Heparin-Sparing Anticoagulation Strategies Are Viable Options for Patients on Veno-Venous ECMO

Carter, Kristen T.; Kutcher, Matthew; Shake, Jay G.; Panos, Anthony L.; Cochran, Richard P.; Creswell, Lawrence L.; Copeland, Hannah

doi:10.1016/j.jss.2019.05.050

Cited by 36 publications

(40 citation statements)

References 45 publications

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“…Pathophysiologically, the PT and INR reflect the functional activity of the extrinsic pathway of coagulation, which relies mainly on four coagulation factors: FVII, FX, FV and FII [1]. All our patients received heparin, and theoretically, PT and INR could be increased due to anticoagulation with heparin [23].…”

Section: Plos Onementioning

confidence: 94%

“…Extracorporeal membrane oxygenation (ECMO) is a technique increasingly used in the practice of intensive therapy for extracorporeal gas exchange and/or circulatory support in patients with acute respiratory and/or cardiac failure, when conventional treatment modalities are ineffective [1]. Blood flow within an artificial extracorporeal circuit will lead to thromboembolic events and necessitates therapeutic anticoagulation.…”

Section: Introductionmentioning

confidence: 99%

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Clinical and pathophysiologic aspects of ECMO-associated hemorrhagic complications

et al. 2020

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Extracorporeal membrane oxygenation (ECMO) is increasingly used to treat severe cases of acute respiratory or cardiac failure. Hemorrhagic complications represent one of the most common complications during ECMO, and can be life threatening. The purpose of this study was to elucidate pathophysiological mechanisms of ECMO-associated hemorrhagic complications and their impact on standard and viscoelastic coagulation tests. The study cohort included 27 patients treated with VV-ECMO or VA-ECMO. Hemostasis was evaluated using standard coagulation tests and viscoelastic parameters investigated with rotational thromboelastometry. Anticoagulation and hemorrhagic complications were analyzed for up to seven days depending on ECMO duration. Hemorrhagic complications developed in 16 (59%) patients. There were 102 discrete hemorrhagic episodes among 116 24-hour-intervals, of which 27% were considered to be clinically significant. The highest number of ECMO-associated hemorrhages occurred on the 2 nd and 3 rd day of treatment. Respiratory tract bleeding was the most common hemorrhagic complication, occurring in 62% of the 24hour intervals. All 24-hours-intervals were divided into two groups: "with bleeding" and "without bleeding". The probability of hemorrhage was significantly associated with abnormalities of four parameters: increased international normalized ratio (INR, sensitivity 71%, specificity 94%), increased prothrombin time (PT, sensitivity 90%, specificity 72%), decreased intrinsic pathway maximal clot firmness (MCFin, sensitivity 76%, specificity 89%), and increased extrinsic pathway clot formation time (CFTex, sensitivity 77%, specificity 87%). In conclusions, early ECMO-associated hemorrhagic complications are related to one traditional and two novel viscoelastic coagulation abnormalities: PT/INR elevation, reduced maximum clot firmness due to intrinsic pathway dysfunction (MCFin), and prolonged clot formation time due to extrinsic pathway dysfunction (CFTex). When managing hemostasis during ECMO, derangements in PT/INR, MCFin and CFT ex should be focused on.

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Section: Plos Onementioning

confidence: 94%

Section: Introductionmentioning

confidence: 99%

Clinical and pathophysiologic aspects of ECMO-associated hemorrhagic complications

et al. 2020

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“…Nevertheless, such rate was unusual, particularly among those without hepatic failure. 10 The On the basis of our study, and considering the evidence from Chinese patients, we think that the hypercoagulability state might be a phenomenon among severe cases of COVID-19 that requires to be carefully monitored.…”

Section: Discussionmentioning

confidence: 77%

“…Oxygenator dysfunction leading to oxygenator replacement was seen in 10% to 30% of VV‐ECMO patients. Nevertheless, such rate was unusual, particularly among those without hepatic failure 10 . The fourth patient developed hepatic failure, probably due to a hypercoagulability state.…”

Section: Discussionmentioning

confidence: 90%

Extracorporeal membrane oxygenation and COVID‐19: The causes of failure

et al. 2020

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Introduction Venovenous extracorporeal membrane oxygenation (VV‐ECMO) is a therapeutic strategy for the coronavirus disease 2019 (COVID‐19) induced acute respiratory distress syndrome (ARDS). There are inconclusive data in this regard and causes of VV‐ECMO failure are not yet understood well. Case Series Here, seven patients with COVID‐19‐induced ARDS who underwent VV‐ECMO introduced and causes of VV‐ECMO failure discussed. Medical records of seven COVID‐19 patients treated with VV‐ECMO were retrospectively evaluated to determine the clinical outcomes of VV‐ECMO. Oxygenator failure occurred in four patients whom needed to oxygenator replacement. Successful VV‐ECMO decannulation was done in three patients, however finally one patient survived. Conclusions Hypercoagulability state and oxygenator failure were the most main etiologies for VV‐ECMO failure in our study. All patients with COVID‐19 undergoing VV‐ECMO should be monitored for such problems and highly specialized healthcare team should monitor the patients during VV‐ECMO.

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“…We would like to make some comments. Prior to the COVID-19 pandemic, we routinely used anticoagulation for veno-arterial ECMO (VA-ECMO), but not for veno-venous ECMO (VV-ECMO) [ 4 ]. We have found the situation to be totally different in COVID-19 patients treated with VV-ECMO.…”

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confidence: 99%

Use of multiple laboratory tests including anti-factor Xa to optimally manage anticoagulation during ECMO

et al. 2020

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Heparin-Sparing Anticoagulation Strategies Are Viable Options for Patients on Veno-Venous ECMO

Cited by 36 publications

References 45 publications

Clinical and pathophysiologic aspects of ECMO-associated hemorrhagic complications

Clinical and pathophysiologic aspects of ECMO-associated hemorrhagic complications

Extracorporeal membrane oxygenation and COVID‐19: The causes of failure

Use of multiple laboratory tests including anti-factor Xa to optimally manage anticoagulation during ECMO

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