Fresh and Citrated Whole-Blood Specimens Can Produce Different Thromboelastography Results in Patients on Extracorporeal Membrane Oxygenation

ABSTRACT We describe a 34-year-old soldier who sustained a blast injury in Syria resulting in tracheal 5 cm tracheal loss, cervical spine and cord injury with tetraplegia, multiple bilateral rib fractures, esophageal injury, traumatic brain injury, globe evisceration, and multiple extremity soft tissue and musculoskeletal injuries including a left tibia fracture with compartment syndrome. An emergent intubation of the transected trachea was performed in the field, and the patient was resuscitated with whole blood prehospital. During transport to the Role 2, the patient required cardiopulmonary resuscitation for cardiac arrest. On arrival, he underwent a resuscitative thoracotomy and received a massive transfusion exclusively with whole blood. A specialized critical care team transported the patient to the Role 3 hospital in Baghdad, and the DoD extracorporeal membrane oxygenation (ECMO) team was activated secondary to his unstable airway and severe hypoxia secondary to pulmonary blast injury. The casualty was cannulated in Baghdad approximately 40 hours after injury with bifemoral cannulae in a venovenous configuration. He was transported from Iraq to the U.S. Army Institute of Surgical Research Burn Center in San Antonio without issue. Extracorporeal membrane oxygenation support was successfully weaned, and he was decannulated on ECMO day 4. The early and en route use of venovenous ECMO allowed for maintenance of respiratory support during transport and bridge to operative management and demonstrates the feasibility of prolonged ECMO transport in critically ill combat casualties.

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Pressure and flow properties of cannulae for extracorporeal membrane oxygenation I: return (arterial) cannulae

Perfusion ◽

10.1177/0267659119830521 ◽

2019 ◽

Vol 34 (1_suppl) ◽

pp. 58-64 ◽

Cited By ~ 9

Author(s):

Lars Mikael Broman ◽

Lisa Prahl Wittberg ◽

C Jerker Westlund ◽

Martijn Gilbers ◽

Luisa Perry da Câmara ◽

...

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Newtonian Fluid ◽

Whole Blood ◽

Cylindrical Tube ◽

Fourth Power ◽

Pressure Flow ◽

Blood Flows ◽

Membrane Oxygenation ◽

Poiseuille's Law ◽

Poiseuille’S Law

Adequate extracorporeal membrane oxygenation support in the adult requires cannulae permitting blood flows up to 6-8 L/minute. In accordance with Poiseuille’s law, flow is proportional to the fourth power of cannula inner diameter and inversely proportional to its length. Poiseuille’s law can be applied to obtain the pressure drop of an incompressible, Newtonian fluid (such as water) flowing in a cylindrical tube. However, as blood is a pseudoplastic non-Newtonian fluid, the validity of Poiseuille’s law is questionable for prediction of cannula properties in clinical practice. Pressure–flow charts with non-Newtonian fluids, such as blood, are typically not provided by the manufacturers. A standardized laboratory test of return (arterial) cannulae for extracorporeal membrane oxygenation was performed. The aim was to determine pressure–flow data with human whole blood in addition to manufacturers’ water tests to facilitate an appropriate choice of cannula for the desired flow range. In total, 14 cannulae from three manufacturers were tested. Data concerning design, characteristics, and performance were graphically presented for each tested cannula. Measured blood flows were in most cases 3-21% lower than those provided by manufacturers. This was most pronounced in the narrow cannulae (15-17 Fr) where the reduction ranged from 27% to 40% at low flows and 5-15% in the upper flow range. These differences were less apparent with increasing cannula diameter. There was a marked disparity between manufacturers. Based on the measured results, testing of cannulae including whole blood flows in a standardized bench test would be recommended.

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Evaluation of an ex-vivo neonatal extracorporeal membrane oxygenation circuit on antiepileptic drug sequestration

Perfusion ◽

10.1177/02676591211028183 ◽

2021 ◽

pp. 026765912110281

Author(s):

Shamir N Kalaria ◽

Omayma A Kishk ◽

Mathangi Gopalakrishnan ◽

Dayanand N Bagdure

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Antiepileptic Drug ◽

Centrifugal Pump ◽

Normal Saline ◽

Whole Blood ◽

Ex Vivo ◽

Ecmo Circuit ◽

Human Whole Blood ◽

Membrane Oxygenation ◽

Drug Sequestration

Antiepileptic dosing information used to manage neonatal patients receiving extracorporeal membrane oxygenation (ECMO) is limited. The objective of this study is to quantify the extent of sequestration of various antiepileptic drugs using an ex-vivo neonatal ECMO circuit. Two neonatal closed-loop ECMO circuits were prepared using a Rotaflow centrifugal pump, custom polyvinylchloride tubing and a Quadrox-i Neonatal membrane oxygenator. After 5 minutes of circuit priming and stabilization with normal saline/albumin or expired human whole blood, single boluses of levetiracetam (200 mg), lacosamide (20 mg), and phenytoin (200 mg) were injected into the circuit. To account for spontaneous drug degradation, two polyvinylchloride beakers were filled with normal saline/albumin or expired human whole blood and equivalent antiepileptic drug doses were prepared. Simultaneous pharmacokinetic samples were collected from the control solution and the pre-centrifugal pump, pre-oxygenator, and post-oxygenator sampling ports from each circuit. Similar drug recovery profiles were observed among the three sampling sites investigated. Percent drug sequestration after a 24-hour circuit flow period was relatively similar between the two different circuits and ranged between 5.5%–13.2% for levetiracetam, 18.4%–22.3% for lacosamide, and 24.5%–30.2% for phenytoin. A comparison at 12 and 24 hours demonstrated similar percent drug sequestration across all three drugs in each circuit. Percent drug sequestrations for levetiracetam and lacosamide were less than 20% and for phenytoin were as high as 30% based on the sampling following single bolus dose administration into a neonatal ECMO circuit. Careful consideration of patient clinical status should be taken in consideration when optimizing antiepileptic therapy in neonates receiving ECMO.

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Whole blood activated clotting time in infants during extracorporeal membrane oxygenation

Critical Care Medicine ◽

10.1097/00003246-199005000-00006 ◽

1990 ◽

Vol 18 (5) ◽

pp. 494-498 ◽

Cited By ~ 29

Author(s):

THOMAS P. GREEN ◽

BARBARA ISHAM-SCHOPF ◽

ROBIN H. STEINHORN ◽

CLARK SMITH ◽

RICHARD J. IRMITER

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Whole Blood ◽

Clotting Time ◽

Membrane Oxygenation ◽

Activated Clotting Time

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Transfusion-Dependent Anemia and Coagulopathy in a Porcine Model of Pediatric Extracorporeal Membrane Oxygenation (ECMO)

Blood ◽

10.1182/blood-2019-124524 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 1164-1164

Author(s):

Christopher Robert Reed ◽

Desiree Bonadonna ◽

Jeffrey R Everitt ◽

Victoria Robinson ◽

James Otto ◽

...

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Whole Blood ◽

Porcine Model ◽

Life Support ◽

Extracorporeal Life Support ◽

Congenital Defects ◽

Arterial Line ◽

Human Infants ◽

Membrane Oxygenation ◽

Va Ecmo

Background: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is often required to support infants with congenital defects, congenital heart disease, and other causes of reversible cardiopulmonary insufficiency. Although ECMO can be a life-saving modality, bleeding, inflammation, and thrombosis are well-described complications of ECMO. Adult porcine models of ECMO have been used to recapitulate the physiology and hematologic consequences of ECMO cannulation. However, these models lack the unique physiology and persistence of fetal forms and quantities of coagulation proteins and fibrinogen found in human infants. Furthermore, anticoagulation and hemostatic strategies developed for adults or using adult porcine models are often extrapolated to infants without specific considerations for developmental hemostasis. Therefore, development of an animal model of ECMO that faithfully reproduces both the physiology and coagulation profile of human infants is important to improving anticoagulation strategies and gaining a better mechanistic understanding of hemostatic challenges in infants. We hypothesized that an infant porcine mode (piglets) supported with VA-ECMO would closely recapitulate the physiology and hematology of human infants on ECMO. Methods: Four healthy piglets (5.7-6.4 kg) were cannulated via the jugular vein and carotid artery and supported for 20 hours or until adult whole blood for transfusion was exhausted. Heparin was used with a goal activated clotting time (ACT) of 180-220 seconds. Blood gas (ABG) was performed hourly, and blood was transfused from an adult donor to maintain hematocrit ≥24%. Rotational thromboelastometry (ROTEM) assays were performed at each of seven time points. Specifically, EXTEM, INTEM, and FIBTEM were used to determine the coagulation time (CT) and maximum clot firmness (MCF) of the extrinsically-mediated, intrinsically-mediated, and acellular fibrin clots, respectively. Results: All animals (n=4) had slow but significant hemorrhage at cannulation, arterial line, and bladder catheter sites. All animals required the maximum blood transfusion volume available. All animals became anemic after exhaustion of blood for transfusion, and two required sacrifice before the 20-hour endpoint for critical anemia. ABG showed progressively declining hematocrit and adequate oxygenation. ROTEM demonstrated decreasing FIBTEM clot firmness with preservation of EXTEM and INTEM coagulation times. Histology was overall unremarkable. Conclusion: Our infant porcine model faithfully reproduces the physiology and hematostatic profile of human infants during VA-ECMO, including transfusion dependence and heparin-induced coagulopathy. Weak whole-blood clot firmness by ROTEM suggests defects in fibrinogen. This model serves as an important means to study the complex derangements in hemostasis during VA ECMO in infants, including subtle derangements due to adult blood product transfusions, as well as to investigate novel approaches to anticoagulation and hemostasis during extracorporeal life support. Figure Disclosures Arepally: Veralox Therapeutics: Membership on an entity's Board of Directors or advisory committees; Apotex Pharmaceuticals: Consultancy; Biokit: Patents & Royalties.

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