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Condello I, Nasso G, Scrivo S, Fiore F, Speziale G. Health Technology Assessment of Cardiopulmonary Bypass Circuit with and without Phosphorylcholine Coating: A Retrospective Study on Safety and Efficiency in Cardiac Surgery. Life (Basel) 2024; 14:851. [PMID: 39063605 PMCID: PMC11277647 DOI: 10.3390/life14070851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Revised: 07/04/2024] [Accepted: 07/05/2024] [Indexed: 07/28/2024] Open
Abstract
BACKGROUND Phosphorylcholine has emerged as a potential adjunctive agent in cardiopulmonary bypass (CPB) circuits. Phosphorylcholine serves as a coating for the CPB circuit, potentially enhancing biocompatibility and reducing thrombotic events. However, its impact on specific patient populations and procedural outcomes remains underexplored. MATERIALS AND METHODS In this retrospective study, we analyzed data from 60 patients who underwent cardiac surgery with CPB, comprising 20 cases each of coronary artery bypass grafting (CABG), mitral valve repair, and aortic valve replacement. The patient cohort was divided into two groups-30 patients whose CPB circuits were coated with phosphorylcholine (phosphorylcholine-coated group) and 30 patients who did not receive phosphorylcholine supplementation or circuit coating. Both groups underwent surgery with identical CPB circuit designs. We assessed the absence of adverse events, safety, and efficacy parameters, including blood loss, clotting, and the structural integrity of the CPB circuit. Additionally, we measured changes in mean albumin levels (g/dL), mean platelet counts (×109/L), and antithrombin III (ATIII) levels before and after CPB. RESULTS The retrospective analysis revealed an absence of adverse events in both groups. In the phosphorylcholine-coated group compared to the non-phosphorylcholine-coated group, there was a notable difference in the delta change in mean albumin levels (0.87 ± 0.1 vs. 1.65 ± 0.2 g/dL, p-value 0.021), mean platelet counts (42.251 ± 0.121 vs. 54.21 ± 0.194 × 109/L, p-value 0.049), and ATIII levels (16.85 ± 0.2 vs. 31.21 ± 0.3 p-value 0.017). There was a notable reduction in the perioperative consumption of human complex units after CPB (3 vs. 12, p-value 0.019). CONCLUSIONS Both groups, phosphorylcholine and non-phosphorylcholine, demonstrated the absence of adverse events and that the systems are safe for iatrogenic complication. Our findings suggest that the use of phosphorylcholine coating on the CPB circuit, in the absence of supplementary phosphorylcholine, in cardiac surgery is associated with favorable changes in mean albumin levels, mean platelet counts, and ATIII levels. Further research is warranted to elucidate the full extent of phosphorylcholine's impact on patient outcomes and CPB circuit performance.
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Affiliation(s)
- Ignazio Condello
- Department of Cardiac Surgery, Anthea Hospital, GVM Care & Research, 70124 Bari, Italy
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Bartlett R, Arachichilage DJ, Chitlur M, Hui SKR, Neunert C, Doyle A, Retter A, Hunt BJ, Lim HS, Saini A, Renné T, Kostousov V, Teruya J. The History of Extracorporeal Membrane Oxygenation and the Development of Extracorporeal Membrane Oxygenation Anticoagulation. Semin Thromb Hemost 2024; 50:81-90. [PMID: 36750217 DOI: 10.1055/s-0043-1761488] [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: 02/09/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) was first started for humans in early 1970s by Robert Bartlett. Since its inception, there have been numerous challenges with extracorporeal circulation, such as coagulation and platelet activation, followed by consumption of coagulation factors and platelets, and biocompatibility of tubing, pump, and oxygenator. Unfractionated heparin (heparin hereafter) has historically been the defacto anticoagulant until recently. Also, coagulation monitoring was mainly based on bedside activated clotting time and activated partial thromboplastin time. In the past 50 years, the technology of ECMO has advanced tremendously, and thus, the survival rate has improved significantly. The indication for ECMO has also expanded. Among these are clinical conditions such as postcardiopulmonary bypass, sepsis, ECMO cardiopulmonary resuscitation, and even severe coronavirus disease 2019 (COVID-19). Not surprisingly, the number of ECMO cases has increased according to the Extracorporeal Life Support Organization Registry and prolonged ECMO support has become more prevalent. It is not uncommon for patients with COVID-19 to be on ECMO support for more than 1 year until recovery or lung transplant. With that being said, complications of bleeding, thrombosis, clot formation in the circuit, and intravascular hemolysis still remain and continue to be major challenges. Here, several clinical ECMO experts, including the "Father of ECMO"-Dr. Robert Bartlett, describe the history and advances of ECMO.
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Affiliation(s)
- Robert Bartlett
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Deepa J Arachichilage
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
- Department of Haematology, Imperial College, Healthcare NHS Trust, London, United Kingdom
| | - Meera Chitlur
- Division of Hematology/Oncology, Central Michigan University School of Medicine, Children's Hospital of Michigan, Michigan
| | - Shiu-Ki Rocky Hui
- Department of Pathology & Immunology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Cindy Neunert
- Columbia University Irving Medical Center, New York, New York
| | | | | | | | - Hoong Sern Lim
- University Hospitals Birmingham NHS Foundation Trust, United Kingdom
| | - Arun Saini
- Department of Pathology & Immunology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Thomas Renné
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
- Center for Thrombosis and Hemostasis (CTH), Johannes Gutenberg University Medical Center, Mainz, Germany
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Vadim Kostousov
- Department of Pathology & Immunology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Jun Teruya
- Department of Pathology & Immunology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
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Kakuturu J, Dhamija A, Chan E, Lagazzi L, Thibault D, Badhwar V, Hayanga JWA. Mortality and cost of post-cardiotomy extracorporeal support in the United States. Perfusion 2023; 38:1468-1477. [PMID: 35930658 DOI: 10.1177/02676591221117355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) has been used increasingly for cardiopulmonary rescue. Despite recent advances however, post-cardiotomy shock (PCS)-ECMO survival remains comparatively poor. We sought to evaluate outcomes and define factors that predict in-hospital mortality. METHODS We used the Nationwide Inpatient Sample (NIS) to evaluate adult hospitalizations with a primary procedure code for coronary artery bypass grafting (CABG), and/or valve procedures performed between 2013 and 2018, which also required post cardiotomy ECMO support. Patient-related factors and hospital costs were evaluated to identify those associated with in-hospital mortality. RESULTS There were 1,247,835 admissions for cardiac surgical procedures during the study period. Post-cardiotomy shock-ECMO support was provided in 4475 (0.3%) within the study cohort. A total of 2000 (44.7%) hospitalizations involved isolated valvular procedures, 1700 (38.0%) isolated CABG, and 775 (17.3%) involved a combination of both. Overall, in-hospital mortality was 42.1% (n = 1880). Factors significantly associated with in-hospital mortality included patients with multiple comorbidities (> 7) and those undergoing combination of valve and CABG procedures. Only 26.6% of those who survived to discharge, were discharged home independently. CONCLUSION Survival to independent home discharge is rare following PCS-ECMO. Its high mortality is associated with multiple comorbidities and combination of CABG and valve surgery.
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Affiliation(s)
- Jahnavi Kakuturu
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - Ankit Dhamija
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - Ernest Chan
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Luigi Lagazzi
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - Dylan Thibault
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - J W A Hayanga
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
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Strudthoff LJ, Hesselmann F, Clauser JC, Arens J. Refurbishment of Extracorporeal Life Support Oxygenators in the Context of In Vitro Testing. ASAIO J 2023; 69:924-931. [PMID: 37314830 DOI: 10.1097/mat.0000000000001999] [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: 06/15/2023] Open
Abstract
Refurbishing single use extracorporeal membrane oxygenation (ECMO) oxygenators for in vitro research applications is common. However, the refurbishment protocols that are established in respective laboratories have never been evaluated. In the present study, we aim at proving the relevance of a well-designed refurbishing protocol by quantifying the burden of repeatedly reused oxygenators. We used the same three oxygenators in 5 days of 6 hours whole blood experiments. During each experiment day, the performance of the oxygenators was measured through the evaluation of gas transfer. Between experiment days, each oxygenator was refurbished applying three alternative refurbishment protocols based on purified water, pepsin and citric acid, and hydrogen peroxide solutions, respectively. After the last experiment day, we disassembled the oxygenators for visual inspection of the fiber mats. The refurbishment protocol based on purified water showed strong degeneration with a 40-50 %-performance drop and clearly visible debris on the fiber mats. Hydrogen peroxide performed better; nevertheless, it suffered a 20% decrease in gas transfer as well as clearly visible debris. Pepsin/citric acid performed best in the field, but also suffered from 10% performance loss and very few, but visible debris. The study showed the relevance of a well-suited and well-designed refurbishment protocol. The distinct debris on the fiber mats also suggests that reusing oxygenators is ill-advised for many experiment series, especially regarding hemocompatibility and in vivo testing. Most of all, this study revealed the relevance of stating the status of test oxygenators and, if refurbished, comment on the implemented refurbishment protocol in detail.
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Affiliation(s)
- Lasse J Strudthoff
- From the Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Felix Hesselmann
- From the Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Medical Faculty, RWTH Aachen University, Aachen, Germany
- Enmodes GmbH, Aachen, Germany
| | - Johanna C Clauser
- From the Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Jutta Arens
- From the Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Medical Faculty, RWTH Aachen University, Aachen, Germany
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Lannon M, Duda T, Greer A, Hewitt M, Sharma A, Martyniuk A, Owen J, Amin F, Sharma S. Intracranial hemorrhage in patients treated for SARS-CoV-2 with extracorporeal membrane oxygenation: A systematic review and meta-analysis. J Crit Care 2023; 77:154319. [PMID: 37178492 PMCID: PMC10173703 DOI: 10.1016/j.jcrc.2023.154319] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 12/21/2022] [Accepted: 04/24/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is routinely used in patients with severe respiratory failure and has been increasingly needed during the COVID-19 pandemic. In patients treated with ECMO, significant intracranial hemorrhage (ICH) risk exists due to circuit characteristics, anticoagulation, and disease characteristics. ICH risk may be substantially higher in COVID-19 patients than patients treated with ECMO for other indications. METHODS We systematically reviewed current literature regarding ICH during ECMO treatment of COVID-19. We utilized Embase, MEDLINE, and Cochrane Library databases. Meta-analysis was performed for included comparative studies. Quality assessment was performed using MINORS criteria. RESULTS A total of 54 studies with 4000 ECMO patients were included, all retrospective. Risk of bias was increased via MINORS score primarily due to retrospective designs. ICH was more likely in COVID-19 patients (RR 1.72, 95% CI 1.23, 2.42). Mortality among COVID patients on ECMO with ICH was 64.0%, compared with 41% in patients without ICH (RR1.9, 95% 1.44, 2.51). CONCLUSION This study suggests increased hemorrhage rates in COVID-19 patients on ECMO compared to similar controls. Hemorrhage reduction strategies may include atypical anticoagulants, conservative anticoagulation strategies, or biotechnology advances in circuit design and surface coatings.
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Affiliation(s)
- Melissa Lannon
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada.
| | - Taylor Duda
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada.
| | - Alisha Greer
- Division of Emergency Medicine, Department of Medicine, Division of Critical Care, McMaster University, Hamilton, Ontario, Canada.
| | - Mark Hewitt
- Division of Emergency Medicine, Department of Medicine, Division of Critical Care, McMaster University, Hamilton, Ontario, Canada.
| | - Arjun Sharma
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, Ontario, Canada.
| | - Amanda Martyniuk
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada.
| | - Julian Owen
- Division of Emergency Medicine, Department of Medicine, Division of Critical Care, McMaster University, Hamilton, Ontario, Canada.
| | - Faizan Amin
- Department of Medicine, Divisions of Critical Care and Cardiology, McMaster University, Hamilton, Ontario, Canada.
| | - Sunjay Sharma
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada.
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Park Y, Drucker NA, Gray BW. Device updates in pediatric and neonatal ECMO. Semin Pediatr Surg 2023; 32:151334. [PMID: 37925997 DOI: 10.1016/j.sempedsurg.2023.151334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
Since the early use of extracorporeal life support (ECLS), new innovations and technological advancements have augmented the ability to use this technology in children and neonates. Cannulae have been re-designed to maintain structure and allow for single cannula venovenous (VV) ECLS in smaller patients. Circuit technology, including pumps and tubing, has evolved to permit smaller priming volumes and lower flow rates with fewer thrombotic or hemolytic complications. New oxygenator developments also improve efficiency of gas exchange. This paper serves as an overview of recent device developments in ECLS delivery to pediatric and neonatal patients.
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Affiliation(s)
- Yujin Park
- Department of Surgery, Indiana University, Indianapolis, IN, USA; Section of Pediatric Surgery, Indiana University, Indianapolis, IN, USA
| | - Natalie A Drucker
- Department of Pediatric Surgery, University of Texas in Houston, USA
| | - Brian W Gray
- Section of Pediatric Surgery, Indiana University, Indianapolis, IN, USA.
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Vermeer H, de Jong SF, Koers EJ, Peeters TL, van der Lee R, de Boode WP, Morshuis WJ. Hemostatic Complications During Neonatal Extracorporeal Membrane Oxygenation: Roller Pump and Centrifugal Pump Driven Circuits. ASAIO J 2023; 69:618-624. [PMID: 36574471 PMCID: PMC10226466 DOI: 10.1097/mat.0000000000001878] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Recently three different neonatal extracorporeal membrane oxygenation (ECMO) circuits have been employed in our clinic. These circuits were compared for clotting and bleeding complications. Initially, we used an ECMO circuit containing a roller pump and venous bladder without severe complications. Manufacturing of circuit components was discontinued, necessitating the replacement of this circuit by a circuit with a centrifugal pump with 3/8 inch inlet and outlet. Acute increase of oxygenator resistance requiring emergency changeout became unexpectedly a regularly occurring complication. The increase in resistance was suspected to be caused by oxygenator clotting, although oxygenator function was preserved. To prevent this complication, we changed to a levitating centrifugal pump with 1/4 inch inlet and outlet, after which no oxygenator malfunction has been observed. Macroscopic and electron microscopic analysis demonstrates that small clots are formed within the circuit, presumably in or near the centrifugal pump, which are transported to the oxygenator and clog up the hollow fiber layer at the inlet side, barely penetrating the oxygenator beyond this first layer. Our results suggest that low blood velocities accompanied with recirculation of blood within or near the centrifugal pump and/or heat generation within the pump could contribute to the formation of these clots.
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Affiliation(s)
- Harry Vermeer
- From the Department of Cardiothoracic Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Sytse F. de Jong
- From the Department of Cardiothoracic Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Erik J. Koers
- From the Department of Cardiothoracic Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Theo L.M. Peeters
- Department of Neonatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Robin van der Lee
- Department of Neonatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Willem P. de Boode
- Department of Neonatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Wim J. Morshuis
- From the Department of Cardiothoracic Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
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Tagaya M, Murataka T, Okano S, Handa H, Takahashi S. Comparison of complement consumption and platelet accumulation between membrane oxygenators coated with a polymer or heparin. Perfusion 2023:2676591231177912. [PMID: 37216953 DOI: 10.1177/02676591231177912] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
INTRODUCTION The membrane oxygenator in extracorporeal circulation circuits is coated with acrylate-copolymer (ACP) or immobilized heparin (IHP) to enhance hemocompatibility. To evaluate the relative features of both coatings, we compared blood components circulated in the circuits with ACP-and IHP-coated membranes in vitro using whole human blood. METHODS Whole human blood was heparinized and circulated in two experimental circuits with an ACP-coated reservoir, tubes, and an ACP- or IHP-coated membrane. Platelet (PLT) counts and the amount of total protein (TP), complement component 3 (C3), and complement component 4 (C4) were measured at 0, 8, 16, 24, and 32 h in each experiment (n = 5). RESULTS The PLT count at 0-h circulation was lower in the IHP-coated than in the ACP-coated circuits (p = 0.034); however, no significant difference was observed at other time points. Reduction in TP at 8-h and 16-h circulation and in C3 at 32-h circulation was lesser in the ACP-coated than in the IHP-coated circuits (p = 0.004, 0.034, and 0.027, respectively); reduction in TP and C3 at other time points and C4 at each time point was not significantly different. There were significant interactions between coating type and circulation duration in the PLT, TP, and C3 transitions (p = 0.008, 0.020, and 0.043, respectively). CONCLUSIONS Our findings suggest that ACP-coated membranes can prevent the initial drop in PLT count and C3 consumption over 32 h, whereas IHP-coated membranes could not prevent this drop in extracorporeal circulation. Therefore, ACP-coated membranes are suitable for short- and long-term extracorporeal life support.
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Affiliation(s)
- Masashi Tagaya
- Department of Medical Engineering, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Takuo Murataka
- Department of Medical Engineering, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Shinya Okano
- Department of Medical Engineering, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Hiroki Handa
- Department of Medical Engineering, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Shunsuke Takahashi
- Department of Nephrology, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
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Zhao CY, Sheng KJ, Bao T, Shi T, Liu PN, Yan Y, Zheng XL. Commercial and novel anticoagulant ECMO coatings: a review. J Mater Chem B 2023. [PMID: 37183615 DOI: 10.1039/d3tb00471f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) is an invasive and last-resort treatment for circulatory and respiratory failure. Prolonged ECMO support can disrupt the coagulation and anticoagulation systems in a patient, leading to adverse consequences, such as bleeding and thrombosis. To address this problem, anticoagulation coatings have been developed for use in ECMO circuits. This article reviews commonly used commercial and novel anticoagulant coatings developed in recent years and proposes a new classification of coatings based on the current state. While commercial coatings have been used clinically for decades, this review focuses on comparing the effectiveness and stability of coatings to support clinical selections. Furthermore, novel anticoagulation coatings often involve complex mechanisms and elaborate design strategies, and this review summarises representative studies on mainstream anticoagulation coatings to provide a point of reference for future studies.
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Affiliation(s)
- Chang-Ying Zhao
- Department of Cardiovascular Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China.
| | - Kang-Jia Sheng
- School of Pharmacy, Health Science Center, Xi'an Jiaotong University, Xi'an 710061, China
| | - Tao Bao
- School of Pharmacy, Health Science Center, Xi'an Jiaotong University, Xi'an 710061, China
| | - Tao Shi
- Department of Cardiovascular Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China.
| | - Pei-Nan Liu
- Department of Oncology, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710004, China
| | - Yang Yan
- Department of Cardiovascular Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China.
| | - Xing-Long Zheng
- Department of Cardiovascular Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China.
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Tagaya M, Murataka T, Okano S, Handa H, Tanaka Y, Takahashi S. Activity of anticoagulant proteins on the polymer-coated and heparin-coated membranes in an extracorporeal circulation circuit. Perfusion 2023; 38:600-608. [PMID: 35098806 DOI: 10.1177/02676591211073769] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION We performed in vitro experiments using whole human blood without anticoagulants to clarify the activity of anticoagulant proteins on membranes coated with acrylate-copolymer (ACP) with a hydrophilic blood-contacting layer compared to those coated by immobilizing heparin (IHP) in extracorporeal circulation. METHODS Whole human blood from healthy volunteers was recirculated in two types of experimental circuits with an ACP-coated reservoir and tubes and an ACP-coated or IHP-coated membrane. To compare the fluctuation of anticoagulant proteins, the circuit pressure at the inlet and outlet of the membrane was measured every 5 min; antithrombin antigen (ATQ), antithrombin activity, protein-C quantitation (PCQ), protein-C activity, protein-S free antigen (PSQ), and protein-S activity were measured at 0, 30, 60, 120, and 180 min in each experiment (n = 5). RESULTS The time taken to achieve high circuit pressure (> 300 mmHg) at the inlet of the membrane was significantly shorter in the ACP-coated membrane circuit (28 ± 2.7 min) than in the IHP-coated membrane circuit (54 ± 24 min); however, the ATQ, PCQ, and PSQ at 180 min of recirculation were significantly higher in the former than in the latter (all p < .05). CONCLUSIONS ACP-coated membranes can prevent the consumption of anticoagulant proteins but cannot delay circuit thrombogenicity compared to IHP-coated membranes. Considering patient care during the post-extracorporeal circulation period, the use of ACP coating, which can preserve anticoagulant protein, is better in extracorporeal circulation circuits.
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Affiliation(s)
- Masashi Tagaya
- Department of Medical Engineering, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Takuo Murataka
- Department of Medical Engineering, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Shinya Okano
- Department of Medical Engineering, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Hiroki Handa
- Department of Medical Engineering, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Yuri Tanaka
- Department of Clinical Laboratory, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Shunsuke Takahashi
- Department of Nephrology, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
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Amoako K, Kaufman R, Haddad WAM, Pusey R, Saniesetty VHK, Sun H, Skoog D, Cook K. Zwitterionic Polysulfobetaine Coating and Antiplatelet Liposomes Reduce Fouling in Artificial Lung Circuits. Macromol Biosci 2023; 23:e2200479. [PMID: 36609882 PMCID: PMC10121813 DOI: 10.1002/mabi.202200479] [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: 11/22/2022] [Indexed: 01/08/2023]
Abstract
The artificial lung has provided life-saving support for pulmonary disease patients and recently afforded patients with severe cases of COVID-19 better prognostic outcomes. While it addresses a critical medical need, reducing the risk of clotting inside the device remains challenging. Herein, a two-step surface coating process of the lung circuit using Zwitterionic polysulfobetaine methacrylate is evaluated for its nonspecific protein antifouling activity. It is hypothesized that similarly applied coatings on materials integrated (IT) or nonintegrated (NIT) into the circuit will yield similar antifouling activity. The effects of human plasma preconditioned with nitric oxide-loaded liposome on platelet (plt) fouling are also evaluated. Fibrinogen antifouling activities in coated fibers are similar in the IT and NIT groups. It however decreases in coated polycarbonate (PC) in the IT group. Also, plt antifouling activity in coated fibers is similar in the IT and NIT groups and is lower in coated PC and Tygon in the IT group compared to the NIT group. Coating process optimization in the IT lung circuit may help address difference in the coating appearance of outer and inner fiber bundle fibers, and the NO-liposome significantly reduces (86%) plt fouling on fibers indicating its potential use for blood anticoagulation.
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Affiliation(s)
- Kagya Amoako
- Department of Chemistry and Chemical and Biomedical Engineering, Interim Chair, Mechanical and Industrial Engineering, University of New Haven, West Haven, CT, 06516, USA
| | - Rikki Kaufman
- Department of Chemistry and Chemical and Biomedical Engineering, University of New Haven, West Haven, CT, 06516, USA
| | - Waad A M Haddad
- Department of Chemistry and Chemical and Biomedical Engineering, University of New Haven, West Haven, CT, 06516, USA
| | - Romario Pusey
- Department of Chemistry and Chemical and Biomedical Engineering, University of New Haven, West Haven, CT, 06516, USA
| | - Venkata H K Saniesetty
- Department of Chemistry and Chemical and Biomedical Engineering, University of New Haven, West Haven, CT, 06516, USA
| | - Hao Sun
- Department of Chemistry and Chemical and Biomedical Engineering, University of New Haven, West Haven, CT, 06516, USA
| | - David Skoog
- Advanced Respiratory Technologies, LLC, Pittsburgh, PA, 15238, USA
| | - Keith Cook
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA, 15213, USA
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Strudthoff LJ, Focke J, Hesselmann F, Kaesler A, Martins Costa A, Schlanstein PC, Schmitz-Rode T, Steinseifer U, Steuer NB, Wiegmann B, Arens J, Jansen SV. Novel Size-Variable Dedicated Rodent Oxygenator for ECLS Animal Models-Introduction of the "RatOx" Oxygenator and Preliminary In Vitro Results. MICROMACHINES 2023; 14:800. [PMID: 37421033 DOI: 10.3390/mi14040800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 03/22/2023] [Accepted: 03/24/2023] [Indexed: 07/09/2023]
Abstract
The overall survival rate of extracorporeal life support (ECLS) remains at 60%. Research and development has been slow, in part due to the lack of sophisticated experimental models. This publication introduces a dedicated rodent oxygenator ("RatOx") and presents preliminary in vitro classification tests. The RatOx has an adaptable fiber module size for various rodent models. Gas transfer performances over the fiber module for different blood flows and fiber module sizes were tested according to DIN EN ISO 7199. At the maximum possible amount of effective fiber surface area and a blood flow of 100 mL/min, the oxygenator performance was tested to a maximum of 6.27 mL O2/min and 8.2 mL CO2/min, respectively. The priming volume for the largest fiber module is 5.4 mL, while the smallest possible configuration with a single fiber mat layer has a priming volume of 1.1 mL. The novel RatOx ECLS system has been evaluated in vitro and has demonstrated a high degree of compliance with all pre-defined functional criteria for rodent-sized animal models. We intend for the RatOx to become a standard testing platform for scientific studies on ECLS therapy and technology.
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Affiliation(s)
- Lasse J Strudthoff
- Institute of Applied Medical Engineering, Department of Cardiovascular Engineering, Medical Faculty, RWTH Aachen University, 52074 Aachen, Germany
| | - Jannis Focke
- Institute of Applied Medical Engineering, Department of Cardiovascular Engineering, Medical Faculty, RWTH Aachen University, 52074 Aachen, Germany
| | - Felix Hesselmann
- Institute of Applied Medical Engineering, Department of Cardiovascular Engineering, Medical Faculty, RWTH Aachen University, 52074 Aachen, Germany
| | - Andreas Kaesler
- Institute of Applied Medical Engineering, Department of Cardiovascular Engineering, Medical Faculty, RWTH Aachen University, 52074 Aachen, Germany
| | - Ana Martins Costa
- Department of Biomechanical Engineering, Faculty of Engineering Technologies, University of Twente, 7522 LW Enschede, The Netherlands
| | - Peter C Schlanstein
- Institute of Applied Medical Engineering, Department of Cardiovascular Engineering, Medical Faculty, RWTH Aachen University, 52074 Aachen, Germany
| | - Thomas Schmitz-Rode
- Institute of Applied Medical Engineering, Medical Faculty, RWTH Aachen University, 52074 Aachen, Germany
| | - Ulrich Steinseifer
- Institute of Applied Medical Engineering, Department of Cardiovascular Engineering, Medical Faculty, RWTH Aachen University, 52074 Aachen, Germany
| | - Niklas B Steuer
- Institute of Applied Medical Engineering, Department of Cardiovascular Engineering, Medical Faculty, RWTH Aachen University, 52074 Aachen, Germany
| | - Bettina Wiegmann
- Department for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, 30625 Hanover, Germany
- Lower Saxony Center for Biomedical Engineering, Implant Research and Development (NIFE), 30625 Hanover, Germany
- German Center for Lung Research (DLZ), 30625 Hanover, Germany
| | - Jutta Arens
- Institute of Applied Medical Engineering, Department of Cardiovascular Engineering, Medical Faculty, RWTH Aachen University, 52074 Aachen, Germany
- Department of Biomechanical Engineering, Faculty of Engineering Technologies, University of Twente, 7522 LW Enschede, The Netherlands
| | - Sebastian V Jansen
- Institute of Applied Medical Engineering, Department of Cardiovascular Engineering, Medical Faculty, RWTH Aachen University, 52074 Aachen, Germany
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13
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Worku ET, Win AM, Parmar D, Anstey C, Shekar K. Haematological Trends and Transfusion during Adult Extracorporeal Membrane Oxygenation: A Single Centre Study. J Clin Med 2023; 12:2629. [PMID: 37048711 PMCID: PMC10095131 DOI: 10.3390/jcm12072629] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 03/28/2023] [Accepted: 03/30/2023] [Indexed: 04/03/2023] Open
Abstract
The temporal trends in haematological parameters and their associations with blood product transfusion requirements in patients supported with extracorporeal membrane oxygenation (ECMO) are poorly understood. We performed a retrospective data analysis to better understand the behaviour of haematological and coagulation parameters and their associations with transfusion requirements during ECMO. METHODS Patient demographics, haematological and coagulation parameters, plasma haemoglobin and fibrinogen concentrations, platelet count, the international normalised ratio (INR), the activated partial thromboplastin time (APTT), and blood product transfusion data from 138 patients who received ECMO in a single high-volume centre were analysed. RESULTS Ninety-two patients received venoarterial (VA) ECMO and 46 patients received venovenous (VV) ECMO. The median (IQR) duration of VA, and VV ECMO was 8 (5-13) days and 13 (8-23) days, respectively. There were significant reductions in haemoglobin, the platelet count, and the fibrinogen concentration upon initiation of ECMO. On average, over time, patients on VV ECMO had platelet counts 44 × 109/L higher than those on VA ECMO (p ≤ 0.001). Fibrinogen and APTT did not vary significantly based on the mode of ECMO (p = 0.55 and p = 0.072, respectively). A platelet count < 50 × 109/L or a fibrinogen level < 1.8 g/L was associated with 50% chance of PRBC transfusion, regardless of the ECMO type, and packed red blood cell (PRBC) transfusion was more common with VA ECMO. APTT was predictive of the transfusion requirement, and the decrement in APTT was discriminatory between VVECMO survivors and nonsurvivors. CONCLUSION ECMO support is associated with reductions in haemoglobin, platelet count, and fibrinogen. Patients supported with VA ECMO are more likely to receive a PRBC transfusion compared to those on VV ECMO. Thrombocytopaenia, hypofibrinogenaemia, and anticoagulation effect the likelihood of requiring PRBC transfusion. Further research is needed to define optimal blood management during ECMO, including appropriate transfusion triggers and the anticoagulation intensity.
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Affiliation(s)
- Elliott T. Worku
- Adult Intensive Care Services, The Prince Charles Hospital, Chermside, QLD 4032, Australia
- School of Medicine, University of Queensland, St Lucia, QLD 4072, Australia
| | - April M. Win
- Intensive Care Unit, The Townsville Hospital, Townsville, QLD 4810, Australia
| | - Dinesh Parmar
- Adult Intensive Care Services, The Prince Charles Hospital, Chermside, QLD 4032, Australia
| | - Chris Anstey
- School of Medicine, University of Queensland, St Lucia, QLD 4072, Australia
- Intensive Care Unit, Sunshine Coast University Hospital, Birtinya, QLD 4575, Australia
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Chermside, QLD 4032, Australia
- School of Medicine, University of Queensland, St Lucia, QLD 4072, Australia
- Faculty of Medicine, Bond University, Gold Coast, QLD 4226, Australia
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14
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The Evolution of Extracorporeal Membrane Oxygenation Circuitry and Impact on Clinical Outcomes in Children: A Systematic Review. ASAIO J 2023; 69:247-253. [PMID: 35749749 DOI: 10.1097/mat.0000000000001785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
This systematic review summarizes the major developments in extracorporeal membrane oxygenation (ECMO) circuitry in pediatrics over the past 20 years and demonstrates the impacts of those developments on clinical outcomes. This systematic review followed structured Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of 1987 studies were retrieved, of which 82 were included in the final analysis. Over the past 20 years, ECMO pumps have shifted from roller pumps to centrifugal pumps. Silicone and polypropylene hollow fiber membrane oxygenators were initially used but have been replaced by polymethylpentene hollow fiber membrane oxygenators, with other ECMO components poorly reported. Considerable variability in mortality was found across studies and there was no statistical difference in mortality rates across different periods. The duration of ECMO and other outcome measures were inconsistently reported across studies. This systematic review demonstrated technological developments in pumps and oxygenators over the last two decades, although patient mortality rates remained unchanged. This could be because of ECMO support applied to patients in more critical conditions over the years. We also highlighted the limitations of methodology information disclosure and outcome measures in current ECMO studies, showing the need of reporting standardization for future ECMO studies.
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15
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Roberts SH, Goodwin ML, Bobba CM, Al-Qudsi O, Satyapriya SV, Tripathi RS, Papadimos TJ, Whitson BA. Continuous renal replacement therapy and extracorporeal membrane oxygenation: implications in the COVID-19 era. Perfusion 2023; 38:18-27. [PMID: 34494489 DOI: 10.1177/02676591211042561] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
The novel severe acute respiratory syndrome coronavirus 2, SARS-CoV-2 (coronavirus Disease 19 (COVID-19)) was identified as the causative agent of viral pneumonias in Wuhan, China in December 2019, and has emerged as a pandemic causing acute respiratory distress syndrome (ARDS) and multiple organ dysfunction. Interim guidance by the World Health Organization states that extracorporeal membrane oxygenation (ECMO) should be considered as a rescue therapy in COVID-19-related ARDS. International registries tracking ECMO in COVID-19 patients reveal a 21%-70% incidence of acute renal injury requiring renal replacement therapy (RRT) during ECMO support. The indications for initiating RRT in patients on ECMO are similar to those for patients not requiring ECMO. RRT can be administered during ECMO via a temporary dialysis catheter, placement of a circuit in-line hemofilter, or direct connection of continuous RRT in-line with the ECMO circuit. Here we review methods for RRT during ECMO, RRT initiation and timing during ECMO, anticoagulation strategies, and novel cytokine filtration approaches to minimize COVID-19's pathophysiological impact.
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Affiliation(s)
- Sophia H Roberts
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,The Ohio State University College of Medicine, Columbus, OH, USA
| | - Matthew L Goodwin
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Christopher M Bobba
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,The Ohio State University College of Medicine, Columbus, OH, USA
| | - Omar Al-Qudsi
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - S Veena Satyapriya
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Ravi S Tripathi
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Thomas J Papadimos
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Bryan A Whitson
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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16
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Anticoagulation Management during Extracorporeal Membrane Oxygenation-A Mini-Review. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58121783. [PMID: 36556985 PMCID: PMC9782867 DOI: 10.3390/medicina58121783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 11/25/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) has been established as a life-saving technique for patients with the most severe forms of respiratory or cardiac failure. It can, however, be associated with severe complications. Anticoagulation therapy is required to prevent ECMO circuit thrombosis. It is, however, associated with an increased risk of hemocoagulation disorders. Thus, safe anticoagulation is a cornerstone of ECMO therapy. The most frequently used anticoagulant is unfractionated heparin, which can, however, cause significant adverse effects. Novel drugs (e.g., argatroban and bivalirudin) may be superior to heparin in the better predictability of their effects, functioning independently of antithrombin, inhibiting thrombin bound to fibrin, and eliminating heparin-induced thrombocytopenia. It is also necessary to keep in mind that hemocoagulation tests are not specific, and their results, used for setting up the dosage, can be biased by many factors. The knowledge of the advantages and disadvantages of particular drugs, limitations of particular tests, and individualization are cornerstones of prevention against critical events, such as life-threatening bleeding or acute oxygenator failure followed by life-threatening hypoxemia and hemodynamic deterioration. This paper describes the effects of anticoagulant drugs used in ECMO and their monitoring, highlighting specific conditions and factors that might influence coagulation and anticoagulation measurements.
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17
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Deetect: A Deep Learning-Based Image Analysis Tool for Quantification of Adherent Cell Populations on Oxygenator Membranes after Extracorporeal Membrane Oxygenation Therapy. Biomolecules 2022; 12:biom12121810. [PMID: 36551238 PMCID: PMC9776364 DOI: 10.3390/biom12121810] [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: 10/26/2022] [Revised: 11/27/2022] [Accepted: 12/01/2022] [Indexed: 12/09/2022] Open
Abstract
The strong interaction of blood with the foreign surface of membrane oxygenators during ECMO therapy leads to adhesion of immune cells on the oxygenator membranes, which can be visualized in the form of image sequences using confocal laser scanning microscopy. The segmentation and quantification of these image sequences is a demanding task, but it is essential to understanding the significance of adhering cells during extracorporeal circulation. The aim of this work was to develop and test a deep learning-supported image processing tool (Deetect), suitable for the analysis of confocal image sequences of cell deposits on oxygenator membranes at certain predilection sites. Deetect was tested using confocal image sequences of stained (DAPI) blood cells that adhered to specific predilection sites (junctional warps and hollow fibers) of a phosphorylcholine-coated polymethylpentene membrane oxygenator after patient support (>24 h). Deetect comprises various functions to overcome difficulties that occur during quantification (segmentation, elimination of artifacts). To evaluate Deetects performance, images were counted and segmented manually as a reference and compared with the analysis by a traditional segmentation approach in Fiji and the newly developed tool. Deetect outperformed conventional segmentation in clustered areas. In sections where cell boundaries were difficult to distinguish visually, previously defined post-processing steps of Deetect were applied, resulting in a more objective approach for the resolution of these areas.
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18
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Hemocompatibility challenge of membrane oxygenator for artificial lung technology. Acta Biomater 2022; 152:19-46. [PMID: 36089235 DOI: 10.1016/j.actbio.2022.09.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/25/2022] [Accepted: 09/04/2022] [Indexed: 11/24/2022]
Abstract
The artificial lung (AL) technology is one of the membrane-based artificial organs that partly augments lung functions, i.e. blood oxygenation and CO2 removal. It is generally employed as an extracorporeal membrane oxygenation (ECMO) device to treat acute and chronic lung-failure patients, and the recent outbreak of the COVID-19 pandemic has re-emphasized the importance of this technology. The principal component in AL is the polymeric membrane oxygenator that facilitates the O2/CO2 exchange with the blood. Despite the considerable improvement in anti-thrombogenic biomaterials in other applications (e.g., stents), AL research has not advanced at the same rate. This is partly because AL research requires interdisciplinary knowledge in biomaterials and membrane technology. Some of the promising biomaterials with reasonable hemocompatibility - such as emerging fluoropolymers of extremely low surface energy - must first be fabricated into membranes to exhibit effective gas exchange performance. As AL membranes must also demonstrate high hemocompatibility in tandem, it is essential to test the membranes using in-vitro hemocompatibility experiments before in-vivo test. Hence, it is vital to have a reliable in-vitro experimental protocol that can be reasonably correlated with the in-vivo results. However, current in-vitro AL studies are unsystematic to allow a consistent comparison with in-vivo results. More specifically, current literature on AL biomaterial in-vitro hemocompatibility data are not quantitatively comparable due to the use of unstandardized and unreliable protocols. Such a wide gap has been the main bottleneck in the improvement of AL research, preventing promising biomaterials from reaching clinical trials. This review summarizes the current state-of-the-art and status of AL technology from membrane researcher perspectives. Particularly, most of the reported in-vitro experiments to assess AL membrane hemocompatibility are compiled and critically compared to suggest the most reliable method suitable for AL biomaterial research. Also, a brief review of current approaches to improve AL hemocompatibility is summarized. STATEMENT OF SIGNIFICANCE: The importance of Artificial Lung (AL) technology has been re-emphasized in the time of the COVID-19 pandemic. The utmost bottleneck in the current AL technology is the poor hemocompatibility of the polymer membrane used for O2/CO2 gas exchange, limiting its use in the long-term. Unfortunately, most of the in-vitro AL experiments are unsystematic, irreproducible, and unreliable. There are no standardized in-vitro hemocompatibility characterization protocols for quantitative comparison between AL biomaterials. In this review, we tackled this bottleneck by compiling the scattered in-vitro data and suggesting the most suitable experimental protocol to obtain reliable and comparable hemocompatibility results. To the best of our knowledge, this is the first review paper focusing on the hemocompatibility challenge of AL technology.
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19
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Zhang Y, Zhang M, Xu X, Chan CHH, Peng H, Hill DJT, Fu C, Fraser J, Whittaker AK. Anti-Fouling Surfaces for Extracorporeal Membrane Oxygenation by Surface Grafting of Hydrophilic Sulfoxide Polymers. Biomacromolecules 2022; 23:4318-4326. [PMID: 36048616 DOI: 10.1021/acs.biomac.2c00775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Non-thrombogenic surfaces for extracorporeal membrane oxygenation (ECMO) devices are important to increase their duration of usage and to enable long-term life support. However, the contact of blood with the hydrophobic synthetic ECMO membrane materials such as poly(4-methyl-1-pentene) (PMP) can activate the coagulation cascade, causing thrombosis and a series of consequent complications during ECMO operation. Targeting this problem, we proposed to graft highly hydrophilic sulfoxide polymer brushes onto the PMP surfaces via gamma ray irradiation-initiated polymerization to improve the hemocompatibility of the membrane. Through this chemical modification, the surface of the PMP film is altered from hydrophobic to hydrophilic. The extent of plasma protein adsorption and platelet adhesion, the prerequisite mediators of the coagulation cascade and thrombus formation, are drastically reduced compared with those of the unmodified PMP film. Therefore, the method provides a facile approach to modify PMP materials with excellent antifouling properties and improved hemocompatibility demanded by the applications in ECMO and other blood-contacting medical devices.
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Affiliation(s)
- Yuhao Zhang
- Australian Institute for Bioengineering and Nanotechnology and ARC Centre of Excellence in Convergent Bio-Nano Science and Technology, The University of Queensland, St Lucia, Queensland 4072, Australia
| | - Meili Zhang
- Critical Care Research Group, The Prince Charles Hospital, Brisbane 4032, Queensland, Australia.,School of Mechanical and Mining Engineering, The University of Queensland, St Lucia 4072, Queensland, Australia
| | - Xin Xu
- Australian Institute for Bioengineering and Nanotechnology and ARC Centre of Excellence in Convergent Bio-Nano Science and Technology, The University of Queensland, St Lucia, Queensland 4072, Australia
| | - Chris H H Chan
- Critical Care Research Group, The Prince Charles Hospital, Brisbane 4032, Queensland, Australia.,School of Engineering and Built Environment, Griffith University, Southport 4222, Queensland, Australia
| | - Hui Peng
- Australian Institute for Bioengineering and Nanotechnology and ARC Centre of Excellence in Convergent Bio-Nano Science and Technology, The University of Queensland, St Lucia, Queensland 4072, Australia
| | - David J T Hill
- Australian Institute for Bioengineering and Nanotechnology and ARC Centre of Excellence in Convergent Bio-Nano Science and Technology, The University of Queensland, St Lucia, Queensland 4072, Australia.,School of Chemistry and Molecular Biosciences, The University of Queensland, St Lucia 4072, Queensland, Australia
| | - Changkui Fu
- Australian Institute for Bioengineering and Nanotechnology and ARC Centre of Excellence in Convergent Bio-Nano Science and Technology, The University of Queensland, St Lucia, Queensland 4072, Australia
| | - John Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane 4032, Queensland, Australia.,Faculty of Medicine, The University of Queensland, St Lucia 4072, Queensland, Australia.,School of Medicine, Griffith University, Southport 4215, Queensland, Australia
| | - Andrew K Whittaker
- Australian Institute for Bioengineering and Nanotechnology and ARC Centre of Excellence in Convergent Bio-Nano Science and Technology, The University of Queensland, St Lucia, Queensland 4072, Australia
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20
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Sakurai K, Singhal N. Extracorporeal membrane oxygenation in children: A brief review. J Paediatr Child Health 2022; 58:1525-1531. [PMID: 35932281 PMCID: PMC9545746 DOI: 10.1111/jpc.16151] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 05/12/2022] [Accepted: 07/21/2022] [Indexed: 01/24/2023]
Abstract
With the advancement in technology and increasing familiarity, the use of extracorporeal membrane oxygenation (ECMO) has expanded in the past decade. Although ECMO can be lifesaving for critically ill children, it is an invasive therapy associated with complications that may necessitate rehabilitation and long-term follow-up. Paediatric clinicians play an essential role in managing these children, especially after the acute phase of their illness. This review provides an overview of ECMO and will provide a basic understanding of ECMO and its principles.
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Affiliation(s)
- Ken Sakurai
- Department of Paediatric Intensive CareThe Children's Hospital at WestmeadSydneyNew South WalesAustralia
| | - Nitesh Singhal
- Department of Paediatric Intensive CareThe Children's Hospital at WestmeadSydneyNew South WalesAustralia,Sydney Medical SchoolUniversity of SydneySydneyNSWAustralia
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21
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Rajsic S, Breitkopf R, Jadzic D, Popovic Krneta M, Tauber H, Treml B. Anticoagulation Strategies during Extracorporeal Membrane Oxygenation: A Narrative Review. J Clin Med 2022; 11:jcm11175147. [PMID: 36079084 PMCID: PMC9457503 DOI: 10.3390/jcm11175147] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 08/24/2022] [Accepted: 08/29/2022] [Indexed: 11/30/2022] Open
Abstract
The development of extracorporeal life support technology has added a new dimension to the care of critically ill patients who fail conventional treatment options. Extracorporeal membrane oxygenation (ECMO)—specialized temporary life support for patients with severe cardiac or pulmonary failure—plays a role in bridging the time for organ recovery, transplant, or permanent assistance. The overall patient outcome is dependent on the underlying disease, comorbidities, patient reaction to critical illness, and potential adverse events during ECMO. Moreover, the contact of the blood with the large artificial surface of an extracorporeal system circuit triggers complex inflammatory and coagulation responses. These processes may further lead to endothelial injury and disrupted microcirculation with consequent end-organ dysfunction and the development of adverse events like thromboembolism. Therefore, systemic anticoagulation is considered crucial to alleviate the risk of thrombosis and failure of ECMO circuit components. The gold standard and most used anticoagulant during extracorporeal life support is unfractionated heparin, with all its benefits and disadvantages. However, therapeutic anticoagulation of a critically ill patient carries the risk of clinically relevant bleeding with the potential for permanent injury or death. Similarly, thrombotic events may occur. Therefore, different anticoagulation strategies are employed, while the monitoring and the balance of procoagulant and anticoagulatory factors is of immense importance. This narrative review summarizes the most recent considerations on anticoagulation during ECMO support, with a special focus on anticoagulation monitoring and future directions.
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Affiliation(s)
- Sasa Rajsic
- Department of Anaesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Robert Breitkopf
- Department of Anaesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Dragana Jadzic
- Anaesthesia and Intensive Care Department, Pain Therapy Service, Cagliari University, 09042 Cagliari, Italy
| | | | - Helmuth Tauber
- Department of Anaesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Benedikt Treml
- Department of Anaesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
- Correspondence: ; Tel.: +43-50504-82231
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22
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Canjuga D, Hansen C, Halbrügge F, Hann L, Weiß S, Schlensak C, Wendel HP, Avci-Adali M. Improving hemocompatibility of artificial lungs by click conjugation of glycoengineered endothelial cells onto blood-contacting surfaces. BIOMATERIALS ADVANCES 2022; 137:212824. [PMID: 35929239 DOI: 10.1016/j.bioadv.2022.212824] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 04/01/2022] [Accepted: 04/20/2022] [Indexed: 06/15/2023]
Abstract
Artificial lungs, also known as oxygenators, allow adequate oxygenation of the blood in patients with severe respiratory failure and enable patient survival. However, the insufficient hemocompatibility of the current of artificial lungs hampers their long-term use. Therefore, in this study, a novel strategy was developed to efficiently endothelialize blood-contacting surfaces to improve their hemocompatibility. Hollow fiber membranes (HFMs) were functionalized with dibenzylcyclooctyne (DBCO), and endothelial cells were glycoengineered for covalent conjugation to DBCO by a copper-free click reaction. Metabolic glycoengineering using azidoacetylmannosamine-tetraacylated (Ac4ManNAz) resulted in highly efficient functionalization of endothelial cells with azide (N3) molecules on the cell surface without negative impact on cell viability. After 48 h, significantly improved endothelialization was detected on the HFM surfaces functionalized with DBCO compared to unmodified HFMs. Endothelial cells were responsive to inflammatory stimulus and expressed adhesion-promoting molecules (E-selectin, VCAM-1, and ICAM-1). Furthermore, the hemocompatibility of HFMs was analyzed by dynamic incubation with fresh human blood. DBCO-coated and uncoated HFMs showed a comparable hemocompatibility, but the endothelialization of HFMs significantly reduced the activation of blood coagulation and platelets. Interestingly, the incubation of endothelialized HFMs with human blood further reduced the expression of E-selectin and VCAM-1 in endothelial cells. In this study, a highly efficient, cell-compatible method for endothelialization of artificial lungs was established. This click chemistry-based method can be also applied for the endothelialization of other artificial surfaces for tissue engineering and regenerative medicine applications.
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Affiliation(s)
- Denis Canjuga
- University Hospital Tuebingen, Department of Thoracic and Cardiovascular Surgery, Calwerstraße 7/1, 72076 Tuebingen, Germany
| | - Caroline Hansen
- University Hospital Tuebingen, Department of Thoracic and Cardiovascular Surgery, Calwerstraße 7/1, 72076 Tuebingen, Germany
| | - Franziska Halbrügge
- University Hospital Tuebingen, Department of Thoracic and Cardiovascular Surgery, Calwerstraße 7/1, 72076 Tuebingen, Germany
| | - Ludmilla Hann
- University Hospital Tuebingen, Department of Thoracic and Cardiovascular Surgery, Calwerstraße 7/1, 72076 Tuebingen, Germany
| | - Sarina Weiß
- University Hospital Tuebingen, Department of Thoracic and Cardiovascular Surgery, Calwerstraße 7/1, 72076 Tuebingen, Germany
| | - Christian Schlensak
- University Hospital Tuebingen, Department of Thoracic and Cardiovascular Surgery, Calwerstraße 7/1, 72076 Tuebingen, Germany
| | - Hans-Peter Wendel
- University Hospital Tuebingen, Department of Thoracic and Cardiovascular Surgery, Calwerstraße 7/1, 72076 Tuebingen, Germany
| | - Meltem Avci-Adali
- University Hospital Tuebingen, Department of Thoracic and Cardiovascular Surgery, Calwerstraße 7/1, 72076 Tuebingen, Germany.
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23
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Martin AA, Bhat R, Chitlur M. Hemostasis in Pediatric Extracorporeal Life Support: Overview and Challenges. Pediatr Clin North Am 2022; 69:441-464. [PMID: 35667756 DOI: 10.1016/j.pcl.2022.01.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) and ventricular assist devices (VADs) are increasingly used in critically ill children. Despite improvements in mechanical design and clinical management, thromboembolic and hemorrhagic events remain significant causes of morbidity and mortality related to the use of both devices. Choice of anticoagulant agents and assays for monitoring continue to present challenges in management. In this review, we describe the incidence and risk factors for thrombosis and hemorrhage, the different types of anticoagulants currently in use, the assays available for monitoring anticoagulation, and management of thromboembolic and bleeding complications in children on mechanical circulatory support (MCS). We conclude by emphasizing the areas that need further study to minimize the risk for thrombosis and hemorrhage in the use of ECMO and VAD in children.
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Affiliation(s)
- Amarilis A Martin
- Division of Pediatric Critical Care Medicine, Central Michigan University College of Medicine, Children's Hospital of Michigan, Carl's Building Suite 4114, 3901 Beaubien Street, Detroit, MI 48201, USA.
| | - Rukhmi Bhat
- Division of Hematology, Oncology and Stem Cell Transplantation, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago, Box #30, Chicago, IL 60611, USA
| | - Meera Chitlur
- Wayne State University, Central Michigan University, Hemophilia Treatment Center and Hemostasis Program, Special Coagulation Laboratory, Division of Hematology/Oncology, Children's Hospital of Michigan, 3901 Beaubien Street, Detroit, MI 48201, USA
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24
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van Minnen O, Oude Lansink-Hartgring A, van den Boogaard B, van den Brule J, Bulpa P, Bunge JJH, Delnoij TSR, Elzo Kraemer CV, Kuijpers M, Lambermont B, Maas JJ, de Metz J, Michaux I, van de Pol I, van de Poll M, Raasveld SJ, Raes M, Dos Reis Miranda D, Scholten E, Simonet O, Taccone FS, Vallot F, Vlaar APJ, van den Bergh WM. Reduced anticoagulation targets in extracorporeal life support (RATE): study protocol for a randomized controlled trial. Trials 2022; 23:405. [PMID: 35578271 PMCID: PMC9108348 DOI: 10.1186/s13063-022-06367-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 04/28/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Although life-saving in selected patients, ECMO treatment still has high mortality which for a large part is due to treatment-related complications. A feared complication is ischemic stroke for which heparin is routinely administered for which the dosage is usually guided by activated partial thromboplastin time (aPTT). However, there is no relation between aPTT and the rare occurrence of ischemic stroke (1.2%), but there is a relation with the much more frequent occurrence of bleeding complications (55%) and blood transfusion. Both are strongly related to outcome. METHODS We will conduct a three-arm non-inferiority randomized controlled trial, in adult patients treated with ECMO. Participants will be randomized between heparin administration with a target of 2-2.5 times baseline aPTT, 1.5-2 times baseline aPTT, or low molecular weight heparin guided by weight and renal function. Apart from anticoagulation targets, treatment will be according to standard care. The primary outcome parameter is a combined endpoint consisting of major bleeding including hemorrhagic stroke, severe thromboembolic complications including ischemic stroke, and mortality at 6 months. DISCUSSION We hypothesize that with lower anticoagulation targets or anticoagulation with LMWH during ECMO therapy, patients will have fewer hemorrhagic complications without an increase in thromboembolic complication or a negative effect on their outcome. If our hypothesis is confirmed, this study could lead to a change in anticoagulation protocols and a better outcome for patients treated with ECMO. TRIAL REGISTRATION ClinicalTrials.gov NCT04536272 . Registered on 2 September 2020. Netherlands Trial Register NL7969.
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Affiliation(s)
- Olivier van Minnen
- Department of Critical Care, University Medical Center Groningen, Room R3.904, PO BOX 30001, 9700, RB, Groningen, The Netherlands.
| | - Annemieke Oude Lansink-Hartgring
- Department of Critical Care, University Medical Center Groningen, Room R3.904, PO BOX 30001, 9700, RB, Groningen, The Netherlands
| | | | - Judith van den Brule
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Pierre Bulpa
- Department of Intensive Care, CHU UCL Namur site Mont-Godinne, Yvoir, Belgium
| | - Jeroen J H Bunge
- Department of Intensive Care Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Thijs S R Delnoij
- Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Carlos V Elzo Kraemer
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Marijn Kuijpers
- Department of Intensive Care Medicine, Isala Clinics, Zwolle, The Netherlands
| | | | - Jacinta J Maas
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Jesse de Metz
- Department of Intensive Care, OLVG, Amsterdam, The Netherlands
| | - Isabelle Michaux
- Department of Intensive Care, CHU UCL Namur site Mont-Godinne, Yvoir, Belgium
| | - Ineke van de Pol
- Department of Intensive Care Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Marcel van de Poll
- Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - S Jorinde Raasveld
- Department of Intensive Care Medicine, Amsterdam University Medical Center, Location AMC, Amsterdam, The Netherlands
| | - Matthias Raes
- Department of Intensive Care, University Hospital Brussels, Brussels, Belgium
| | - Dinis Dos Reis Miranda
- Department of Intensive Care Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Erik Scholten
- Department of Intensive Care Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Olivier Simonet
- Department of Intensive Care, Centre Hospitalier de Wallonie Picarde (CHwapi), Tournai, Belgium
| | - Fabio S Taccone
- Department of Intensive Care, Hôpital Erasme Bruxelles, Brussels, Belgium
| | - Frederic Vallot
- Department of Intensive Care, Centre Hospitalier de Wallonie Picarde (CHwapi), Tournai, Belgium
| | - Alexander P J Vlaar
- Department of Intensive Care Medicine, Amsterdam University Medical Center, Location AMC, Amsterdam, The Netherlands
| | - Walter M van den Bergh
- Department of Critical Care, University Medical Center Groningen, Room R3.904, PO BOX 30001, 9700, RB, Groningen, The Netherlands
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25
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Prakash M, Sharma V, Oh T, Lo C, Parkinson G, McCormack D, Conaglen P, Lin Z, Kejriwal N, Meikle F, Peplow E, Bhana J, El Gamel A. Evaluation of the effects of three designs of oxygenators with integrated filters on clinical and haematological outcomes at an Australasian cardiothoracic unit. Perfusion 2022:2676591221090751. [PMID: 35514051 DOI: 10.1177/02676591221090751] [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: 11/17/2022]
Abstract
INTRODUCTION Cardiopulmonary bypass (CPB) machines have oxygenators with integrated filters and unique biocompatible coatings to combat systemic inflammatory response syndrome (SIRS) and mitigate coagulopathy. Contemporary oxygenators have undergone comparative studies; however, our study aimed to identify the most appropriate oxygenator for our regional Cardiothoracic unit in Australasia. METHODS A prospective audit consecutively recruited one-hundred and fifty patients undergoing cardiac surgery at Waikato Hospital, New Zealand between the periods of 29th January 2018 and 31st July 2018. Fifty patients were recruited for each oxygenator arm: Sorin INSPIRE' (Group-S); Terumo CAPIOX'FX (Group-T); and Medtronic Affinity Fusion' (Group-M). The clinical outcomes were transfusions, chest drain output, reoperation and length of hospital stay (LOHS). Routine blood testing protocol included: haemoglobin, protein, albumin, white cell count (WCC), C-reactive protein (CRP), platelet count and coagulations tests including international normalized ratio (INR). RESULTS Comparing Groups S, T and M there was no statistical difference in chest drain output (650 vs. 500 vs. 595 ml respectively, p = 0.45), transfusions (61 vs. 117 vs. 70 units, p = 0.67), reoperation (6 vs. 8 vs. 12%, p = 0.99) and LOHS (median 7.4 vs. 7.6 vs. 9.5 days, p = 0.42). Group-T had fewer SIRS cases but similar increase in CRP (p = 0.12) and WCC (p = 0.35). Group-M had a significant rise in post-op INR (p = 0.005) but no associated increase in chest drain output (p = 0.62). Group-S and -M required more 4%-albumin and Group-T had more transfusions. Only fresh frozen plasma (FFP) and red blood cell (RBC) transfusion had a significant relationship with LOHS (p < 0.05). CONCLUSION Biochemically, there was slight difference among the oxygenators which did not translate into clinical difference in outcomes. The oxygenator design and perfusionist choice aided in our decision-making process.
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Affiliation(s)
- Minesh Prakash
- Waikato District Health Board, Vascular Surgery Unit, Hamilton, New Zealand
| | - Varun Sharma
- Waikato District Health Board, Vascular Surgery Unit, Hamilton, New Zealand
| | - Timothy Oh
- Auckland District Health Board, Cardiothoracic Unit, Auckland, New Zealand
| | - Casey Lo
- Auckland District Health Board, Cardiothoracic Unit, Auckland, New Zealand
| | - Grant Parkinson
- Waikato District Health Board, Waikato Cardiothoracic Unit, Hamilton, New Zealand
| | - David McCormack
- Waikato District Health Board, Waikato Cardiothoracic Unit, Hamilton, New Zealand
| | - Paul Conaglen
- Waikato District Health Board, Waikato Cardiothoracic Unit, Hamilton, New Zealand
| | - Zaw Lin
- Waikato District Health Board, Waikato Cardiothoracic Unit, Hamilton, New Zealand
| | - Nand Kejriwal
- Waikato District Health Board, Waikato Cardiothoracic Unit, Hamilton, New Zealand
| | - Felicity Meikle
- Waikato District Health Board, Waikato Cardiothoracic Unit, Hamilton, New Zealand
| | - Emma Peplow
- Waikato District Health Board, Waikato Perfusion Department, Hamilton, New Zealand
| | - Jack Bhana
- Waikato District Health Board, Waikato Perfusion Department, Hamilton, New Zealand
| | - Adam El Gamel
- Waikato District Health Board, Waikato Cardiothoracic Unit, Hamilton, New Zealand
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26
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Hesselmann F, Halwes M, Bongartz P, Wessling M, Cornelissen C, Schmitz-Rode T, Steinseifer U, Jansen SV, Arens J. TPMS-based membrane lung with locally-modified permeabilities for optimal flow distribution. Sci Rep 2022; 12:7160. [PMID: 35504939 PMCID: PMC9065140 DOI: 10.1038/s41598-022-11175-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 04/11/2022] [Indexed: 11/09/2022] Open
Abstract
Membrane lungs consist of thousands of hollow fiber membranes packed together as a bundle. The devices often suffer from complications because of non-uniform flow through the membrane bundle, including regions of both excessively high flow and stagnant flow. Here, we present a proof-of-concept design for a membrane lung containing a membrane module based on triply periodic minimal surfaces (TPMS). By warping the original TPMS geometries, the local permeability within any region of the module could be raised or lowered, allowing for the tailoring of the blood flow distribution through the device. By creating an iterative optimization scheme for determining the distribution of streamwise permeability inside a computational porous domain, the desired form of a lattice of TPMS elements was determined via simulation. This desired form was translated into a computer-aided design (CAD) model for a prototype device. The device was then produced via additive manufacturing in order to test the novel design against an industry-standard predicate device. Flow distribution was verifiably homogenized and residence time reduced, promising a more efficient performance and increased resistance to thrombosis. This work shows the promising extent to which TPMS can serve as a new building block for exchange processes in medical devices.
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Affiliation(s)
- Felix Hesselmann
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Pauwelsstr. 20, 52074, Aachen, Germany.
| | - Michael Halwes
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Pauwelsstr. 20, 52074, Aachen, Germany
| | - Patrick Bongartz
- Chair of Chemical Process Engineering, RWTH Aachen University, Forckenbeckstr. 51, 52074, Aachen, Germany
| | - Matthias Wessling
- Chair of Chemical Process Engineering, RWTH Aachen University, Forckenbeckstr. 51, 52074, Aachen, Germany.,DWI-Leibniz Institute for Interactive Materials, RWTH Aachen University, Forckenbeckstr. 50, 52074, Aachen, Germany
| | - Christian Cornelissen
- Department of Pneumology and Internal Intensive Care Medicine, Medical Clinic V, RWTH Aachen University Hospital, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Thomas Schmitz-Rode
- Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Pauwelsstr. 20, 52074, Aachen, Germany
| | - Ulrich Steinseifer
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Pauwelsstr. 20, 52074, Aachen, Germany
| | - Sebastian Victor Jansen
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Pauwelsstr. 20, 52074, Aachen, Germany
| | - Jutta Arens
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Pauwelsstr. 20, 52074, Aachen, Germany.,Chair of Engineering Organ Support Technologies, Department of Biomechanical Engineering, Faculty of Engineering, Technology University of Twente, Enschede, The Netherlands
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27
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Yi E, Kang HS, Lim SM, Heo HJ, Han D, Kim JF, Park A, Choi DH, Park YI, Park H, Cho YH, Sohn EH. Superamphiphobic blood-repellent surface modification of porous fluoropolymer membranes for blood oxygenation applications. J Memb Sci 2022. [DOI: 10.1016/j.memsci.2022.120363] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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28
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O'Neil ER, Quinn RE, Olson TL, Rycus PT, Anders MM, Chartan CA, Vogel TP, Silva-Carmona M, Coleman RD. Extracorporeal Membrane Oxygenation Support for Antineutrophil Cytoplasmic Antibody-associated Vasculitides: An ELSO Registry Analysis. ASAIO J 2022; 68:553-560. [PMID: 34324445 DOI: 10.1097/mat.0000000000001539] [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: 11/26/2022] Open
Abstract
Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides with pulmonary involvement include granulomatosis with polyangiitis, microscopic polyangiitis, and eosinophilic granulomatosis with polyangiitis, and can present with life-threatening pulmonary hemorrhage in up to 40% of patients. Mortality in those patients who require intubation and mechanical ventilation can reach 77%. Extracorporeal membrane oxygenation (ECMO) can be used to support these patients through definitive diagnosis and treatment, although minimizing the risk of ventilator-induced lung injury. We aimed to determine factors associated with favorable outcomes in patients with (ANCA)-associated vasculitides supported on ECMO. We performed a retrospective observational study using the Extracorporeal Life Support Organization registry of pediatric and adult patients with ANCA-associated vasculitis supported on ECMO from 2010 to 2020. One hundred thirty-five patients were included for analysis. Many patients had renal involvement (39%) in addition to pulmonary involvement (93%). Survival was 73% in AAV patients supported on ECMO. The presence of pulmonary hemorrhage was not associated with worse outcomes in our cohort. Older age, the use of venoarterial ECMO, ECMO-cardiopulmonary resuscitation, or sustaining a cardiac arrest before ECMO was associated with decreased survival. In conclusion, venovenous ECMO should be considered as a supportive bridge to definitive diagnosis and treatment in (ANCA)-associated vasculitides, regardless if pulmonary hemorrhage is present.
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Affiliation(s)
- Erika R O'Neil
- From the Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Rachel E Quinn
- From the Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Taylor L Olson
- Children's National Hospital, Washington, District of Columbia
| | - Peter T Rycus
- The Extracorporeal Life Support Organization, Ann Arbor, Michigan
| | - Marc M Anders
- From the Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Corey A Chartan
- From the Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Tiphanie P Vogel
- From the Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | | | - Ryan D Coleman
- From the Department of Pediatrics, Baylor College of Medicine, Houston, Texas
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29
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Palazzolo T, Hirschhorn M, Garven E, Day S, Stevens RM, Rossano J, Tchantchaleishvili V, Throckmorton AL. Technology Landscape of Pediatric Mechanical Circulatory Support Devices- A Systematic Review 2010-2021. Artif Organs 2022; 46:1475-1490. [PMID: 35357020 PMCID: PMC9256769 DOI: 10.1111/aor.14242] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 02/17/2022] [Accepted: 03/15/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Mechanical circulatory support (MCS) devices, such as ventricular assist devices (VADs) and total artificial hearts (TAHs), have become a vital therapeutic option in the treatment of end-stage heart failure for adult patients. Such therapeutic options continue to be limited for pediatric patients. Clinicians initially adapted or scaled existing adult devices for pediatric patients; however, these adult devices are not designed to support the anatomical structure and varying flow capacities required for this population and are generally operated "off-design", which risks complications such as hemolysis and thrombosis. Devices designed specifically for the pediatric population that seek to address these shortcomings are now emerging and gaining FDA approval. METHODS To analyze the competitive landscape of pediatric MCS devices, we conducted a systematic literature review. Approximately 27 devices were studied in detail: 8 were established or previously approved designs, and 19 were under development (11 VADs, 5 Fontan assist devices, and 3 TAHs). RESULTS Despite significant progress, there is still no pediatric pump technology that satisfies the unique and distinct design constraints and requirements to support pediatric patients, including the wide range of patient sizes, increased cardiovascular demand with growth, and anatomic and physiologic heterogeneity of congenital heart disease. CONCLUSIONS Forward-thinking design solutions are required to overcome these challenges and to ensure the translation of new therapeutic MCS devices for pediatric patients.
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Affiliation(s)
- Thomas Palazzolo
- BioCirc Research Laboratory, School of Biomedical Engineering, Science, and Health Systems, Drexel University, Philadelphia, PA, USA
| | - Matthew Hirschhorn
- BioCirc Research Laboratory, School of Biomedical Engineering, Science, and Health Systems, Drexel University, Philadelphia, PA, USA
| | - Ellen Garven
- BioCirc Research Laboratory, School of Biomedical Engineering, Science, and Health Systems, Drexel University, Philadelphia, PA, USA
| | - Steven Day
- Department of Biomedical Engineering, Kate Gleason College of Engineering, Rochester Institute of Technology, Rochester, NY, USA
| | - Randy M Stevens
- College of Medicine, St. Christopher's Hospital for Children, Drexel University, Philadelphia, PA, USA
| | - Joseph Rossano
- Division of Pediatric Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Vakhtang Tchantchaleishvili
- Division of Cardiac Surgery, Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Amy L Throckmorton
- BioCirc Research Laboratory, School of Biomedical Engineering, Science, and Health Systems, Drexel University, Philadelphia, PA, USA
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30
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Prat NJ, Meyer AD, Scaravilli V, Cannon J, Cancio LC, Cap AP, Batchinsky AI. Regional blood acidification inhibits coagulation during extracorporeal carbon dioxide removal (ECCO 2 R). Artif Organs 2022; 46:1181-1191. [PMID: 35289412 DOI: 10.1111/aor.14233] [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: 12/17/2021] [Revised: 02/17/2022] [Accepted: 03/04/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Consumption of platelets and coagulation factors during extracorporeal carbon dioxide removal (ECCO2 R) increases bleeding complications and associated mortality. Regional infusion of lactic acid enhances ECCO2 R by shifting the chemical equilibrium from bicarbonate to carbon dioxide. Our goal was to test if regional blood acidification during ECCO2 R inhibits platelet function and coagulation. METHODS An ECCO2 R system containing a hemofilter circulated blood at 0.25 L/min in 8 healthy ewes (Ovis aries) for 36 hours. Three of the sheep received ECCO2 R with no recirculation compared to 5 sheep that received ECCO2 R plus 12 hours of regional blood acidification via the hemofilter, placed upstream from the oxygenator, into which 4.4 M lactic acid was infused. Blood gases, platelet count and function, thromboelastography, coagulation-factor activity, and von Willebrand factor activity (vWF:Ag) were measured at baseline, at start of lactic acid infusion, and after 36 hours of extracorporeal circulation. RESULTS Twelve hours of regional acid infusion significantly inhibited platelet aggregation response to adenosine diphosphate; vWF; and platelet expression of P-selectin compared to control. It also significantly reduced consumption of fibrinogen and of coagulation factors V, VII, IX, compared to control. CONCLUSIONS Regional acidification reduces platelet activation and vitamin-K-dependent coagulation-factor consumption during ECCO2 R. This is the first report of a simple method that may enhance effective anticoagulation for ECCO2 R.
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Affiliation(s)
- Nicolas J Prat
- French Armed Forces Biomedical Research Institute (IRBA), Paris, France.,U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas, USA
| | - Andrew D Meyer
- Division of Critical Care Medicine, Department of Pediatrics, Long School of Medicine, University of Texas Health Science Center, San Antonio, Texas, USA.,U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas, USA
| | - Vittorio Scaravilli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy.,Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Jeremy Cannon
- Division of Traumatology, Surgical Critical Care & Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Leopoldo C Cancio
- U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas, USA
| | - Andrew P Cap
- U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas, USA
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31
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Griffin L, Douglass M, Goudie M, Hopkins SP, Schmiedt C, Handa H. Improved Polymer Hemocompatibility for Blood-Contacting Applications via S-Nitrosoglutathione Impregnation. ACS APPLIED MATERIALS & INTERFACES 2022; 14:11116-11123. [PMID: 35225600 PMCID: PMC9793915 DOI: 10.1021/acsami.1c24557] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Blood-contacting medical devices (BCMDs) are inevitably challenged by thrombi formation, leading to occlusion of flow and device failure. Ideal BCMDs seek to mimic the intrinsic antithrombotic properties of the human vasculature to locally prevent thrombotic complications, negating the need for systemic anticoagulation. An emerging category of BCMD technology utilizes nitric oxide (NO) as a hemocompatible agent, as the vasculature's endothelial layer naturally releases NO to inhibit platelet activation and consumption. In this paper, we report for the first time the novel impregnation of S-nitrosoglutathione (GSNO) into polymeric poly(vinyl chloride) (PVC) tubing via an optimized solvent-swelling method. Material testing revealed an optimized GSNO-PVC material that had adequate GSNO loading to achieve NO flux values within the physiological endothelial NO flux range for a 4 h period. Through in vitro hemocompatibility testing, the optimized material was deemed nonhemolytic (hemolytic index <2%) and capable of reducing platelet activation, suggesting that the material is suitable for contact with whole blood. Furthermore, an in vivo 4 h extracorporeal circulation (ECC) rabbit thrombogenicity model confirmed the blood biocompatibility of the optimized GSNO-PVC. Platelet count remained near 100% for the novel GSNO-impregnated PVC loops (1 h, 91.08 ± 6.27%; 2 h, 95.68 ± 0.61%; 3 h, 97.56 ± 8.59%; 4 h, 95.11 ± 8.30%). In contrast, unmodified PVC ECC loops occluded shortly after the 2 h time point and viable platelet counts quickly diminished (1 h, 85.67 ± 12.62%; 2 h, 54.46 ± 10.53%; 3 h, n/a; 4 h, n/a). The blood clots for GSNO-PVC loops (190.73 ± 72.46 mg) compared to those of unmodified PVC loops (866.50 ± 197.98 mg) were significantly smaller (p < 0.01). The results presented in this paper recommend further investigation in long-term animal models and suggest that GSNO-PVC has the potential to serve as an alternative to systemic anticoagulation in BCMD applications.
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Affiliation(s)
- Lauren Griffin
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, 220 Riverbend Road, Athens, Georgia 30602, United States
| | - Megan Douglass
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, 220 Riverbend Road, Athens, Georgia 30602, United States
| | - Marcus Goudie
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, 220 Riverbend Road, Athens, Georgia 30602, United States
| | - Sean P Hopkins
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, 220 Riverbend Road, Athens, Georgia 30602, United States
| | - Chad Schmiedt
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, 220 Riverbend Road, Athens, Georgia 30602, United States
| | - Hitesh Handa
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, 220 Riverbend Road, Athens, Georgia 30602, United States
- Department of Pharmaceutical and Biomedical Sciences, College of Pharmacy, University of Georgia, 220 Riverbend Road, Athens, Georgia 30602, United States
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32
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Hatami S, Hefler J, Freed DH. Inflammation and Oxidative Stress in the Context of Extracorporeal Cardiac and Pulmonary Support. Front Immunol 2022; 13:831930. [PMID: 35309362 PMCID: PMC8931031 DOI: 10.3389/fimmu.2022.831930] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 02/08/2022] [Indexed: 12/12/2022] Open
Abstract
Extracorporeal circulation (ECC) systems, including cardiopulmonary bypass, and extracorporeal membrane oxygenation have been an irreplaceable part of the cardiothoracic surgeries, and treatment of critically ill patients with respiratory and/or cardiac failure for more than half a century. During the recent decades, the concept of extracorporeal circulation has been extended to isolated machine perfusion of the donor organ including thoracic organs (ex-situ organ perfusion, ESOP) as a method for dynamic, semi-physiologic preservation, and potential improvement of the donor organs. The extracorporeal life support systems (ECLS) have been lifesaving and facilitating complex cardiothoracic surgeries, and the ESOP technology has the potential to increase the number of the transplantable donor organs, and to improve the outcomes of transplantation. However, these artificial circulation systems in general have been associated with activation of the inflammatory and oxidative stress responses in patients and/or in the exposed tissues and organs. The activation of these responses can negatively affect patient outcomes in ECLS, and may as well jeopardize the reliability of the organ viability assessment, and the outcomes of thoracic organ preservation and transplantation in ESOP. Both ECLS and ESOP consist of artificial circuit materials and components, which play a key role in the induction of these responses. However, while ECLS can lead to systemic inflammatory and oxidative stress responses negatively affecting various organs/systems of the body, in ESOP, the absence of the organs that play an important role in oxidant scavenging/antioxidative replenishment of the body, such as liver, may make the perfused organ more susceptible to inflammation and oxidative stress during extracorporeal circulation. In the present manuscript, we will review the activation of the inflammatory and oxidative stress responses during ECLP and ESOP, mechanisms involved, clinical implications, and the interventions for attenuating these responses in ECC.
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Affiliation(s)
- Sanaz Hatami
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
- Canadian National Transplant Research Program, Edmonton, AB, Canada
| | - Joshua Hefler
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Darren H. Freed
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
- Canadian National Transplant Research Program, Edmonton, AB, Canada
- Department of Biomedical Engineering, University of Alberta, Edmonton, AB, Canada
- Alberta Transplant Institute, Edmonton, AB, Canada
- Department of Physiology, University of Alberta, Edmonton, AB, Canada
- *Correspondence: Darren H. Freed,
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Reed CR, Bonadonna D, Otto JC, McDaniel CG, Chabata CV, Kuchibhatla M, Frederiksen J, Layzer JM, Arepally GM, Sullenger BA, Tracy ET. Aptamer-based factor IXa inhibition preserves hemostasis and prevents thrombosis in a piglet model of ECMO. MOLECULAR THERAPY - NUCLEIC ACIDS 2022; 27:524-534. [PMID: 35036063 PMCID: PMC8728519 DOI: 10.1016/j.omtn.2021.12.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 12/09/2021] [Indexed: 11/30/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) requires anticoagulation to prevent clotting when the patient’s blood contacts the circuit. Unfractionated heparin (UFH) usually prevents clotting but can cause life-threatening bleeding. An anticoagulant that selectively inhibits the contact activation (intrinsic) pathway while sparing the tissue factor (extrinsic) pathway of coagulation might prevent clotting triggered by the circuit while permitting physiologic coagulation at surgical sites. DTRI-178 is an RNA anticoagulant aptamer conjugated to polyethylene glycol that increases its half-life in circulation. This aptamer is based on a previously described molecule (9.3t) that inhibits intrinsic tenase activity by binding to factor IXa on an exosite. Using a piglet model of pediatric venoarterial (VA) ECMO, we compared thromboprevention and blood loss using a single dose of DTRI-178 versus UFH. In each of five experiments, we subjected two litter-matched piglets, one anticoagulated with DTRI-178 and the other with UFH, to simultaneous 12-h periods of VA ECMO. Both anticoagulants achieved satisfactory and comparable thromboprotection. However, UFH piglets had increased surgical site bleeding and required significantly greater blood transfusion volumes than piglets anticoagulated with DTRI-178. Our results indicate that DTRI-178, an aptamer against factor IXa, may be feasible, safer, and result in fewer transfusions and clinical bleeding events in ECMO.
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Affiliation(s)
- Christopher R. Reed
- Department of Surgery, Duke University Medical Center and Health System, 2301 Erwin Road, Box 3443, Durham, NC 27710, USA
- Corresponding author Christopher R. Reed, MD, Department of Surgery, Duke University Medical Center and Health System, 2301 Erwin Road, Box 3443, Durham, NC 27710, USA
| | - Desiree Bonadonna
- Extracorporeal Life Support, Duke University Medical Center, Durham, NC 27710, USA
| | - James C. Otto
- Department of Surgery, Duke University Medical Center and Health System, 2301 Erwin Road, Box 3443, Durham, NC 27710, USA
| | | | - Charlene Vongai Chabata
- Departments of Surgery; and Pharmacology and Cancer Biology, Duke University, Durham, NC 27710, USA
| | - Maragatha Kuchibhatla
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC 27710, USA
| | - James Frederiksen
- Department of Surgery, Duke University Medical Center and Health System, 2301 Erwin Road, Box 3443, Durham, NC 27710, USA
| | - Juliana M. Layzer
- Duke University Clinical and Translational Science Institute, Durham, NC 27710, USA
| | - Gowthami M. Arepally
- Division of Hematology, Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA
| | - Bruce A. Sullenger
- Department of Surgery, Duke University Medical Center and Health System, 2301 Erwin Road, Box 3443, Durham, NC 27710, USA
| | - Elisabeth T. Tracy
- Department of Surgery, Duke University Medical Center and Health System, 2301 Erwin Road, Box 3443, Durham, NC 27710, USA
- Division of Pediatric Surgery, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
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Endogenous Nitric Oxide-Releasing Microgel Coating Prevents Clot Formation on Oxygenator Fibers Exposed to In Vitro Blood Flow. MEMBRANES 2022; 12:membranes12010073. [PMID: 35054599 PMCID: PMC8779597 DOI: 10.3390/membranes12010073] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 12/23/2021] [Accepted: 12/28/2021] [Indexed: 02/04/2023]
Abstract
Background: Clot formation on foreign surfaces of extracorporeal membrane oxygenation systems is a frequent event. Herein, we show an approach that mimics the enzymatic process of endogenous nitric oxide (NO) release on the oxygenator membrane via a biomimetic, non-fouling microgel coating to spatiotemporally inhibit the platelet (PLT) activation and improve antithrombotic properties. This study aims to evaluate the potential of this biomimetic coating towards NO-mediated PLT inhibition and thereby the reduction of clot formation under flow conditions. Methods: Microgel-coated (NOrel) or bare (Control) poly(4-methyl pentene) (PMP) fibers were inserted into a test channel and exposed to a short-term continuous flow of human blood. The analysis included high-resolution PLT count, pooled PLT activation via β-Thromboglobulin (β-TG) and the visualization of remnants and clots on the fibers using scanning electron microscopy (SEM). Results: In the Control group, PLT count was significantly decreased, and β-TG concentration was significantly elevated in comparison to the NOrel group. Macroscopic and microscopic visualization showed dense layers of stable clots on the bare PMP fibers, in contrast to minimal deposition of fibrin networks on the coated fibers. Conclusion: Endogenously NO-releasing microgel coating inhibits the PLT activation and reduces the clot formation on PMP fibers under dynamic flow.
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35
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Pollak U, Feinstein Y, Mannarino CN, McBride ME, Mendonca M, Keizman E, Mishaly D, van Leeuwen G, Roeleveld PP, Koers L, Klugman D. The horizon of pediatric cardiac critical care. Front Pediatr 2022; 10:863868. [PMID: 36186624 PMCID: PMC9523119 DOI: 10.3389/fped.2022.863868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 08/22/2022] [Indexed: 11/21/2022] Open
Abstract
Pediatric Cardiac Critical Care (PCCC) is a challenging discipline where decisions require a high degree of preparation and clinical expertise. In the modern era, outcomes of neonates and children with congenital heart defects have dramatically improved, largely by transformative technologies and an expanding collection of pharmacotherapies. Exponential advances in science and technology are occurring at a breathtaking rate, and applying these advances to the PCCC patient is essential to further advancing the science and practice of the field. In this article, we identified and elaborate on seven key elements within the PCCC that will pave the way for the future.
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Affiliation(s)
- Uri Pollak
- Section of Pediatric Critical Care, Hadassah University Medical Center, Jerusalem, Israel.,Faculty of Medicine, the Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yael Feinstein
- Pediatric Intensive Care Unit, Soroka University Medical Center, Be'er Sheva, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Candace N Mannarino
- Divisions of Cardiology and Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Mary E McBride
- Divisions of Cardiology and Critical Care Medicine, Departments of Pediatrics and Medical Education, Northwestern University Feinberg School of Medicine, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Malaika Mendonca
- Pediatric Intensive Care Unit, Children's Hospital, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Eitan Keizman
- Department of Cardiac Surgery, The Leviev Cardiothoracic and Vascular Center, The Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - David Mishaly
- Pediatric and Congenital Cardiac Surgery, Edmond J. Safra International Congenital Heart Center, The Chaim Sheba Medical Center, The Edmond and Lily Safra Children's Hospital, Tel Hashomer, Israel
| | - Grace van Leeuwen
- Pediatric Cardiac Intensive Care Unit, Sidra Medicine, Ar-Rayyan, Qatar.,Department of Pediatrics, Weill Cornell Medicine, Ar-Rayyan, Qatar
| | - Peter P Roeleveld
- Department of Pediatric Intensive Care, Leiden University Medical Center, Leiden, Netherlands
| | - Lena Koers
- Department of Pediatric Intensive Care, Leiden University Medical Center, Leiden, Netherlands
| | - Darren Klugman
- Pediatrics Cardiac Critical Care Unit, Blalock-Taussig-Thomas Pediatric and Congenital Heart Center, Johns Hopkins Medicine, Baltimore, MD, United States
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36
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Nishida K, Baba K, Murakami D, Tanaka M. Nanoscopic Analyses of Protein Adsorption on Poly(2-methoxyethyl acrylate) Surfaces for Tailoring Cell Adhesiveness. Biomater Sci 2022; 10:2953-2963. [DOI: 10.1039/d2bm00093h] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Regulation of protein adsorption on the surface of biomaterials is important for modulating cell adhesion. Two important proteins in this regard are fibrinogen and fibronectin. Poly(2-methoxyethyl acrylate) (PMEA) and its...
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37
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Nunez JI, Gosling AF, O'Gara B, Kennedy KF, Rycus P, Abrams D, Brodie D, Shaefi S, Garan AR, Grandin EW. Bleeding and thrombotic events in adults supported with venovenous extracorporeal membrane oxygenation: an ELSO registry analysis. Intensive Care Med 2021; 48:213-224. [PMID: 34921625 DOI: 10.1007/s00134-021-06593-x] [Citation(s) in RCA: 94] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 11/24/2021] [Indexed: 12/20/2022]
Abstract
PURPOSE This study aimed at analyzing the prevalence, mortality association, and risk factors for bleeding and thrombosis events (BTEs) among adults supported with venovenous extracorporeal membrane oxygenation (VV-ECMO). METHODS We queried the Extracorporeal Life Support Organization registry for adults supported with VV-ECMO from 2010 to 2017. Multivariable logistic regression modeling was used to assess the association between BTEs and in-hospital mortality and the predictors of BTEs. RESULTS Among 7579 VV-ECMO patients meeting criteria, 40.2% experienced ≥ 1 BTE. Thrombotic events comprised 54.9% of all BTEs and were predominantly ECMO circuit thrombosis. BTE rates decreased significantly over the study period (p < 0.001). The inpatient mortality rate was 34.9%. Bleeding events (1.69 [1.49-1.93]) were more strongly associated with in-hospital mortality than thrombotic events (1.23 [1.08-1.41]) p < 0.01 for both. The BTEs most strongly associated with mortality were ischemic stroke (4.50 [2.55-7.97]) and medical bleeding, including intracranial (5.71 [4.02-8.09]), pulmonary (2.02 [1.54-2.67]), and gastrointestinal (1.54 [1.2-1.98]) hemorrhage, all p < 0.01. Risk factors for bleeding included acute kidney injury and pre-ECMO vasopressor support and for thrombosis were higher weight, multisite cannulation, pre-ECMO arrest, and higher PaCO2 at ECMO initiation. Longer time on ECMO, younger age, higher pH, and earlier year of support were associated with bleeding and thrombosis. CONCLUSIONS Although decreasing over time, BTEs remain common during VV-ECMO and have a strong, cumulative association with in-hospital mortality. Thrombotic events are more frequent, but bleeding carries a higher risk of inpatient mortality. Differential risk factors for bleeding and thrombotic complications exist, raising the possibility of a tailored approach to VV-ECMO management.
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Affiliation(s)
- Jose I Nunez
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Andre F Gosling
- Department of Anesthesiology, Duke University Hospital, Durham, NC, USA
| | - Brian O'Gara
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Kevin F Kennedy
- Smith Center for Cardiology Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Peter Rycus
- Extracorporeal Life Support Organization, Ann Arbor, MI, USA
| | - Darryl Abrams
- Division of Pulmonary and Critical Care Medicine, Columbia Presbyterian Medical Center, New York, NY, USA
| | - Daniel Brodie
- Division of Pulmonary and Critical Care Medicine, Columbia Presbyterian Medical Center, New York, NY, USA
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - A Reshad Garan
- Division of Cardiovascular Medicine, Section of Advanced Heart Failure, Department of Medicine, Beth Israel Deaconess Medical Center, 185 Pilgrim Road, DE-319, Boston, MA, 02215, USA
| | - E Wilson Grandin
- Smith Center for Cardiology Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA, USA. .,Division of Cardiovascular Medicine, Section of Advanced Heart Failure, Department of Medicine, Beth Israel Deaconess Medical Center, 185 Pilgrim Road, DE-319, Boston, MA, 02215, USA.
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38
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Lahmann JM, Faase RA, Leu HY, Jacques SL, Scottoline B, Schilke KF, Baio JE, Higgins AZ. Microfluidic photoreactor to treat neonatal jaundice. BIOMICROFLUIDICS 2021; 15:064104. [PMID: 34853627 PMCID: PMC8616629 DOI: 10.1063/5.0066073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 11/09/2021] [Indexed: 06/13/2023]
Abstract
While in most cases, jaundice can be effectively treated using phototherapy, severe cases require exchange transfusion, a relatively risky procedure in which the neonate's bilirubin-rich blood is replaced with donor blood. Here, we examine extracorporeal blood treatment in a microfluidic photoreactor as an alternative to exchange transfusion. This new treatment approach relies on the same principle as phototherapy but leverages microfluidics to speed up bilirubin removal. Our results demonstrate that high-intensity light at 470 nm can be used to rapidly reduce bilirubin levels without causing appreciable damage to DNA in blood cells. Light at 470 nm was more effective than light at 505 nm. Studies in Gunn rats show that photoreactor treatment for 4 h significantly reduces bilirubin levels, similar to the bilirubin reduction observed for exchange transfusion and on a similar time scale. Predictions for human neonates demonstrate that this new treatment approach is expected to exceed the performance of exchange transfusion using a low blood flow rate and priming volume, which will facilitate vascular access and improve safety.
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Affiliation(s)
- John M. Lahmann
- School of Chemical, Biological, and Environmental Engineering, Oregon State University, Corvallis, Oregon 97331, USA
| | - Ryan A. Faase
- School of Chemical, Biological, and Environmental Engineering, Oregon State University, Corvallis, Oregon 97331, USA
| | - Hsuan Yu Leu
- School of Chemical, Biological, and Environmental Engineering, Oregon State University, Corvallis, Oregon 97331, USA
| | - Steven L. Jacques
- Department of Bioengineering, University of Washington, Seattle, Washington 98105, USA
| | - Brian Scottoline
- Division of Neonatology, Department of Pediatrics, Oregon Health & Science University, Portland, Oregon 97239, USA
| | - Kate F. Schilke
- School of Chemical, Biological, and Environmental Engineering, Oregon State University, Corvallis, Oregon 97331, USA
| | - Joe E. Baio
- School of Chemical, Biological, and Environmental Engineering, Oregon State University, Corvallis, Oregon 97331, USA
| | - Adam Z. Higgins
- School of Chemical, Biological, and Environmental Engineering, Oregon State University, Corvallis, Oregon 97331, USA
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39
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Liu Y, Zhang F, Lang S, Yang L, Gao S, Wu D, Liu G, Wang Y. A Uniform and Robust Bioinspired Zwitterion Coating for Use in Blood-Contacting Catheters with Improved Anti-Inflammatory and Antithrombotic Properties. Macromol Biosci 2021; 21:e2100341. [PMID: 34644005 DOI: 10.1002/mabi.202100341] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 10/10/2021] [Indexed: 11/10/2022]
Abstract
Inflammation and thrombosis are two major complications of blood-contacting catheters that are used as extracorporeal circuits for hemodialysis and life-support systems. In clinical applications, complications can lead to increased mortality and morbidity rates. In this work, a biomimetic erythrocyte membrane zwitterion coating based on poly(2-methacryloyloxyethyl phosphorylcholine-co-dopamine methacrylate) (pMPCDA) copolymers is uniformly and robustly modified onto a polyvinyl chloride (PVC) catheter via mussel-inspired surface chemistry. The zwitterionic pMPCDA coating exhibits excellent antifouling activity and resists bacterial adhesion, fibrinogen adsorption, and platelet adhesion/activation. The material also demonstrates great hemocompatibility, cytocompatibility, and anticoagulation properties in vitro. Additionally, this biocompatible pMPCDA coating reduces in vivo foreign-body reactions by mitigating inflammatory response and collagen capsule formation, due to its outstanding ability to resist nonspecific protein adsorption. More importantly, when compared with a bare PVC catheter, the pMPCDA coating exhibits outstanding antithrombotic properties when tested in an ex vivo rabbit perfusion model. Thus, it is envisioned that this biomimetic erythrocyte membrane surface strategy will provide a promising way to mitigate inflammation and thrombosis caused by the use of blood-contacting catheters.
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Affiliation(s)
- Yuqi Liu
- Collage of Biomass Chemistry and Engineering, Sichuan University, Chengdu, 610065, China.,National Engineering Research Center of Clean Technology in Leather Industry, Sichuan University, Chengdu, 610065, China
| | - Fanjun Zhang
- National Engineering Research Center for Biomaterials, Sichuan University, Chengdu, 610064, China
| | - Shiying Lang
- Collage of Biomass Chemistry and Engineering, Sichuan University, Chengdu, 610065, China.,National Engineering Research Center of Clean Technology in Leather Industry, Sichuan University, Chengdu, 610065, China
| | - Li Yang
- National Engineering Research Center for Biomaterials, Sichuan University, Chengdu, 610064, China
| | - Shuai Gao
- National Engineering Research Center for Biomaterials, Sichuan University, Chengdu, 610064, China.,Chengdu Daxan Innovative Medical Tech. Co., Ltd, Chengdu, 611135, China
| | - Dimeng Wu
- National Engineering Research Center for Biomaterials, Sichuan University, Chengdu, 610064, China.,Chengdu Daxan Innovative Medical Tech. Co., Ltd, Chengdu, 611135, China
| | - Gongyan Liu
- Collage of Biomass Chemistry and Engineering, Sichuan University, Chengdu, 610065, China.,National Engineering Research Center of Clean Technology in Leather Industry, Sichuan University, Chengdu, 610065, China
| | - Yunbing Wang
- National Engineering Research Center for Biomaterials, Sichuan University, Chengdu, 610064, China
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40
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Giorni C, Rizza A, Favia I, Amodeo A, Chiusolo F, Picardo SG, Luciani M, Di Felice G, Di Chiara L. Pediatric Mechanical Circulatory Support: Pathophysiology of Pediatric Hemostasis and Available Options. Front Cardiovasc Med 2021; 8:671241. [PMID: 34540910 PMCID: PMC8440876 DOI: 10.3389/fcvm.2021.671241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 06/17/2021] [Indexed: 01/01/2023] Open
Abstract
Pediatric mechanical circulatory support (MCS) is considered a strategy for heart failure management as a bridge to recovery and transplantation or as a destination therapy. The final outcome is significantly impacted by the number of complications that may occur during MCS. Children on ventricular assist devices (VADs) and extracorporeal membrane oxygenation (ECMO) are at high risk for bleeding and thrombotic complications that are managed through anticoagulation. The first detailed guideline in pediatric VADs (Edmonton Anticoagulation and Platelet Inhibition Protocol) was based on conventional antithrombotic drugs, such as unfractionated heparin (UFH) and warfarin. UFH is the first-line anticoagulant in pediatric MCS, although its profile is not considered optimal in pediatric setting. The broad variation in heparin doses among children is associated with frequent occurrence of cerebrovascular accidents, bleeding, and thrombocytopenia. Direct thrombin inhibitors (DTIs) have been utilized as alternative strategies to heparin. Since 2018, bivalirudin has become the chosen anticoagulant in the long-term therapy of patients undergoing MCS implantation, according to the most recent protocols shared in North America. This article provides a review of the non-traditional anticoagulation strategies utilized in pediatric MCS, focusing on pharmacodynamics, indications, doses, and monitoring aspects of bivalirudin. Moreover, it exposes the efforts and the collaborations among different specialized centers, which are committed to an ongoing learning in order to minimize major complications in this special pediatric population. Further prospective trials regarding DTIs in a pediatric MCS setting are necessary and in specific well-designed randomized control trials between UFH and bivalirudin. To conclude, based on the reported literature, the clinical use of the bivalirudin in pediatric MCS seems to be a value added in controlling and maybe reducing thromboembolic complications. Further research is necessary to confirm all the results provided by this literature review.
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Affiliation(s)
- Chiara Giorni
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Alessandra Rizza
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Isabella Favia
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Antonio Amodeo
- Mechanical Circulatory Support Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Fabrizio Chiusolo
- Department of Anesthesia and Critical Care, Anestesia Rianimazione Comparto Operatorio, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Sergio G Picardo
- Department of Anesthesia and Critical Care, Anestesia Rianimazione Comparto Operatorio, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Matteo Luciani
- Department of Oncohematology, Haemostasis and Thrombosis Center, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Giovina Di Felice
- Hemostasis Laboratory, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Luca Di Chiara
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
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Zhang M, Pauls JP, Bartnikowski N, Haymet AB, Chan CHH, Suen JY, Schneider B, Ki KK, Whittaker AK, Dargusch MS, Fraser JF. Anti-thrombogenic Surface Coatings for Extracorporeal Membrane Oxygenation: A Narrative Review. ACS Biomater Sci Eng 2021; 7:4402-4419. [PMID: 34436868 DOI: 10.1021/acsbiomaterials.1c00758] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) is used in critical care to manage patients with severe respiratory and cardiac failure. ECMO brings blood from a critically ill patient into contact with a non-endothelialized circuit which can cause clotting and bleeding simultaneously in this population. Continuous systemic anticoagulation is needed during ECMO. The membrane oxygenator, which is a critical component of the extracorporeal circuit, is prone to significant thrombus formation due to its large surface area and areas of low, turbulent, and stagnant flow. Various surface coatings, including but not limited to heparin, albumin, poly(ethylene glycol), phosphorylcholine, and poly(2-methoxyethyl acrylate), have been developed to reduce thrombus formation during ECMO. The present work provides an up-to-date overview of anti-thrombogenic surface coatings for ECMO, including both commercial coatings and those under development. The focus is placed on the coatings being developed for oxygenators. Overall, zwitterionic polymer coatings, nitric oxide (NO)-releasing coatings, and lubricant-infused coatings have attracted more attention than other coatings and showed some improvement in in vitro and in vivo anti-thrombogenic effects. However, most studies lacked standard hemocompatibility assessment and comparison studies with current clinically used coatings, either heparin coatings or nonheparin coatings. Moreover, this review identifies that further investigation on the thrombo-resistance, stability and durability of coatings under rated flow conditions and the effects of coatings on the function of oxygenators (pressure drop and gas transfer) are needed. Therefore, extensive further development is required before these new coatings can be used in the clinic.
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Affiliation(s)
- Meili Zhang
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland 4032, Australia.,School of Mechanical and Mining Engineering, The University of Queensland, Brisbane, Queensland 4072,Australia
| | - Jo P Pauls
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland 4032, Australia.,School of Engineering and Built Environment, Griffith University, Southport, Queensland 4222, Australia
| | - Nicole Bartnikowski
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland 4032, Australia.,School of Mechanical, Medical and Process Engineering, Queensland University of Technology, Brisbane, Queensland 4000, Australia
| | - Andrew B Haymet
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland 4032, Australia
| | - Chris H H Chan
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland 4032, Australia.,School of Engineering and Built Environment, Griffith University, Southport, Queensland 4222, Australia
| | - Jacky Y Suen
- Scientific and Translational Research Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland 4032, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Queensland 4072, Australia
| | - Bailey Schneider
- Scientific and Translational Research Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland 4032, Australia
| | - Katrina K Ki
- Scientific and Translational Research Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland 4032, Australia
| | - Andrew K Whittaker
- Australian Institute for Bioengineering and Nanotechnology and ARC Center of Excellence in Convergent Bio-Nano Science and Technology, The University of Queensland, Brisbane, Queensland 4072, Australia
| | - Matthew S Dargusch
- School of Mechanical and Mining Engineering, The University of Queensland, Brisbane, Queensland 4072,Australia
| | - John F Fraser
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland 4032, Australia.,Scientific and Translational Research Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland 4032, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Queensland 4072, Australia.,School of Medicine, Griffith University, Southport, Queensland 4222, Australia
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42
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Sun D, Gao W, Wu P, Liu J, Li S, Li S, Yu M, Ning M, Bai R, Li T, Liu Y, Chen C. A One-pot-synthesized Double-layered Anticoagulant Hydrogel Tube. Chem Res Chin Univ 2021; 37:1085-1091. [PMID: 34511841 PMCID: PMC8418287 DOI: 10.1007/s40242-021-1267-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 08/16/2021] [Indexed: 11/30/2022]
Abstract
Extracorporeal membrane oxygenation(ECMO) has emerged as a viable treatment in severe cases of acute respiratory distress syndrome, acute respiratory failure, and adult respiratory distress syndrome. However, thromboembolic events stemming from the use of ECMO devices results in significant morbidity and mortality rates; the inner surface of the ECMO tubing comes into contact with the blood and can readily initiate coagulation. In addition, the tubing needs to be continually replaced due to thromboses on the inner tube wall, which not only increases the risk of infection but also the economic burden. Despite considerable effort, a surface modification strategy that effectively addresses these challenges has not yet been realized. In this study, we developed an integrated hollow core-shell-shell hydrogel tube of gelatin/alginate/acrylamide-bacterial nanocellulose(GAA) that meets the anticoagulant requirements for the inner tubing layer as well as the highly elastic soft material needed for the outer layer. Using static blood from healthy volunteers, we confirmed that the platelets or coagulation is not stimulated by the GAA tubing. Importantly, experiments with dynamic blood also demonstrated that the inner layer of the tubing does not elicit blood clotting. The one-pot-synthesized process may provide guidance for the design of anticoagulation tubes used clinically. Electronic Supplementary Material Supplementary material is available in the online version of this article at 10.1007/s40242-021-1267-3.
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Affiliation(s)
- Di Sun
- GBA Research Innovation Institute for Nanotechnology, Guangzhou, 510700 P. R. China.,CAS Key Laboratory for Biomedical Effects of Nanomaterials and Nanosafety & CAS Center for Excellence in Nanoscience, National Center for Nanoscience and Technology of China, Beijing, 100190 P. R. China
| | - Wenqing Gao
- Department of Cardiac Center, the Third Central Hospital, Tianjin, 300170 P. R. China.,Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, 300170 P. R. China
| | - Peng Wu
- Department of Cardiac Center, the Third Central Hospital, Tianjin, 300170 P. R. China.,Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, 300170 P. R. China
| | - Jie Liu
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, 100853 P. R. China
| | - Shengmei Li
- CAS Key Laboratory for Biomedical Effects of Nanomaterials and Nanosafety & CAS Center for Excellence in Nanoscience, National Center for Nanoscience and Technology of China, Beijing, 100190 P. R. China
| | - Shilin Li
- CAS Key Laboratory for Biomedical Effects of Nanomaterials and Nanosafety & CAS Center for Excellence in Nanoscience, National Center for Nanoscience and Technology of China, Beijing, 100190 P. R. China
| | - Meili Yu
- Department of Cardiac Center, the Third Central Hospital, Tianjin, 300170 P. R. China.,Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, 300170 P. R. China
| | - Meng Ning
- Department of Cardiac Center, the Third Central Hospital, Tianjin, 300170 P. R. China.,Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, 300170 P. R. China
| | - Ru Bai
- CAS Key Laboratory for Biomedical Effects of Nanomaterials and Nanosafety & CAS Center for Excellence in Nanoscience, National Center for Nanoscience and Technology of China, Beijing, 100190 P. R. China
| | - Tong Li
- Department of Cardiac Center, the Third Central Hospital, Tianjin, 300170 P. R. China.,Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, 300170 P. R. China
| | - Ying Liu
- GBA Research Innovation Institute for Nanotechnology, Guangzhou, 510700 P. R. China.,CAS Key Laboratory for Biomedical Effects of Nanomaterials and Nanosafety & CAS Center for Excellence in Nanoscience, National Center for Nanoscience and Technology of China, Beijing, 100190 P. R. China
| | - Chunying Chen
- GBA Research Innovation Institute for Nanotechnology, Guangzhou, 510700 P. R. China.,CAS Key Laboratory for Biomedical Effects of Nanomaterials and Nanosafety & CAS Center for Excellence in Nanoscience, National Center for Nanoscience and Technology of China, Beijing, 100190 P. R. China
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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: 29] [Impact Index Per Article: 9.7] [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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Pepe A, Guevara MG, Abraham GA, Caracciolo PC. Lysine-oligoether-modified electrospun poly(carbonate urethane) matrices for improving hemocompatibility response. Polym J 2021. [DOI: 10.1038/s41428-021-00534-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Tethered Liquid Perfluorocarbon Coating for 72 Hour Heparin-Free Extracorporeal Life Support. ASAIO J 2021; 67:798-808. [PMID: 33534236 DOI: 10.1097/mat.0000000000001292] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Coagulopathic complications during extracorporeal life support (ECLS) result from two parallel processes: 1) foreign surface contact and shear stress during blood circulation and 2) administration of anticoagulant drugs to prevent circuit thrombosis. To address these problems, biocompatible surfaces are developed to prevent foreign surface-induced coagulopathy, reducing or eliminating the need for anticoagulants. Tethered liquid perfluorocarbon (TLP) is a nonadhesive coating that prevents adsorption of plasma proteins and thrombus deposition. We examined application of TLP to complete ECLS circuits (membranes, tubing, pumps, and catheters) during 72 hours of ECLS in healthy swine (n = 5/group). We compared TLP-coated circuits used without systemic anticoagulation to standard of care: heparin-coated circuits with continuous heparin infusion. Coagulopathic complications, device performance, and systemic effects were assessed. We hypothesized that TLP reduces circuit thrombosis and iatrogenic bleeding, without impeding gas exchange performance or causing untoward effects. No difference in bleeding or thrombotic complication rate was observed; however, circuit occlusion occurred in both groups (TLP = 2/5; CTRL = 1/5). TLP required elevated sweep gas rate to maintain normocapnia during ECLS versus CTRL (10-20 vs. 5 L/min; p = 0.047), suggesting impaired gas exchange. Thrombus deposition and protein adhesion on explanted membranes were comparable, and TLP did not preserve platelet or blood cell counts relative to controls. We conclude that neither TLP nor standard of care is an efficacious solution to prevent coagulation disturbances during ECLS. Further testing of promising biomaterials for ECLS utilizing the model outlined here is warranted.
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Hosseinnejad A, Fischer T, Jain P, Bleilevens C, Jakob F, Schwaneberg U, Rossaint R, Singh S. Enzyme mimetic microgel coating for endogenous nitric oxide mediated inhibition of platelet activation. J Colloid Interface Sci 2021; 601:604-616. [PMID: 34116469 DOI: 10.1016/j.jcis.2021.05.143] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 05/20/2021] [Accepted: 05/23/2021] [Indexed: 01/28/2023]
Abstract
Nitric oxide (NO) continuously generated by healthy endothelium prevents platelet activation and maintains vascular homeostasis. However, when artificial surfaces, like of extracorporeal membrane oxygenator comes in contact with blood, protein adsorption and thereby platelet activation takes place, which eventually leads to thrombus formation. To overcome this, we present an antifouling microgel coating mimicking the function of enzyme glutathione peroxidase to endogenously generate NO in the blood plasma from endogenous NO-donors and maintain a physiological NO flux. Microgels are synthesized by copolymerization of highly hydrophilic N-(2-hydroxypropyl)methacrylamide (HPMA) and glycidyl methacrylate (GMA) with diselenide crosslinks. For immobilization of the microgels on hydrophobic poly(4-methylpentene) (TPX) membranes bioengineered amphiphilic anchor peptides with free thiols are used. The anchor peptide attaches to the TPX membranes by hydrophobic interactions while the free thiols are presented for crosslinking with the microgels. The hydrophilic nature of the microgel coating prevents protein adsorption while the reversible diselenide bridges make the microgels responsive to the reducing environment and lead to the formation of reactive selenols/selenolates. The generated selenols/selenolates provide an efficient and sustained NO-release from endogenous S-nitrosothiols (RSNOs) mimicking the enzymatic function of glutathione peroxidase. On exposure to the whole blood, the microgel coating inhibited platelet activation and prolonged the blood clotting time.
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Affiliation(s)
- Aisa Hosseinnejad
- DWI-Leibniz-Institute for Interactive Materials e.V., Forckenbeckstr. 50, 52056 Aachen, Germany.
| | - Thorsten Fischer
- DWI-Leibniz-Institute for Interactive Materials e.V., Forckenbeckstr. 50, 52056 Aachen, Germany.
| | - Puja Jain
- DWI-Leibniz-Institute for Interactive Materials e.V., Forckenbeckstr. 50, 52056 Aachen, Germany.
| | - Christian Bleilevens
- Department of Anaesthesiology of the University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany.
| | - Felix Jakob
- DWI-Leibniz-Institute for Interactive Materials e.V., Forckenbeckstr. 50, 52056 Aachen, Germany; Institute for Biotechnology, RWTH Aachen University, Worringerweg 3, 52074 Aachen, Germany.
| | - Ulrich Schwaneberg
- DWI-Leibniz-Institute for Interactive Materials e.V., Forckenbeckstr. 50, 52056 Aachen, Germany; Institute for Biotechnology, RWTH Aachen University, Worringerweg 3, 52074 Aachen, Germany.
| | - Rolf Rossaint
- Department of Anaesthesiology of the University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany.
| | - Smriti Singh
- DWI-Leibniz-Institute for Interactive Materials e.V., Forckenbeckstr. 50, 52056 Aachen, Germany; Max-Planck-Institut für medizinische Forschung, Jahnstraße 29, 69120 Heidelberg, Germany.
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He T, He J, Wang Z, Cui Z. Modification strategies to improve the membrane hemocompatibility in extracorporeal membrane oxygenator (ECMO). ADVANCED COMPOSITES AND HYBRID MATERIALS 2021; 4:847-864. [PMID: 33969267 PMCID: PMC8091652 DOI: 10.1007/s42114-021-00244-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 02/26/2021] [Accepted: 03/16/2021] [Indexed: 05/26/2023]
Abstract
ABSTRACT Since extracorporeal membrane oxygenator (ECMO) has been utilized to save countless lives by providing continuous extracorporeal breathing and circulation to patients with severe cardiopulmonary failure. In particular, it has played an important role during the COVID-19 epidemic. One of the important composites of ECMO is membrane oxygenator, and the core composite of the membrane oxygenator is hollow fiber membrane, which is not only a place for blood oxygenation, but also is a barrier between the blood and gas side. However, the formation of blood clots in the oxygenator is a key problem in the using process. According to the study of the mechanism of thrombosis generation, it was found that improving the hemocompatibility is an efficient approach to reduce thrombus formation by modifying the surface of materials. In this review, the corresponding modification methods (surface property regulation, anticoagulant grafting, and bio-interface design) of hollow fiber membranes in ECMO are classified and discussed, and then, the research status and development prospects are summarized.
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Affiliation(s)
- Ting He
- State Key Laboratory of Materials-Oriented Chemical Engineering, College of Chemistry and Chemical Engineering, Nanjing Tech University, 210009 Nanjing, China
| | - Jinhui He
- National Engineering Research Center for Special Separation Membrane, Nanjing Tech University, 210009 Nanjing, China
| | - Zhaohui Wang
- Jiangsu National Synergetic Innovation Center for Advanced Materials (SICAM), Nanjing Tech University, 210009 Nanjing, China
| | - Zhaoliang Cui
- State Key Laboratory of Materials-Oriented Chemical Engineering, College of Chemistry and Chemical Engineering, Nanjing Tech University, 210009 Nanjing, China
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Salas De Armas IA, Akkanti B, Doshi PB, Patel M, Kumar S, Akay MH, Hussain R, Dinh K, Baloch MY, Ahmed MS, Banjac I, Jumean MF, McGinness K, Janowiak LM, Mittal Agrawal K, Nathan S, Zaki J, Nieto L, Klein K, Taub E, Tint H, Patel JA, Nascimbene A, Kar B, Gregoric ID. Traumatic respiratory failure and veno-venous extracorporeal membrane oxygenation support. Perfusion 2021; 37:477-483. [PMID: 33926332 DOI: 10.1177/02676591211012840] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Respiratory failure (RF) is a common cause of death and morbid complication in trauma patients. Extracorporeal membrane oxygenation (ECMO) is increasingly used in adults with RF refractory to invasive mechanical ventilation. However, use of ECMO remains limited for this patient population as they often have contraindications for anticoagulation. STUDY DESIGN Medical records were retroactively searched for all adult patients who were admitted to the trauma service and received veno-venous ECMO (VV ECMO) support between June 2015 and August 2018. Survival to discharge and ECMO-related complications were collected and analyzed. RESULTS Fifteen patients from a large Level I trauma center met the criteria. The median PaO2/FiO2 ratio was 53.0 (IQR, 27.0-76.0), median injury severity score was 34.0 (IQR, 27.0-43.0), and the median duration of ECMO support was 11 days (IQR, 7.5-20.0). For this cohort, the survival-to-discharge rate was 87% (13/15). The incidence of neurologic complications was 13%, and deep vein thrombosis was reported in two cases (13%). CONCLUSIONS Survival rates of trauma patients in this study are equivalent to, or may exceed, those of non-trauma patients who receive ECMO support for other types of RF. With the employment of a multidisciplinary team assessment and proper patient selection, early cannulation, traumatic RF may be safely supported with VV ECMO in experienced centers.
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Affiliation(s)
- Ismael A Salas De Armas
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Bindu Akkanti
- Division of Pulmonary, Critical Care and Sleep Medicine, UTHealth, Houston, TX, USA
| | - Pratik B Doshi
- Division of Pulmonary, Critical Care and Sleep Medicine, UTHealth, Houston, TX, USA.,Department of Emergency Medicine, UTHealth, Houston, TX, USA
| | - Manish Patel
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Sachin Kumar
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - M Hakan Akay
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Rahat Hussain
- Division of Pulmonary, Critical Care and Sleep Medicine, UTHealth, Houston, TX, USA
| | - Kha Dinh
- Division of Pulmonary, Critical Care and Sleep Medicine, UTHealth, Houston, TX, USA
| | | | - Mahmoud Samy Ahmed
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Igor Banjac
- Department of Emergency Medicine, UTHealth, Houston, TX, USA
| | - Marwan F Jumean
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Kelly McGinness
- Cardiovascular Perfusion Program, UTHealth, Houston, TX, USA
| | - Lisa M Janowiak
- Department of Emergency Medicine, UTHealth, Houston, TX, USA
| | | | - Sriram Nathan
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - John Zaki
- Department of Anesthesia, UTHealth, Houston, TX, USA
| | - Luis Nieto
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Kimberly Klein
- Department of Pathology and Laboratory Medicine, UTHealth, Houston, TX, USA
| | - Ethan Taub
- Division of Acute Care Surgery, Trauma & Critical Care, UTHealth, Houston, TX, USA
| | - Hlaing Tint
- Department of Pathology and Laboratory Medicine, UTHealth, Houston, TX, USA
| | - Jayeshkumar A Patel
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Angelo Nascimbene
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Biswajit Kar
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Igor D Gregoric
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
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50
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Geli J, Capoccia M, Maybauer DM, Maybauer MO. Argatroban Anticoagulation for Adult Extracorporeal Membrane Oxygenation: A Systematic Review. J Intensive Care Med 2021; 37:459-471. [PMID: 33653194 DOI: 10.1177/0885066621993739] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Heparin is the widely used anti-coagulation strategy for patients on extracorporeal membrane oxygenation (ECMO). Nevertheless, heparin-induced thrombocytopenia (HIT) and acquired anti-thrombin (AT) deficiency preclude the use of heparin requiring utilization of an alternative anticoagulant agent. Direct thrombin inhibitors are being proposed as potential alternatives with argatroban as one of the main agents. We aimed to review the evidence with regard to safety and efficacy of argatroban as a potential definitive alternative to heparin in the adult patient population undergoing ECMO support. METHODS A web-based systematic literature search was performed in Medline (PubMed) and Embase from inception until June 18, 2020. RESULTS The search identified 13 publications relevant to the target (4 cohort studies and 9 case series). Case reports and case series with less than 3 cases were not included in the qualitative synthesis. The aggregate number of argatroban treated patients on ECMO was n = 307. In the majority of studies argatroban was used as a continuous infusion without loading dose. Starting doses on ECMO varied between 0.05 and 2 μg/kg/min and were titrated to achieve the chosen therapeutic target range. The activated partial thormboplastin time (aPTT) was the anticoagulation parameter used for monitoring purposes in most studies, whereas some utilized the activated clotting time (ACT). Optimal therapeutic targets varied between 43-70 and 60-100 seconds for aPTT and between 150-210 and 180-230 seconds for ACT. Bleeding and thromboembolic complication rates were comparable to patients treated with unfractionated heparin (UFH). CONCLUSIONS Argatroban infusion rates and anticoagulation target ranges showed substantial variations. The rational for divergent dosing and monitoring approaches are discussed in this paper. Argatroban appears to be a potential alternative to UFH in patients requiring ECMO. To definitively establish its safety, efficacy and ideal dosing strategy, larger prospective studies on well-defined patient populations are warranted.
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Affiliation(s)
- Janos Geli
- Department of Cardiothoracic Anaesthesia and Critical Care, 59562Karolinska University Hospital, Stockholm, Sweden
| | - Massimo Capoccia
- Department of Aortic and Cardiac Surgery, 156726Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | - Dirk M Maybauer
- Department of Anaesthesiology and Intensive Care Medicine, Philipps University, Marburg, Germany
| | - Marc O Maybauer
- Department of Anaesthesiology and Intensive Care Medicine, Philipps University, Marburg, Germany.,Department of Anaesthesia, 105551Manchester Royal Infirmary, Manchester University NHS Foundation Trust, The University of Manchester and Manchester Academic Health Science Centre, Manchester, United Kingdom.,Critical Care Research Group, The Prince Charles Hospital and The University of Queensland, Brisbane, Queensland, Australia.,Nazih Zuhdi Transplant Institute, Advanced Critical Care, Integris Baptist Medical Centre, Oklahoma City, and Oklahoma State University, Tulsa, Oklahoma, USA
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