Abstract
BackgroundHemorrhagic events remain a major concern in patients under extracorporeal membrane oxygenation (ECMO) support. We tested the association between anticoagulation levels and hemorrhagic events under ECMO using anti-Xa activity monitoring.MethodsWe performed a retrospective multicenter cohort study in three ECMO centers. All adult patients treated with veno-venous (VV)- or veno-arterial (VA)-ECMO in 6 intensive care units between September 2017 and August 2019 were included. Anti-Xa activities were collected until a hemorrhagic event in the bleeding group and for the duration of ECMO in the non-bleeding group. All dosages were averaged to obtain means of anti-Xa activity for each patient, and patients were compared according to the occurrence or not of bleeding.ResultsAmong 367 patients assessed for eligibility, 121 were included. Thirty-five (29%) presented a hemorrhagic complication. In univariate analysis, anti-Xa activities were significantly higher in the bleeding group than in the non-bleeding group, both for the mean anti-Xa activity (0.38 [0.29–0.67] vs 0.33 [0.22–0.42] IU/mL; p = 0.01) and the maximal anti-Xa activity (0.83 [0.47–1.46] vs 0.66 [0.36–0.91] IU/mL; p = 0.05). In the Cox proportional hazard model, mean anti-Xa activity was associated with bleeding (p = 0.0001). By Kaplan–Meier analysis with the cutoff value at 0.46 IU/mL obtained by ROC curve analysis, the probability of survival under ECMO without bleeding was significantly lower when mean anti-Xa was > 0.46 IU/mL (p = 0.0006).ConclusionIn critically ill patients under ECMO, mean anti-Xa activity was an independent risk factor for hemorrhagic complications. Anticoagulation targets could be revised downward in both VV- and VA-ECMO.
Highlights
The use of extracorporeal membrane oxygenation (ECMO) is increasing in intensive care unit (ICU) settings, either for hemodynamic failure [veno-arterial (VA) extracorporeal membrane oxygena‐ tion (ECMO)] or for respiratory failure [veno-venous (VV) ECMO]
Focusing on associated circulatory support, intra-aortic balloon pump (IABP) or IMPELLA were present in 43% of patients in the bleeding group and 16% in the non-bleeding group (p = 0.08), irrespective of the type of ECMO
There was no correlation between mean anti-Xa value and heparin dose under ECMO: Pearson’s r value 0.190 (− 0.011–0.376), p = 0.064 (Additional file 7). In this multicenter cohort study assessing hemorrhagic events under VV- and VA-ECMO, we found a significant association between the anti-Xa activity and the Indication, n (%) Cardiogenic shock Refractory cardiac arrest Acute respiratory distress syndrome (ARDS) Intoxication
Summary
The use of extracorporeal membrane oxygenation (ECMO) is increasing in intensive care unit (ICU) settings, either for hemodynamic failure [veno-arterial (VA) ECMO] or for respiratory failure [veno-venous (VV) ECMO]. These techniques are used as rescue therapies in most cases and are associated with a high mortality rate, ranging from 31% for VV-ECMO to 59% for Descamps et al Crit Care (2021) 25:127 extracorporeal pulmonary resuscitation [1]. In the LIFEGARDS international cohort including 350 patients with ARDS, authors reported hemorrhagic events in 25% of patients These events were associated with a higher 6-month mortality [4]. We tested the association between anticoagulation levels and hemorrhagic events under ECMO using anti-Xa activity monitoring
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