Ellen Colman1, Ellen B Yin2, Greg Laine2, Subhasis Chatterjee3, Siavosh Saatee4, J Patrick Herlihy4, Meredith A Reyes5, Arthur W Bracey5,6. 1. Department of Pharmacy, Houston Methodist The Woodlands Hospital, The Woodlands, TX, USA. 2. Department of Pharmacy, CHI St. Luke's Health-Baylor St. Luke's Medical Center, Houston, TX, USA. 3. Michael E. DeBakey Department of Surgery, Divisions of General and Cardiothoracic Surgery, Baylor College of Medicine, Houston, TX, USA. 4. Department of Anesthesiology and Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA. 5. Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, USA. 6. Department of Cardiovascular Pathology, Texas Heart Institute, Houston, TX, USA.
Abstract
BACKGROUND: Bleeding complications are common with extracorporeal membrane oxygenation (ECMO). We investigated whether a heparin monitoring protocol using activated partial thromboplastin time (aPTT) and thromboelastography (TEG) affected clinical outcomes. METHODS: This retrospective chart review stratified cohorts by study interval: pre-protocol (January 2016-March 2017) or post-protocol (March 2017-December 2017). The protocol defined therapeutic anticoagulation as aPTT of 60-80 seconds and a TEG reaction (TEG-R) time of 2-4× baseline; pre-protocol management used aPTT alone. The primary endpoints were the rates of bleeding and thrombotic events (clinical/device thrombosis) as defined by Extracorporeal Life Support Organization (ELSO) guidelines. Secondary endpoints included time in therapeutic aPTT range, rate of physician compliance with the protocol, time to heparin initiation, intensive care unit length of stay, mortality, and antithrombin III (ATIII) supplementation. RESULTS: The pre-protocol (n=72) and post-protocol (n=51) groups (age 60±12 years; 80% on venoarterial ECMO; average ECMO duration of 6 days) showed no difference in baseline characteristics. Major bleeding events occurred in 69% of pre-protocol patients, versus 67% of post-protocol patients (P=0.85). The post-protocol group had fewer retroperitoneal bleeds (P=0.01) and had a non-significantly lower rate of pulmonary or central nervous system (CNS) bleeding (P=0.07). Thrombotic events occurred in 21% of the pre-protocol group, versus 28% of the post-protocol group (P=0.39). Mortality during ECMO support was significantly lower in the post-protocol group (56.9% vs. 33.3%, P=0.01). The thrombosis rate was higher in patients who received ATIII than in those who did not (48.2% vs. 15.9%, P<0.01). CONCLUSIONS: Major bleeding did not differ between the treatment groups. However, we observed significantly less mortality and retroperitoneal bleeding in the post-protocol group, suggesting an important gain from the intervention. Further study of the value of ATIII supplementation in ECMO patients is needed since we observed that a lower baseline ATIII level may indicate higher risk for thrombosis.
BACKGROUND: Bleeding complications are common with extracorporeal membrane oxygenation (ECMO). We investigated whether a heparin monitoring protocol using activated partial thromboplastin time (aPTT) and thromboelastography (TEG) affected clinical outcomes. METHODS: This retrospective chart review stratified cohorts by study interval: pre-protocol (January 2016-March 2017) or post-protocol (March 2017-December 2017). The protocol defined therapeutic anticoagulation as aPTT of 60-80 seconds and a TEG reaction (TEG-R) time of 2-4× baseline; pre-protocol management used aPTT alone. The primary endpoints were the rates of bleeding and thrombotic events (clinical/device thrombosis) as defined by Extracorporeal Life Support Organization (ELSO) guidelines. Secondary endpoints included time in therapeutic aPTT range, rate of physician compliance with the protocol, time to heparin initiation, intensive care unit length of stay, mortality, and antithrombin III (ATIII) supplementation. RESULTS: The pre-protocol (n=72) and post-protocol (n=51) groups (age 60±12 years; 80% on venoarterial ECMO; average ECMO duration of 6 days) showed no difference in baseline characteristics. Major bleeding events occurred in 69% of pre-protocol patients, versus 67% of post-protocol patients (P=0.85). The post-protocol group had fewer retroperitoneal bleeds (P=0.01) and had a non-significantly lower rate of pulmonary or central nervous system (CNS) bleeding (P=0.07). Thrombotic events occurred in 21% of the pre-protocol group, versus 28% of the post-protocol group (P=0.39). Mortality during ECMO support was significantly lower in the post-protocol group (56.9% vs. 33.3%, P=0.01). The thrombosis rate was higher in patients who received ATIII than in those who did not (48.2% vs. 15.9%, P<0.01). CONCLUSIONS: Major bleeding did not differ between the treatment groups. However, we observed significantly less mortality and retroperitoneal bleeding in the post-protocol group, suggesting an important gain from the intervention. Further study of the value of ATIII supplementation in ECMO patients is needed since we observed that a lower baseline ATIII level may indicate higher risk for thrombosis.
Authors: Anna Liveris; Ricardo A Bello; Patricia Friedmann; Melissa A Duffy; Deepa Manwani; James S Killinger; Daniel Rodriquez; Samuel Weinstein Journal: Pediatr Crit Care Med Date: 2014-02 Impact factor: 3.624
Authors: Michael S Northrop; Robert F Sidonio; Sharon E Phillips; Andrew H Smith; Hardison C Daphne; John B Pietsch; Brian C Bridges Journal: Pediatr Crit Care Med Date: 2015-01 Impact factor: 3.624
Authors: Robert A Niebler; Melissa Christensen; Richard Berens; Heidi Wellner; Theresa Mikhailov; James S Tweddell Journal: Artif Organs Date: 2011-11 Impact factor: 3.094
Authors: Melania M Bembea; Gail Annich; Peter Rycus; Gary Oldenburg; Ivor Berkowitz; Peter Pronovost Journal: Pediatr Crit Care Med Date: 2013-02 Impact factor: 3.624
Authors: Melania M Bembea; Jamie M Schwartz; Nilay Shah; Elizabeth Colantuoni; Christoph U Lehmann; Thomas Kickler; Peter Pronovost; John J Strouse Journal: ASAIO J Date: 2013 Jan-Feb Impact factor: 2.872
Authors: Timothy M Maul; Erin L Wolff; Bradley A Kuch; Adam Rosendorff; Victor O Morell; Peter D Wearden Journal: Pediatr Crit Care Med Date: 2012-11 Impact factor: 3.624
Authors: Bruce Cartwright; Hannah M Bruce; Geoffrey Kershaw; Nancy Cai; Jad Othman; David Gattas; Jacqueline L Robson; Sarah Hayes; Hayden Alicajic; Anna Hines; Alice Whyte; Nophanan Chaikittisilpa; Timothy James Southwood; Paul Forrest; Richard J Totaro; Paul G Bannon; Scott Dunkley; Vivien M Chen; Mark Dennis Journal: Sci Rep Date: 2021-04-12 Impact factor: 4.379
Authors: Connor M Bunch; Anthony V Thomas; John E Stillson; Laura Gillespie; Kevin P Lin; Jacob Speybroeck; Hau C Kwaan; Daniel H Fulkerson; Mahmud Zamlut; Rashid Khan; Mark M Walsh Journal: Am J Case Rep Date: 2021-04-01
Authors: Christoph Fisser; Maren Winkler; Maximilian V Malfertheiner; Alois Philipp; Maik Foltan; Dirk Lunz; Florian Zeman; Lars S Maier; Matthias Lubnow; Thomas Müller Journal: Crit Care Date: 2021-04-29 Impact factor: 9.097