Thromboelastography-based anticoagulation management during extracorporeal membrane oxygenation: a safety and feasibility pilot study

Abstract

BackgroundThere is no consensus on the management of anticoagulation during extracorporeal membrane oxygenation (ECMO). ECMO is currently burdened by a high rate of hemostatic complications, possibly associated with inadequate monitoring of heparin anticoagulation. This study aims to assess the safety and feasibility of an anticoagulation protocol for patients undergoing ECMO based on thromboelastography (TEG) as opposed to an activated partial thromboplastin time (aPTT)-based protocol.MethodsWe performed a multicenter, randomized, controlled trial in two academic tertiary care centers. Adult patients with acute respiratory failure treated with veno-venous ECMO were randomized to manage heparin anticoagulation using a TEG-based protocol (target 16–24 min of the R parameter, TEG group) or a standard of care aPTT-based protocol (target 1.5–2 of aPTT ratio, aPTT group). Primary outcomes were safety and feasibility of the study protocol.ResultsForty-two patients were enrolled: 21 were randomized to the TEG group and 21 to the aPTT group. Duration of ECMO was similar in the two groups (9 (7–16) days in the TEG group and 11 (4–17) days in the aPTT group, p = 0.74). Heparin dosing was lower in the TEG group compared to the aPTT group (11.7 (9.5–15.3) IU/kg/h vs. 15.7 (10.9–21.3) IU/kg/h, respectively, p = 0.03). Safety parameters, assessed as number of hemorrhagic or thrombotic events and transfusions given, were not different between the two study groups. As for the feasibility, the TEG-based protocol triggered heparin infusion rate adjustments more frequently (p < 0.01) and results were less frequently in the target range compared to the aPTT-based protocol (p < 0.001). Number of prescribed TEG or aPTT controls (according to study groups) and protocol violations were not different between the study groups.ConclusionsTEG seems to be safely used to guide anticoagulation management during ECMO. Its use was associated with the administration of lower heparin doses compared to a standard of care aPTT-based protocol.Trial registration ClinicalTrials.gov, October 22,2014. Identifier: NCT02271126.Electronic supplementary materialThe online version of this article (10.1186/s13613-017-0352-8) contains supplementary material, which is available to authorized users.

Clinical controversies in anticoagulation monitoring and antithrombin supplementation for ECMO

“…To date, there are no large multicenter trials comparing viscoelastic tests with conventional coagulation measures and their ability to guide anticoagulation therapy. One small pilot RCT was performed indicating that it is feasible to conduct such a trial [46].…”

“…In addition, heparin dosing was lower in the TEG group compared to the aPTT group (12 IU/kg/ h vs. 16 IU/kg/h, respectively, p = 0.03) with no increase in thrombotic complications. While a larger trial is needed, the results are encouraging that a TEG-driven protocol is both safe and feasible in adult patients requiring V-V ECMO [46]. In a recent pediatric study, a retrospective chart review of patients requiring venovenous (VV) and venoarterial (VA) ECMO was performed within a singlecenter, tertiary care children's hospital.…”

Extracorporeal Membrane Oxygenation in Predominantly Leuco- and Thrombocytopenic Haematologic/Oncologic Patients with Acute Respiratory Distress Syndrome - a Single-Centre Experience

“…However, the bleeding rate is slightly higher than in a general ECMO cohort, reporting on a bleeding rate of approximately 11% [25]. All 4 patients with severe bleeding complications suffered from severe thrombocytopenia (< 10 G/l); 2 of them were treated with a continuous intravenous infusion of unfractionated heparin to maintain an aPTT of 50-70 s. The way of anti-coagulation in ECMO therapy is still a controversial field [26,27]. The way between providing enough anti-coagulation to prevent thrombotic events and avoiding bleeding events is a walk on the tightrope.…”

Extracorporeal Membrane Oxygenation Support for Post- Cardiotomy Cardiogenic Shock

“…Blood transfusion is to be expected due to blood loss and coagulopathy. Some centers use thromboelastography to guide what blood products (platelets, fresh frozen plasma, or cryoprecipitate) are necessary during ECMO management [11].…”