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.

scholarly journals Context-Responsive Anticoagulation Reduces Complications in Pediatric Extracorporeal Membrane Oxygenation

2021 ◽  
Vol 8 ◽  
Author(s):  
John C. Lin ◽  
Lauren M. Barron ◽  
Adam M. Vogel ◽  
Ryan M. Colvin ◽  
Sirine A. Baltagi ◽  
...  
Keyword(s):  
Data Collection ◽  
Extracorporeal Membrane Oxygenation ◽  
Blood Product ◽  
Complication Rates ◽  
Membrane Oxygenation ◽  
Hemorrhagic Complications ◽  
Implementation Period ◽  
Thrombotic Complications ◽  
The Impact ◽  
Rbc Transfusion

Purpose: We sought to determine the impact of a comprehensive, context-responsive anticoagulation and transfusion guideline on bleeding and thrombotic complication rates and blood product utilization during extracorporeal membrane oxygenation (ECMO).Design: Single-center, observational pre- and post-implementation cohort study.Setting: Academic pediatric hospital.Patients: Patients in the PICU, CICU, and NICU receiving ECMO support.Interventions: Program-wide implementation of a context-responsive anticoagulation and transfusion guideline.Measurements: Pre-implementation subjects consisted of all patients receiving ECMO between January 1 and December 31, 2012, and underwent retrospective chart review. Post-implementation subjects consisted of all ECMO patients between September 1, 2013, and December 31, 2014, and underwent prospective data collection. Data collection included standard demographic and admission data, ECMO technical specifications, non-ECMO therapies, coagulation parameters, and blood product administration. A novel grading scale was used to define hemorrhagic complications (major, intermediate, and minor) and major thromboembolic complications.Main Results: Seventy-six ECMO patients were identified: 31 during the pre-implementation period and 45 in the post-implementation period. The overall observed mortality was 33% with no difference between groups. Compared to pre-implementation, the post-implementation group experienced fewer major hemorrhagic and major thrombotic complications and less severe hemorrhagic complications and received less RBC transfusion volume per kg.Conclusions: Use of a context-responsive anticoagulation and transfusion guideline was associated with a reduction in hemorrhagic and thrombotic complications and reduced RBC transfusion requirements. Further evaluation of guideline content, compliance, performance, and sustainability is needed.

scholarly journals Antithrombin Supplementation during Extracorporeal Membrane Oxygenation: Study Protocol for a Pilot Randomized Clinical Trial

2018 ◽  
Author(s):  
Mauro Panigada ◽  
Elena Spinelli ◽  
Alberto Cucino ◽  
Elisa Cipriani ◽  
Giovanna Panarello ◽  
...  
Keyword(s):  
Extracorporeal Membrane Oxygenation ◽  
Pilot Trial ◽  
Study Groups ◽  
Control Group ◽  
Membrane Oxygenation ◽  
Transfusion Requirements ◽  
Hemorrhagic Events ◽  
Secondary Endpoints ◽  
Thrombotic Complications ◽  
The Impact

Abstract Background: Normal levels of plasma antithrombin (AT) activity might decrease heparin requirements to achieve anticoagulation target during treatment with extracorporeal membrane oxygenation (ECMO), possibly reducing the risk of bleeding. Acquired AT deficiency during ECMO is common, but formal recommendation on target, timing, and rate of AT supplementation is lacking. Thus, we conceived a pilot trial to evaluate the feasibility and safety of prolonged AT supplementation in patients requiring veno-venous ECMO for respiratory failure. Methods: GATRA is a phase 3, prospective, randomized, single blinded multicenter controlled two-arm trial. Patients undergoing veno-venous ECMO will be randomized to either receive AT supplementation to maintain a functional AT level between 80%-120% (AT supplementation group) or not (control group) for the entire ECMO course. In both study groups anticoagulation will be provided with unfractionated heparin following a standardized protocol. The primary endpoint will be the dose of heparin required to maintain ratio of activated partial thromboplastin time between 1.5-2. Secondary endpoints will be the adequacy of anticoagulation and the incidence of hemorrhagic and thrombotic complications. Discussion: GATRA is a pilot trial that will test the efficacy of a protocol of AT supplementation in decreasing the heparin dose and improving anticoagulation adequacy during ECMO. If positive, it might provide the basis for a future larger trial aimed at verifying the impact of AT supplementation on a composite outcome endpoint including hemorrhagic events, transfusion requirements and mortality. Trial registration: ClinicalTrials.gov, NCT03208270. Registered on 5 July 2017.

scholarly journals Antithrombin Supplementation during Extracorporeal Membrane Oxygenation: Study Protocol for a Pilot Randomized Clinical Trial

2019 ◽  
Author(s):  
Mauro Panigada ◽  
Elena Spinelli ◽  
Alberto Cucino ◽  
Elisa Cipriani ◽  
Stefano De Falco ◽  
...  
Keyword(s):  
Extracorporeal Membrane Oxygenation ◽  
Pilot Trial ◽  
Study Groups ◽  
Control Group ◽  
Membrane Oxygenation ◽  
Transfusion Requirements ◽  
Hemorrhagic Events ◽  
Secondary Endpoints ◽  
Thrombotic Complications ◽  
The Impact

Abstract Background: Normal levels of plasma antithrombin (AT) activity might decrease heparin requirements to achieve an adequate level of anticoagulation during treatment with extracorporeal membrane oxygenation (ECMO). Acquired AT deficiency during ECMO is common, but formal recommendation on target, timing, and rate of AT supplementation is lacking. Thus, we conceived a pilot trial to evaluate the feasibility and safety of prolonged AT supplementation in patients requiring veno-venous ECMO for respiratory failure. Methods: GATRA is a phase 3, prospective, randomized, single blinded multicenter controlled two-arm trial. Patients undergoing veno-venous ECMO will be randomized to either receive AT supplementation to maintain a functional AT level between 80%-120% (AT supplementation group) or not (control group) for the entire ECMO course. In both study groups anticoagulation will be provided with unfractionated heparin following a standardized protocol. The primary endpoint will be the dose of heparin required to maintain ratio of activated partial thromboplastin time between 1.5-2. Secondary endpoints will be the adequacy of anticoagulation and the incidence of hemorrhagic and thrombotic complications. Discussion: GATRA is a pilot trial that will test the efficacy of a protocol of AT supplementation in decreasing the heparin dose and improving anticoagulation adequacy during ECMO. If positive, it might provide the basis for a future larger trial aimed at verifying the impact of AT supplementation on a composite outcome endpoint including hemorrhagic events, transfusion requirements and mortality. Trial registration ClinicalTrials.gov, NCT03208270. Registered on 5 July 2017.

scholarly journals CT fatty muscle fraction as a new parameter for muscle quality assessment predicts outcome in venovenous extracorporeal membrane oxygenation

2020 ◽  
Vol 10 (1) ◽  
Author(s):  
Anton Faron ◽  
Stefan Kreyer ◽  
Alois M. Sprinkart ◽  
Thomas Muders ◽  
Stefan F. Ehrentraut ◽  
...  
Keyword(s):  
Skeletal Muscle ◽  
Extracorporeal Membrane Oxygenation ◽  
Adverse Outcomes ◽  
Muscle Quality ◽  
Imaging Biomarker ◽  
Survival Prediction ◽  
Multivariable Logistic Regression Model ◽  
Muscle Area ◽  
Membrane Oxygenation ◽  
The Impact

AbstractImpaired skeletal muscle quality is a major risk factor for adverse outcomes in acute respiratory failure. However, conventional methods for skeletal muscle assessment are inapplicable in the critical care setting. This study aimed to determine the prognostic value of computed tomography (CT) fatty muscle fraction (FMF) as a biomarker of muscle quality in patients undergoing extracorporeal membrane oxygenation (ECMO). To calculate FMF, paraspinal skeletal muscle area was obtained from clinical CT and separated into areas of fatty and lean muscle based on densitometric thresholds. The cohort was binarized according to median FMF. Patients with high FMF displayed significantly increased 1-year mortality (72.7% versus 55.8%, P = 0.036) on Kaplan–Meier analysis. A multivariable logistic regression model was built to test the impact of FMF on outcome. FMF was identified as a significant predictor of 1-year mortality (hazard ratio per percent FMF, 1.017 [95% confidence interval, 1.002–1.033]; P = 0.031), independent of anthropometric characteristics, Charlson Comorbidity Index, Simplified Acute Physiology Score, Respiratory Extracorporeal Membrane Oxygenation Survival Prediction Score, and duration of ECMO support. To conclude, FMF predicted 1-year mortality independently of established clinical prognosticators in ECMO patients and may have the potential to become a new muscle quality imaging biomarker, which is available from clinical CT.

Reducing Broad Spectrum Antimicrobial Use in Extracorporeal Membrane Oxygenation (ECMO): Reduce AMMO Study

2021 ◽  
Author(s):  
Aditya Shah ◽  
Priya Sampathkumar ◽  
Ryan W Stevens ◽  
John K Bohman ◽  
Brian D Lahr ◽  
...  
Keyword(s):  
Time Series ◽  
Extracorporeal Membrane Oxygenation ◽  
Broad Spectrum ◽  
Antimicrobial Prophylaxis ◽  
Current Evidence ◽  
Antimicrobial Use ◽  
Infection Rates ◽  
Interrupted Time Series Analysis ◽  
Membrane Oxygenation ◽  
The Impact

Abstract Background The use of extracorporeal membrane oxygenation (ECMO) in critically ill adults is increasing. There are currently no guidelines for antimicrobial prophylaxis. We analyzed 7 years of prophylactic antimicrobial use across three time series for patients on ECMO at our institution in the development, improvement, and streamlining of our ECMO antimicrobial prophylaxis protocol. Study design and Methods In this quasi-experimental interrupted time series analysis, we evaluated the impact of an initial ECMO antimicrobial prophylaxis protocol, implemented in 2014, on antimicrobial use and NHSN reportable infection rates. Then, following a revision and streamlining of the protocol in November 2018, we re-evaluated the same metrics. Results Our study population included 338 ICU patients who received ECMO between July 2011 and November 2019. After implementation of the first version of the protocol we did not observe significant changes in antimicrobial use or infection rates in these patients; however, following revision and streamlining of the protocol, we demonstrated a significant reduction in broad spectrum antimicrobial use for prophylaxis in patients on ECMO without any evidence of a compensatory increase in infection rates. Conclusion Our final protocol significantly reduces broad spectrum antimicrobial use for prophylaxis in patients on ECMO. We propose a standard antimicrobial prophylaxis regimen for patients on ECMO based on current evidence and our experience.

scholarly journals Effects of Extracorporeal Membrane Oxygenation Initiation on Oxygenation and Pulmonary Opacities

2021 ◽  
Vol 7 (1) ◽  
pp. 6-13
Author(s):  
Kiran Batra ◽  
Manish Mohanka ◽  
Srinivas Bollineni ◽  
Vaidehi Kaza ◽  
Prabhakar Rajiah ◽  
...  
Keyword(s):  
Extracorporeal Membrane Oxygenation ◽  
P Value ◽  
Limited Data ◽  
Hospital Survival ◽  
Membrane Oxygenation ◽  
Pulmonary Physiology ◽  
Before And After ◽  
Laboratory Variables ◽  
The Difference ◽  
The Impact

Abstract Introduction There is limited data on the impact of extracorporeal membrane oxygenation (ECMO) on pulmonary physiology and imaging in adult patients. The current study sought to evaluate the serial changes in oxygenation and pulmonary opacities after ECMO initiation. Methods Records of patients started on veno-venous, or veno-arterial ECMO were reviewed (n=33; mean (SD): age 50(16) years; Male: Female 20:13). Clinical and laboratory variables before and after ECMO, including daily PaO2 to FiO2 ratio (PFR), were recorded. Daily chest radiographs (CXR) were prospectively appraised in a blinded fashion and scored for the extent and severity of opacities using an objective scoring system. Results ECMO was associated with impaired oxygenation as reflected by the drop in median PFR from 101 (interquartile range, IQR: 63-151) at the initiation of ECMO to a post-ECMO trough of 74 (IQR: 56-98) on post-ECMO day 5. However, the difference was not statistically significant. The appraisal of daily CXR revealed progressively worsening opacities, as reflected by a significant increase in the opacity score (Wilk’s Lambda statistic 7.59, p=0.001). During the post-ECMO period, a >10% increase in the opacity score was recorded in 93.9% of patients. There was a negative association between PFR and opacity scores, with an average one-unit decrease in the PFR corresponding to a +0.010 increase in the opacity score (95% confidence interval: 0.002 to 0.019, p-value=0.0162). The median opacity score on each day after ECMO initiation remained significantly higher than the pre-ECMO score. The most significant increase in the opacity score (9, IQR: -8 to 16) was noted on radiographs between pre-ECMO and forty-eight hours post-ECMO. The severity of deteriorating oxygenation or pulmonary opacities was not associated with hospital survival. Conclusions The use of ECMO is associated with an increase in bilateral opacities and a deterioration in oxygenation that starts early and peaks around 48 hours after ECMO initiation.

scholarly journals Evolution of the United States Military Extracorporeal Membrane Oxygenation Transport Team

2020 ◽  
Vol 185 (11-12) ◽  
pp. e2055-e2060
Author(s):  
Matthew D Read ◽  
Jason J Nam ◽  
Mauer Biscotti ◽  
Lydia C Piper ◽  
Sarah B Thomas ◽  
...  
Keyword(s):  
Critical Care ◽  
Extracorporeal Membrane Oxygenation ◽  
Demographic Data ◽  
The United States ◽  
Published Data ◽  
Medical Treatment Facility ◽  
Membrane Oxygenation ◽  
Transport Distance ◽  
Primary Indication ◽  
The U.S

Abstract Introduction The use of extracorporeal membrane oxygenation (ECMO) for the care of critically ill adult patients has increased over the past decade. It has been utilized in more austere locations, to include combat wounded. The U.S. military established the Acute Lung Rescue Team in 2005 to transport and care for patients unable to be managed by standard medical evacuation resources. In 2012, the U.S. military expanded upon this capacity, establishing an ECMO program at Brooke Army Medical Center. To maintain currency, the program treats both military and civilian patients. Materials and methods We conducted a single-center retrospective review of all patients transported by the sole U.S. military ECMO program from September 2012 to December 2019. We analyzed basic demographic data, ECMO indication, transport distance range, survival to decannulation and discharge, and programmatic growth. Results The U.S. military ECMO team conducted 110 ECMO transports. Of these, 88 patients (80%) were transported to our facility and 81 (73.6%) were cannulated for ECMO by our team prior to transport. The primary indication for ECMO was respiratory failure (76%). The range of transport distance was 6.5 to 8,451 miles (median air transport distance = 1,328 miles, median ground transport distance = 16 miles). In patients who were cannulated remotely, survival to decannulation was 76% and survival to discharge was 73.3%. Conclusions Utilization of the U.S. military ECMO team has increased exponentially since January 2017. With an increased tempo of transport operations and distance of critical care transport, survival to decannulation and discharge rates exceed national benchmarks as described in ELSO published data. The ability to cannulate patients in remote locations and provide critical care transport to a military medical treatment facility has allowed the U.S. military to maintain readiness of a critical medical asset.

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