central Hospital, Tianjin, China
- Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, China
- School of Medicine, Nankai University, Tianjin, China
- Tianjin ECMO Treatment and Training Base, Tianjin, China
| | - Qin Tang
- Department of Ophthalmology, West China Hospital Sichuan University, Chengdu, Sichuan, China
| | - Tong Li
- Department of Cardiac Center, Tianjin Third Central Hospital, Tianjin, China
- Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, China
- School of Medicine, Nankai University, Tianjin, China
- Tianjin ECMO Treatment and Training Base, Tianjin, China
- The Third Central Clinical College of Tianjin Medical University, Tianjin, China
| | - Di Sun
- Key Laboratory of Photochemical Conversion and Optoelectronic Material, Technical Institute of Physics and Chemistry, Chinese Academy of Sciences, Beijing, China
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5
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Graboyes SDT, Owen PS, Evans RA, Berei TJ, Hryniewicz KM, Hollis IB. Review of anticoagulation considerations in extracorporeal membrane oxygenation support. Pharmacotherapy 2023; 43:1339-1363. [PMID: 37519116 DOI: 10.1002/phar.2857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 06/10/2023] [Accepted: 06/16/2023] [Indexed: 08/01/2023]
Abstract
Since its first success in 1975, extracorporeal membrane oxygenation (ECMO) has been used with increasing frequency for pulmonary and cardiopulmonary bypass. Use in adults has increased exponentially since the early 2000s, but despite thousands of international cannulations using both veno-arterial (VA) and veno-venous (VV) ECMO, there are still significant hemocompatibility-related adverse events. Current management of anticoagulation has been based on the Extracorporeal Life Support Organization guidance published in 2014 with recent updates published in 2022. Despite this guidance, there is still limited international consensus on how to manage anticoagulation in ECMO. For this review, we completed a comprehensive search of multiple electronic databases to identify studies pertaining to anticoagulation of adult patients on VV or VA-ECMO. The highest priority was given to sources that were prospective, randomized, controlled studies, but in the absence of such resources, observational studies, retrospective uncontrolled studies, and case series/reports were considered for inclusion. This document serves to provide a comprehensive review of the current understanding of management pertaining to anticoagulation relating to ECMO.
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Affiliation(s)
- Sydney D T Graboyes
- Department of Pharmacy, University of California, Davis Medical Center, Sacramento, California, USA
| | - Phillip S Owen
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
| | - Rickey A Evans
- Department of Pharmacy, University of Kentucky HealthCare, Lexington, Kentucky, USA
| | - Theodore J Berei
- Department of Pharmacy, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin, USA
| | - Katarzyna M Hryniewicz
- Heart Failure Section, Minneapolis Heart Institute at Abbot Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Ian B Hollis
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
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6
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Seeliger B, Bode C, Shaefi S, Hofmaenner DA, David S. D-dimer trends in ECMO patients: don't shoot the messenger. Intensive Care Med 2023; 49:1563-1564. [PMID: 37906256 DOI: 10.1007/s00134-023-07258-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2023] [Indexed: 11/02/2023]
Affiliation(s)
- 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 Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Daniel A Hofmaenner
- Institute of Intensive Care Medicine, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Sascha David
- Institute of Intensive Care Medicine, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland.
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7
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Natanov R, Kunkel ER, Wiesner O, Haverich A, Wiegmann B, Rümke S, Kühn C. Determinants of survival in patients on extracorporeal membrane oxygenation therapy due to severe covid-19. Perfusion 2023; 38:1393-1398. [PMID: 35786064 PMCID: PMC9260190 DOI: 10.1177/02676591221113135] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Severe acute respiratory distress syndrome (ARDS) due to Coronavirus Disease-19 (COVID-19) is associated with high mortality. Although survival on mechanical circulatory support has improved, determinants for better prognosis are still unclear. Here, we report on the outcome of our patient population with the need for mechanical circulatory support due to severe COVID-19 (sCOVID-19) induced ARDS. METHODS All patients treated with extracorporeal membrane oxygenation (ECMO) for severe ARDS due to sCOVID-19 were analysed. Patients > 18 years of age at the time of initiation of ECMO were included. Pre-existing comorbidities, complications during ECMO implantation, and ECMO runtime were reviewed. The latency to intubation, proning, tracheotomy, and ECMO implantation was analysed. Furthermore, the survival and non-survival population were compared to determine factors in favour of a better outcome. RESULTS In total, 85 patients were treated with veno-venous membrane oxygenation (vv-ECMO) for severe ARDS in our medical centre. The patient population was predominantly male (83.5%) with a mean patient age of 54.9 years. A history of cardiovascular disease (p = .01), smoking (p < .05), need for vasopressor- (p < .05), and renal replacement therapy (p < .001) was associated with a worse prognosis. Overall survival was 50%. The survival population was significantly younger (p = .004), had a significantly higher body weight (p = .02) and body mass index (BMI) (p = .01). Furthermore, survival was significantly better when vv-ECMO was initiated within 48 h after admission (p < .001). CONCLUSIONS Pre-existing cardiovascular disease, higher age, history of nicotine abuse, and development of renal failure are associated with poor outcome. Early start of vv-ECMO therapy may lead to better survival in sCOVID-19 patients, although complications during ECMO therapy are associated with a worse prognosis.
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Affiliation(s)
- Ruslan Natanov
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Elena R. Kunkel
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Olaf Wiesner
- Department of Pneumology, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Bettina Wiegmann
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Stefan Rümke
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Christian Kühn
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
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8
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Mang S, Karagiannidis C, Lepper PM. [When mechanical ventilation fails-Venovenous extracorporeal membrane oxygenation]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2023; 64:922-931. [PMID: 37721597 DOI: 10.1007/s00108-023-01586-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/14/2023] [Indexed: 09/19/2023]
Abstract
Venovenous extracorporeal membrane oxygenation (VV-ECMO) is predominantly being used as a rescue strategy in patients with acute lung failure, suffering from severe oxygenation and/or decarboxylation impairment. Cannulas introduced into the central veins lead blood through a membrane oxygenator in which it is oxygenated via sweep gas (pO2 up to 600 mm Hg) flow, eliminating CO2. According to the largest randomized studies carried out so far, the two most important indications for VV-ECMO are hypoxic respiratory failure (paO2 < 80 mm Hg for more than 6 h) and refractory hypercapnia (pH < 7.25 und pCO2 > 60 mm Hg with a breathing frequency of >30/min) despite optimal protective mechanical ventilation settings (ARDS, Δp < 14 mbar, plateau pressure < 30 mbar, tidal volume VT < 6 ml/kg idealized body weight). Relative contraindications are life-limiting comorbidities and terminal pulmonary diseases that cannot be treated by lung transplantation. Advanced patient age is not regarded as an absolute contraindication, though it highly impacts ARDS survival rates, especially for pneumonia associated with coronavirus disease 2019 (COVID-19). The most frequent complications of VV-ECMO include bleeding, thrombus formation and rare cases of cannula-associated infections. Its use in nonintubated patients (awake ECMO) is possible in specific cases and has proven valuable as a bridge to lung transplant approach. Some ECMO centers offer cannulation of a patient at primary care hospitals, facilitating subsequent transport to the center (ECMO transport). The COVID-19 pandemic not only caused the number of VV-ECMO runs to skyrocket but has also drawn public attention to this extracorporeal procedure. Strict quality control to improve vvECMO outcomes according to the German hospital reform is urgently needed, especially so since the technique has a high demand in resources and bears significant risks when performed by untrained personnel.
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Affiliation(s)
- Sebastian Mang
- Klinik für Innere Medizin V - Pneumologie, Allergologie, Intensivmedizin, Notfallmedizin, ECLS-Center Saar, Universitätsklinik des Saarlandes, Kirrberger Str. 100, 66421, Homburg/Saar, Deutschland
| | - Christian Karagiannidis
- Lungenklinik Köln-Merheim, Kliniken der Stadt Köln gGmbH, Köln, Deutschland
- Universität Witten/Herdecke, Witten/Herdecke, Deutschland
| | - Philipp M Lepper
- Klinik für Innere Medizin V - Pneumologie, Allergologie, Intensivmedizin, Notfallmedizin, ECLS-Center Saar, Universitätsklinik des Saarlandes, Kirrberger Str. 100, 66421, Homburg/Saar, Deutschland.
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9
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Sanivarapu RR, Osman U, Latha Kumar A. A Systematic Review of Mortality Rates Among Adult Acute Respiratory Distress Syndrome Patients Undergoing Extracorporeal Membrane Oxygenation Therapy. Cureus 2023; 15:e43590. [PMID: 37719572 PMCID: PMC10503872 DOI: 10.7759/cureus.43590] [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: 06/09/2023] [Accepted: 08/16/2023] [Indexed: 09/19/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a severe lung disease associated with a high mortality rate. Extracorporeal membrane oxygenation (ECMO) is a life-saving therapy for severe ARDS patients who do not respond to conventional treatments. Nevertheless, the optimal management of ARDS patients undergoing ECMO and their mortality rates remain subjects of controversy. Thus, this systematic review aims to assess mortality rates in ARDS patients on ECMO and identify associated factors. The review adhered to the Preferred Reporting Items for Systemic Review and Meta-Analysis (PRISMA) 2020 guidelines. A comprehensive literature search was conducted on PubMed, PubMed Central (PMC), Medline, and Embase. In accordance with our inclusion and exclusion criteria, filters, and key terms, we proceeded to screen the articles. After assessing the relevance of each article to our topic, further screening was carried out. Quality assessment of the articles was conducted, resulting in the inclusion of a total of 12 articles for the review. The primary outcome focused on mortality rates among ARDS patients undergoing ECMO. Secondary outcomes explored potential contributors to mortality, including patient age, underlying cause of ARDS, and Sequential Organ Failure Assessment (SOFA) scores at the initiation of ECMO. Mortality rates exhibited significant variation, ranging from 22% to 62.6%. Several factors emerged as potential predictors of mortality, encompassing patient age, comorbidities, complications during ECMO therapy, and treatment-related variables. This systematic review offers valuable insights into the intricate factors influencing mortality rates among ARDS patients on ECMO. A comprehension of these factors is essential to steer clinical practice and enhance patient outcomes. While ECMO serves as a restorative avenue for ARDS patients, future research is warranted to further elucidate these complex interactions and refine ECMO therapy protocols.
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Affiliation(s)
- Raghavendra R Sanivarapu
- Pulmonary and Critical Care Medicine, Texas Tech University Health Sciences Center, Lubbock, USA
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Usama Osman
- Research, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
- Geriatrics, Michigan State University College of Human Medicine, East Lansing, USA
| | - Abishek Latha Kumar
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
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10
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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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11
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Skidmore KL, Rajabi A, Nguyen A, Imani F, Kaye AD. Veno-venous Extracorporeal Membrane Oxygenation: Anesthetic Considerations in Clinical Practice. Anesth Pain Med 2023; 13:e136524. [PMID: 38021335 PMCID: PMC10664155 DOI: 10.5812/aapm-136524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 05/28/2023] [Accepted: 06/04/2023] [Indexed: 12/01/2023] Open
Abstract
Context After the COVID-19 pandemic, multiple reviews have documented the success of veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Patients who experience hypoxemia but have normal contractility may be switched to veno-venous-ECMO (VV-ECMO). Purpose In this review, we present three protocols for anesthesiologists. Firstly, transesophageal echocardiography (TEE) aids in cannulation and weaning off inotropes and fluids. Our main objective is to assist in patient selection for the Avalon Elite single catheter, which is inserted into the right internal jugular vein and terminates in the right atrium. Secondly, we propose appropriate anticoagulant doses. We outline day-to-day monitoring protocols to prevent heparin-induced thrombocytopenia (HIT) or resistance. Once the effects of neuromuscular paralysis subside, sedation should be reduced. Therefore, we describe techniques that may prevent delirium from progressing into permanent cognitive decline. Methods We conducted a PubMed search using the keywords VV-ECMO, TEE, Avalon Elite (Maquet, Germany), and quetiapine. We combined these findings with interviews conducted with nurses and anesthesiologists from two academic ECMO centers, focusing on anticoagulation and sedation. Results Our qualitative evidence synthesis reveals how TEE confirms cannulation while avoiding right atrial rupture or low flows. Additionally, we discovered that typically, after initial heparinization, activated partial thromboplastin time (PTT) is drawn every 1 to 2 hours or every 6 to 8 hours once stable. Daily thromboelastograms, along with platelet counts and antithrombin III levels, may detect HIT or resistance, respectively. These side effects can be prevented by discontinuing heparin on day two and initiating argatroban at a dose of 1 μg/kg/min while maintaining PTT between 61 - 80 seconds. The argatroban dose is adjusted by 10 - 20% if PTT is between 40 - 60 or 80 - 90 seconds. Perfusionists assist in establishing protocols following manufacturer guidelines. Lastly, we describe the replacement of narcotics and benzodiazepines with dexmedetomidine at a dose of 0.5 to 1 μg/kg/hour, limited by bradycardia, and the use of quetiapine starting at 25 mg per day and gradually increasing up to 200 mg twice a day, limited by prolonged QT interval. Conclusions The limitation of this review is that it necessarily covers a broad range of ECMO decisions faced by an anesthesiologist. However, its main advantage lies in the identification of straightforward argatroban protocols through interviews, as well as the discovery, via PubMed, of the usefulness of TEE in determining cannula position and contractility estimates for transitioning from VA-ECMO to VV-ECMO. Additionally, we emphasize the benefits in terms of morbidity and mortality of a seldom-discussed sedation supplement, quetiapine, to dexmedetomidine.
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Affiliation(s)
- Kimberly L. Skidmore
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, USA
| | - Alireza Rajabi
- Department of Anesthesiology and Critical Care, Iran University of Medical Sciences, Tehran, Iran
| | - Angela Nguyen
- School of Medicine, Louisiana State University Health Sciences Center at Shreveport, Shreveport, USA
| | - Farnad Imani
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Alan D. Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, USA
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12
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Umei N, Shin S, Lai A, Miller J, Roberts K, Strelkova D, Chaudhary N, Ichiba S, Sakamoto A, Whitehead K, Cook K. Factor XII Silencing Using siRNA Prevents Thrombus Formation in a Rat Model of Extracorporeal Life Support. ASAIO J 2023; 69:527-532. [PMID: 36728837 DOI: 10.1097/mat.0000000000001876] [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: 02/03/2023] Open
Abstract
Heparin anticoagulation increases the bleeding risk during extracorporeal life support (ECLS). This study determined whether factor XII (FXII) silencing using short interfering RNA (siRNA) can provide ECLS circuit anticoagulation without bleeding. Adult male, Sprague-Dawley rats were randomized to four groups (n = 3 each) based on anticoagulant: (1) no anticoagulant, (2) heparin, (3) FXII siRNA, or (4) nontargeting siRNA. Heparin was administered intravenously before and during ECLS. FXII or nontargeting siRNA were administered intravenously 3 days before the initiation of ECLS via lipidoid nanoparticles. The rats were placed on pumped, arteriovenous ECLS for 8 hours or until the blood flow resistance reached three times its baseline resistance. Without anticoagulant, mock-oxygenator resistance tripled within 7 ± 2 minutes. The resistance in the FXII siRNA group did not increase for 8 hours. There were no significant differences in resistance or mock-oxygenator thrombus volume between the FXII siRNA and the heparin groups. However, the bleeding time in the FXII siRNA group (3.4 ± 0.6 minutes) was significantly shorter than that in the heparin group (5.5 ± 0.5 minutes, p < 0.05). FXII silencing using siRNA provided simpler anticoagulation of ECLS circuits with reduced bleeding time as compared to heparin. http://links.lww.com/ASAIO/A937.
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Affiliation(s)
- Nao Umei
- From the Departments of Anesthesiology
- Surgical Intensive Care Medicine, Nippon Medical School Hospital, Tokyo, Japan
- Departments of Biomedical Engineering
| | - Suji Shin
- Departments of Biomedical Engineering
| | | | | | | | - Daria Strelkova
- Chemical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Namit Chaudhary
- Chemical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Shingo Ichiba
- From the Departments of Anesthesiology
- Surgical Intensive Care Medicine, Nippon Medical School Hospital, Tokyo, Japan
| | - Atsuhiro Sakamoto
- From the Departments of Anesthesiology
- Surgical Intensive Care Medicine, Nippon Medical School Hospital, Tokyo, Japan
| | - Kathryn Whitehead
- Departments of Biomedical Engineering
- Chemical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania
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13
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Menninger L, Körner A, Mirakaj V, Heck-Swain KL, Haeberle HA, Althaus K, Baumgaertner M, Jost W, Schlensak C, Rosenberger P, Koeppen M. Membrane oxygenator longevity was higher in argatroban-treated patients undergoing vvECMO. Eur J Clin Invest 2023; 53:e13963. [PMID: 36718989 DOI: 10.1111/eci.13963] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 01/23/2023] [Accepted: 01/28/2023] [Indexed: 02/01/2023]
Abstract
BACKGROUND In severe acute respiratory distress syndrome (ARDS), venovenous extracorporeal membrane oxygenation (vvECMO) can be a lifesaver. However, anticoagulation therapy is mandatory because the nonendothelial extracorporeal surface increases the risk of thromboembolic problems. Heparin is still the most common anticoagulant, but argatroban could be an alternative. This work investigates whether argatroban offers a therapeutic advantage over heparin during vvECMO. METHODS We performed a retrospective cohort study of patients who underwent vvECMO for severe ARDS and received heparin or argatroban as anticoagulation therapy. Demographic variables, intensive care unit (ICU) treatment and outcome parameters were evaluated. The primary outcome parameter was the operating time of the membrane oxygenator normalized to the duration of vvECMO treatment. Secondary outcome parameters were transfusion requirements normalized to the duration of vvECMO therapy. RESULTS Fifty seven patients from January 2019 to February 2021 underwent vvECMO and were included in this study. Thirty three patients received heparin and 24 patients argatroban as anticoagulatory therapy. The groups did not differ in demographics, ICU scoring systems, or comorbidities. Platelet counts and partial prothrombin time did not differ between the two groups during the first 6 days of vvECMO. The argatroban group had lower requirements for red blood cells, platelets and fresh frozen plasma. The mean runtime of the individual membrane oxygenator increased from 12.3 days (heparin group) to 16.6 days in the argatroban group. CONCLUSIONS Our findings suggest that argatroban can be considered as anticoagulant during vvECMO.
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Affiliation(s)
- Loredana Menninger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital, Tübingen, Germany
| | - Andreas Körner
- Department of Anesthesiology and Intensive Care Medicine, University Hospital, Tübingen, Germany
| | - Valbona Mirakaj
- Department of Anesthesiology and Intensive Care Medicine, University Hospital, Tübingen, Germany
| | - Ka-Lin Heck-Swain
- Department of Anesthesiology and Intensive Care Medicine, University Hospital, Tübingen, Germany
| | - Helene A Haeberle
- Department of Anesthesiology and Intensive Care Medicine, University Hospital, Tübingen, Germany
| | - Karina Althaus
- Medical Faculty of Tuebingen, Institute for Clinical and Experimental Transfusion Medicine, Tübingen, Germany
- Center for Clinical Transfusion Medicine, University Hospital of Tuebingen, Tuebingen, Germany
| | - Michael Baumgaertner
- Department of Thoracic and Cardiovascular Surgery, University Hospital Tübingen, Tübingen, Germany
| | - Walter Jost
- Department of Thoracic and Cardiovascular Surgery, University Hospital Tübingen, Tübingen, Germany
| | - Christian Schlensak
- Department of Thoracic and Cardiovascular Surgery, University Hospital Tübingen, Tübingen, Germany
| | - Peter Rosenberger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital, Tübingen, Germany
| | - Michael Koeppen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital, Tübingen, Germany
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14
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Buckley MS, Benanti GE, Meckel J, Tekle LA, Gilbert B, Puebla Neira D, McNierney DA, Korkames G, Yerondopoulos M, Park A, O'Hea JA, MacLaren R. Correlation between partial thromboplastin time and thromboelastography in adult critically ill patients requiring bivalirudin for extracorporeal membrane oxygenation. Pharmacotherapy 2023; 43:196-204. [PMID: 36759323 DOI: 10.1002/phar.2776] [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: 11/17/2022] [Revised: 12/29/2022] [Accepted: 12/30/2022] [Indexed: 02/11/2023]
Abstract
STUDY OBJECTIVE Thromboelastography (TEG) offers a more dynamic assessment of hemostasis over activated partial thromboplastin time (aPTT). However, the clinical utility of TEG in monitoring bivalirudin during extracorporeal membrane oxygenation (ECMO) remains unknown. The purpose of this study was to evaluate the correlation between aPTT and TEG in adult ECMO patients anticoagulated with bivalirudin. DESIGN Multicenter, retrospective, cohort study conducted over a 2-year period. SETTING Two academic university medical centers (Banner University Medical Center) in Phoenix and Tucson, AZ. PATIENTS Adult patients requiring ECMO and bivalirudin therapy with ≥1 corresponding standard TEG and aPTT plasma samples drawn ≤4 h of each other were included. The primary endpoint was to determine the correlation coefficient between the standard TEG reaction (R) time and bivalirudin aPTT serum concentrations. MEASUREMENTS AND MAIN RESULTS A total of 104 patients consisting of 848 concurrent laboratory assessments of R time and aPTT were included. A moderate correlation between TEG R time and aPTT was demonstrated in the study population (r = 0.41; p < 0.001). Overall, 502 (59.2%) concurrent assessments of TEG R time and aPTT values showed agreement on whether they were sub-, supra-, or therapeutic according to the institution's classification for bivalirudin. The 42.2% (n = 271/642) discordant TEG R times among "therapeutic" aPTT were almost equally distributed between subtherapeutic and supratherapeutic categories. CONCLUSIONS Moderate correlation was found between TEG R time and aPTT associated with bivalirudin during ECMO in critically ill adults. Further research is warranted to address the optimal test to guide clinical decision-making for anticoagulation dosing in ECMO patients.
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Affiliation(s)
- Mitchell S Buckley
- Department of Pharmacy, Banner University Medical Center Phoenix, Phoenix, Arizona, USA
| | - Grace E Benanti
- Department of Pharmacy, Loyola University Medical Center, Maywood, Illinois, USA
| | - Jordan Meckel
- Department of Pharmacy, Loyola University Medical Center, Maywood, Illinois, USA
| | - Luwam A Tekle
- Department of Pharmacy, Banner University Medical Center Phoenix, Phoenix, Arizona, USA
| | - Brian Gilbert
- Department of Pharmacy, Wesley Medical Center, Wichita, Kansas, USA
| | - Daniel Puebla Neira
- Department of Pulmonary and Critical Care, University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Dakota A McNierney
- Department of Medicine, Banner University Medical Center Phoenix, Phoenix, Arizona, USA
| | - Grace Korkames
- Department of Pharmacy, Banner University Medical Center Phoenix, Phoenix, Arizona, USA
| | - Melanie Yerondopoulos
- Department of Pharmacy, Banner University Medical Center Phoenix, Phoenix, Arizona, USA
| | - Andrew Park
- Department of Pharmacy, Banner University Medical Center Phoenix, Phoenix, Arizona, USA
| | - Jennifer A O'Hea
- Division of Pulmonary/Critical Care, Banner University Medical Center Phoenix, Phoenix, Arizona, USA
| | - Robert MacLaren
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
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15
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Helms J, Frere C, Thiele T, Tanaka KA, Neal MD, Steiner ME, Connors JM, Levy JH. Anticoagulation in adult patients supported with extracorporeal membrane oxygenation: guidance from the Scientific and Standardization Committees on Perioperative and Critical Care Haemostasis and Thrombosis of the International Society on Thrombosis and Haemostasis. J Thromb Haemost 2023; 21:373-396. [PMID: 36700496 DOI: 10.1016/j.jtha.2022.11.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 11/08/2022] [Accepted: 11/09/2022] [Indexed: 01/26/2023]
Abstract
Anticoagulation of patients supported by extracorporeal membrane oxygenation is challenging because of a high risk of both bleeding and thrombotic complications, and often empirical. Practice in anticoagulation management is therefore highly variable. The scope of this guidance document is to provide clinicians with practical advice on the choice of an anticoagulant agent, dosing, and the optimal anticoagulant monitoring strategy during extracorporeal membrane oxygenation support in adult patients.
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Affiliation(s)
- Julie Helms
- Strasbourg University (UNISTRA), Strasbourg University Hospital, Medical Intensive Care Unit - NHC, INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Strasbourg, France.
| | - Corinne Frere
- Sorbonne Université, UMRS 1166, AP-HP. Sorbonne Université, Pitié-Salpêtrière Hospital, Paris, France
| | - Thomas Thiele
- Institut für Transfusionsmedizin, Universitätsmedizin Rostock, Schillingallee 36, Rostock, Germany
| | - Kenichi A Tanaka
- Department of Anesthesiology, Universit of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Matthew D Neal
- Department of Surgery, Trauma and Transfusion Medicine Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Marie E Steiner
- Division of Hematology/Oncology and Division of Critical Care, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - Jean M Connors
- Hematology Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC, USA
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16
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Sommer P, Nunnally M. Mechanical circulatory support in the intensive care unit. Int Anesthesiol Clin 2022; 60:46-54. [PMID: 35993668 DOI: 10.1097/aia.0000000000000381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Philip Sommer
- Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Langone Health, New York, New York
| | - Mark Nunnally
- Departments of Anesthesiology, Perioperative Care and Pain Medicine, Medicine, Surgery, Neurology, NYU Langone Medical Center, New York, New York
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17
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Schmandt M, Putensen C, Stiehl T, Wagenpfeil J, Schewe JC, Ehrentraut SF. Be Patient: Prolonged Extracorporeal Membrane Oxygenation Support Including Full System Switch With Favorable Outcome. J Med Cases 2022; 13:483-490. [PMID: 36407859 PMCID: PMC9635769 DOI: 10.14740/jmc3979] [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: 07/03/2022] [Accepted: 09/21/2022] [Indexed: 01/25/2023] Open
Abstract
Despite tremendous advances in treatment, acute respiratory distress syndrome (ARDS) remains a disease with high mortality (42-48%). Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is often used as a last treatment option, which poses complex problems for the treatment team, especially with prolonged ECMO support. We report an interesting case of a 40-year-old female patient who developed influenza pneumonia leading to ARDS and subsequently requiring ECMO. Due to severe clotting complications, a prolonged ECMO run time with numerous filter changes was required. After a total of 56 days of ECMO therapy, the patient was successfully weaned. Fortunately, further in the course of treatment, complete recovery with restitutio ad integrum was achieved. A distinguishing feature of this case report is the description of a complete ECMO system change and the concurrent use of two ECMO systems for the same patient. Additionally, we provide data on the patient's current health-related quality of life as measured using the World Health Organization Disability Assessment Schedule 2.0.
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Affiliation(s)
- Mathias Schmandt
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany,Corresponding Author: Mathias Schmandt, Department of Anesthesiology and Intensive Care Medicine, Venusberg-Campus 1, 53127 Bonn, Germany.
| | - Christian Putensen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Tatjana Stiehl
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Julia Wagenpfeil
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Bonn, Germany
| | - Jens-Christian Schewe
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Stefan Felix Ehrentraut
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
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18
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Umei N, Ichiba S, Genda Y, Mase H, Sakamoto A. Early predictors of oxygenator exchange during veno-venous extracorporeal membrane oxygenation: A retrospective analysis. Int J Artif Organs 2022; 45:927-935. [PMID: 35982583 DOI: 10.1177/03913988221118382] [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: 11/15/2022]
Abstract
INTRODUCTION Oxygenator exchange during extracorporeal membrane oxygenation (ECMO) is a life-threatening procedure. D-dimer has been used to predict oxygenator failure, but it is a parameter used a few days before oxygenator exchange. This study investigated parameters before and immediately after ECMO initiation that predict oxygenator exchange. METHODS This was a single-center, retrospective study of 28 patients who received veno-venous ECMO with heparin/silicone-coated polypropylene oxygenator (NSH-R HPO-23WH-C; Senko Medical Inc., Tokyo, Japan), due to acute respiratory failure, from April 2015 to March 2020. Clinical data before ECMO initiation and during the first 3 days on ECMO were compared between the patients with oxygenator exchange (exchange group) and those without oxygenator exchange (non-exchange group). RESULTS Nine (32%) patients required oxygenator exchange. The exchange group had significantly higher white blood cell count (WBC) (16,944 ± 2423/µL vs 10,342 ± 1442/µL, p < 0.05) and Acute Physiology and Chronic Health Evaluation (APACHE) II score (31 ± 5 vs 25 ± 8, p < 0.05) before ECMO initiation than the non-exchange group. The partial pressure of oxygen at the outlet of the oxygenator (PO2 outlet) and activated partial thromboplastin time (aPTT) during the first 3 days on ECMO were significantly lower in the exchange group than in the non-exchange group. CONCLUSIONS High WBC and APACHE II score before ECMO initiation, low PO2 outlet, and aPTT during the first 3 days on ECMO were associated with oxygenator exchange during veno-venous ECMO. These parameters could be used to avoid unexpected oxygenator exchange.
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Affiliation(s)
- Nao Umei
- Department of Anesthesiology, Nippon Medical School, Tokyo, Japan.,Department of Surgical Intensive Care Medicine, Nippon Medical School Hospital, Tokyo, Japan
| | - Shingo Ichiba
- Department of Anesthesiology, Nippon Medical School, Tokyo, Japan.,Department of Surgical Intensive Care Medicine, Nippon Medical School Hospital, Tokyo, Japan
| | - Yuki Genda
- Department of Anesthesiology, Nippon Medical School, Tokyo, Japan.,Department of Surgical Intensive Care Medicine, Nippon Medical School Hospital, Tokyo, Japan
| | - Hiroshi Mase
- Department of Anesthesiology, Nippon Medical School, Tokyo, Japan.,Department of Surgical Intensive Care Medicine, Nippon Medical School Hospital, Tokyo, Japan
| | - Atsuhiro Sakamoto
- Department of Anesthesiology, Nippon Medical School, Tokyo, Japan.,Department of Surgical Intensive Care Medicine, Nippon Medical School Hospital, Tokyo, Japan
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19
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Wiegele M, Laxar D, Schaden E, Baierl A, Maleczek M, Knöbl P, Hermann M, Hermann A, Zauner C, Gratz J. Subcutaneous Enoxaparin for Systemic Anticoagulation of COVID-19 Patients During Extracorporeal Life Support. Front Med (Lausanne) 2022; 9:879425. [PMID: 35899208 PMCID: PMC9309531 DOI: 10.3389/fmed.2022.879425] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 06/22/2022] [Indexed: 12/11/2022] Open
Abstract
Background Extracorporeal membrane oxygenation, with an inherent requirement for anticoagulation to avoid circuit thrombosis, is a key element in the treatment of respiratory failure associated with COVID-19. Anticoagulation remains challenging, the standard of care being intravenous continuous administration of unfractionated heparin. Yet regimens vary. Some intensive care units in our center have successfully used enoxaparin subcutaneously in recent years and throughout the pandemic. Methods We retrospectively analyzed adult COVID-19 patients with respiratory failure who had been systemically anticoagulated using either enoxaparin or unfractionated heparin. The choice of anticoagulant therapy was based on the standard of the intensive care unit. Defined thromboembolic and hemorrhagic events were analyzed as study endpoints. Results Of 98 patients, 62 had received enoxaparin and 36 unfractionated heparin. All hazard ratios for the thromboembolic (3.43; 95% CI: 1.08–10.87; p = 0.04), hemorrhagic (2.58; 95% CI: 1.03–6.48; p = 0.04), and composite (2.86; 95% CI: 1.41–5.92; p = 0.007) endpoints favored enoxaparin, whose efficient administration was verified by peak levels of anti-factor Xa (median: 0.45 IU ml−1; IQR: 0.38; 0.56). Activated partial thromboplastin time as well as thrombin time differed significantly (both p<0.001) between groups mirroring the effect of unfractionated heparin. Conclusions This study demonstrates the successful use of subcutaneous enoxaparin for systemic anticoagulation in patients with COVID-19 during extracorporeal membrane oxygenation. Our findings are to be confirmed by future prospective, randomized, controlled trials.
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Affiliation(s)
- Marion Wiegele
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Daniel Laxar
- Ludwig Boltzmann Institute Digital Health and Patient Safety, Medical University of Vienna, Vienna, Austria
| | - Eva Schaden
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Institute Digital Health and Patient Safety, Medical University of Vienna, Vienna, Austria
| | - Andreas Baierl
- Department of Statistics and Operations Research University of Vienna, Vienna, Austria
| | - Mathias Maleczek
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Institute Digital Health and Patient Safety, Medical University of Vienna, Vienna, Austria
| | - Paul Knöbl
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Martina Hermann
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Institute Digital Health and Patient Safety, Medical University of Vienna, Vienna, Austria
| | - Alexander Hermann
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Christian Zauner
- Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Johannes Gratz
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
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20
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Bleeding and thrombotic events in patients with severe COVID-19 supported with extracorporeal membrane oxygenation: a nationwide cohort study. Intensive Care Med 2022; 48:1039-1052. [PMID: 35829723 DOI: 10.1007/s00134-022-06794-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 06/01/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE To describe bleeding and thrombotic events and their risk factors in patients receiving extracorporeal membrane oxygenation (ECMO) for severe coronavirus disease 2019 (COVID-19) and to evaluate their impact on in-hospital mortality. METHODS The ECMOSARS registry included COVID-19 patients supported by ECMO in France. We analyzed all patients included up to March 31, 2022 without missing data regarding bleeding and thrombotic events. The association of bleeding and thrombotic events with in-hospital mortality and pre-ECMO variables was assessed using multivariable logistic regression models. RESULTS Among 620 patients supported by ECMO, 29% had only bleeding events, 16% only thrombotic events and 20% both bleeding and thrombosis. Cannulation site (18% of patients), ear nose and throat (12%), pulmonary bleeding (9%) and intracranial hemorrhage (8%) were the most frequent bleeding types. Device-related thrombosis and pulmonary embolism/thrombosis accounted for most of thrombotic events. In-hospital mortality was 55.7%. Bleeding events were associated with in-hospital mortality (adjusted odds ratio (adjOR) = 2.91[1.94-4.4]) but not thrombotic events (adjOR = 1.02[0.68-1.53]). Intracranial hemorrhage was strongly associated with in-hospital mortality (adjOR = 13.5[4.4-41.5]). Ventilation duration before ECMO ≥ 7 days and length of ECMO support were associated with bleeding. Thrombosis-associated factors were fibrinogen ≥ 6 g/L and length of ECMO support. CONCLUSIONS In a nationwide cohort of COVID-19 patients supported by ECMO, bleeding incidence was high and associated with mortality. Intracranial hemorrhage incidence was higher than reported for non-COVID patients and carried the highest risk of death. Thrombotic events were less frequent and not associated with mortality. Length of ECMO support was associated with a higher risk of both bleeding and thrombosis, supporting the development of strategies to minimize ECMO duration.
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21
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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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Abruzzo A, Gorantla V, Thomas SE. Venous thromboembolic events in the setting of extracorporeal membrane oxygenation support in adults: A systematic review. Thromb Res 2022; 212:58-71. [DOI: 10.1016/j.thromres.2022.02.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 02/01/2022] [Accepted: 02/18/2022] [Indexed: 01/04/2023]
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It takes two to bleed: anticoagulation intensity and the host’s vascular susceptibility. Author’s reply. Intensive Care Med 2022; 48:621-623. [PMID: 35284944 PMCID: PMC8918361 DOI: 10.1007/s00134-022-06636-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2022] [Indexed: 11/05/2022]
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Kimura T, Kobayashi T, Kobori F, Goto M, Takemitsu M, Tanaka A, Sato J, Isomine S. Massive hemoptysis managed by prolonged anticoagulation-free veno-venous extracorporeal membrane oxygenation with which thoracic surgeries were accompanied: a case report. JA Clin Rep 2022; 8:11. [PMID: 35190925 PMCID: PMC8861252 DOI: 10.1186/s40981-022-00503-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 02/09/2022] [Accepted: 02/11/2022] [Indexed: 12/29/2022] Open
Abstract
Background Massive hemoptysis causing inadequate ventilation results in life-threatening consequences. We present a patient who developed respiratory insufficiency produced by bronchiectatic massive hemoptysis and underwent prolonged anticoagulation-free veno-venous extracorporeal membrane oxygenation (VV-ECMO) during which thoracic surgeries were performed. Case presentation A 79-year-old woman suffered massive hemoptysis resulting in respiratory failure during fiberoptic bronchoscopy. Bronchial intubation followed by one lung ventilation failed to ensure adequate oxygenation. Anticoagulation-free VV-ECMO, therefore, was installed immediately. Since conservative hemostatic measures including bronchial arterial embolization were not effective, resection of the culprit lung was performed while on VV-ECMO. Next day an exploratory thoracotomy and intercostal artery embolization were needed for recurrent bleeding. The VV-ECMO was withdrawn after five days of operation. Conclusions Massive hemoptysis can be fatal and needs instantaneous and intensive treatments. In our case, long-term anticoagulation-free VV-ECMO during which thoracic surgeries and endovascular interventions were performed provided a favorable outcome.
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Seeliger B, Wendel-Garcia PD, Stahl K, Bode C, David S. It takes two to bleed: anticoagulation intensity and the host's vascular susceptibility. Intensive Care Med 2022; 48:619-620. [PMID: 35142897 PMCID: PMC8830966 DOI: 10.1007/s00134-022-06643-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2022] [Indexed: 01/01/2023]
Affiliation(s)
- Benjamin Seeliger
- Hannover Medical School, Department of Respiratory Medicine and Biomedical Research in End-Stage and Obstructive Lung Disease Hannover, German Center for Lung Research, Hannover, Germany
| | | | - Klaus Stahl
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Christian Bode
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Sascha David
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland.
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Takauji S, Tanaka H, Hayakawa M, Horioka K, Isozaki S, Konishi H. Soluble thrombomodulin ameliorates aberrant hemostasis after rewarming in a rat accidental hypothermia model. Biochem Biophys Res Commun 2022; 587:1-8. [PMID: 34856423 DOI: 10.1016/j.bbrc.2021.11.086] [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: 10/05/2021] [Revised: 11/10/2021] [Accepted: 11/24/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Accidental hypothermia (AH) sometimes leads to coagulation disorder, especially in severe AH. We previously demonstrated that intrasplenic platelet activation caused aberrant hemostasis and thrombus formation after rewarming in a murine AH model. However, no study has focused on the appropriate management of platelets causing coagulation activation after rewarming of AH. We investigated whether or not recombinant soluble thrombomodulin (rTM) can suppress thrombosis formation after rewarming using a rat AH model. METHODS Wistar rats were exposed to an ambient temperature of -20 °C under general anesthesia until their rectal temperature decreased to 26 °C. The Hypo group rats (n = 5) were immediately euthanized, while the Hypo/Re group (n = 5) and rTM group rats (n = 5), which were administered rTM (1 mg/kg) via the tail vein, were rewarmed until the rectal temperature returned to 34 °C and then euthanized 6 h later. Tissue and blood samples were collected from all rats for histopathological and coagulation analyses at euthanasia. RESULTS There was no significant change in the D-dimer level in the Hypo group rats, while the D-dimer level was significantly elevated at 6 h after rewarming in the Hypo/Re group rats (P = 0.015), and histopathology detected both fibrin and platelets in the renal glomerulus. However, the rTM group rats did not show any elevation of the D-dimer levels at 6 h after rewarming, and no fibrin was noted on histopathology. CONCLUSIONS rTM may be useful as an appropriate anticoagulant in cases of aberrant hemostasis after rewarming of AH.
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Affiliation(s)
- Shuhei Takauji
- Department of Emergency Medicine, Asahikawa Medical University Hospital, Japan.
| | - Hiroki Tanaka
- Division of Tumor Pathology, Department of Pathology, Asahikawa Medical University, Japan
| | - Mineji Hayakawa
- Department of Emergency Medicine, Hokkaido University Hospital, Japan
| | - Kie Horioka
- Department of Legal Medicine, International University of Health and Welfare, Japan; Department of Oncology-Pathology, Karolinska Institutet, Japan
| | - Shotaro Isozaki
- Gastroenterology and Endoscopy, Division of Metabolism and Biosystemic Science, Gastroenterology, and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Japan
| | - Hiroaki Konishi
- Department of Gastroenterology and Advanced Medical Sciences, Asahikawa Medical University, Japan
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Willers A, Arens J, Mariani S, Pels H, Maessen JG, Hackeng TM, Lorusso R, Swol J. New Trends, Advantages and Disadvantages in Anticoagulation and Coating Methods Used in Extracorporeal Life Support Devices. MEMBRANES 2021; 11:membranes11080617. [PMID: 34436380 PMCID: PMC8399034 DOI: 10.3390/membranes11080617] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 08/06/2021] [Accepted: 08/08/2021] [Indexed: 11/16/2022]
Abstract
The use of extracorporeal life support (ECLS) devices has significantly increased in the last decades. Despite medical and technological advancements, a main challenge in the ECLS field remains the complex interaction between the human body, blood, and artificial materials. Indeed, blood exposure to artificial surfaces generates an unbalanced activation of the coagulation cascade, leading to hemorrhagic and thrombotic events. Over time, several anticoagulation and coatings methods have been introduced to address this problem. This narrative review summarizes trends, advantages, and disadvantages of anticoagulation and coating methods used in the ECLS field. Evidence was collected through a PubMed search and reference scanning. A group of experts was convened to openly discuss the retrieved references. Clinical practice in ECLS is still based on the large use of unfractionated heparin and, as an alternative in case of contraindications, nafamostat mesilate, bivalirudin, and argatroban. Other anticoagulation methods are under investigation, but none is about to enter the clinical routine. From an engineering point of view, material modifications have focused on commercially available biomimetic and biopassive surfaces and on the development of endothelialized surfaces. Biocompatible and bio-hybrid materials not requiring combined systemic anticoagulation should be the future goal, but intense efforts are still required to fulfill this purpose.
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Affiliation(s)
- Anne Willers
- ECLS Centre, Cardio-Thoracic Surgery, and Cardiology Department, Heart & Vascular Centre, Maastricht University Medical Centre (MUMC), P. Debyelaan 25, 6229 HX Maastricht, The Netherlands; (S.M.); (J.G.M.); (R.L.)
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands;
- Correspondence: (A.W.); (J.S.); Tel.: +31-(0)649-07-9752 (A.W.); +49-(911)-398-0 (J.S.)
| | - Jutta Arens
- Engineering Organ Support Technologies Group, Department of Biomechanical Engineering, Faculty of Engineering Technology, University of Twente, P.O. Box 217, 7500 AE Enschede, The Netherlands; (J.A.); (H.P.)
| | - Silvia Mariani
- ECLS Centre, Cardio-Thoracic Surgery, and Cardiology Department, Heart & Vascular Centre, Maastricht University Medical Centre (MUMC), P. Debyelaan 25, 6229 HX Maastricht, The Netherlands; (S.M.); (J.G.M.); (R.L.)
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands;
| | - Helena Pels
- Engineering Organ Support Technologies Group, Department of Biomechanical Engineering, Faculty of Engineering Technology, University of Twente, P.O. Box 217, 7500 AE Enschede, The Netherlands; (J.A.); (H.P.)
| | - Jos G. Maessen
- ECLS Centre, Cardio-Thoracic Surgery, and Cardiology Department, Heart & Vascular Centre, Maastricht University Medical Centre (MUMC), P. Debyelaan 25, 6229 HX Maastricht, The Netherlands; (S.M.); (J.G.M.); (R.L.)
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands;
| | - Tilman M. Hackeng
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands;
- Department of Biochemistry, Faculty of Health, Medicine and Life, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - Roberto Lorusso
- ECLS Centre, Cardio-Thoracic Surgery, and Cardiology Department, Heart & Vascular Centre, Maastricht University Medical Centre (MUMC), P. Debyelaan 25, 6229 HX Maastricht, The Netherlands; (S.M.); (J.G.M.); (R.L.)
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands;
| | - Justyna Swol
- Department of Respiratory Medicine, Allergology and Sleep Medicine, Paracelsus Medical University, Ernst-Nathan Str. 1, 90419 Nuremberg, Germany
- Correspondence: (A.W.); (J.S.); Tel.: +31-(0)649-07-9752 (A.W.); +49-(911)-398-0 (J.S.)
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Contraindications to the Initiation of Veno-Venous ECMO for Severe Acute Respiratory Failure in Adults: A Systematic Review and Practical Approach Based on the Current Literature. MEMBRANES 2021; 11:membranes11080584. [PMID: 34436348 PMCID: PMC8400963 DOI: 10.3390/membranes11080584] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/19/2021] [Accepted: 07/27/2021] [Indexed: 12/21/2022]
Abstract
(1) Background: Extracorporeal membrane oxygenation (ECMO) is increasingly used for acute respiratory failure with few absolute but many relative contraindications. The provider in charge often has a difficult time weighing indications and contraindications to anticipate if the patient will benefit from this treatment, a decision that often decides life and death for the patient. To assist in this process in coming to a good evidence-based decision, we reviewed the available literature. (2) Methods: We performed a systematic review through a literature search of the MEDLINE database of former and current absolute and relative contraindications to the initiation of ECMO treatment. (3) Results: The following relative and absolute contraindications were identified in the literature: absolute-refusal of the use of extracorporeal techniques by the patient, advanced stage of cancer, fatal intracerebral hemorrhage/cerebral herniation/intractable intracranial hypertension, irreversible destruction of the lung parenchyma without the possibility of transplantation, and contraindications to lung transplantation; relative-advanced age, immunosuppressed patients/pharmacological immunosuppression, injurious ventilator settings > 7 days, right-heart failure, hematologic malignancies, especially bone marrow transplantation and graft-versus-host disease, SAPS II score ≥ 60 points, SOFA score > 12 points, PRESERVE score ≥ 5 points, RESP score ≤ -2 points, PRESET score ≥ 6 points, and "do not attempt resuscitation" order (DN(A)R status). (4) Conclusions: We provide a simple-to-follow algorithm that incorporates absolute and relative contraindications to the initiation of ECMO treatment. This algorithm attempts to weigh pros and cons regarding the benefit for an individual patient and hopefully assists caregivers to make better, informed decisions.
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Descamps R, Moussa MD, Besnier E, Fischer MO, Preau S, Tamion F, Daubin C, Cousin N, Vincentelli A, Goutay J, Du Cheyron D. Anti-Xa activity and hemorrhagic events under extracorporeal membrane oxygenation (ECMO): a multicenter cohort study. Crit Care 2021; 25:127. [PMID: 33810800 PMCID: PMC8019180 DOI: 10.1186/s13054-021-03554-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 03/26/2021] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Hemorrhagic events remain a major concern in patients under extracorporeal membrane oxygenation (ECMO) support. We tested the association between anticoagulation levels and hemorrhagic events under ECMO using anti-Xa activity monitoring. METHODS We performed a retrospective multicenter cohort study in three ECMO centers. All adult patients treated with veno-venous (VV)- or veno-arterial (VA)-ECMO in 6 intensive care units between September 2017 and August 2019 were included. Anti-Xa activities were collected until a hemorrhagic event in the bleeding group and for the duration of ECMO in the non-bleeding group. All dosages were averaged to obtain means of anti-Xa activity for each patient, and patients were compared according to the occurrence or not of bleeding. RESULTS Among 367 patients assessed for eligibility, 121 were included. Thirty-five (29%) presented a hemorrhagic complication. In univariate analysis, anti-Xa activities were significantly higher in the bleeding group than in the non-bleeding group, both for the mean anti-Xa activity (0.38 [0.29-0.67] vs 0.33 [0.22-0.42] IU/mL; p = 0.01) and the maximal anti-Xa activity (0.83 [0.47-1.46] vs 0.66 [0.36-0.91] IU/mL; p = 0.05). In the Cox proportional hazard model, mean anti-Xa activity was associated with bleeding (p = 0.0001). By Kaplan-Meier analysis with the cutoff value at 0.46 IU/mL obtained by ROC curve analysis, the probability of survival under ECMO without bleeding was significantly lower when mean anti-Xa was > 0.46 IU/mL (p = 0.0006). CONCLUSION In critically ill patients under ECMO, mean anti-Xa activity was an independent risk factor for hemorrhagic complications. Anticoagulation targets could be revised downward in both VV- and VA-ECMO.
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Affiliation(s)
- Richard Descamps
- Department of Medical Intensive Care, Caen University Hospital, 14000, Caen, France.
| | - Mouhamed D Moussa
- Inserm, CHU Lille, Surgical Critical Care, Department of Anesthesiology and Critical Care, Institut Pasteur de Lille, UMR1011-EGID, Univ. Lille, 59000, Lille, France
| | - Emmanuel Besnier
- Department of Anesthesiology and Critical Care, Rouen University Hospital, 76000, Rouen, France
| | - Marc-Olivier Fischer
- Department of Anesthesiology and Critical Care, Caen University Hospital, 14000, Caen, France
| | - Sébastien Preau
- Department of Medical Intensive Care, Lille University Hospital, 59000, Lille, France
| | - Fabienne Tamion
- UNIROUEN, Inserm U1096, FHU- REMOD-VHF, Normandie Univ, 76000, Rouen, France
- Department of Medical Intensive Care, Rouen University Hospital, 76000, Rouen, France
| | - Cédric Daubin
- Department of Medical Intensive Care, Caen University Hospital, 14000, Caen, France
| | - Nicolas Cousin
- Department of Medical Intensive Care, Lille University Hospital, 59000, Lille, France
| | - André Vincentelli
- Inserm, CHU Lille, Department of Cardiac Surgery, Institut Pasteur de Lille, UMR1011-EGID, Univ. Lille, 59000, Lille, France
| | - Julien Goutay
- Department of Medical Intensive Care, Lille University Hospital, 59000, Lille, France
| | - Damien Du Cheyron
- Department of Medical Intensive Care, Caen University Hospital, 14000, Caen, France
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Moussa MD, Abou-Arab O, Robin E, Vincentelli A. Comments on 'Comparison of anticoagulation strategies for veno-venous ECMO support in acute respiratory failure': the bitter truth about unfractionated heparin monitoring assays. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:124. [PMID: 33781295 PMCID: PMC8006337 DOI: 10.1186/s13054-021-03525-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 03/02/2021] [Indexed: 12/05/2022]
Affiliation(s)
- Mouhamed Djahoum Moussa
- CHU Lille, Pôle d'Anesthésie-Réanimation, F-59000, Lille, France. .,Service d'Anesthésie-Réanimation Cardiovasculaire et Thoracique, Institut Cœur - Poumon, CHU Lille, 2 avenue Oscar Lambret, 59 037, Lille, France.
| | - Osama Abou-Arab
- CHU Lille, Pôle d'Anesthésie-Réanimation, F-59000, Lille, France.,Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, Amiens, France
| | - Emmanuel Robin
- CHU Lille, Pôle d'Anesthésie-Réanimation, F-59000, Lille, France
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