A narrative review of the technical standards for extracorporeal life support devices (pumps and oxygenators) in Europe

Nardo, Matteo Di; Vercaemst, Leen; Swol, Justyna; Barret, Nicholas; Taccone, Fabio Silvio; Malfertheiner, Maximilian; Broman, Lars Mikael; Pappalardo, Federico; Bělohlávek, Jan; Mueller, Thomas; Lorusso, Roberto; Lonero, Margherita; Belliato, Mirko

doi:10.1177/0267659118772452

Cited by 12 publications

(13 citation statements)

References 3 publications

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“…We sought to determine how different flow rates in an ECMO circuit would affect haemolysis and coagulation parameters. Recommended flow rates for ECMO support are well-recognized [5]. On the other hand, lower flow rates and how they alter coagulation have not been thoroughly explored.…”

Section: Discussionmentioning

confidence: 99%

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Low flow rate alters haemostatic parameters in an ex-vivo extracorporeal membrane oxygenation circuit

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Chan

et al. 2019

ICMx

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Background Extracorporeal membrane oxygenation (ECMO) is a life-saving modality used to manage cardiopulmonary failure refractory to conventional medical and surgical therapies. Despite advances in ECMO equipment, bleeding and thrombosis remain significant complications. While the flow rate for ECMO support is well recognized, less is known about the minimum-rate requirements and haemostasis. We investigated the relationship between different ECMO flow rates, and their effect on haemolysis and coagulation. Methods Ten ex-vivo ECMO circuits were tested using donated, < 24-h-old human whole blood, with two flow rates: high-flow at 4 L/min (normal adult cardiac output; n = 5) and low-flow at 1.5 L/min (weaning; n = 5). Serial blood samples were taken for analysis of haemolysis, von Willebrand factor (vWF) multimers by immunoblotting, rotational thromboelastometry, platelet aggregometry, flow cytometry and routine coagulation laboratory tests. Results Low-flow rates increased haemolysis after 2 h ( p = 0.02), 4 h ( p = 0.02) and 6 h ( p = 0.02) and the loss of high-molecular-weight vWF multimers ( p = 0.01), while reducing ristocetin-induced platelet aggregation ( p = 0.0002). Additionally, clot formation times were prolonged ( p = 0.006), with a corresponding decrease in maximum clot firmness ( p = 0.006). Conclusions In an ex-vivo model of ECMO, low-flow rate (1.5 L/min) altered haemostatic parameters compared to high-flow (4 L/min). Observed differences in haemolysis, ristocetin-induced platelet aggregation, high-molecular-weight vWF multimers and clot formation time suggest an increased risk of bleeding complications. Since patients are often on ECMO for protracted periods, extended-duration studies are required to characterise long-term ECMO-induced haemostatic changes.

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Section: Discussionmentioning

confidence: 99%

“…Recommended flow rates for ECMO support have been well-documented [5]; however, less is known about how minimum blood flow rates affect haemolysis and coagulation. This is especially relevant during ECMO weaning.…”

Section: Introductionmentioning

confidence: 99%

Low flow rate alters haemostatic parameters in an ex-vivo extracorporeal membrane oxygenation circuit

Passmore

Chan

et al. 2019

ICMx

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“…[39][40][41][42] As soon as ECMO blood flow commences, plasmatic proteins (in particular, coagulation factors), fibrinogen, and von Willebrand factor (vWF) are consumed by the cleavage by the ADAMTS-13 protein. 37,43 Fibrinogen may contribute to thrombus formation, while loss of high-molecular vWF may contribute to a bleeding tendency. 44 Platelets can be activated by multiple mechanisms: contact with biomaterial interface causes exposure of surface integrins and adhesion to the circuit; high shear stress, due to blood flow through the pump and oxygenator, induces activation of surface proteins, spreading the process, and exposing the phospholipids.…”

Section: Pathophysiology Of Coagulation Activation During Ecmomentioning

confidence: 99%

A narrative review of antithrombin use during veno-venous extracorporeal membrane oxygenation in adults: rationale, current use, effects on anticoagulation, and outcomes

et al. 2020

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Background: During extracorporeal membrane oxygenation, the large contact surface between the blood and the extracorporeal circuit causes a continuous activation of coagulation and inflammation. Unfractionated heparin, a glycosaminoglycan that must bind to antithrombin as a cofactor, is currently the standard anticoagulant adopted during extracorporeal membrane oxygenation. Antithrombin, beyond being a potent natural anticoagulant, acts in the cross-talk between coagulation and inflammatory system through anticoagulation and coagulation-independent effects. Objectives: In this review, we describe, in the adult setting of veno-venous extracorporeal membrane oxygenation, the pathophysiological rationale for antithrombin use, the current practice of administration, and the effects of antithrombin on anticoagulation, bleeding, and outcomes. Data sources: Studies on adults (18 years or older) on veno-venous extracorporeal membrane oxygenation published from 1995 to 2018 in order to evaluate the use of antithrombin. Results: In adults on veno-venous extracorporeal membrane oxygenation, antithrombin supplementation has a highly pathophysiological rationale since coagulation factor consumption, systemic inflammatory response syndrome, and endothelial activation are triggered by extracorporeal membrane oxygenation. Eleven articles are focused on the topic but among the authors there is no consensus on the threshold for supplementation (ranging from 70% to 80%) as well as on the dose (rarely standardized) and time of administration (bolus vs continuous infusion). Consistently, antithrombin is considered able to achieve better anticoagulation targets in or not in the presence of heparin resistance. The impact of antithrombin administration on bleeding still shows contrasting results. Conclusion: Antithrombin use in veno-venous extracorporeal membrane oxygenation should be investigated on the threshold for supplementation, dose, and time of administration.

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“…Bleeding is one of the most significant complications of extracorporeal membrane oxygenation (ECMO), and even today, with more biocompatible and easierto-use devices, hemorrhage is still one of the main causes of mortality during ECMO, above all for intracranial hemorrhage. [1][2][3][4][5] Causes of bleeding in ECMO are multifactorial and include heparin administration, coagulopathy, thrombocytopenia, platelet dysfunction, acquired von Willebrand syndrome, and hyperfibrinolysis. 6,7 The main sites of bleeding during ECMO according to the extracorporeal life support organization (ELSO) registry are cannulation site, chest, nose, central nervous system, and gastrointestinal (GI) system.…”

Section: Introductionmentioning

confidence: 99%

The role of endoscopy as non-invasive procedure to manage gastrointestinal complications during extracorporeal membrane oxygenation

et al. 2020

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Introduction: Gastrointestinal bleeding is a life-threatening complication in patients undergoing extracorporeal membrane oxygenation support. Despite data on increased mortality due to gastrointestinal bleeding, there is little data on the treatment of such conditions under extracorporeal membrane oxygenation, and on the possibilities of advanced endoscopic therapy to non-invasively solve these bleeding complications. No clear treatment in the case of extracorporeal membrane oxygenation support is recommended in the guidelines. Methods: Retrospective observational cohort study including 134 veno-venous extracorporeal membrane oxygenation patients for acute respiratory failure from 2009 to 2018 at IRCCS-ISMETT (Italy). Patients were divided into two groups according to gastrointestinal bleeding episodes and reviewed for type of endoscopic therapy. Gastrointestinal bleeding group was characterized for pre–extracorporeal membrane oxygenation characteristics, management variables—including amount of transfusions and clinical outcomes. Results: Fourteen (14) patients (10.4%) experienced upper (n = 13) or lower (n = 1) gastrointestinal bleeding. Gastrointestinal bleeding and no-gastrointestinal bleeding group had similar characteristics apart from higher creatinine in the gastrointestinal bleeding group (1.9 mg/dL (1.3-4.9) vs 1.2 mg/dL (0.7-1.8), p = 0.03). In 3 of the 14 patients (21%), endoscopy showed no signs of active bleeding (nasogastric or feeding tube decubitus), and no specific intervention was performed. Active bleeding was recognized in 11 of the 14 patients (79 %). No patients died of fatal bleeding in the gastrointestinal bleeding group. Endoscopic therapy was feasible, with a complete bleeding control in all the cases: five Hemospray®, two fibrin glue, two metallic clips, one combined approach metallic clips with epinephrine, and one cyanoacrylate. The extracorporeal membrane oxygenation course was significantly longer in the gastrointestinal bleeding group: 19.5 (15-36) days vs 13.5 (8-25) days, p = 0.01. No significant differences in mortality were found between the two groups (all p values > 0.05). Conclusion: Advanced endoscopic therapy during veno-venous extracorporeal membrane oxygenation may contribute to reducing the negative effects on mortality for gastrointestinal bleeding episodes.

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A narrative review of the technical standards for extracorporeal life support devices (pumps and oxygenators) in Europe

Cited by 12 publications

References 3 publications

Low flow rate alters haemostatic parameters in an ex-vivo extracorporeal membrane oxygenation circuit

Low flow rate alters haemostatic parameters in an ex-vivo extracorporeal membrane oxygenation circuit

A narrative review of antithrombin use during veno-venous extracorporeal membrane oxygenation in adults: rationale, current use, effects on anticoagulation, and outcomes

The role of endoscopy as non-invasive procedure to manage gastrointestinal complications during extracorporeal membrane oxygenation

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