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Martin-Villen L, Adsuar-Gomez A, Garrido-Jimenez JM, Perez-Vela JL, Fuset-Cabanes MP. Mechanical circulatory support in cardiogenic shock patients. Med Intensiva 2024:S2173-5727(24)00230-3. [PMID: 39394008 DOI: 10.1016/j.medine.2024.09.006] [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: 07/16/2024] [Accepted: 07/22/2024] [Indexed: 10/13/2024]
Abstract
Cardiogenic shock (CS) is a highly complex clinical condition that requires a management strategy focused on early resolution of the underlying cause and the provision of circulatory support. In cases of refractory CS, mechanical circulatory support (MCS) is employed to replace the failed cardiocirculatory system, thereby preventing the development of multiorgan failure. There are various types of MCS, and patients with CS typically require devices that are either short-term (< 15 days) or intermediate-term (15-30 days). When choosing the device the underlying cause of CS, as well as the presence or absence of concomitant conditions such as failed ventricle, respiratory failure, and the intended purpose of the support should be taken into consideration. Patients with MCS require the comprehensive care indicated in complex critically ill patients with multiorgan dysfunction, with an emphasis on device monitoring and control. Different complications may arise during support management, and its withdrawal must be protocolized.
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Affiliation(s)
- Luis Martin-Villen
- Department of Intensive Care Medicine, Hospital Universitario Virgen del Rocío, Seville, Spain.
| | - Alejandro Adsuar-Gomez
- Department of Cardiovascular Surgery, Hospital Universitario Virgen del Rocío, Seville, Spain
| | | | - Jose Luis Perez-Vela
- Department of Intensive Care Medicine, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Mari Paz Fuset-Cabanes
- Department of Intensive Care Medicine, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Spain
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Volleman C, Raasveld SJ, Jamaludin FS, Vlaar APJ, van den Brom CE. Microcirculatory Perfusion Disturbances During Veno-Arterial Extracorporeal Membrane Oxygenation: A Systematic Review. Microcirculation 2024:e12891. [PMID: 39387210 DOI: 10.1111/micc.12891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2024] [Revised: 09/10/2024] [Accepted: 09/26/2024] [Indexed: 10/15/2024]
Abstract
Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is used in case of potentially reversible cardiac failure and restores systemic hemodynamics. However, whether this is followed by improvement of microcirculatory perfusion is unknown. Moreover, critically ill patients have possible pre-existing microcirculatory perfusion disturbances. Therefore, this review provides an overview of alterations in sublingual microcirculatory perfusion in critically ill adult patients receiving VA-ECMO support. Pubmed, Embase (Ovid), Cochrane Central Register of Controlled Trials, and Web of Science were systematically searched according to PRISMA guidelines. Studies reporting sublingual microcirculatory perfusion measurements in adult patients supported by VA-ECMO were included. Outcome parameters included small vessel density (SVD), perfused vessel density (PVD), perfused small vessel density (PSVD), proportion of perfused vessels (PPV), microvascular flow index (MFI) and the heterogeneity index (HI). The protocol was registered at PROSPERO (CRD42021243930). The search identified 1215 studies of which 11 were included. Cardiogenic shock was the most common indication for VA-ECMO (n=8). Three studies report increased PSVD, PPV, and MFI 24 hours after initiation of ECMO compared to pre-ECMO. Nonetheless, microcirculatory perfusion stabilized thereafter. Four out of four studies showed higher PSVD and PPV in survivors compared to non-survivors. Over time, survivors showed recovery of microcirculatory perfusion within hours of initiation of ECMO, whereas this was absent in non-survivors. Notwithstanding the limited sample, VA-ECMO seems to improve microcirculatory perfusion shortly after initiation of ECMO, especially in survivors. Further research in larger cohorts is needed to clarify the longitudinal effects of ECMO on microcirculatory perfusion.
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Affiliation(s)
- Carolien Volleman
- Department of Intensive Care Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Department of Anesthesiology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - S Jorinde Raasveld
- Department of Intensive Care Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Faridi S Jamaludin
- Medical Library AMC, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Alexander P J Vlaar
- Department of Intensive Care Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Charissa E van den Brom
- Department of Intensive Care Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Department of Anesthesiology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Li Y, Volleman C, Dubelaar DPC, Vlaar APJ, van den Brom CE. Exploring the Impact of Extracorporeal Membrane Oxygenation on the Endothelium: A Systematic Review. Int J Mol Sci 2024; 25:10680. [PMID: 39409009 PMCID: PMC11477268 DOI: 10.3390/ijms251910680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2024] [Revised: 09/04/2024] [Accepted: 10/01/2024] [Indexed: 10/20/2024] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a life-saving intervention for patients with circulatory and/or pulmonary failure; however, the rate of complications remains high. ECMO induces systemic inflammation, which may activate and damage the endothelium, thereby causing edema and organ dysfunction. Advancing our understanding in this area is crucial for improving patient outcomes during ECMO. The goal of this review is to summarize the current evidence of the effects of ECMO on endothelial activation and damage in both animals and patients. PubMed and Embase databases were systematically searched for both clinical and animal studies including ECMO support. The outcome parameters were markers of endothelial activation and damage or (in)direct measurements of endothelial permeability, fluid leakage and edema. In total, 26 studies (patient n = 16, animal n = 10) fulfilled all eligibility criteria, and used VA-ECMO (n = 13) or VV-ECMO (n = 6), or remained undefined (n = 7). The most frequently studied endothelial activation markers were adhesion molecules (ICAM-1) and selectins (E- and P-selectin). The levels of endothelial activation markers were comparable to or higher than in healthy controls. Compared to pre-ECMO or non-ECMO, the majority of studies showed stable or decreased levels. Angiopoietin-2, von Willebrand Factor and extracellular vesicles were the most widely studied circulating markers of endothelial damage. More than half of the included studies showed increased levels when compared to normal ranges, and pre-ECMO or non-ECMO values. In healthy animals, ECMO itself leads to vascular leakage and edema. The effect of ECMO support in critically ill animals showed contradicting results. ECMO support (further) induces endothelial damage, but endothelial activation does not, in the critically ill. Further research is necessary to conclude on the effect of the underlying comorbidity and type of ECMO support applied on endothelial dysfunction.
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Affiliation(s)
- Yakun Li
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (Y.L.); (C.V.); (D.P.C.D.); (A.P.J.V.)
- Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Carolien Volleman
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (Y.L.); (C.V.); (D.P.C.D.); (A.P.J.V.)
- Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Department of Anesthesiology, Amsterdam UMC, VU University Amsterdam, 1081 HV Amsterdam, The Netherlands
| | - Dionne P. C. Dubelaar
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (Y.L.); (C.V.); (D.P.C.D.); (A.P.J.V.)
- Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Alexander P. J. Vlaar
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (Y.L.); (C.V.); (D.P.C.D.); (A.P.J.V.)
- Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Charissa E. van den Brom
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (Y.L.); (C.V.); (D.P.C.D.); (A.P.J.V.)
- Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Department of Anesthesiology, Amsterdam UMC, VU University Amsterdam, 1081 HV Amsterdam, The Netherlands
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Erlebach R, Buhlmann A, Andermatt R, Seeliger B, Stahl K, Bode C, Schuepbach R, Wendel-Garcia PD, David S. Carboxyhemoglobin predicts oxygenator performance and imminent oxygenator change in extracorporeal membrane oxygenation. Intensive Care Med Exp 2024; 12:41. [PMID: 38656714 PMCID: PMC11043307 DOI: 10.1186/s40635-024-00626-7] [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: 02/05/2024] [Accepted: 04/17/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND The continuous exposure of blood to a non-biological surface during extracorporeal membrane oxygenation (ECMO) may lead to progressive thrombus formation in the oxygenator, hemolysis and consequently impaired gas exchange. In most centers oxygenator performance is monitored only on a once daily basis. Carboxyhemoglobin (COHb) is generated upon red cell lysis and is routinely measured with any co-oximetry performed to surveille gas exchange and acid-base homeostasis every couple of hours. This retrospective cohort study aims to evaluate COHb in the arterial blood gas as a novel marker of oxygenator dysfunction and its predictive value for imminent oxygenator change. RESULTS Out of the 484 screened patients on ECMO 89, cumulatively requiring 116 oxygenator changes within 1833 patient days, including 19,692 arterial COHb measurements were analyzed. Higher COHb levels were associated with lower post-oxygenator pO2 (estimate for log(COHb): - 2.176 [95% CI - 2.927, - 1.427], p < 0.0001) and with a shorter time to oxygenator change (estimate for log(COHb): - 67.895 [95% CI - 74.209, - 61.542] hours, p < 0.0001). COHb was predictive of oxygenator change within 6 h (estimate for log(COHb): 5.027 [95% CI 1.670, 15.126], p = 0.004). CONCLUSION COHb correlates with oxygenator performance and can be predictive of imminent oxygenator change. Therefore, longitudinal measurements of COHb in clinical routine might be a cheap and more granular candidate for ECMO surveillance that should be further analyzed in a controlled prospective trial design.
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Affiliation(s)
- Rolf Erlebach
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Alix Buhlmann
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Rea Andermatt
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Benjamin Seeliger
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Klaus Stahl
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Christian Bode
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Reto Schuepbach
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | | | - Sascha David
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland.
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Premraj L, Brown A, Fraser JF, Pellegrino V, Pilcher D, Burrell A. Oxygenation During Venoarterial Extracorporeal Membrane Oxygenation: Physiology, Current Evidence, and a Pragmatic Approach to Oxygen Titration. Crit Care Med 2024; 52:637-648. [PMID: 38059745 DOI: 10.1097/ccm.0000000000006134] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
OBJECTIVES This review aims to: 1) identify the key circuit and patient factors affecting systemic oxygenation, 2) summarize the literature reporting the association between hyperoxia and patient outcomes, and 3) provide a pragmatic approach to oxygen titration, in patients undergoing peripheral venoarterial extracorporeal membrane oxygenation (ECMO). DATA SOURCES Searches were performed using PubMed, SCOPUS, Medline, and Google Scholar. STUDY SELECTION All observational and interventional studies investigating the association between hyperoxia, and clinical outcomes were included, as well as guidelines from the Extracorporeal Life Support Organization. DATA EXTRACTION Data from relevant literature was extracted, summarized, and integrated into a concise narrative review. For ease of reference a summary of relevant studies was also produced. DATA SYNTHESIS The extracorporeal circuit and the native cardiorespiratory circuit both contribute to systemic oxygenation during venoarterial ECMO. The ECMO circuit's contribution to systemic oxygenation is, in practice, largely determined by the ECMO blood flow, whereas the native component of systemic oxygenation derives from native cardiac output and residual respiratory function. Interactions between ECMO outflow and native cardiac output (as in differential hypoxia), the presence of respiratory support, and physiologic parameters affecting blood oxygen carriage also modulate overall oxygen exposure during venoarterial ECMO. Physiologically those requiring venoarterial ECMO are prone to hyperoxia. Hyperoxia has a variety of definitions, most commonly Pa o2 greater than 150 mm Hg. Severe hypoxia (Pa o2 > 300 mm Hg) is common, seen in 20%. Early severe hyperoxia, as well as cumulative hyperoxia exposure was associated with in-hospital mortality, even after adjustment for disease severity in both venoarterial ECMO and extracorporeal cardiopulmonary resuscitation. A pragmatic approach to oxygenation during peripheral venoarterial ECMO involves targeting a right radial oxygen saturation target of 94-98%, and in selected patients, titration of the fraction of oxygen in the mixture via the air-oxygen blender to target postoxygenator Pa o2 of 150-300 mm Hg. CONCLUSIONS Hyperoxia results from a range of ECMO circuit and patient-related factors. It is common during peripheral venoarterial ECMO, and its presence is associated with poor outcome. A pragmatic approach that avoids hyperoxia, while also preventing hypoxia has been described for patients receiving peripheral venoarterial ECMO.
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Affiliation(s)
- Lavienraj Premraj
- Griffith University School of Medicine and Dentistry, Brisbane, QLD, Australia
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- Hopkins Education, Research, and Advancement in Life Support Devices (HERALD) Group, Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Intensive Care, The Alfred Hospital, Melbourne, VIC, Australia
- Department of Critical Care Medicine, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health, Monash University, Melbourne, VIC, Australia
- The University of Queensland, Faculty of Medicine, Brisbane, QLD, Australia
- Australian Centre for Health Services Innovation (AusHSI) and Centre for Healthcare Transformation, School of Public Health & Social Work, Queensland University of Technology (QUT), Brisbane, QLD, Australia
- St Andrew's War Memorial Hospital, UnitingCare, Brisbane, QLD, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- The Australian and New Zealand Intensive Care Society (ANZICS), Centre for Outcome and Resources Evaluation, Melbourne, VIC, Australia
| | - Alastair Brown
- Griffith University School of Medicine and Dentistry, Brisbane, QLD, Australia
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- Hopkins Education, Research, and Advancement in Life Support Devices (HERALD) Group, Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Intensive Care, The Alfred Hospital, Melbourne, VIC, Australia
- Department of Critical Care Medicine, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health, Monash University, Melbourne, VIC, Australia
- The University of Queensland, Faculty of Medicine, Brisbane, QLD, Australia
- Australian Centre for Health Services Innovation (AusHSI) and Centre for Healthcare Transformation, School of Public Health & Social Work, Queensland University of Technology (QUT), Brisbane, QLD, Australia
- St Andrew's War Memorial Hospital, UnitingCare, Brisbane, QLD, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- The Australian and New Zealand Intensive Care Society (ANZICS), Centre for Outcome and Resources Evaluation, Melbourne, VIC, Australia
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Vincent Pellegrino
- Department of Intensive Care, The Alfred Hospital, Melbourne, VIC, Australia
| | - David Pilcher
- Department of Intensive Care, The Alfred Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health, Monash University, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- The Australian and New Zealand Intensive Care Society (ANZICS), Centre for Outcome and Resources Evaluation, Melbourne, VIC, Australia
| | - Aidan Burrell
- Department of Intensive Care, The Alfred Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health, Monash University, Melbourne, VIC, Australia
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Lee Y, Jang I, Hong J, Son YJ. Factors associated with 30-day in-hospital mortality in critically ill adult patients receiving extracorporeal membrane oxygenation: A retrospective cohort study. Intensive Crit Care Nurs 2023; 79:103489. [PMID: 37451086 DOI: 10.1016/j.iccn.2023.103489] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/21/2023] [Accepted: 07/04/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE To identify factors associated with the 30-day in-hospital mortality rate among adult patients requiring extracorporeal membrane oxygenation (ECMO) in intensive care units. RESEARCH METHODOLOGY Retrospective cohort study including 148 patients who underwent ECMO for at least 48 h between March 2010 and August 2021. The patients were divided into survivors and non-survivors based on their 30-day in-hospital survival. We obtained the sociodemographic information and pre- and post-ECMO data from electronic medical records. Kaplan-Meier survival curves and Multivariate Cox proportional hazards regression were used to analyse the data. SETTING A tertiary-care university hospital in South Korea. MAIN OUTCOME MEASURES The 30-day in-hospital mortality rate was the principal outcome measure. RESULTS The 30-day in-hospital mortality rate was 49.3% (n = 73). Kaplan-Meier analysis demonstrated that the duration of ECMO support in the 50th percentile of surviving patients was 13 days. Multivariable Cox regression analysis showed that new-onset renal failure, lower mean arterial pressure, and ECMO weaning failure were associated with an increased 30-day in-hospital mortality risk among patients who received ECMO. Subgroup analysis also revealed a significant association between weaning failure and 30-day in-hospital mortality after adjusting for covariates in patients undergoing veno-arterial ECMO. CONCLUSION Close monitoring of post-ECMO renal function and mean arterial pressure is required to minimize the risk of 30-day in-hospital mortality, especially in adults within the first two weeks of ECMO initiation. Moreover, the success of ECMO weaning should be optimized by collaboration within the ECMO team. IMPLICATIONS FOR CLINICAL PRACTICE Critical care nurses should pay close attention to patients' response to weaning trials as well as alternations in renal function and mean arterial pressure during ECMO support. Furthermore, developing nursing care guidelines for adult patients receiving ECMO and standardized training programs for nurses in intensive care, are required in Korea.
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Affiliation(s)
- Youngeon Lee
- Emergency Intensive Care Unit, Department of Nursing, Chung-Ang University Hospital, 102 Heukseok-ro, Dongjak-gu, Seoul 06973, South Korea.
| | - Insil Jang
- Red Cross College of Nursing, Chung-Ang University, 84 Heukseok ro, Dongjak-gu, Seoul 06974, South Korea.
| | - Joonhwa Hong
- Department of Thoracic and Cardiovascular Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, 84 Heukseok ro, Dongjak-gu, Seoul 06974, South Korea.
| | - Youn-Jung Son
- Red Cross College of Nursing, Chung-Ang University, 84 Heukseok ro, Dongjak-gu, Seoul 06974, South Korea.
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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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