Anti-Xa activity and hemorrhagic events under extracorporeal membrane oxygenation (ECMO): a multicenter cohort study

Abstract

Background Hemorrhagic events remain a major concern in patients under extracorporeal membrane oxygenation (ECMO) support. We tested the association between anticoagulation levels and hemorrhagic events under ECMO using anti-Xa activity monitoring. Methods We performed a retrospective multicenter cohort study in three ECMO centers. All adult patients treated with veno-venous (VV)- or veno-arterial (VA)-ECMO in 6 intensive care units between September 2017 and August 2019 were included. Anti-Xa activities were collected until a hemorrhagic event in the bleeding group and for the duration of ECMO in the non-bleeding group. All dosages were averaged to obtain means of anti-Xa activity for each patient, and patients were compared according to the occurrence or not of bleeding. Results Among 367 patients assessed for eligibility, 121 were included. Thirty-five (29%) presented a hemorrhagic complication. In univariate analysis, anti-Xa activities were significantly higher in the bleeding group than in the non-bleeding group, both for the mean anti-Xa activity (0.38 [0.29–0.67] vs 0.33 [0.22–0.42] IU/mL; p = 0.01) and the maximal anti-Xa activity (0.83 [0.47–1.46] vs 0.66 [0.36–0.91] IU/mL; p = 0.05). In the Cox proportional hazard model, mean anti-Xa activity was associated with bleeding (p = 0.0001). By Kaplan–Meier analysis with the cutoff value at 0.46 IU/mL obtained by ROC curve analysis, the probability of survival under ECMO without bleeding was significantly lower when mean anti-Xa was > 0.46 IU/mL (p = 0.0006). Conclusion In critically ill patients under ECMO, mean anti-Xa activity was an independent risk factor for hemorrhagic complications. Anticoagulation targets could be revised downward in both VV- and VA-ECMO.

The Janus Face of Coronavirus Disease 2019–Associated Coagulopathy

“…One could hypothesize that the theoretical rational regarding endotheliopathy and bleeding vulnerability might justify 1) a narrow and 2) a lower range of anti-Xa. Interestingly, recent evidence supports the notion that target levels above 0.46 IU/mL might represent an independent risk factor for severe bleeding under ECMO support ( 4 ). At the same time, hemostaseologists would probably argue that anti-Xa levels do not fully reflect the important effects heparin has on other coagulation enzymes and the expression of tissue factor and tissue factor pathway inhibitor ( 5 ).…”

Subcutaneous Enoxaparin for Systemic Anticoagulation of COVID-19 Patients During Extracorporeal Life Support

“…At the same time, this requirement increases the risk of bleeding complications, which sometimes may be fatal ( 8 , 9 ). To strike a correct balance between these potential complications, adequate dosing and efficient monitoring of the anticoagulant drug needs to be ensured ( 5 , 6 , 10 ).…”

Gerinnungsdiagnostik im klinischen Alltag – Teil 2

“…Die Anti-Xa-Bestimmung ist weniger störanfällig und zunehmend in der klinischen Routine akzeptiert. Im Gegensatz zur aPTT liegen klinische Daten zur Verhinderung von Blutungskomplikationen vor [ 22 ].…”