Eric Sy1, Michael C Sklar2, Laurence Lequier3, Eddy Fan4, Hussein D Kanji5. 1. Department of Critical Care, Regina General Hospital, Regina, Saskatchewan, Canada; Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada; Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada. Electronic address: eric.julian.sy@gmail.com. 2. Department of Anaesthesia, University of Toronto, Toronto, Ontario, Canada. 3. Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada. 4. Critical Care Medicine, University Health Network and Mount Sinai Hospitals, Toronto, Ontario; Interdepartmental Division of Critical Care, University of Toronto, Toronto General Hospital, Toronto, Ontario, Canada. 5. Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver General Hospital, Vancouver, BC, Canada.
Abstract
PURPOSE: The purpose was to evaluate the safety of anticoagulation in venoarterial extracorporeal membrane oxygenation (VA-ECMO). DESIGN: We performed a systematic review and meta-analysis using multiple electronic databases. Studies were from 1977 to September 27, 2016. We evaluated the effect of anticoagulation in VA-ECMO on outcomes including major bleeding, thromboembolic events, and in-hospital mortality using a random effects model meta-analysis. RESULTS: Twenty-six studies (1496 patients) were included. Ten studies only had patients with postcardiotomy shock, 4 studies only included extracorporeal cardiopulmonary resuscitation patients, and 10 studies had a mixture of patients. Most studies (n=17) were low quality with a Newcastle-Ottawa Scale score ≤5. The summary prevalence of major bleeding was 27% (95% confidence interval [CI], 18%-35%), with considerable between-study heterogeneity (I2=91%). Major bleeding requiring reoperation was the most common bleeding event. The summary prevalence of thromboembolic events was 8% (95% CI, 4%-13%; I2=83%). Limb ischemia, circuit-related clotting, and stroke were the most commonly reported events. The summary prevalence for in-hospital mortality was 59% (95% CI, 52%-67%; I2=78%). CONCLUSIONS: The optimal targets and strategies for anticoagulation in VA-ECMO are unclear. Evaluation of major bleeding and thromboembolic events is limited by study quality and between-study heterogeneity. Clinical trials are needed to investigate the optimal anticoagulation strategy.
PURPOSE: The purpose was to evaluate the safety of anticoagulation in venoarterial extracorporeal membrane oxygenation (VA-ECMO). DESIGN: We performed a systematic review and meta-analysis using multiple electronic databases. Studies were from 1977 to September 27, 2016. We evaluated the effect of anticoagulation in VA-ECMO on outcomes including major bleeding, thromboembolic events, and in-hospital mortality using a random effects model meta-analysis. RESULTS: Twenty-six studies (1496 patients) were included. Ten studies only had patients with postcardiotomy shock, 4 studies only included extracorporeal cardiopulmonary resuscitation patients, and 10 studies had a mixture of patients. Most studies (n=17) were low quality with a Newcastle-Ottawa Scale score ≤5. The summary prevalence of major bleeding was 27% (95% confidence interval [CI], 18%-35%), with considerable between-study heterogeneity (I2=91%). Major bleeding requiring reoperation was the most common bleeding event. The summary prevalence of thromboembolic events was 8% (95% CI, 4%-13%; I2=83%). Limb ischemia, circuit-related clotting, and stroke were the most commonly reported events. The summary prevalence for in-hospital mortality was 59% (95% CI, 52%-67%; I2=78%). CONCLUSIONS: The optimal targets and strategies for anticoagulation in VA-ECMO are unclear. Evaluation of major bleeding and thromboembolic events is limited by study quality and between-study heterogeneity. Clinical trials are needed to investigate the optimal anticoagulation strategy.
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