Comparison of Coagulation Parameters, Anticoagulation, and Need for Transfusion in Patients on Interventional Lung Assist or Veno-Venous Extracorporeal Membrane Oxygenation

Abstract

Clinical data on anticoagulation needs of modern extracorporeal membrane oxygenation (ECMO) and its impact on coagulation are scarce. Therefore, we analyzed coagulation-related parameters, need for transfusion, and management of anticoagulation in adult patients with severe acute respiratory failure during treatment with either pumpless interventional lung assist (iLA) or veno-venous ECMO (vv-ECMO). Sixty-three patients treated with iLA and 192 patients treated with vv-ECMO at Regensburg University Hospital between January 2005 and May 2011 were analyzed. Data related to anticoagulation, transfusion, and coagulation parameters were collected prospectively by the Regensburg ECMO registry. Except for a higher, sequential organ failure assessment (SOFA) score in the ECMO group (12 [9-15] vs. 11 [7-14], P = 0.007), a better oxygenation, and a lower dosage of vasopressors in the iLA patients, both groups had similar baseline characteristics. No difference was noted in terms of outcome and overall transfusion requirements. Factors of the plasmatic coagulation system were only marginally altered over time and did not differ between groups. Platelet counts in ECMO-treated patients, but not in those treated with iLA, dropped significantly during extracorporeal support. A more intense systemic anticoagulation with a mean activated partial thromboplastin time (aPTT) > 53 s led to a higher need for transfusions compared with the group with a mean aPTT < 53 s, whereas the average durability of membrane oxygenators was not affected. Need for red blood cell (RBC) transfusion was highest in patients with extrapulmonary sepsis (257 mL/day), and was significantly lower in primary pulmonary adult respiratory distress syndrome (ARDS) (102 mL/day). Overall, 110 (0-274) mL RBC was transfused in the ECMO group versus 146 (41-227) mL in the iLA group per day on support. The impact of modern iLA and ECMO systems on coagulation allows comparatively safe long-term treatment of adult patients with acute respiratory failure. A moderate systemic anticoagulation seems to be sufficient. Importantly, platelets are more affected by vv-ECMO compared with pumpless iLA.

Extracorporeal Membrane Oxygenation Support in Trauma Versus Nontrauma Patients with Noninfectious Acute Respiratory Failure

“…This could be related to blood–surface interactions or clotting within the ECMO device. However, D‐dimer and fibrinogen levels evolved in the direction opposite to that of coagulopathy, in contrast to the results of Weingart et al . Although we had few patients, this might be attributable to the anticoagulation agents used in our study.…”

Thrombocytopenia and extracorporeal membrane oxygenation in adults with acute respiratory failure: a cohort study

“…There are several reasons why our findings contradict two prior cohort studies that concluded that platelets counts decline with ECMO use [13, 22]. In a cohort study of 225 adults with severe ARDS who were supported with either venovenous ECMO or pumpless arteriovenous interventional Lung Assist (iLA), platelet counts decreased significantly in those who received ECMO but not in those who received iLA.…”

“…The potential platelet-reducing effect of ECMO therapy is clinically important since ECMO patients who develop thrombocytopenia may have an increased risk of bleeding [10]. Two recent single-center cohort studies examined the association between ECMO use and the development of thrombocytopenia among adults with acute respiratory failure [13, 22]. While both studies report a significant decline in platelet count over days on ECMO, neither controlled for potential confounding factors including subjects' severity of illness or the duration of ECMO therapy.…”

COVID-19 and ECMO: the interplay between coagulation and inflammation—a narrative review

“…Unfortunately, the current data do not allow conclusions on this issue. Thrombocytopenia, on the other hand, is one of the many complications of ECMO [48][49][50]. It is estimated that approximately 1 in 5 patients may experience severe thrombocytopenia (platelets < 50 × 109/L) [48].…”