scholarly journals Anticoagulation Practices Using Activated Clotting Time in Veno-Venous Extracorporeal Membrane Oxygenation for Patients with Respiratory Failure: A Systematic Review and Met-Analysis

Blood ◽  
2021 ◽  
Vol 138 (Supplement 1) ◽  
pp. 2137-2137
Author(s):  
Kanak Parmar ◽  
Wasawat Vutthikraivit ◽  
Amritpal Singh ◽  
Christina Morataya ◽  
Gaspar Del Rio Pertuz ◽  
...  
Keyword(s):  
Respiratory Failure ◽  
Extracorporeal Membrane Oxygenation ◽  
Risk Ratio ◽  
Bleeding Complications ◽  
Cochrane Central Register ◽  
Clotting Time ◽  
Membrane Oxygenation ◽  
Activated Clotting Time ◽  
Bedside Test ◽  
Vv Ecmo

Abstract Background Veno-Venous Extracorporeal Membrane Oxygenation (ECMO) technology provides as a alternative approach in the intensive care of patients with respiratory failure due to varied causes who are not responsive to conventional treatment. As per the 2014 Extracorporeal Life Support Organization (ELSO) guidelines, in order to to maintain circuit patency and minimize thromboembolic complications, anticoagulation is used, but the optimal strategy remains to be defined. Activated clotting time (ACT) is the most utilized bedside test to adjust anticoagulation. Therefore, we performed an extended analysis of all published studies on the incidence of thromboembolic and bleeding events in patients with acute respiratory distress syndrome who were put on ECMO. Methods A comprehensive search of several databases from inception to November 25, 2020, limited to English language and excluding animal studies, was conducted. The databases included Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily, Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus. The studies were classified into low anticoagulation target (ACT<180) or high anticoagulation target (ACT>180). A meta-analysis was performed of all eligible studies with the data on the incidences of thromboembolic and bleeding complications in patients with ARDS on VV-ECMO during different intensities of anticoagulation. Results A total of 6 eligible studies (4 retrospective and 2 case series) were identified, including in total 190 patients for 100 patient years. Our study showed that there is two times higher chances of bleeding when ACT goal is >180 versus a lower ACT range of <180 (Risk ratio 2.07, 95% CI 1.23-3.46, P 0.0056). The incidence of thrombosis did not change in the two group (Risk ratio 1.17, 95% CI 0.45-3, P 0.7516). Conclusions Currently there is a lack of data for anticoagulation strategies during VV-ECMO for patients in respiratory failure. Our study aimed to find an appropriate anticoagulation target for this patient group. The results show that although anticoagulation is required for circuit patency, there is an increased risk of bleeding when higher anticoagulation targets are set. Disclosures No relevant conflicts of interest to declare.

Traumatic respiratory failure and veno-venous extracorporeal membrane oxygenation support

Perfusion ◽  
2021 ◽  
pp. 026765912110128
Author(s):  
Ismael A Salas De Armas ◽  
Bindu Akkanti ◽  
Pratik B Doshi ◽  
Manish Patel ◽  
Sachin Kumar ◽  
...  
Keyword(s):  
Respiratory Failure ◽  
Extracorporeal Membrane Oxygenation ◽  
Injury Severity ◽  
Invasive Mechanical Ventilation ◽  
Ecmo Support ◽  
Trauma Patients ◽  
Membrane Oxygenation ◽  
Trauma Service ◽  
Proper Patient Selection ◽  
Vv Ecmo

Background: Respiratory failure (RF) is a common cause of death and morbid complication in trauma patients. Extracorporeal membrane oxygenation (ECMO) is increasingly used in adults with RF refractory to invasive mechanical ventilation. However, use of ECMO remains limited for this patient population as they often have contraindications for anticoagulation. Study design: Medical records were retroactively searched for all adult patients who were admitted to the trauma service and received veno-venous ECMO (VV ECMO) support between June 2015 and August 2018. Survival to discharge and ECMO-related complications were collected and analyzed. Results: Fifteen patients from a large Level I trauma center met the criteria. The median PaO2/FiO2 ratio was 53.0 (IQR, 27.0–76.0), median injury severity score was 34.0 (IQR, 27.0–43.0), and the median duration of ECMO support was 11 days (IQR, 7.5–20.0). For this cohort, the survival-to-discharge rate was 87% (13/15). The incidence of neurologic complications was 13%, and deep vein thrombosis was reported in two cases (13%). Conclusions: Survival rates of trauma patients in this study are equivalent to, or may exceed, those of non-trauma patients who receive ECMO support for other types of RF. With the employment of a multidisciplinary team assessment and proper patient selection, early cannulation, traumatic RF may be safely supported with VV ECMO in experienced centers.

Venovenous Extracorporeal Membrane Oxygenation in Pediatric Respiratory Failure

2016 ◽  
Vol 82 (9) ◽  
pp. 787-788 ◽  
Author(s):  
P. Benson Ham ◽  
Brice Hwang ◽  
Linda J. Wise ◽  
K. Christian Walters ◽  
Walter L. Pipkin ◽  
...  
Keyword(s):  
Respiratory Failure ◽  
Extracorporeal Membrane Oxygenation ◽  
Pediatric Patients ◽  
Oxygenation Index ◽  
Lung Damage ◽  
Positive Pressure ◽  
Membrane Oxygenation ◽  
Short Run ◽  
Va Ecmo ◽  
Vv Ecmo

Conventional treatment of respiratory failure involves positive pressure ventilation that can worsen lung damage. Extracorporeal membrane oxygenation (ECMO) is typically used when conventional therapy fails. In this study, we evaluated the use of venovenous (VV)-ECMO for the treatment of severe pediatric respiratory failure at our institution. A retrospective analysis of pediatric patients (age 1–18) placed on ECMO in the last 15 years (1999–2014) by the pediatric surgery team for respiratory failure was performed. Five pediatric patients underwent ECMO (mean age 10 years; range, 2–16). All underwent VV-ECMO. Diagnoses were status asthmaticus (2), acute respiratory distress syndrome due to septic shock (1), aspergillus pneumonia (1), and respiratory failure due to parainfluenza (1). Two patients had severe barotrauma prior to ECMO initiation. Average oxygenation index (OI) prior to cannulation was 74 (range 23–122). No patients required conversion to VA-ECMO. The average ECMO run time was 4.4 days (range 2–6). The average number of days on the ventilator was 15 (range 4–27). There were no major complications due to the procedure. Survival to discharge was 100%. Average follow up is 4.4 years (range 1–15). A short run of VV-ECMO can be lifesaving for pediatric patients in respiratory failure. Survival is excellent despite severely elevated oxygen indices. VV-ECMO may be well tolerated and can be considered for severe pediatric respiratory failure.

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

2020 ◽  
Author(s):  
Jing Xiong ◽  
Li Zhang ◽  
Lei Bao
Keyword(s):  
Systematic Review ◽  
Respiratory Failure ◽  
Extracorporeal Membrane Oxygenation ◽  
Meta Analysis ◽  
Cochrane Library ◽  
Membrane Oxygenation ◽  
Complications And Mortality ◽  
Vv Ecmo ◽  
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 (VV ECMO) in the treatment of neonatal respiratory failure, we performed a systematic review and meta-analysis of all the related studies. 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. VV ECMO was used for neonates with refractory respiratory failure unresponsive to maximal medical therapy. Median ages of the newborns at cannulation were 43.2 hours, 23 hours, 19hours, and 71 hours in the included four studies, respectively. The overall mortality at hospital charge was 12% (5%-18%) with a heterogeneity of I 2 =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 VV 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 VV 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 (RCTs) are needed to clarify the efficacy and safety of this technique in the treatment of neonatal respiratory failure.

scholarly journals CRITICAL CARE ECHO ROUNDS: Extracorporeal membrane oxygenation

2015 ◽  
Vol 2 (2) ◽  
pp. D1-D11 ◽  
Author(s):  
Kelly Victor ◽  
Nicholas A Barrett ◽  
Stuart Gillon ◽  
Abigail Gowland ◽  
Christopher I S Meadows ◽  
...  
Keyword(s):  
Respiratory Failure ◽  
Extracorporeal Membrane Oxygenation ◽  
Ventilatory Support ◽  
Ecmo Support ◽  
Respiratory Physiology ◽  
Organ Support ◽  
Septic Cardiomyopathy ◽  
Significant Past Medical History ◽  
Membrane Oxygenation ◽  
Vv Ecmo

Extracorporeal membrane oxygenation (ECMO) is an advanced form of organ support indicated in selected cases of severe cardiovascular and respiratory failure. Echocardiography is an invaluable diagnostic and monitoring tool in all aspects of ECMO support. The unique nature of ECMO, and its distinct effects upon cardio-respiratory physiology, requires the echocardiographer to have a sound understanding of the technology and its interaction with the patient. In this article, we introduce the key concepts underpinning commonly used modes of ECMO and discuss the role of echocardiography.CaseA 38-year-old lady, with no significant past medical history, was admitted to her local hospital with group A Streptococcal pneumonia. Rapidly progressive respiratory failure ensued and, despite intubation and maximal ventilatory support, adequate oxygenation proved impossible. She was attended by the regional severe respiratory failure service who established her on veno-venous (VV)-ECMO for respiratory support. Systemic oxygenation improved; however, significant cardiovascular compromise was encountered and echocardiography demonstrated a severe septic cardiomyopathy (ejection fraction <15%, aortic velocity time integral 5.9 cm and mitral regurgitation dP/dt 672 mmHg/s). Her ECMO support was consequently converted to a veno-veno-arterial configuration, thus providing additional haemodynamic support. As the sepsis resolved, arterial ECMO support was weaned under echocardiographic guidance; subsequent resolution of intrinsic respiratory function allowed the weaning of VV-ECMO support. The patient was liberated from ECMO 7 days after hospital admission.

Extracorporeal membrane oxygenation in carbamate (methomyl) intoxication: systematic review of the literature and case presentation

2020 ◽  
Keyword(s):  
Respiratory Failure ◽  
Extracorporeal Membrane Oxygenation ◽  
Controlled Trial ◽  
Neurological Deficits ◽  
Cochrane Central Register ◽  
Scientific Publications ◽  
Cardiovascular Failure ◽  
Cardiorespiratory Failure ◽  
Organophosphate Intoxication ◽  
Membrane Oxygenation

Background and Objective: Since methomyl shows a highly significant toxicity, the clinical outcome of acute methomyl pesticide intoxication is extremely critical. Methomyl is a kind of carbamate poisons. Similar to intoxications with other carbamate insecticides, methomyl intoxication inhibits the activity of acetylcholinesterase, which is contained within synaptic junctions between neurons. Most of the methomyl intoxication cases present with symptoms of cholinergic excess, which provokes respiratory failure, cardiovascular failure, and/or cardiorespiratory failure. Methomyl poisoning in humans has not yet been fully evaluated and most studies have reported sporadic cases or series of intoxication. Methomyl poisoning remains a continuing challenge, because this difficult-to-treat clinical condition is frequently associated with significantly high mortality and morbidity. We evaluated the usefulness of extracorporeal membrane oxygenation in the treatment of methomyl intoxication. Methods: A systematic literature review was conducted using the PRISMA guidelines without language restriction. We searched for scientific publications via PubMed, Embase, Cochrane central register of controlled trial, Google Scholar, the KoreaMed, and the Research Information Sharing Service database. The goal of this study was to report on incidence, associated complications, and morbidity/mortality of methomyl poisoning, and to draw special attention to its management with extracorporeal membrane oxygenation. Results: Only 1 case of a child treated with extracorporeal membrane oxygenation for carbamate or organophosphate intoxication was identified in the literature. After carbamate or organophosphate intoxication, the patient suffered from severe complications including neurological deficits, renal insufficiency, and severe respiratory failure. This child was treated with continuous hemofiltration and extracorporeal membrane oxygenation, but expired after 38 days of extracorporeal membrane oxygenation. In case of our patient, he recovered from the methomyl intoxication after 7 days of VA-ECMO. Conclusions: With only a few exceptions, acute methomyl poisoning is potentially life-threatening and has high incidences of morbidity and mortality. Therefore, physicians should keep in mind the possibility of extracorporeal membrane oxygenation for the quick support of intoxication. Extracorporeal membrane oxygenation support might be an alternative to overcome the cholinergic excess, such as respiratory failure, cardiovascular failure, and/or cardiorespiratory failure, especially in the case of severe acute methomyl intoxication.

Antithrombin Concentrate Use in Pediatric Extracorporeal Membrane Oxygenation: A Retrospective Cohort Study

Blood ◽  
2012 ◽  
Vol 120 (21) ◽  
pp. 1170-1170
Author(s):  
Trisha E. Wong ◽  
Meghan Delaney ◽  
Terry B. Gernsheimer ◽  
Dana C. Matthews ◽  
Tom Brogan ◽  
...  
Keyword(s):  
Respiratory Failure ◽  
Length Of Stay ◽  
Extracorporeal Membrane Oxygenation ◽  
Hospital Mortality ◽  
Retrospective Cohort ◽  
Bleeding Complications ◽  
Adjusted Relative Risk ◽  
Membrane Oxygenation ◽  
Number Of Patients ◽  
The Impact

Abstract Abstract 1170 BACKGROUND: Many complications, particularly hematological ones, affect the outcome of children on extracorporeal membrane oxygenation (ECMO). In an effort to minimize clotting and bleeding complications, some pediatric ECMO centers administer antithrombin (AT) concentrate to augment heparin's anticoagulant activity. However, the impact on clinical outcomes is unclear. OBJECTIVE: To investigate whether intermittent AT concentrate administration improves outcome in pediatric ECMO patients METHODS: This is a retrospective cohort analysis of 64 youths aged 0 to 21 years who received ECMO for respiratory failure at a single institution between 1/2007 and 9/2011. Subjects either received 1+ dose of plasma-derived AT concentrate (Thrombate III®, Grifols) at the discretion of the attending critical care physician (“AT+” cohort), typically for an AT antigen level <80% with either a high unfractionated heparin (UFH) need or ex vivothrombosis, or did not (“No AT” cohort). Dose was calculated to obtain an AT antigen target level of 120% (IU = [(120-AT level) × weight (kg)]/1.4). AT antigen levels were assayed by an immuno-turbidimetric method (Liatest® ATIII, Stago). Short-term increase in AT antigen levels was the primary endpoint. Secondary endpoints included UFH requirement, number of bleeding and thrombotic complications, number of ECMO circuit changes, length of stay and in-hospital mortality. RESULTS: Of 64 subjects, 30 subjects in the AT+ cohort received a total of 77 AT doses (range 1–8 doses/pt) while the No AT cohort contained 34 subjects. For the AT+ and No AT cohort, respectively: median age was 0.1 (range 0–188) mos. vs 1.7 (0–250) mos. (p=0.21); median first AT level was 50.5% (15–75) vs 54% (19–108, p=0.48); and median ECMO duration was 180 (71–613) hrs vs 146 (44–1,467) hrs (p=0.76). When comparing all AT levels drawn within 12 hrs of a prior measurement, AT antigen was on average 66% in the AT+ cohort compared to 42.2% in the No AT cohort [23.8% higher in AT+; 95% confidence interval (CI), 10.2 – 37.5%], adjusted for age, ECMO duration and first AT level. When comparing only the first AT level drawn within 12 hrs of a prior measurement after an AT dose, AT levels were on average 80.1% in the AT+ cohort compared to 41.7% in patients in the No AT cohort (38.4% higher in AT+; 95% CI, 36.1 – 45.2%). Only 6 of 77 doses reached the targeted AT level of 120% (8%). Of the 28 doses after which the AT level was followed sufficiently, median time to fall to an AT level of 80% was 6.8hrs after receiving the dose (mean: 9.8 hrs, Figure 1). For the AT+ cohort, mean UFH rate decreased by 10.1 u/kg/hr for the 3hrs following the AT dose (95% CI, 7.6–36.6; p<0.001) compared to the 3hrs prior. The UFH rate remained significantly lower 12hrs following administration (10.2 u/kg/hr lower; 95% CI, 6.2–14.1; p=<0.001). No significant differences existed in the number of patients with an in vivo thrombosis (14.7% vs. 13.3%, p=1.0); hemorrhagic complications (0.14 more bleeds in AT+ vs. No AT cohort; 95% CI, −0.34–0.63; p=0.56); number of circuit changes (0.15 changes more in AT+; 95% CI −0.002–0.001, p=0.88); median length of stay in the hospital (36.8d for AT+ vs. 49.8d for No AT, p=0.91) or intensive care unit (25.3d for AT+ vs. 34.1d for No AT, p=0.63), or adjusted relative risk for in-hospital mortality (0.6; 95% CI, 0.2–1.5). CONCLUSIONS: Intermittent, on-demand dosing of AT concentrate in pediatric patients on ECMO for respiratory failure increased AT levels, but not typically to the targeted level. Following doses with a measurable AT level, the majority of AT levels fell to <80% by 6.8 hrs. The UFH rate remained lower than before the AT dose for > 12 hours. However, in this retrospective study, no differences were noted in the measured clinical endpoints. A prospective randomized study of this intervention may require different dosing strategies; such a study is warranted given the variable use of this costly product across institutions. Disclosures: Off Label Use: Antithrombin concentrate. Gernsheimer:Amgen: Consultancy, Honoraria; Symphogen: Consultancy; Laboratorios Raffo SA: Honoraria; Clinical Options: Consultancy; Hemedicus Corporation: Honoraria; Glaxo Smith Kline Corporation: Consultancy; Shionogi Corporation: Research Funding; Cangene Corporation: Consultancy.

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