Coagulation abnormalities in patients with COVID‐19 on venovenous ECLS increased risk for technical complications and support times but had no impact on survival

Abstract

Background Patients with severe coronavirus disease‐19 (COVID‐19)‐associated acute respiratory distress on venovenous extracorporeal lung support (V‐V ECLS) showed a high incidence of vascular as well as ECLS‐related thrombotic complications. The latter may influence the outcome of the patients. Methods This is a retrospective monocentric study on prospectively collected data of technical complications including 69 adult COVID‐19 patients on V‐V ECLS (ECLS Registry, March 2020 until April 2021) without and with system exchanges. Alterations in ECLS‐specific data, hemolysis, coagulation, and hemostasis parameters were analyzed. Results Every second COVID‐19 patient on V‐V ECLS developed technical complications. Optimized ECLS management at our ECLS center reduced cases of acute clot formation (pump head thrombosis, acute oxygenator thrombosis) (17%), and allowed early identification of progressive clotting processes (worsened gas transfer, coagulation disorder) (14%, 54%) with a significant overhang of hyperfibrinolysis (37%). Although COVID‐19 disease and technical complications caused the prolonged length of stay at the intensive care unit and ECLS support times, the proportion of successful weaning and survival rates were comparable with patients without system exchange. Conclusion The survival of ECLS patients with COVID‐19 was independent of the requirement for system exchange due to technical‐induced coagulation disorders. Close monitoring for circuit clotting is mandatory in COVID‐19 patients and is one prerequisite for successful organ support in these difficult patients.

Neutrophil extracellular traps - a potential trigger for the development of thrombocytopenia during extracorporeal membrane oxygenation

“…There are countless references in the literature for the thrombogenic potential of NETs in the context of infections ( 25 , 26 , 68 ) and with coagulation-associated technical complications, such as clot formation or critical bleeding as a major cause of mortality and morbidity during ECMO therapy ( 3 , 6 , 7 ), a major focus of this study was to examine platelet counts and parameters of plasmatic coagulation during the course of therapy. As frequently described ( 6 , 7 , 9 , 13 , 69 , 70 ), also in this evaluation the collective of all patients, as well as the HIGH- and the LOW-NET subgroups showed a significant decrease in platelet counts after ECMO initiation. It was noticeable that patients with a high NET rate prior to ECMO initiation presented a more pronounced and earlier platelet drop, as well as a significantly reduced antithrombin III activity immediately after initiation of therapy compared to the patients with an initial lower NET rate.…”

“…Technical complications occur in 30-51% of non-COVID-19 and COVID-19 patients during ECMO therapy, leading to an exchange of ECMO components after a median of 9-10 days ( 6 , 7 ). In this study, technical complications requiring replacement of ECMO components, mostly the membrane oxygenator, also occurred in 4 patients (40%).…”

“…Since its first use, continuous improvement of the ECMO devices used as well as the care of ECMO patients has resulted in major advances, especially regarding the recognition and treatment of ECMO related complications. Nevertheless, coagulation-associated technical complications, such as clot formation or critical bleeding, remain a major cause of mortality and morbidity during ECMO therapy ( 5 ) leading to device malfunction and the necessity for high-risk system replacement in 31-51% of all patients on veno-venous (VV) ECMO ( 3 , 6 , 7 ).…”

Clinical relevance of cell‐free DNA during venovenous extracorporeal membrane oxygenation

“…Non‐physiological shear forces and the contact of the patient's blood with artificial surfaces within the extracorporeal circuit are associated with an immediate activation of both the inflammatory response and the coagulation cascade 1,6–8 . As a result, 30%–50% of all ECMO patients develop thrombotic complications 4,9 . When occurring within the membrane oxygenator, these complications are still unpredictable and may lead to equipment malfunction and circuit loss, necessitating an emergency high‐risk system replacement 4,10 .…”

“…1,[6][7][8] As a result, 30%-50% of all ECMO patients develop thrombotic complications. 4,9 When occurring within the membrane oxygenator, these complications are still unpredictable and may lead to equipment malfunction and circuit loss, necessitating an emergency high-risk system replacement. 4,10 The underlying mechanisms are unclear but include the activation of platelets, neutrophils, and the coagulation system.…”