It takes two to bleed: anticoagulation intensity and the host’s vascular susceptibility

Seeliger, Benjamin; Wendel‐Garcia, Pedro David; Stahl, Klaus; Bode, Christian; David, Sascha

doi:10.1007/s00134-022-06643-y

Cited by 5 publications

(4 citation statements)

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“…Seeliger et al (1) have reported a higher mortality in patients receiving ECMO support for COVID-19 than that published by our group; 90-day survival of 38.7% versus 74% (5). This is likely multifactorial with older age (median 59 vs 46 yr), increased rates of comorbidity and more multiple organ failure prior to initiating ECMO, further increasing the risk of hemorrhage.…”

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confidence: 51%

“…Although the center performing routine postcannulation CTs identified more ICHs early, this did not reduce mortality in these patients despite a management similar to the one described by Clarke et al (1). It thus seems warranted to conclude that both COVID-19-induced endothelial inflammation (4) and the higher anticoagulation target in waves 1 and 2 were conjointly responsible for increased ICH rates during ECMO support (5). In fact, our observations have since then prompted us to adapt our standards regarding anticoagulation aiming for a lower anti-Xa of 0.2–0.3.…”

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confidence: 99%

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Seeliger

Stahl

Wendel‐Garcia

et al. 2022

Critical Care Medicine

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confidence: 51%

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confidence: 99%

The authors reply

Seeliger

Stahl

Wendel‐Garcia

et al. 2022

Critical Care Medicine

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“…It has been speculated that this unacceptably high bleeding rate was driven by both intensified anticoagulation and the hosts’ vascular vulnerability as a characteristic feature of COVID-19 [ 27 ]. The latter notion is supported by the observation that in non-COVID-19 ARDS patients requiring ECMO support, a higher anticoagulation target was not associated with an increased ICH rate [ 26 ].…”

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confidence: 99%

Reduced anticoagulation strategy is associated with a lower incidence of intracerebral hemorrhage in COVID-19 patients on extracorporeal membrane oxygenation

Hofmaenner¹,

Furfaro²,

Wild³

et al. 2023

ICMx

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Background Optimal anticoagulation strategies for COVID-19 patients with the acute respiratory distress syndrome (ARDS) on venovenous extracorporeal membrane oxygenation (VV ECMO) remain uncertain. A higher incidence of intracerebral hemorrhage (ICH) during VV ECMO support compared to non-COVID-19 viral ARDS patients has been reported, with increased bleeding rates in COVID-19 attributed to both intensified anticoagulation and a disease-specific endotheliopathy. We hypothesized that lower intensity of anticoagulation during VV ECMO would be associated with a lower risk of ICH. In a retrospective, multicenter study from three academic tertiary intensive care units, we included patients with confirmed COVID-19 ARDS requiring VV ECMO support from March 2020 to January 2022. Patients were grouped by anticoagulation exposure into higher intensity, targeting anti-factor Xa activity (anti-Xa) of 0.3–0.4 U/mL, versus lower intensity, targeting anti-Xa 0.15–0.3 U/mL, cohorts. Mean daily doses of unfractionated heparin (UFH) per kg bodyweight and effectively measured daily anti-factor Xa activities were compared between the groups over the first 7 days on ECMO support. The primary outcome was the rate of ICH during VV ECMO support. Results 141 critically ill COVID-19 patients were included in the study. Patients with lower anticoagulation targets had consistently lower anti-Xa activity values over the first 7 ECMO days (p < 0.001). ICH incidence was lower in patients in the lower anti-Xa group: 4 (8%) vs 32 (34%) events. Accounting for death as a competing event, the adjusted subhazard ratio for the occurrence of ICH was 0.295 (97.5% CI 0.1–0.9, p = 0.044) for the lower anti-Xa compared to the higher anti-Xa group. 90-day ICU survival was higher in patients in the lower anti-Xa group, and ICH was the strongest risk factor associated with mortality (odds ratio [OR] 6.8 [CI 2.1–22.1], p = 0.001). Conclusions For COVID-19 patients on VV ECMO support anticoagulated with heparin, a lower anticoagulation target was associated with a significant reduction in ICH incidence and increased survival.

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“…We appreciate the thoughtful letter by Seeliger and colleagues [ 1 ] in response to our manuscript published in Intensive Care Medicine [ 2 ]. They raise a few important points that are worth discussion.…”

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confidence: 99%