Anticoagulation in Critically Ill Adults during Extracorporeal Circulation

Buchtele, Nina; Staudinger, Thomas; Schäfer, Anne-Kristin; Bögl, Magdalena S.; Schoergenhofer, Christian; Schwameis, Michael

doi:10.1055/a-1389-8216

Cited by 7 publications

(5 citation statements)

References 46 publications

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“…For each day in the ICU (defined as 4:00 to 3:59 a.m. to harmonize unit-specific workflows), mean values and standard deviations were calculated for continuous measurements and total values for drug doses. The extracorporeal circuits were coated with heparin and all patients received a bolus of 50–100 IU of unfractionated heparin per kilogram of body weight during cannulation ( 11 ). While this bolus was applied regardless of the subsequent anticoagulant regimen, all data analysis in the unfractionated heparin group is based on its continuous intravenous administration.…”

Section: Methodsmentioning

confidence: 99%

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

et al. 2022

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BackgroundExtracorporeal membrane oxygenation, with an inherent requirement for anticoagulation to avoid circuit thrombosis, is a key element in the treatment of respiratory failure associated with COVID-19. Anticoagulation remains challenging, the standard of care being intravenous continuous administration of unfractionated heparin. Yet regimens vary. Some intensive care units in our center have successfully used enoxaparin subcutaneously in recent years and throughout the pandemic.MethodsWe retrospectively analyzed adult COVID-19 patients with respiratory failure who had been systemically anticoagulated using either enoxaparin or unfractionated heparin. The choice of anticoagulant therapy was based on the standard of the intensive care unit. Defined thromboembolic and hemorrhagic events were analyzed as study endpoints.ResultsOf 98 patients, 62 had received enoxaparin and 36 unfractionated heparin. All hazard ratios for the thromboembolic (3.43; 95% CI: 1.08–10.87; p = 0.04), hemorrhagic (2.58; 95% CI: 1.03–6.48; p = 0.04), and composite (2.86; 95% CI: 1.41–5.92; p = 0.007) endpoints favored enoxaparin, whose efficient administration was verified by peak levels of anti-factor Xa (median: 0.45 IU ml−1; IQR: 0.38; 0.56). Activated partial thromboplastin time as well as thrombin time differed significantly (both p<0.001) between groups mirroring the effect of unfractionated heparin.ConclusionsThis study demonstrates the successful use of subcutaneous enoxaparin for systemic anticoagulation in patients with COVID-19 during extracorporeal membrane oxygenation. Our findings are to be confirmed by future prospective, randomized, controlled trials.

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Section: Methodsmentioning

confidence: 99%

“…There is ongoing discussion as to which anticoagulant medication has the best safety profile ( 11 ). Current guidelines recommend the use of unfractionated heparin for anticoagulation during extracorporeal membrane oxygenation (ECMO) ( 12 ).…”

Section: Introductionmentioning

confidence: 99%

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

et al. 2022

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“…The institutional protocol for anticoagulation on PC-ECLS has been described previously [ 11 , 13 ]. When ELCS is implemented in the operating room for failure to wean from CPB, full-dose protamine is administered for complete heparin reversal, and anticoagulation for ECLS is started 24–48 h postoperatively, given that no bleeding tendency is present.…”

Section: Management Of Patients On Extracorporeal Life Supportmentioning

confidence: 99%

“…If heparin-induced thrombocytopaenia is suspected, anticoagulation is switched to argatroban and continued in case heparin-induced thrombocytopaenia is confirmed by diagnostic testing [ 14 ]. Anticoagulation is reduced at the discretion of the treating intensivists and surgeons in case of a tendency to bleed and discontinued in case of severe mediastinal haemorrhage [ 13 ].…”

Section: Management Of Patients On Extracorporeal Life Supportmentioning

confidence: 99%

Bleeding and thrombotic events in post-cardiotomy extracorporeal life support

Schaefer

Latus

Riebandt

et al. 2023

European Journal of Cardio-Thoracic Surgery

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OBJECTIVES Hemorrhagic and thrombotic complications are known obstacles in extracorporeal life support (ECLS), and patients requiring postcardiotomy ECLS are particularly prone. The objective of the study was to characterize incidence, type and clinical relevance of bleeding and thrombotic events on PC-ECLS. METHODS 504 patients receiving PC-ECLS between 2000–2021 at a single center were included in a retrospective analysis. Incidence and type of hemorrhagic and thrombotic complications on PC-ECLS were assessed. Overall survival was compared and perioperative risk factors for bleeding and thrombotic events assessed by binary logistic regression. RESULTS Of 504 patients requiring PC-ECLS, 196 patients(38.9%) had 235 bleeding events (surgical site: n = 135(26.8%); cannulation site: n = 68(13.4%); requiring surgical revision, n = 39(7.7%) cannulation site change: n = 17(3.4%), fatal cannulation site bleeding: n = 4(0.8%); intracranial haemorrhage: n = 11(2.1%); gastrointestinal: n = 8(1.6%); pulmonary: n = 8(1.6%), and intra-abdominal/retroperitoneal: n = 5 (1%)). Overall mortality was higher in patients with major bleeding complications than in patients without bleeding complications (p < 0.0001). 74 patients (14.7%) had 84 thrombotic events (ischaemic stroke n = 39 (7.7%); cannula/circuit thrombosis n = 26 (5.2%); peripheral embolism n = 11 (2.2%), device exchange for hemolysis n = 8 (1.6%)). 246 patients (48.8%) had at least one hemocompatibility-related adverse event. Preoperative dual antiplatelet therapy (adjusted OR: 1.83, 95% CI: 1.063–3.137) and ECLS duration (adjusted OR: 1.14, 95% CI: 1.086–1.197) were identified as independent risk factors for haemorrhage, and prior stroke/transient ischaemic attack (adjusted OR: 1.91, 95% CI: 1.08–3.83) and ECLS duration (adjusted OR: 1.09, 95% CI: 1.04–1.15) were identified as risk factors for thrombotic events. CONCLUSIONS Bleeding complications on ECLS are common and significantly impair survival. Nearly half of patients were affected by any hemocompatibility-related event.

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“…The use of ECMO has increased over the past few decades, and there is a growing demand for ECMO component technologies [ 1 ]. During ECMO treatment, exposure of blood to the large non-endothelial surface of the ECMO circuit, blood pump, and oxygenator system based on the type of ECMO causes contact activation and an associated risk of thrombus formation within the circuits or human circulation [ 2 ]. Therefore, effective systemic anticoagulation is usually required.…”

Section: Introductionmentioning

confidence: 99%

The role of nafamostat mesilate as a regional anticoagulant during extracorporeal membrane oxygenation

Lee¹,

Park²,

Jang³

et al. 2022

Acute Crit Care

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Background: Anticoagulation during extracorporeal membrane oxygenation (ECMO) usually is required to prevent thrombosis. The aim of this study was to investigate the usefulness of nafamostat mesilate (NM) as a regional anticoagulant during veno-arterial ECMO (VA-ECMO) treatment. Methods: We retrospectively reviewed the medical records of 16 patients receiving VA-ECMO and NM from January 2017 to June 2020 at Haeundae Paik Hospital. We compared clinical and laboratory data, including activated partial thromboplastin time (aPTT), which was measured simultaneously in patients and the ECMO site, to estimate the efficacy of regional anticoagulation. Results: The median patient age was 68.5 years, and 56.3% of patients were men. Cardiovascular disease was the most common primary disease (75.0%) requiring ECMO treatment, followed by respiratory disease (12.5%). The median duration of ECMO treatment was 7.5 days. Among 16 patients, seven were switched to NM after first using heparin as an anticoagulation agent, and nine received only NM. When comparing aPTT values in the NM group between patients and the ECMO site, that in patients was significantly lower than that at the ECMO site (73.57 vs. 79.25 seconds; P=0.010); in contrast, no difference was observed in the heparin group. Conclusions: NM showed efficacy as a regional anticoagulation method by sustaining a lower aPTT value compared to that measured at the ECMO site. NM should be considered as a safer regional anticoagulation method in VA-ECMO for patients at high risk of bleeding.

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Anticoagulation in Critically Ill Adults during Extracorporeal Circulation

Cited by 7 publications

References 46 publications

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

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

Bleeding and thrombotic events in post-cardiotomy extracorporeal life support

The role of nafamostat mesilate as a regional anticoagulant during extracorporeal membrane oxygenation

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