CP-031 Influence of administration of antithrombin concentrate in children on heparin infusion rate during extracorporeal membrane oxygenation

Background: Anticoagulation monitoring practices vary during extracorporeal membrane oxygenation (ECMO). The Extracorporeal Life Support Organization describes that a multimodal approach is needed to overcome assay limitations and minimize complications. Objective: Compare activated clotting time (ACT) versus multimodal approach (activated partial thromboplastin time (aPTT)/anti-factor Xa) for unfractionated heparin (UFH) monitoring in adult ECMO patients. Methods: We conducted a single-center retrospective pre- (ACT) versus post-implementation (multimodal approach) study. The incidence of major bleeding and thrombosis, blood product and antithrombin III (ATIII) administration, and UFH infusion rates were compared. Results: Incidence of major bleeding (69.2% versus 62.2%, p = 0.345) and thrombosis (23% versus 14.9%, p = 0.369) was similar between groups. Median number of ATIII doses was reduced in the multimodal group (1.0 [IQR 0.0-2.0] versus 0.0 [0.0 -1.0], p = 0.007). The median UFH infusion rate was higher in the ACT group, but not significant (16.9 [IQR 9.6-22.4] versus 13 [IQR 9.6-15.4] units/kg/hr, p = 0.063). Fewer UFH infusion rate changes occurred prior to steady state in the multimodal group (0.9 [IQR 0.3 -1.7] versus 0.1 [IQR 0.0-0.2], p < 0.001). Conclusion: The incidence of major bleeding and thrombosis was similar between groups. Our multimodal monitoring protocol standardized UFH infusion administration and reduced ATIII administration.

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Extracorporeal membrane oxygenation (ECMO) for COVID-19 patients

Clinical Critical Care ◽

10.54205/ccc.v29i.252413 ◽

2021 ◽

Author(s):

Surat Tongyoo ◽

Suneerat Kongsayreepong

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Ecmo Support ◽

Janus Kinase ◽

Systemic Steroid ◽

Heparin Infusion ◽

Membrane Oxygenation ◽

Rescue Treatment ◽

Threatening Condition ◽

Life Threatening ◽

The Individual

During the current outbreak of coronavirus disease 2019 (COVID-19), Extracorporeal Membrane Oxygenation (ECMO) support could be considered as the rescue treatment from life threatening condition among severe COVID-19 patients who did not respond to mechanical ventilation. We propose that veno-venous ECMO should be considered if patient has persistence PaO2:FiO2 ratio lower than 100 mmHg after appropriate mechanical ventilator adjustment, muscle relaxant and prone position. During ECMO support, treatment against cytokine storm, including non-selective immune suppression with systemic steroid, or selective interleukin-6 inhibition and Janus Kinase inhibition should be considered. Heparin infusion is still the recommended anticoagulant to maintain activated partial thromboplastin time (APTT) ratio range 1.5-2.0. The overall hospital mortality was comparable with respiratory failure patients, requiring ECMO support from other causes, which was reported about 37-50%. The decision to initiate ECMO could be depended on the individual hospital capacity and treatment availability.

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Antithrombin III infusion improves anticoagulation in congenital diaphragmatic hernia patients on extracorporeal membrane oxygenation

Perfusion ◽

10.1177/02676591211063805 ◽

2021 ◽

pp. 026765912110638

Author(s):

Tanya Perry ◽

Brandon Henry ◽

David S Cooper ◽

Sundeep G Keswani ◽

Kimberly S Burton ◽

...

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Congenital Diaphragmatic Hernia ◽

Continuous Infusion ◽

Diaphragmatic Hernia ◽

Antithrombin Iii ◽

Factor Xa ◽

Heparin Infusion ◽

Membrane Oxygenation ◽

At Iii ◽

Life Threatening

Purpose Achieving effective anticoagulation during neonatal extracorporeal membrane oxygenation (ECMO) without increasing the risk of hemorrhage remains challenging. The use of antithrombin III (AT-III) for this purpose has been examined, but studies have been limited to intermittent bolus dosing. We aimed to evaluate the efficacy and safety of an institutionally developed AT-III continuous infusion protocol in neonates receiving ECMO for the treatment of congenital diaphragmatic hernia (CDH). Methods In this single center, retrospective study, all neonates with a CDH who received ECMO support during the study period were included. Data on anticoagulation labs and therapy, life-threatening bleeding, and circuit changes were analyzed. Results Eleven patients were divided into two groups: patients with AT-III continuous infusion ( n = 5) and without ( n = 6). There were no differences in the gestational age ( p = 0.29), sex ( p = 1.00), ECMO duration ( p = 0.59), or initial AT-III levels ( p = 0.76) between groups. Patients in the AT-III infusion group had on average 18.5% higher AT-III levels ( p < 0.0001). Patients receiving continuous AT-III infusions spent a significantly higher percentage of ECMO time within the therapeutic range, measured using anti-Factor Xa levels (64.9±4.2% vs. 29.1±8.57%, p = 0.008), and required fewer changes to the heparin infusion rate (6.48±0.88 vs 2.38±0.36 changes/day changes/day, p = 0.005). Multivariate analysis revealed continuous infusion of AT-III did not increase the rate of intracranial or surgical bleeding ( p = 0.27). Conclusion AT-III as a continuous infusion in CDH neonates on ECMO provides a decreased need to modify heparin infusion and more consistent therapeutic anticoagulation without increasing the risk of life-threatening bleeding.

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Antithrombin supplementation in adult patients receiving extracorporeal membrane oxygenation

Perfusion ◽

10.1177/0267659119856229 ◽

2019 ◽

Vol 35 (1) ◽

pp. 66-72 ◽

Cited By ~ 6

Author(s):

Matthew J Morrisette ◽

Amanda Zomp-Wiebe ◽

Katherine L Bidwell ◽

Steven P Dunn ◽

Michael G Gelvin ◽

...

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Unfractionated Heparin ◽

Adult Patients ◽

Bleeding Events ◽

Median Percentage ◽

Heparin Infusion ◽

Antithrombin Activity ◽

Membrane Oxygenation ◽

Number Of Patients ◽

Increased Risk

Introduction: Extracorporeal membrane oxygenation is associated with an increased risk of thrombosis and hemorrhage. Acquired antithrombin deficiency often occurs in patients receiving extracorporeal membrane oxygenation, necessitating supplementation to restore adequate anticoagulation. Criteria for antithrombin supplementation in adult extracorporeal membrane oxygenation patients are not well defined. Methods: In this retrospective observational study, adult patients receiving antithrombin supplementation while supported on extracorporeal membrane oxygenation were evaluated. Antithrombin was supplemented when anti-Xa levels were subtherapeutic with unfractionated heparin infusion rates of 15-20 units/kg/h and measured antithrombin activity <50%. Patients were evaluated for changes in degree of anticoagulation and signs of bleeding 24 hours pre- and post-antithrombin supplementation. Results: A total of 14 patients received antithrombin supplementation while on extracorporeal membrane oxygenation. The median percentage of time therapeutic anti-Xa levels were maintained was 0% (0-43%) and 40% (9-84%) in the pre-antithrombin and post-antithrombin groups, respectively (p = 0.13). No difference was observed in the number of patients attaining a single therapeutic anti-Xa level (pre-antithrombin = 6, post-antithrombin = 13; p = 0.37) or unfractionated heparin infusion rate (pre-antithrombin = 7.35 (1.95-10.71) units/kg/h, post-antithrombin = 6.81 (3.45-12.58) units/kg/h; p = 0.33). Thirteen patients (92%) achieved an antithrombin activity at goal following supplementation. Antithrombin activity was maintained within goal range 52% of the time during the replacement period. Four bleeding events occurred pre-antithrombin and 10 events post-antithrombin administration (p = 0.26) with significantly more platelets administered post-antithrombin (pre-antithrombin = 0.5 units, post-antithrombin = 4.5 units; p = 0.01). Conclusion: Therapeutic anticoagulation occurred more frequently following antithrombin supplementation; however, this difference was not statistically significant. More bleeding events occurred following antithrombin supplementation while observing an increase in platelet transfusions.

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Pilot study evaluating a non-titrating, weight-based anticoagulation scheme for patients on veno-venous extracorporeal membrane oxygenation

Perfusion ◽

10.1177/0267659119850024 ◽

2019 ◽

Vol 35 (1) ◽

pp. 13-18 ◽

Cited By ~ 3

Author(s):

Kristopher B Deatrick ◽

Samuel M Galvagno ◽

Michael A Mazzeffi ◽

David J Kaczoroswki ◽

Daniel L Herr ◽

...

Keyword(s):

Pilot Study ◽

Extracorporeal Membrane Oxygenation ◽

Peak Inspiratory Pressure ◽

Bleeding Complications ◽

Heparin Infusion ◽

Exact Test ◽

Membrane Oxygenation ◽

Thrombotic Complications ◽

Secondary Outcomes ◽

Titration Algorithm

Objective: There is no universally accepted algorithm for anticoagulation in patients on veno-venous extracorporeal membrane oxygenation. The purpose of this pilot study was to compare a non-titrating weight-based heparin infusion to that of a standard titration algorithm. Methods: We performed a prospective randomized non-blinded study of patients: Arm 1—standard practice of titrating heparin to activated partial thromboplastin times goal of 45-55 seconds, and Arm 2—a non-titrating weight-based (10 units/kg/h) infusion. Primary outcome was need for oxygenator/circuit changes. Secondary outcomes included differences in hemolysis and bleeding episodes. Descriptive statistics were performed for the continuous data, and primary and secondary outcomes were compared using Fisher’s exact test as appropriate. Results: Six patients were randomized to Arm 1 and four to Arm 2. There was no difference in age, pH, PaO2/FiO2 ratio, peak inspiratory pressure, positive end expiratory pressure, mean airway pressure at time of cannulation, time on extracorporeal membrane oxygenation, or survival to hospital discharge in the two arms. Arm 1 had a statistically higher median activated partial thromboplastin times (48 (43, 52) vs 38 (35, 42), p < 0.008) and lower LDH (808 units/L (727, 1112) vs 940 units/L (809, 1137), p = 0.02) than Arm 2. There was no difference in plasma hemoglobin (4.3 (2.5, 8.7) vs 4.3 (3.0, 7.3), p = 0.65) between the two arms. There was no difference in mean oxygenator/circuit change, transfused packed red blood cell, or documented bleeding complications per patient in each arm (p = 0.56, 0.43, 0.77, respectively). Conclusion: In this pilot study, a non-titrating, weight-based heparin infusion appears safe and as effective in preventing veno-venous extracorporeal membrane oxygenation circuit thrombotic complications as compared to a titration algorithm. Larger studies are needed to confirm these preliminary findings.

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Use of Thromboelastogram in Venovenous Extracorporeal Membrane Oxygenation for a Patient with Pulmonary Hemorrhage due to Microscopic Polyangiitis

Case Reports in Critical Care ◽

10.1155/2019/7241264 ◽

2019 ◽

Vol 2019 ◽

pp. 1-3 ◽

Cited By ~ 1

Author(s):

Chak-Kwan Tong ◽

Jun Jin ◽

Qian Du

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Microscopic Polyangiitis ◽

Pulmonary Hemorrhage ◽

Activated Partial Thromboplastin Time ◽

Clotting Time ◽

Heparin Dose ◽

Heparin Infusion ◽

Membrane Oxygenation ◽

Activated Clotting Time ◽

Venovenous Extracorporeal Membrane Oxygenation

Systemic heparinisation is required for extracorporeal membrane oxygenation therapy, to prevent clotting of circuit and formation of thrombus in patient. Activated clotting time (ACT) or activated partial thromboplastin time (aPTT) has been the mainstay of monitoring of heparin dose. Thromboelastogram (TEG) is increasingly being used again in recent years with the advancement in technology. Its clinical usefulness in the monitoring of anticoagulation of ECMO therapy is demonstrated in the case presented. Our patient suffered from severe hemoptysis due to active microscopic polyangiitis and respiratory failure. Heparin infusion was given at the initiation of ECMO support without further aggravation of hemoptysis. Dose of heparin was adjusted successfully with the integration of the clotting profile and TEG results.

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Exogenous supplementation of antithrombin III in adult and pediatric patients receiving extracorporeal membrane oxygenation

The International Journal of Artificial Organs ◽

10.1177/0391398819888932 ◽

2019 ◽

Vol 43 (5) ◽

pp. 315-322 ◽

Cited By ~ 1

Author(s):

Mark N Sorial ◽

Rebecca A Greene ◽

Andrew R Zullo ◽

Christine Berard-Collins ◽

Steve Willis

Keyword(s):

Standard Deviation ◽

Extracorporeal Membrane Oxygenation ◽

Antithrombin Iii ◽

P Value ◽

Heparin Infusion ◽

Membrane Oxygenation ◽

Heparin Resistance ◽

Heparin Anticoagulation ◽

Antithrombin Iii Deficiency ◽

Antithrombin Iii Activity

Background: Antithrombin III deficiency can occur with heparin anticoagulation during extracorporeal membrane oxygenation leading to heparin resistance. Antithrombin III supplementation has been shown to improve anticoagulation; however, there is no consensus on appropriate administration. We described the effect of antithrombin III supplementation on coagulation parameters in adult and pediatric extracorporeal membrane oxygenation patients. Methods: We conducted a retrospective cohort study using electronic medical records of patients who received ⩾1 dose of antithrombin III during extracorporeal membrane oxygenation while on continuous heparin. Endpoints included the change in anti-Xa levels and antithrombin III activity at −6 versus 6 h relative to antithrombin III supplementation, and heparin infusion rates at 6 versus 12 h after antithrombin III supplementation. Results: Eighteen patients receiving 36 antithrombin III administrations were analyzed. Mean (standard deviation) anti-Xa values at −6 versus 6 h were 0.15 (0.07) versus 0.24 (0.15) IU/mL ( p-value: 0.250) for pediatrics and 0.19 (0.22) versus 0.31 (0.27) IU/mL ( p-value: 0.052) for adults. Mean (standard deviation) plasma antithrombin III activity at the same intervals were 32% (14.2%) versus 66.8% (25.1%; p-value: 0.062) for pediatrics and 30.3% (14%) versus 52.8% (8.1%; p-value: 0.094) for adults. Mean (standard deviation) heparin rates at 6 versus 12 h after antithrombin III for pediatrics were 23.6 (6) versus 23.5 (6.5) units/kg/h ( p-value: 0.728), and 15.3 (6.6) versus 13.5 (8) units/kg/h ( p-value: 0.188) for adults. Conclusion: Administration of antithrombin III improved anti-Xa levels in both populations, however, did not significantly reduce heparin rates. Our findings suggest that the use of antithrombin III restores heparin responsiveness in patients with low antithrombin III activity and low anti-Xa activity.

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