1
|
Rajsic S, Breitkopf R, Treml B, Jadzic D, Innerhofer N, Eckhardt C, Oberleitner C, Nawabi F, Bukumiric Z. Anti-Xa-guided Anticoagulation With Unfractionated Heparin and Thrombosis During Extracorporeal Membrane Oxygenation Support: A Systematic Review and Meta-analysis. J Cardiothorac Vasc Anesth 2024; 38:1662-1672. [PMID: 38839489 DOI: 10.1053/j.jvca.2024.03.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 03/27/2024] [Accepted: 03/29/2024] [Indexed: 06/07/2024]
Abstract
OBJECTIVE The initiation of extracorporeal membrane oxygenation (ECMO) triggers complex coagulation processes necessitating systemic anticoagulation. Therefore, anticoagulation monitoring is crucial to avoid adverse events such as thrombosis and hemorrhage. The main aim of this work was to analyze the association between anti-Xa levels and thrombosis occurrence during ECMO support. DESIGN Systematic literature review and meta-analysis (Scopus and PubMed, up to July 29, 2023). SETTING All retrospective and prospective studies. PARTICIPANTS Patients receiving ECMO support. INTERVENTION Anticoagulation monitoring during ECMO support. MEASUREMENTS AND MAIN RESULTS A total of 16 articles with 1,968 patients were included in the review and 7 studies in the meta-analysis (n = 374). Patients with thrombosis had significantly lower mean anti-Xa values (standardized mean difference -0.36, 95% confidence interval [CI] -0.62 to -0.11, p < 0.01). Furthermore, a positive correlation was observed between unfractionated heparin infusion and anti-Xa levels (pooled estimate of correlation coefficients 0.31, 95% CI 0.19 to 0.43, p < 0.001). The most common adverse events were major bleeding (42%) and any kind of hemorrhage (36%), followed by thromboembolic events (30%) and circuit or oxygenator membrane thrombosis (19%). More than half of the patients did not survive to discharge (52%). CONCLUSIONS This work revealed significantly lower levels of anti-Xa in patients experiencing thromboembolic events and a positive correlation between anti-Xa and unfractionated heparin infusion. Considering the contemplative limitations of conventional monitoring tools, further research on the role of anti-Xa is warranted. New trials should be encouraged to confirm these findings and determine the most suitable monitoring strategy for patients receiving ECMO support.
Collapse
Affiliation(s)
- Sasa Rajsic
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020, Innsbruck, Austria.
| | - Robert Breitkopf
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020, Innsbruck, Austria
| | - Benedikt Treml
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020, Innsbruck, Austria
| | - Dragana Jadzic
- Anesthesia and Intensive Care Department, Pain Therapy Service, Cagliari University, Cagliari, Italy
| | - Nicole Innerhofer
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020, Innsbruck, Austria
| | - Christine Eckhardt
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020, Innsbruck, Austria
| | - Christoph Oberleitner
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020, Innsbruck, Austria
| | - Fariha Nawabi
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020, Innsbruck, Austria
| | - Zoran Bukumiric
- Institute of Medical Statistics and Informatics, Faculty of Medicine, University of Belgrade, 11000, Belgrade, Serbia
| |
Collapse
|
2
|
Lanoiselée J, Mourer J, Jungling M, Molliex S, Thellier L, Tabareau J, Jeanpierre E, Robin E, Susen S, Tavernier B, Vincentelli A, Ollier E, Moussa MD. Heparin Dosing Regimen Optimization in Veno-Arterial Extracorporeal Membrane Oxygenation: A Pharmacokinetic Analysis. Pharmaceutics 2024; 16:770. [PMID: 38931891 PMCID: PMC11207075 DOI: 10.3390/pharmaceutics16060770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 05/24/2024] [Accepted: 05/31/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND Unfractionated heparin is administered in patients undergoing veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Anticoagulation monitoring is recommended, with an anti-activated factor X (anti-Xa) targeting 0.3 to 0.7 IU/mL. Owing to heparin's heterogeneous pharmacokinetic properties, anti-Xa is unpredictable, generating a challenge in anticoagulation practices. The aim of this study was to build a pharmacokinetic model of heparin accounting for potential confounders, and derive an optimized dosing regimen for a given anti-Xa target. METHODS Adult patients undergoing VA-ECMO were included between January 2020 and June 2021. Anticoagulation was managed with an initial 100 IU/kg heparin loading dose followed by a continuous infusion targeting 0.2 to 0.7 IU/mL anti-Xa. The data were split into model development and model validation cohorts. Statistical analysis was performed using a nonlinear mixed effects modeling population approach. Model-based simulations were performed to develop an optimized dosing regimen targeting the desired anti-Xa. RESULTS A total of 74 patients were included, with 1703 anti-Xa observations. A single-compartment model best fitted the data. Interpatient variability for distribution volume was best explained by body weight, C-reactive protein and ECMO indication (post-cardiotomy shock or medical cardiogenic shock), and interpatient variability for elimination clearance was best explained by serum creatinine and C-reactive protein. Simulations using the optimized regimen according to these covariates showed accurate anti-Xa target attainment. CONCLUSION In adult patients on VA-ECMO, heparin's effect increased with serum creatinine and medical indication, whereas it decreased with body weight and systemic inflammation. We propose an optimized dosing regimen accounting for key covariates, capable of accurately predicting a given anti-Xa target.
Collapse
Affiliation(s)
- Julien Lanoiselée
- Department of Anesthesiology and Intensive Care Medicine, Saint-Etienne University Hospital, F-42055 Saint-Etienne, France
- INSERM U1059, Dysfonction Vasculaire et Hémostase, F-42055 Saint-Etienne, France
| | - Jérémy Mourer
- Department of Anesthesiology and Intensive Care Medicine, CHU Lille, F-59000 Lille, France
| | - Marie Jungling
- Department of Cardiac Surgery, CHU Lille, F-59000 Lille, France
| | - Serge Molliex
- Department of Anesthesiology and Intensive Care Medicine, Saint-Etienne University Hospital, F-42055 Saint-Etienne, France
- INSERM U1059, Dysfonction Vasculaire et Hémostase, F-42055 Saint-Etienne, France
| | - Lise Thellier
- Department of Anesthesiology and Intensive Care Medicine, CHU Lille, F-59000 Lille, France
| | - Julien Tabareau
- Department of Anesthesiology and Intensive Care Medicine, CHU Lille, F-59000 Lille, France
| | - Emmanuelle Jeanpierre
- Inserm, CHU Lille, Institut Pasteur de Lille, U1011-EGID, University of Lille, F-59000 Lille, France
| | - Emmanuel Robin
- Department of Anesthesiology and Intensive Care Medicine, CHU Lille, F-59000 Lille, France
| | - Sophie Susen
- Inserm, CHU Lille, Institut Pasteur de Lille, U1011-EGID, University of Lille, F-59000 Lille, France
| | - Benoit Tavernier
- Department of Anesthesiology and Intensive Care Medicine, CHU Lille, F-59000 Lille, France
- ULR 2694-METRICS, Évaluation des Technologies de Santé et des Pratiques Médicales, University of Lille, F-59000 Lille, France
| | - André Vincentelli
- Department of Cardiac Surgery, CHU Lille, F-59000 Lille, France
- Inserm, CHU Lille, Institut Pasteur de Lille, U1011-EGID, University of Lille, F-59000 Lille, France
| | - Edouard Ollier
- INSERM U1059, Dysfonction Vasculaire et Hémostase, F-42055 Saint-Etienne, France
- Unité de Recherche Clinique Innovation et Pharmacologie, Saint-Etienne University Hospital, F-42270 Saint-Etienne, France
| | - Mouhamed Djahoum Moussa
- Department of Anesthesiology and Intensive Care Medicine, CHU Lille, F-59000 Lille, France
- ULR 2694-METRICS, Évaluation des Technologies de Santé et des Pratiques Médicales, University of Lille, F-59000 Lille, France
| |
Collapse
|
3
|
Taha D, Drop JG, Wildschut ED, De Hoog M, van Ommen CH, Reis Miranda DD. Evaluation of an aPTT guided versus a multimodal heparin monitoring approach in patients on extra corporeal membrane oxygenation: A retrospective cohort study. Perfusion 2024:2676591241253474. [PMID: 38739366 DOI: 10.1177/02676591241253474] [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: 05/14/2024]
Abstract
INTRODUCTION Bleeding and thrombotic complications are common in extracorporeal membrane oxygenation (ECMO) patients and are associated with increased mortality and morbidity. The optimal anticoagulation monitoring protocol in these patients is unknown. This study aims to compare the incidence of thrombotic and hemorrhagic complications before and after a protocol change. In addition, the association between hemostatic complications, coagulation tests and risk factors is evaluated. METHODS This is a retrospective single center cohort study of adult ECMO patients. We collected demographics, ECMO parameters and coagulation test results. Outcomes of the aPTT guided and multimodal protocol, including aPTT, anti-Xa assay and rotational thromboelastometry were compared and the association between coagulation tests, risk factors and hemostatic complications was determined using a logistic regression analysis for repeated measurements. RESULTS In total, 250 patients were included, 138 in the aPTT protocol and 112 in the multimodal protocol. The incidence of thrombosis (aPTT: 14%; multimodal: 12%) and bleeding (aPTT: 36%; multimodal: 40%), did not significantly differ between protocols. In the aPTT guided protocol, the aPTT was associated with thrombosis (Odds Ratio [OR] 1.015; 95% confidence interval [CI] 1.004-1.027). In both protocols, surgical interventions were risk factors for bleeding and thrombotic complications (aPTT: OR 93.2, CI 39.9-217.6; multimodal OR 17.5, CI 6.5-46.9). DISCUSSION The incidence of hemostatic complications was similar between both protocols and surgical interventions were a risk factor for hemostatic complications. Results from this study help to elucidate the role of coagulation tests and risk factors in predicting hemostatic complications in patients undergoing ECMO support.
Collapse
Affiliation(s)
- Diman Taha
- Department of Adult Intensive Care, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Joppe G Drop
- Department of Pediatric Hematology, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Enno D Wildschut
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Matthijs De Hoog
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, The Netherlands
| | - C Heleen van Ommen
- Department of Pediatric Hematology, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, The Netherlands
| | | |
Collapse
|
4
|
Moussa MD, Soquet J, Robin E, Labreuche J, Rousse N, Rauch A, Loobuyck V, Leroy G, Duburcq T, Gantois G, Leroy X, Ait-Ouarab S, Lamer A, Thellier L, Lukowiak O, Schurtz G, Muller C, Juthier F, Susen S, Vincentelli A. Definitions of major bleeding for predicting mortality in critically ill adult patients who survived 24 hours while supported with peripheral veno-arterial extracorporeal membrane oxygenation for cardiogenic shock: a comparative historical cohort study. Can J Anaesth 2024; 71:523-534. [PMID: 38438682 DOI: 10.1007/s12630-024-02704-6] [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: 09/25/2022] [Revised: 10/30/2023] [Accepted: 11/01/2023] [Indexed: 03/06/2024] Open
Abstract
PURPOSE The severity of bleeding events is heterogeneously defined during peripheral veno-arterial extracorporeal membrane oxygenation (pVA-ECMO). We studied three bleeding definitions in pVA-ECMO: the Extracorporeal Life Support Organization (ELSO)-serious bleeding, the Bleeding Academic Research Consortium (BARC), and the universal definition of postoperative bleeding (UPDB) classifications. METHODS We included consecutive adult patients supported by pVA-ECMO for refractory cardiogenic shock admitted to Lille academic hospitals between January 2013 and December 2019. We assessed the association of bleeding definitions with the primary endpoint of 28-day all-cause mortality with the use of multivariate models accounting for time-dependent and competing variables. We compared models' performances using the Harrell's C-Index and the Akaike information criteria. RESULTS Twenty-eight-day mortality occurred in 128/308 (42%) 308 patients. The ELSO-serious bleeding (hazard ratio [HR], 1.67; 95% confidence interval [CI], 1.09 to 2.56) and BARC ≥ type 2 (HR, 1.55; 95% CI, 1.01 to 2.37) were associated with 28-day mortality (Harrell's C-index, 0.69; 95% CI, 0.63 to 0.74 for both). Predictors of ELSO-serious bleeding were postcardiotomy, body mass index, baseline platelets count, fibrinogen, and hemoglobin levels. CONCLUSION Extracorporeal Life Support Organization-serious bleeding and BARC ≥ type 2 are relevant definitions of major bleeding regarding their association with mortality in critically ill patients who survived the first 24 hr while supported with pVA-ECMO for cardiogenic shock. STUDY REGISTRATION CERAR (IRB 00010254-2022-050, Paris, France); first submitted on 18 April 2022.
Collapse
Affiliation(s)
- Mouhamed D Moussa
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France.
- Pôle d'Anesthésie-Réanimation, CHU Lille, Lille, France.
- Service d'Anesthésie-Réanimation Cardiovasculaire et thoracique, Institut Cœur - Poumon, CHU Lille, 2 avenue Oscar Lambret, 59 037, Lille, France.
| | - Jérôme Soquet
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France
- Department of Cardiac Surgery, CHU Lille, Lille, France
| | - Emmanuel Robin
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France
- Pôle d'Anesthésie-Réanimation, CHU Lille, Lille, France
| | | | - Natacha Rousse
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France
- Department of Cardiac Surgery, CHU Lille, Lille, France
| | - Antoine Rauch
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France
| | - Valentin Loobuyck
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France
- Department of Cardiac Surgery, CHU Lille, Lille, France
| | | | | | | | - Xavier Leroy
- Pôle d'Anesthésie-Réanimation, CHU Lille, Lille, France
| | | | - Antoine Lamer
- Pôle d'Anesthésie-Réanimation, CHU Lille, Lille, France
| | - Lise Thellier
- Pôle d'Anesthésie-Réanimation, CHU Lille, Lille, France
| | | | - Guillaume Schurtz
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France
- Department of Cardiology, CHU Lille, Lille, France
| | | | - Francis Juthier
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France
- Department of Cardiac Surgery, CHU Lille, Lille, France
| | - Sophie Susen
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France
| | - André Vincentelli
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France
- Department of Cardiac Surgery, CHU Lille, Lille, France
| |
Collapse
|
5
|
Rajsic S, Treml B, Jadzic D, Breitkopf R, Oberleitner C, Bachler M, Bösch J, Bukumiric Z. aPTT-guided anticoagulation monitoring during ECMO support: A systematic review and meta-analysis. J Crit Care 2023; 77:154332. [PMID: 37244207 DOI: 10.1016/j.jcrc.2023.154332] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 05/03/2023] [Accepted: 05/08/2023] [Indexed: 05/29/2023]
Abstract
INTRODUCTION The initiation of the extracorporeal membrane oxygenation (ECMO) is associated with complex coagulatory and inflammatory processes and consequently needed anticoagulation. Systemic anticoagulation bears an additional risk of serious bleeding, and its monitoring is of immense importance. Therefore, our work aims to analyze the association of anticoagulation monitoring with bleeding during ECMO support. MATERIAL AND METHODS Systematic literature review and meta-analysis, complying with the PRISMA guidelines (PROSPERO-CRD42022359465). RESULTS Seventeen studies comprising 3249 patients were included in the final analysis. Patients experiencing hemorrhage had a longer activated partial thromboplastin time (aPTT), a longer ECMO duration, and higher mortality. We could not find strong evidence of any aPTT threshold association with the bleeding occurrence, as less than half of authors reported a potential relationship. Finally, we identified the acute kidney injury (66%, 233/356) and hemorrhage (46%, 469/1046) to be the most frequent adverse events, while almost one-half of patients did not survive to discharge (47%, 1192/2490). CONCLUSION The aPTT-guided anticoagulation is still the standard of care in ECMO patients. We did not find strong evidence supporting the aPTT-guided monitoring during ECMO. Based on the weight of the available evidence, further randomized trials are crucial to clarify the best monitoring strategy.
Collapse
Affiliation(s)
- Sasa Rajsic
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, Innsbruck 6020, Austria.
| | - Benedikt Treml
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, Innsbruck 6020, Austria.
| | - Dragana Jadzic
- Anesthesia and Intensive Care Department, Pain Therapy Service, Cagliari University, Cagliari, Italy
| | - Robert Breitkopf
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, Innsbruck 6020, Austria
| | - Christoph Oberleitner
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, Innsbruck 6020, Austria
| | - Mirjam Bachler
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, Innsbruck 6020, Austria
| | - Johannes Bösch
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, Innsbruck 6020, Austria
| | - Zoran Bukumiric
- Institute of Medical Statistics and Informatics, Faculty of Medicine, University of Belgrade, Belgrade 11000, Serbia
| |
Collapse
|
6
|
Sun J, Ma Y, Su W, Miao H, Guo Z, Chen Q, Zhang Y, Ma X, Chen S, Ding R. Comparison of anticoagulation monitoring strategies for adults supported on extracorporeal membrane oxygenation: A systematic review. Heart Lung 2023; 61:72-83. [PMID: 37167901 DOI: 10.1016/j.hrtlng.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 04/19/2023] [Accepted: 05/06/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND Anticoagulation is critical in patients supported on extracorporeal membrane oxygenation (ECMO). The appropriate monitoring strategies for heparin remain unclear. OBJECTIVES This systematic review aimed to compare the accuracy and safety of various monitoring strategies for patients supported on ECMO. METHODS The PubMed and Web of Science databases were searched for articles in March 2023 without restrictions on publication date. Anticoagulation monitoring strategies for adults supported on ECMO were compared across all included studies. The incidence of bleeding, thrombosis, mortality, blood transfusion, correlation between tests and heparin dose, and the discordance between different tests were discussed in the included studies. The risk of bias was assessed using the Newcastle-Ottawa Scale and Cochrane Collaboration's tool. RESULTS Twenty-six studies, including a total of 1,684 patients, met the inclusion criteria. The monitoring of anticoagulation by activated partial thromboplastin time (aPTT) resulted in less blood product transfusion than that by activated clotting time (ACT). Moreover, the monitoring of anticoagulation by anti-factor Xa (Anti-Xa) resulted in a more stable anticoagulation than that by aPTT. Anti-Xa and aPTT correlated with heparin dose better than ACT, and the discordance between different monitoring tests was common. Finally, combined monitoring showed some advantages in reducing mortality and blood product transfusion. CONCLUSION Anti-Xa and aPTT are more suitable for anticoagulation monitoring for patients supported on ECMO than ACT. Thromboelastography and combination strategies are less applied. Most of the studies were retrospective, and their sample sizes were relatively small; thus, more appropriate monitoring strategies and higher quality research are needed.
Collapse
Affiliation(s)
- Jinhe Sun
- Department of Intensive Care Unit, The First Hospital of China Medical University, Shenyang, China
| | - Yuteng Ma
- Department of Gastrointestinal Surgery, The First Hospital of China Medical University, Shenyang, China
| | - Wanting Su
- Department of Intensive Care Unit, The First Hospital of China Medical University, Shenyang, China
| | - He Miao
- Department of Intensive Care Unit, The First Hospital of China Medical University, Shenyang, China
| | - Zhaotian Guo
- Department of Intensive Care Unit, The First Hospital of China Medical University, Shenyang, China
| | - Qianhui Chen
- Department of Intensive Care Unit, The First Hospital of China Medical University, Shenyang, China
| | - Yuzhong Zhang
- Department of Intensive Care Unit, The First Hospital of China Medical University, Shenyang, China
| | - Xiaochun Ma
- Department of Intensive Care Unit, The First Hospital of China Medical University, Shenyang, China
| | - Song Chen
- Department of Intensive Care Unit, Wanning People's Hospital, Wanning, China.; Key Laboratory of Emergency and Trauma of Ministry of Education, Hainan Medical University, Haikou, China.
| | - Renyu Ding
- Department of Intensive Care Unit, The First Hospital of China Medical University, Shenyang, China.
| |
Collapse
|
7
|
Rajsic S, Breitkopf R, Treml B, Jadzic D, Oberleitner C, Oezpeker UC, Innerhofer N, Bukumiric Z. Association of aPTT-Guided Anticoagulation Monitoring with Thromboembolic Events in Patients Receiving V-A ECMO Support: A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:jcm12093224. [PMID: 37176673 PMCID: PMC10179156 DOI: 10.3390/jcm12093224] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 04/19/2023] [Accepted: 04/27/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND The initiation of extracorporeal membrane oxygenation (ECMO) is associated with complex inflammatory and coagulatory processes, raising the need for systemic anticoagulation. The balance of anticoagulatory and procoagulant factors is essential, as therapeutic anticoagulation confers a further risk of potentially life-threatening bleeding. Therefore, our study aims to systematize and analyze the most recent evidence regarding anticoagulation monitoring and the thromboembolic events in patients receiving veno-arterial ECMO support. METHODS Using the PRISMA guidelines, we systematically searched the Scopus and PubMed databases up to October 2022. A weighted effects model was employed for the meta-analytic portion of the study. RESULTS Six studies comprising 1728 patients were included in the final analysis. Unfractionated heparin was used for anticoagulation, with an activated partial thromboplastin time (aPTT) monitoring goal set between 45 and 80 s. The majority of studies aimed to investigate the incidence of adverse events and potential risk factors for thromboembolic and bleeding events. None of the authors found any association of aPTT levels with the occurrence of thromboembolic events. Finally, the most frequent adverse events were hemorrhage (pooled 43%, 95% CI 28.4; 59.5) and any kind of thrombosis (pooled 36%, 95% CI 21.7; 53.7), and more than one-half of patients did not survive to discharge (pooled 54%). CONCLUSIONS Despite the tremendous development of critical care, aPTT-guided systemic anticoagulation is still the standard monitoring tool. We did not find any association of aPTT levels with thrombosis. Further evidence and new trials should clarify the true incidence of thromboembolic events, along with the best anticoagulation and monitoring strategy in veno-arterial ECMO patients.
Collapse
Affiliation(s)
- Sasa Rajsic
- Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Robert Breitkopf
- Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Benedikt Treml
- Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Dragana Jadzic
- Anesthesia and Intensive Care Department, Pain Therapy Service, Cagliari University, 09042 Cagliari, Italy
| | - Christoph Oberleitner
- Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Ulvi Cenk Oezpeker
- Department of Cardiac Surgery, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Nicole Innerhofer
- Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Zoran Bukumiric
- Institute of Medical Statistics and Informatics, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| |
Collapse
|
8
|
Anticoagulation Monitoring with Activated Partial ThromboPlastin Time and Anti-Xa Activity in Intensive Care Unit Patients: Interest of Thrombin Generation Assay. Int J Mol Sci 2022; 23:ijms231911219. [PMID: 36232517 PMCID: PMC9570449 DOI: 10.3390/ijms231911219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 09/20/2022] [Accepted: 09/22/2022] [Indexed: 11/30/2022] Open
Abstract
Current guidelines recommend monitoring the anticoagulant effect of unfractionated heparin (UFH) by measuring anti-Xa activity rather than activated partial thromboplastin time (aPTT) in intensive care unit (ICU) patients. The primary objective of this study was to evaluate the correlation of aPTT, anti-Xa activity, and thrombin generation in UFH-treated ICU patients. A prospective observational pilot study was conducted in adult surgical ICU patients treated with UFH. aPTT and anti-Xa activity were monitored daily. The therapeutic target was aPTT between 50 s and 84 s, and/or anti-Xa between 0.3 and 0.7 U/mL. Correlation among aPTT, anti-Xa activity, and thrombin generation was determined by measuring endogenous thrombin potential (ETP), with the inflammatory response evaluated. C-reactive protein (CRP) was used as a marker of inflammatory response. The plasma of 107 samples from 30 ICU patients was analyzed. The correlation between aPTT and anti-Xa activity was 0.66, CI95% [0.54;0.76] (p < 0.0001). Although thrombin generation, aPTT, and anti-Xa were correlated with inflammatory responses, the correlation was higher with thrombin generation and anti-Xa activity compared to aPTT. When aPTT was in a therapeutic range, a low thrombin generation was observed but was 50% inhibited when anti-Xa was in a therapeutic range. Coagulation testing with aPTT, anti-Xa correlated with thrombin generation. A 50% decrease in thrombin generation was observed when anti-Xa was within a therapeutic range. Further work is needed to evaluate coagulation biomarker responses and clinical outcomes in specific ICU populations.
Collapse
|
9
|
Bleeding and Thrombotic Issues during Extracorporeal Membrane Oxygenation. J Clin Med 2022; 11:jcm11185375. [PMID: 36143022 PMCID: PMC9503624 DOI: 10.3390/jcm11185375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 09/10/2022] [Indexed: 12/02/2022] Open
|
10
|
Moussa MD, Beyls C, Lamer A, Roksic S, Juthier F, Leroy G, Petitgand V, Rousse N, Decoene C, Dupré C, Caus T, Huette P, Guilbart M, Guinot PG, Besserve P, Mahjoub Y, Dupont H, Robin E, Meynier J, Vincentelli A, Abou-Arab O. Early hyperoxia and 28-day mortality in patients on venoarterial ECMO support for refractory cardiogenic shock: a bicenter retrospective propensity score-weighted analysis. Crit Care 2022; 26:257. [PMID: 36028883 PMCID: PMC9414410 DOI: 10.1186/s13054-022-04133-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 08/22/2022] [Indexed: 11/10/2022] Open
Abstract
Background The mortality rate for a patient with a refractory cardiogenic shock on venoarterial (VA) extracorporeal membrane oxygenation (ECMO) remains high, and hyperoxia might worsen this prognosis. The objective of the present study was to evaluate the association between hyperoxia and 28-day mortality in this setting.
Methods We conducted a retrospective bicenter study in two French academic centers. The study population comprised adult patients admitted for refractory cardiogenic shock. The following arterial partial pressure of oxygen (PaO2) variables were recorded for 48 h following admission: the absolute peak PaO2 (the single highest value measured during the 48 h), the mean daily peak PaO2 (the mean of each day’s peak values), the overall mean PaO2 (the mean of all values over 48 h), and the severity of hyperoxia (mild: PaO2 < 200 mmHg, moderate: PaO2 = 200–299 mmHg, severe: PaO2 ≥ 300 mmHg). The main outcome was the 28-day all-cause mortality. Inverse probability weighting (IPW) derived from propensity scores was used to reduce imbalances in baseline characteristics. Results From January 2013 to January 2020, 430 patients were included and assessed. The 28-day mortality rate was 43%. The mean daily peak, absolute peak, and overall mean PaO2 values were significantly higher in non-survivors than in survivors. In a multivariate logistic regression analysis, the mean daily peak PaO2, absolute peak PaO2, and overall mean PaO2 were independent predictors of 28-day mortality (adjusted odds ratio [95% confidence interval per 10 mmHg increment: 2.65 [1.79–6.07], 2.36 [1.67–4.82], and 2.85 [1.12–7.37], respectively). After IPW, high level of oxygen remained significantly associated with 28-day mortality (OR = 1.41 [1.01–2.08]; P = 0.041). Conclusions High oxygen levels were associated with 28-day mortality in patients on VA-ECMO support for refractory cardiogenic shock. Our results confirm the need for large randomized controlled trials on this topic. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-04133-7.
Collapse
Affiliation(s)
| | - Christophe Beyls
- Anesthesia and Critical Care Medicine Department, Amiens University Medical Center, 1 rue du Professeur Christian Cabrol, 80054, Amiens, France
| | - Antoine Lamer
- CHU Lille, ULR 2694-METRICS : Évaluation des Technologies de Santé Et des Pratiques Médicales, 59000, Lille, France
| | - Stefan Roksic
- Anesthesia and Critical Care Medicine Department, Amiens University Medical Center, 1 rue du Professeur Christian Cabrol, 80054, Amiens, France
| | - Francis Juthier
- Cardiac Surgery, Lille Hospital University, 59000, Lille, France
| | - Guillaume Leroy
- Pôle d'Anesthésie-Réanimation, Lille Hospital University, 59000, Lille, France
| | - Vincent Petitgand
- Pôle d'Anesthésie-Réanimation, Lille Hospital University, 59000, Lille, France
| | - Natacha Rousse
- Cardiac Surgery, Lille Hospital University, 59000, Lille, France
| | - Christophe Decoene
- Pôle d'Anesthésie-Réanimation, Lille Hospital University, 59000, Lille, France
| | - Céline Dupré
- Pôle d'Anesthésie-Réanimation, Lille Hospital University, 59000, Lille, France
| | - Thierry Caus
- Cardiac Surgery, Amiens University Medical Center, 80054, Amiens, France
| | - Pierre Huette
- Anesthesia and Critical Care Medicine Department, Amiens University Medical Center, 1 rue du Professeur Christian Cabrol, 80054, Amiens, France
| | - Mathieu Guilbart
- Anesthesia and Critical Care Medicine Department, Amiens University Medical Center, 1 rue du Professeur Christian Cabrol, 80054, Amiens, France
| | - Pierre-Grégoire Guinot
- Department of Anesthesiology and Critical Care Medicine, Dijon University Hospital, 21000, Dijon, France
| | - Patricia Besserve
- Anesthesia and Critical Care Medicine Department, Amiens University Medical Center, 1 rue du Professeur Christian Cabrol, 80054, Amiens, France
| | - Yazine Mahjoub
- Anesthesia and Critical Care Medicine Department, Amiens University Medical Center, 1 rue du Professeur Christian Cabrol, 80054, Amiens, France
| | - Hervé Dupont
- Anesthesia and Critical Care Medicine Department, Amiens University Medical Center, 1 rue du Professeur Christian Cabrol, 80054, Amiens, France
| | - Emmanuel Robin
- Pôle d'Anesthésie-Réanimation, Lille Hospital University, 59000, Lille, France
| | - Jonathan Meynier
- Department of Biostatistics, Amiens Picardy University Hospital, 80054, Amiens, France
| | | | - Osama Abou-Arab
- Anesthesia and Critical Care Medicine Department, Amiens University Medical Center, 1 rue du Professeur Christian Cabrol, 80054, Amiens, France.
| |
Collapse
|