scholarly journals Acquired factor XIII deficiency in two patients with bleeding events during veno-venous extracorporeal membrane oxygenation treatment

2019 ◽  
Vol 23 (3) ◽  
pp. 283-287 ◽  
Author(s):  
Asami Ito ◽  
Yoshiaki Iwashita ◽  
Ryo Esumi ◽  
Ken Sasaki ◽  
Masahiro Yukimitsu ◽  
...  
Keyword(s):  
Extracorporeal Membrane Oxygenation ◽  
Factor Xiii ◽  
Bloody Stool ◽  
Ecmo Patient ◽  
Bleeding Events ◽  
Factor Xiii Deficiency ◽  
Blood Tests ◽  
Membrane Oxygenation ◽  
Coagulation Tests ◽  
Routine Coagulation

AbstractWe report two cases of acquired factor XIII deficiency with bleeding events during veno-venous extracorporeal membrane oxygenation (ECMO). Case 1: A 76-year-old man diagnosed with aspiration pneumonia after near-drowning was started on ECMO. Later, the patient presented with hemoptysis and anemia. Blood tests showed a decreased factor XIII activity of 29%. Although the patient recovered after receiving 1200 International Units of factor XIII concentrate, the patient had another episode of decreased factor XIII activity and bloody stool and was treated again with factor XIII concentrate. Case 2: A 48-year-old female diagnosed with pneumonia was started on ECMO. Soon after, she presented with hemoptysis and anemia. Blood tests showed a decreased factor XIII activity of 39%. The patient was treated with 720 IU of factor XIII concentrate with good recovery. Acquired factor XIII deficiency cannot be detected by routine coagulation tests, therefore it may be under-diagnosed in the ICU. Detection of acquired factor XIII deficiency is essential when treating a bleeding ECMO patient.

scholarly journals Anticoagulation after VA-ECMO decannulation, providing new insights

2021 ◽  
Vol 10 (Supplement_1) ◽  
Author(s):  
A Maestro-Benedicto ◽  
A Duran-Cambra ◽  
M Vila-Perales ◽  
J Sans-Rosello ◽  
J Carreras-Mora ◽  
...  
Keyword(s):  
Extracorporeal Membrane Oxygenation ◽  
Cardiogenic Shock ◽  
Anticoagulation Therapy ◽  
Thromboembolic Events ◽  
Bleeding Events ◽  
Membrane Oxygenation ◽  
Funding Sources ◽  
Va Ecmo ◽  
A Prospective Study

Abstract Funding Acknowledgements Type of funding sources: None. INTRODUCTION Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is an essential tool for the management of refractory cardiogenic shock. Little is known about the incidence of thromboembolic events after V-A ECMO decannulation, although some studies report a high incidence of cannula-related venous thrombosis after venovenous extracorporeal membrane oxygenation (VV-ECMO). Due to this fact, in our institution anticoagulation therapy is systematically prescribed for at least 3 months after VA-ECMO per protocol.  AIM The main objective of this study was to explore the feasibility of 3-month anticoagulation therapy after VA-ECMO decannulation. METHODS We performed a prospective study that included 27 consecutive patients who were successfully treated with VA-ECMO in a medical ICU between 2016 and 2019 and were prescribed 3-month anticoagulation therapy per protocol after decannulation. Exclusion criteria was dying on ECMO or while on the ICU. Data analysis included demographics, mean days on ECMO, 3-month survival, and thromboembolic and bleeding events (excluding immediate post-decannulation bleeding, since anticoagulation was prescribed 24h after). RESULTS Our cohort consisted mainly of men (N = 21, 78%), with a mean age of 60 ± 11 years and a mean time on VA-ECMO of 8 ± 3 days, who primarily suffered from post-cardiotomy cardiogenic shock (N = 9, 34%) or acute myocardial infarction (N = 6, 23%). 5 patients (18%) received a heart transplant. Regarding anticoagulation, 15 patients (60%) had other indications apart from the protocol, like incidental thrombus diagnosis (N = 7, 26%) or valve surgery (N = 5, 18%). Anticoagulation therapy was not feasible in 1 patient (4%) with severe thrombopenia. No patients had severe or life-threatening bleeding events in the follow-up, although 8 patients (30%) had bleeding events, mainly gastrointestinal bleeding (N = 4, 15%), requiring withdrawal of anticoagulation in 1 patient. The incidence of thromboembolic events was 7%; two patients with low-risk pulmonary embolisms. During the 3-month follow-up survival rate was 95%. CONCLUSIONS This is the only study to date addressing the strategy of 3-month anticoagulation therapy after VAECMO, showing it is feasible and safe and may be helpful in reducing or ameliorate thromboembolic complications in the follow-up, although it is not exempt of complications. Abstract Figure. Kaplan-Meier survival analysis

Extracorporeal Membrane Oxygenation: Current Use and Future Directions

1990 ◽  
Vol 1 (2) ◽  
pp. 348-364 ◽  
Author(s):  
Beth Kaplan McDermott ◽  
Martha A. Q. Curley
Keyword(s):  
Extracorporeal Membrane Oxygenation ◽  
Pediatric Population ◽  
Critical Care Nursing ◽  
Nursing Management ◽  
Ecmo Patient ◽  
Future Directions ◽  
Membrane Oxygenation ◽  
Critically Ill Neonates ◽  
Cardiac System

Extracorporeal membrane oxygenation (ECMO) is the process of using prolonged cardiopulmonary bypass to support patients with reversible respiratory and/or cardiac failure who are refractory to maximal conventional therapy. This process has been used extensively for critically ill neonates, with encouraging results. The use of ECMO in the pediatric population has been limited but is increasing. The history, mechanics, and current applications of ECMO are discussed in this article. Critical care nursing management of the pediatric or neonatal ECMO patient focuses on optimizing recovery of the pulmonary and/or cardiac system while preventing complications. A case study of a pediatric ECMO patient is presented which illustrates the complex nursing care issues related to use of this intervention. Future directions for ECMO are addressed

Cost-effectiveness of Argatroban Versus Heparin Anticoagulation in Adult Extracorporeal Membrane Oxygenation Patients

2019 ◽  
pp. 001857871989009
Author(s):  
Angelina E. Cho ◽  
Kathleen Jerguson ◽  
Joy Peterson ◽  
Deepa V. Patel ◽  
Asif A. Saberi
Keyword(s):  
Cost Effectiveness ◽  
Extracorporeal Membrane Oxygenation ◽  
Average Cost ◽  
P Value ◽  
Bleeding Events ◽  
Membrane Oxygenation ◽  
Increased Risk ◽  
Heparin Anticoagulation ◽  
Ischemic Events ◽  
Ecmo Therapy

Purpose: The purpose of this study was to evaluate the cost effectiveness of argatroban compared to heparin during extracorporeal membrane oxygenation (ECMO) therapy. Methods: This was a retrospective study of patients who received argatroban or heparin infusions with ECMO therapy at a community hospital between January 1, 2017 and June 30, 2018. Adult patients who received heparin or argatroban for at least 48 hours while on venovenous (VV) or venoarterial (VA) ECMO were included. Patients with temporary mechanical circulatory assist devices were excluded. Each continuous course of anticoagulant exposure that met the inclusion criteria was evaluated. The primary endpoint was the total cost of anticoagulant therapy for heparin versus argatroban, including all administered study drugs, blood or factor products, and associated laboratory tests. Secondary endpoints included safety and efficacy of anticoagulation with each agent during ECMO. Documentation of bleeding events, circuit clotting, and ischemic events were noted. Partial thromboplastin time (PTT) values were evaluated for time to therapeutic range and percentage of therapeutic PTTs. Results: A total of 11 courses of argatroban and 24 courses of heparin anticoagulation were included in the study. The average cost per course of argatroban was less than the average cost per course of heparin ($7,091.98 vs $15,323.49, respectively; P value = 0.15). Furthermore, argatroban was not associated with an increased incidence of bleeding, thrombotic, or ischemic events. Conclusion: Argatroban may be more cost-effective during ECMO therapy in patients with low antithrombin III levels without increased risk of adverse events.

Coagulation Profile of Children on Extracorporeal Membrane Oxygenation (ECMO) - Is FXIII the Missing Link?

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 3795-3795
Author(s):  
Thorsten Haas ◽  
Carsten Doell ◽  
Markus Schmugge ◽  
Melissa M. Cushing ◽  
Vincenzo Cannizzaro
Keyword(s):  
Extracorporeal Membrane Oxygenation ◽  
Factor Xiii ◽  
Massive Transfusion ◽  
Complete Blood Count ◽  
Published Data ◽  
Reference Ranges ◽  
Bleeding Management ◽  
Membrane Oxygenation ◽  
Thrombotic Complications ◽  
The Impact

Abstract Background Published data about bleeding management on extracorporeal membrane oxygenation (ECMO) in children is sparse and to date no global transfusion algorithm has been established. Viscoelastic testing can be effective for determining the etiology and management of coagulopathic bleeding during cardiothoracic procedures, but data regarding its usefulness in ECMO patients are scarce. Recently, low factor XIII levels were determined to be a frequent finding in adult ECMO patients(Kalbhenn et al; Perfusion 2015;30:675-82). Methods This is a retrospective analysis of thromboelastometry (ROTEM®) and factor XIII data obtained in children (ages 0 to 18 years) undergoing ECMO since 2013 in a single center children's hospital. Acute bleeding treatment was based on daily ROTEM testing, complete blood count and routine plasmatic coagulation testing. The transfusion algorithm targeted a hemoglobin level >13g dL-1, a Quick's value >50%, a plasma fibrinogen level >1.5g L-1, and a platelet count of >100,000 µL-1. Red blood cells (RBC), solvent detergent (S/D) plasma and platelet apheresis concentrates were exclusively used to maintain hemostasis. Measurement of FXIII levels is not part of routine testing, but was assessed when unexplained bleeding was observed. Results Laboratory and transfusion data from sixteen patients, age 4 (1-15) months [median(IQR)] with a body weight of 6 (3-8) kg were included. Median time on ECMO was 7 (4-9) days. Large volumes of allogeneic blood were transfused to all children, meeting criteria for massive transfusion each individual day on ECMO (Tab.1). Overall, median daily ROTEM measurements were within reference ranges (Tab.2), while median levels of FXIII were decreased despite massive transfusion [FXIII levels 42% (28-51%)]. Conclusion Pediatric ECMO was almost always combined with daily massive transfusion, which led to correction of overall ROTEM values. Notably, despite transfusion of large amounts of plasma, decreased FXIII levels were noted. This finding is supported by results of a study in adult ECMO patients, where FXIII levels <50% were observed in 88% of all patients. Although inherited homozygous FXIII deficiency is usually defined by levels <5%, even mildly to moderately reduced FXIII levels have been reported to contribute to increased bleeding after cardiac surgery(Ternström et al; Thromb Res 2010;126:e128-33). Further studies should be performed to assess the impact of FXIII substitution in pediatric ECMO patients and to investigate whether substitution of FXIII may decrease bleeding without increasing thrombotic complications. Disclosures Haas: CSL Behring: Speakers Bureau; TEM International: Speakers Bureau; Octapharma: Consultancy.

Evaluation of a pharmacy managed heparin protocol for extracorporeal membrane oxygenation patients

Perfusion ◽  
2016 ◽  
Vol 32 (3) ◽  
pp. 238-244 ◽  
Author(s):  
Kalliopi Fitousis ◽  
Robin Klasek ◽  
Phillip E Mason ◽  
Faisal Masud
Keyword(s):  
Extracorporeal Membrane Oxygenation ◽  
Study Groups ◽  
Similar Rate ◽  
Bleeding Events ◽  
Membrane Oxygenation ◽  
Activated Clotting Time ◽  
Primary Endpoints ◽  
Significant Difference ◽  
Heparin Anticoagulation ◽  
Thrombotic Complications

Introduction: Unfractionated heparin is the preferred anticoagulant in extracorporeal membrane oxygenation (ECMO) patients. However, there is a lack of consensus on its titration and monitoring. The objective of this study was to describe the efficacy and safety of a pharmacy managed heparin protocol utilizing activated partial thromboplastin time (aPTT) in comparison to our standard physician-managed activated clotting time (ACT)-based anticoagulation in ECMO patients. Methods: Patients administered a heparin drip while on ECMO were included in the study. The primary endpoints were the incidence of hemorrhagic and thrombotic complications. Results: A total of 122 adult patients were identified who were on ECMO with heparin anticoagulation; sixty-one patients were managed with each of the physician-managed ACT and pharmacy managed aPTT protocols. No statistically significant difference was observed between the physician ACT and the pharmacy aPTT groups in overall hemorrhagic (69% vs 80%, p=0.145) or thrombotic complications (41% vs 39%, p=0.853). Conclusion: There was a similar rate of thrombotic and bleeding events between the two study groups. A pharmacy managed heparin protocol utilizing aPTT monitoring appears to be a safe and effective method of providing anticoagulation in adult ECMO patients.

scholarly journals Complications and mortality of venovenous extracorporeal membrane oxygenation in the treatment of neonatal respiratory failure: a systematic review and meta-analysis

2019 ◽  
Author(s):  
Jing Xiong ◽  
Li Zhang ◽  
Lei Bao
Keyword(s):  
Respiratory Failure ◽  
Extracorporeal Membrane Oxygenation ◽  
Meta Analysis ◽  
Cochrane Library ◽  
Bleeding Events ◽  
Membrane Oxygenation ◽  
Venovenous Ecmo ◽  
Complications And Mortality ◽  
Overall Mortality

Abstract Background Extracorporeal membrane oxygenation (ECMO) has been increasingly used for severe neonatal respiratory failure refractory to conventional treatments. To systematically evaluate the complications and mortality of venovenous ECMO in the treatment of neonatal respiratory failure. Methods PubMed, Embase, and Cochrane Library were searched. The retrieval period was from the establishment of the database to February 2019. Two investigators independently screened articles according to the inclusion and exclusion criteria. The quality of article was assessed by the Newcastle-Ottawa scale (NOS). The meta-analysis was performed by Stata 15.0 software. Results Four observational studies were included, with a total of 347 newborns. The overall mortality at hospital charge was 12% (5% - 18%) with a heterogeneity of I2 = 73.8% (p = 0.01). Two studies reported mortality during ECMO and after decannulation, with 10% (0.8% -19.2%) and 6.1% (2.6% - 9.6%) respectively. The most common complications associated with venovenous ECMO were: pneumothorax (20.6%), hypertension (20.4%), cannula dysfunction (20.2%), seizure (14.9%), renal failure requiring hemofiltration (14.7%), infectious complications (10.3%), thrombi (7.4%), intracranial hemorrhage or infarction (6.6%), hemolysis (5.3%), cannula site bleeding (4.4%), gastrointestinal bleeding (3.7%), oxygenator failure (2.8%), other bleeding events (2.8%), brain death (1.9%), and myocardial stun (0.9%). Conclusion The overall mortality at discharge of venovenous ECMO in the treatment of neonatal respiratory failure was 12%. Although complications are frequent, the survival rate during hospitalization is still high. Further larger samples, and higher quality of randomized controlled trials (RCT) are needed to clarify the efficacy and safety of this technique in the treatment of neonatal respiratory failure.

scholarly journals Anti-Xa versus time-guided anticoagulation strategies in extracorporeal membrane oxygenation: a systematic review and meta-analysis

Perfusion ◽  
2020 ◽  
pp. 026765912095298
Author(s):  
Ariane Willems ◽  
Peter P Roeleveld ◽  
Sonia Labarinas ◽  
John W Cyrus ◽  
Jennifer A Muszynski ◽  
...  
Keyword(s):  
Systematic Review ◽  
Mortality Rate ◽  
Extracorporeal Membrane Oxygenation ◽  
Observational Studies ◽  
Meta Analysis ◽  
Lower Mortality ◽  
Bleeding Events ◽  
Membrane Oxygenation ◽  
Significant Difference

The purpose was to compare time-based vs anti-Xa-based anticoagulation strategies in patients on ECMO. We conducted a systematic review and meta-analysis using multiple electronic databases and included studies from inception to July 19, 2019. The proportion of bleeding, thrombosis, and mortality were evaluated. Twenty-six studies (2,086 patients) were included. Bleeding occurred in 34.2% (95%CI 25.1;43.9) of the patients with anti-Xa-based versus 41.6% (95%CI 24.9;59.4) of the patients with time-based anticoagulation strategies. Thrombosis occurred in 32.6% (95%CI 19.1;47.7) of the patients with anti-Xa-based versus 38.4% (95%CI 22.2;56.1) of the patients with time-based anticoagulation strategies. And mortality rate was 35.4% (95%CI 28.9;42.1) of the patients with anti-Xa-based versus 42.9% (95%CI 36.9;48.9) of the patients with time-based anticoagulation strategies. Among the seven studies providing results from both anticoagulation strategies, significantly fewer bleeding events occurred in the anti-Xa-based anticoagulation strategy (adjusted OR 0.49 (95%CI 0.32;0.74), p < 0.001) and a significantly lower mortality rate (adjusted OR 0.61 (95%CI 0.40;0.95), p = 0.03). There was no significant difference in thrombotic events (adjusted OR 0.91 (95%CI 0.56;1.49), p = 0.71). In these seven observational studies, only a small fraction of the patients were adults, and data were insufficient to analyze the effect of the type of ECMO. In this meta-analysis of observational studies of patients on ECMO, an anti-Xa-based anticoagulation strategy, when compared to a time-based strategy, was associated with fewer bleeding events and mortality rate, without an increase in thrombotic events.

Congenital Factor XIII Deficiency as Cause for Intracraneal Hemorrhage.

Blood ◽  
2009 ◽  
Vol 114 (22) ◽  
pp. 4208-4208
Author(s):  
Maria Angeles Dasi ◽  
Bienvenida Argiles ◽  
Ana R Cid ◽  
M. Carmen Carreras ◽  
J. Antonio Aznar ◽  
...  
Keyword(s):  
Umbilical Cord ◽  
Subdural Hematoma ◽  
Factor Xiii ◽  
Conflicts Of Interest ◽  
Hemorrhagic Diathesis ◽  
Minor Trauma ◽  
Factor Xiii Deficiency ◽  
Coagulation Tests ◽  
Fxiii Deficiency ◽  
Congenital Factor

Abstract Abstract 4208 Severe congenital factor XIII (FXIII) deficiency is an autosomal recessive disease of with a low prevalence in the general population (3-5 cases per million), associated with generally severe hemorrhagic diathesis, where the presence of intracraneal hemorrhage (ICH) is much higher than in other coagulopathologies such as hemophilia A or B. However, the basic coagulation tests are normal, which could delay the diagnosis. We present three cases of severe congenital FXIII deficiency (not diagnosed when referred to our center) with severe hemorrhagic pathology. These patients had normal basic coagulation tests and did not have a family bleeding history. The table show the results. Table Patient 1 Patient 2 Patient 3 Date of birth 1959 1978 2006 Sex Female Female Female Age at diagnosis 15 years old 12 years old 18 months old Cause of patient remission Ankle hemarthrosis Seizures Subdural hematoma Subdural hematoma Prior hemorrhagic history -umbilical cord bleeding-frontal hematoma requiring surgical management at 12 months-bleeding with dentition -umbilical cord bleeding-hematoma in buttock requiring RBC transfusion for anemia.-hemarthrosis in both knees -umbilical cord bleeding-growing cephalohematoma until 3rd week of life-hematoma by venipuncture lasting 2-3 weeks at 6 months.-delayed healing-Subdural hematoma after minor trauma 3 days prior. basic coagulation tests (PT, APTT, TT, fibrinogen) Normal Normal Normal Level of functional FXIII <1% < 5 % < 5 % Initial treatment Plasma Plasma FXIII concentrate Prophylaxis -Plasma: 2 Units every 6 weeks -FXIII concentrate every 4 weeks (since 1994) FXIII concentrate every 4 weeks FXIII concentrate every 3 weeks Evolution Major ICH at 30 years old. (had suspended prophylactic treatment in1989) Favorable evolution without consequences. Favorable evolution without consequences. COMMENTS Congenital Factor XIII deficiency, although infrequent, should be included in the differential diagnosis of hemorrhagic processes with normal coagulation tests, especially if triggered spontaneously or in a disproportionate manner (in quantity and/or duration). Bleeding of the umbilical cord in the first days or weeks after birth is characteristic of this deficiency (present in 80% of cases). The prophylactic administration of Factor XIII is fundamental due to the frequency of intracranial hemorrhaging. Disclosures: No relevant conflicts of interest to declare.

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