Thrombopoietin, Soluble CD40 Ligand, and Platelet Count During Veno-arterial Extracorporeal Membrane Oxygenation

Introduction: Extracorporeal membrane oxygenation (ECMO) is used to provide circulatory support and facilitate gas exchange via cardiopulmonary bypass. The relationship between ECMO and the incidence of severe thrombocytopenia (platelet count <50 x 10 9 /L) and subsequent clinical consequences are ill defined. We aimed to identify the risk factors for the development of thrombocytopenia and its clinical implications. Methods: This is a single-center retrospective cohort study of adults who received venoarterial (VA) ECMO. We examined consecutive platelet counts while on ECMO. Univariate logistic regression was used to determine if mean platelet count, platelet count range, or severe thrombocytopenia were predictors of overall survival, hemorrhage and thrombosis. A multivariate logistic regression model was used to identify factors that contribute to the development of the aforementioned patient outcomes. Results: In our cohort, 33 patients were included with a mean age of 55 years and duration of ECMO of 5.9 days. All patients received heparin, 33.3% received antiplatelet therapy and 45.5% developed severe thrombocytopenia. In univariate, analysis the development of severe thrombocytopenia increased the odds of major bleeding by 450% (OR 5.500, 95% CI 1.219 - 24.813, P -value 0.027), and the odds of surviving hospitalization decreased 84.1% (OR 0.159, 95% CI 0.033 - 0.773, P -value 0.023). Multivariate logistic regression controlling for additional clinical variables found no significant association between the development of severe thrombocytopenia and rates of thrombosis, hemorrhage, or overall survival. Platelet count decreased over time while on ECMO. Conclusions: Nearly half of the patients requiring VA-ECMO developed severe thrombocytopenia, which was associated with an increased risk of hemorrhage and in-hospital mortality. Additional studies are required to clarify the clinical implications of severe thrombocytopenia in ECMO patients.

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Platelet Count and Function during Pediatric Extracorporeal Membrane Oxygenation

Seminars in Thrombosis and Hemostasis ◽

10.1055/s-0040-1708542 ◽

2020 ◽

Vol 46 (03) ◽

pp. 357-365

Author(s):

Katherine Cashen ◽

Kathleen Meert ◽

Heidi J. Dalton

Keyword(s):

Platelet Count ◽

Extracorporeal Membrane Oxygenation ◽

Life Support ◽

Bleeding Risk ◽

Platelet Dysfunction ◽

Cardiorespiratory Failure ◽

Form Of Life ◽

Membrane Oxygenation ◽

And Function ◽

Count Function

AbstractExtracorporeal membrane oxygenation (ECMO) is a form of life support used to treat neonates, children, and adults with cardiorespiratory failure refractory to conventional therapy. This therapy requires the use of anticoagulation to prevent clotting in the extracorporeal circuit, but anticoagulation also increases the risk of bleeding on ECMO. Both bleeding and thrombosis remain significant complications on ECMO and balancing these risks is challenging. Acquired platelet dysfunction is common during ECMO and quantitative and qualitative platelet dysfunction contributes to bleeding risk. Optimal platelet count, function, and transfusion thresholds are not well established during pediatric ECMO. In this review, we provide an overview of hemostatic alterations during ECMO, changes in platelet count and function, platelet monitoring techniques, bleeding risk, and future needs to best optimize patient management and care.

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Intracranial hemorrhage in adult patients on venoarterial extracorporeal membrane oxygenation

European Heart Journal Acute Cardiovascular Care ◽

10.1093/ehjacc/zuab020.153 ◽

2021 ◽

Vol 10 (Supplement_1) ◽

Author(s):

E Luesebrink ◽

S Massberg ◽

M Orban

Keyword(s):

Diabetes Mellitus ◽

Platelet Count ◽

Clinical Outcome ◽

Extracorporeal Membrane Oxygenation ◽

Intracranial Hemorrhage ◽

Adult Patients ◽

Membrane Oxygenation ◽

Venoarterial Extracorporeal Membrane Oxygenation ◽

Multivariable Regression ◽

Va Ecmo

Abstract Funding Acknowledgements Type of funding sources: None. Purpose Intracranial hemorrhage (ICH) is one of the most serious complications of adult patients treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO) and is associated with increased morbidity and mortality. However, the prevalence and risk factors of ICH in this cohort are still insufficiently understood. Therefore, the purpose of this study was to further investigate prevalence, associated mortality and predictors of ICH in VAECMO patients. Methods We conducted a retrospective multicenter study including adult patients (≥18 years) treated with VA-ECMO in cardiac intensive care units (ICUs) at five clinical sites between January 2016 and March 2020, excluding patients with ICH upon admission. Differences in baseline characteristics and clinical outcome between VA-ECMO patients with and without ICH were analysed. Predictors of ICH were identified by uni- and multivariable regression models. Results Among 598 patients included, 70 (12%) developed ICH during VA-ECMO treatment with mean duration of 82 ± 84h between ECMO initiation and ICH diagnosis. Out of these ICH, 23% were intraparenchymal, 20% subarachnoid, 10% subdural, 3% intraventricular and 44% combined hemorrhage. In-hospital mortality in the ICH cohort was 81% and 1-month mortality 86%, compared to 63% (p = 0.002) and 64% (p < 0.001), respectively, in the non-ICH cohort. In a multivariable regression model, ICH was independently associated with diabetes mellitus (Odds Ratio [OR] 1.952, 95% confidence interval [CI] [1.082, 3.492], p = 0.025), platelet count (OR 0.990, 95% CI [0.982, 0.996], p = 0.003) and fibrinogen (OR 0.996, 95% CI [0.993, 0.998], p = 0.002). Conclusion ICH occurred frequently in VA-ECMO patients and was associated with a significantly higher mortality rate. Diabetes mellitus, low platelet count and low fibrinogen level are independent predictors of ICH. These findings may help to develop effective strategies to prevent and treat ICH and build the basis for further investigations to optimize clinical outcome in patients on VA-ECMO.

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The Relative Early Decrease in Platelet Count Is Associated With Mortality in Post-cardiotomy Patients Undergoing Venoarterial Extracorporeal Membrane Oxygenation

Frontiers in Medicine ◽

10.3389/fmed.2021.733946 ◽

2021 ◽

Vol 8 ◽

Author(s):

Liangshan Wang ◽

Juanjuan Shao ◽

Chengcheng Shao ◽

Hong Wang ◽

Ming Jia ◽

...

Keyword(s):

Platelet Count ◽

Extracorporeal Membrane Oxygenation ◽

Hospital Mortality ◽

Cardiogenic Shock ◽

Characteristic Curve ◽

Membrane Oxygenation ◽

Venoarterial Extracorporeal Membrane Oxygenation ◽

Relative Decrease ◽

Va Ecmo ◽

The Relationship

Background: The relationship between the magnitude of platelet count decrease and mortality in post-cardiotomy cardiogenic shock (PCS) patients undergoing venoarterial extracorporeal membrane oxygenation (VA-ECMO) has not been well-reported. This study was designed to evaluate the association between the relative decrease in platelet count (RelΔplatelet) at day 1 from VA-ECMO initiation and in-hospital mortality in PCS patients.Methods: Patients (n = 178) who received VA-ECMO for refractory PCS between January 2016 and December 2018 at the Beijing Anzhen Hospital were reviewed retrospectively. Multivariable logistic regression analyses were performed to assess the association between RelΔplatelet and in-hospital mortality.Results: One hundred and sixteen patients (65%) were weaned from VA-ECMO, and 84 patients (47%) survived to hospital discharge. The median [interquartile range (IQR)] time on VA-ECMO support was 5 (3–6) days. The median (IQR) RelΔ platelet was 41% (26–59%). Patients with a RelΔ platelet ≥ 50% had an increased mortality compared to those with a RelΔ platelet < 50% (57 vs. 37%; p < 0.001). A large RelΔplatelet (≥50%) was independently associated with in-hospital mortality after controlling for potential confounders (OR 8.93; 95% CI 4.22–18.89; p < 0.001). The area under the receiver operating characteristic curve for RelΔ platelet was 0.78 (95% CI, 0.71–0.85), which was better than that of platelet count at day 1 (0.69; 95% CI, 0.61–0.77).Conclusions: In patients receiving VA-ECMO for post-cardiotomy cardiogenic shock, a large relative decrease in platelet count in the first day after ECMO initiation is independently associated with an increased in-hospital mortality.

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Oseltamivir Improved Thrombocytopenia During Veno-Arterial Extracorporeal Membrane Oxygenation in Adults With Refractory Cardiac Failure: A Single-Center Retrospective Real-World Study

Frontiers in Cardiovascular Medicine ◽

10.3389/fcvm.2021.645867 ◽

2021 ◽

Vol 8 ◽

Author(s):

Yuan Li ◽

Lin Wang ◽

Jianning Zhang ◽

Hui Han ◽

Han Liu ◽

...

Keyword(s):

Platelet Count ◽

Extracorporeal Membrane Oxygenation ◽

Cardiac Failure ◽

Real World ◽

Severe Thrombocytopenia ◽

Single Center ◽

Membrane Oxygenation ◽

Significant Difference ◽

Va Ecmo ◽

Cox Analysis

Background: Severe thrombocytopenia is a common complication of extracorporeal membrane oxygenation (ECMO). Oseltamivir can be used to treat infection-associated thrombocytopenia.Objective: To evaluate the effect of oseltamivir on attenuating severe thrombocytopenia during ECMO.Methods: This was a single-center real-world study in critically ill patients supported with venous-arterial extracorporeal membrane oxygenation (VA-ECMO). Patients suspected or confirmed with influenza received oseltamivir according to the Chinese guidelines. Thrombocytopenia and survival were compared between the oseltamivir-treated and untreated group. The factors associated with survival were analyzed by multivariable Cox analysis.Results: A total of 82 patients were included. All patients developed thrombocytopenia after initiating VA-ECMO. Twenty-three patients received oseltamivir (O+ group), and 59 did not use oseltamivir (O− group). During the first 8 days after VA-ECMO initiation, the platelet count in the O+ group was higher than that in the O− group (all P < 0.05). The patients in the O+ group had a higher median nadir platelet count (77,000/μl, 6,000–169,000/μl) compared with the O− group (49,000/μl, 2,000–168,000/μl; P = 0.04). A nadir platelet count of <50,000/μl was seen in 26% of the patients in the O+ group, compared with 53% in the O− group (P = 0.031). No significant difference in survival from cardiac failure was seen between the O+ and O− group (48 vs. 56%, P = 0.508). The Sequential Organ Failure Assessment (SOFA) score on initiation of VA-ECMO were independently associated with survival (OR = 1.12, 95% confidence interval (95% CI): 1.02–1.22, P = 0.015).Conclusions: Oseltamivir could ameliorate VA-ECMO-related thrombocytopenia. These findings suggested the prophylactic potential of oseltamivir on severe thrombocytopenia associated with the initiation of VA-ECMO.

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Heparin-induced thrombocytopenia in patients on extracorporeal membrane oxygenation and the role of a heparin-bonded circuit

Perfusion ◽

10.1177/0267659119842056 ◽

2019 ◽

Vol 34 (7) ◽

pp. 584-589 ◽

Cited By ~ 4

Author(s):

Dirk Pabst ◽

Jacqueline B Boone ◽

Behzad Soleimani ◽

Christoph E Brehm

Keyword(s):

Overall Survival ◽

Platelet Count ◽

Retrospective Study ◽

Extracorporeal Membrane Oxygenation ◽

Serotonin Release ◽

Single Center ◽

Heparin Induced Thrombocytopenia ◽

Membrane Oxygenation ◽

Release Assay

Background: In patients supported with extracorporeal membrane oxygenation, and who develop heparin-induced thrombocytopenia, there is no clear evidence to support changing to a non-heparin-coated extracorporeal membrane oxygenation circuit. Our goal was to evaluate clinical outcomes of patients who were continued on heparin-bonded circuits despite diagnosed heparin-induced thrombocytopenia. Methods: We completed a single-center retrospective study of all patients who underwent extracorporeal membrane oxygenation support from July 2008 to July 2017 and were tested heparin-induced thrombocytopenia positive while on extracorporeal membrane oxygenation support. After diagnosis of heparin-induced thrombocytopenia, mean platelet count (k/µL) was measured on consecutive days for 14 days. Results: Out of 455 patients, 14 (3.1%) had a diagnosis of heparin-induced thrombocytopenia by serotonin release assay and systemic heparin treatment was discontinued in every case. In total, 11 of the heparin-induced thrombocytopenia patients (78.6%) survived to discharge. The overall survival of all 455 extracorporeal membrane oxygenation patients was 54.1%. Platelets counts after discontinuation of systemic heparin in the heparin-induced thrombocytopenia patients increased from a mean of 59.8 k/µL at time of heparin-induced thrombocytopenia diagnosis to a mean of 280.2 k/µL at 14 days after discontinuation of heparin despite continuation of the heparin-bonded circuit. Platelet count increased in heparin-induced thrombocytopenia patients on extracorporeal membrane oxygenation support after discontinuation of systemic heparin even if maintained on the heparin-bonded circuit. Conclusion: Discontinuation of systemic heparin but continuation of heparin-coated extracorporeal membrane oxygenation circuits appeared to be an appropriate response for our extracorporeal membrane oxygenation–supported patients who developed heparin-induced thrombocytopenia. Survival in this group was not significantly different to those patients on extracorporeal membrane oxygenation without heparin-induced thrombocytopenia. Larger studies should evaluate the safety of heparin-bonded extracorporeal membrane oxygenation systems in heparin-induced thrombocytopenia patients.

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