Comparison of anticoagulation strategies for veno-venous ECMO support in acute respiratory failure

Benjamin Seeliger,Christian Bode,Folkert Steinhagen,Michael Döbler,Klaus Stahl,Johann Bauersachs,Robert Friedrich,Sascha David,Marius M Hoeper,Andreas Tiede,Stefan F Ehrentraut,Christian Kühn,Christian Putensen,Jens-Christian Schewe,Tobias Welte

doi:10.1186/s13054-020-03348-w

Benjamin Seeliger, Christian Bode + Show 13 more

Open Access

https://doi.org/10.1186/s13054-020-03348-w

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Abstract

BackgroundExtracorporeal membrane oxygenation (ECMO) support in acute respiratory failure may be lifesaving, but bleeding and thromboembolic complications are common. The optimal anticoagulation strategy balancing these factors remains to be determined. This retrospective study compared two institutional anticoagulation management strategies focussing on oxygenator changes and both bleeding and thromboembolic events.MethodsWe conducted a retrospective observational cohort study between 04/2015 and 02/2020 in two ECMO referral centres in Germany in patients receiving veno-venous (VV)-ECMO support for acute respiratory failure for > 24 h. One centre routinely applied low-dose heparinization aiming for a partial thromboplastin time (PTT) of 35–40 s and the other routinely used a high-dose therapeutic heparinization strategy aiming for an activated clotting time (ACT) of 140–180 s. We assessed number of and time to ECMO oxygenator changes, 15-day freedom from oxygenator change, major bleeding events, thromboembolic events, 30-day ICU mortality, activated clotting time and partial thromboplastin time and administration of blood products. Primary outcome was the occurrence of oxygenator changes depending on heparinization strategy; main secondary outcomes were the occurrence of severe bleeding events and occurrence of thromboembolic events. The transfusion strategy was more liberal in the low-dose centre.ResultsOf 375 screened patients receiving VV-ECMO support, 218 were included in the analysis (117 high-dose group; 101 low-dose group). Disease severity measured by SAPS II score was 46 (IQR 36–57) versus 47 (IQR 37–55) and ECMO runtime was 8 (IQR 5–12) versus 11 (IQR 7–17) days (P = 0.003). There were 14 oxygenator changes in the high-dose group versus 48 in the low-dose group. Freedom from oxygenator change at 15 days was 73% versus 55% (adjusted HR 3.34 [95% confidence interval 1.2–9.4]; P = 0.023). Severe bleeding events occurred in 23 (19.7%) versus 14 (13.9%) patients (P = 0.256) and thromboembolic events occurred in 8 (6.8%) versus 19 (19%) patients (P = 0.007). Mortality at 30 days was 33.3% versus 30.7% (P = 0.11).ConclusionsIn this retrospective study, ECMO management with high-dose heparinization was associated with lower rates of oxygenator changes and thromboembolic events when compared to a low-dose heparinization strategy. Prospective, randomized trials are needed to determine the optimal anticoagulation strategy in patients receiving ECMO support.

Highlights

In refractory acute respiratory failure (ARF), implementation of veno-venous extracorporeal membrane oxygenation (VV-Extracorporeal membrane oxygenation (ECMO)) as a rescue strategy may be life-saving and is increasingly applied [1]
Mortality at 30 days was 33.3% versus 30.7% (P = 0.11). In this retrospective study, ECMO management with high-dose heparinization was associated with lower rates of oxygenator changes and thromboembolic events when compared to a low-dose heparinization strat‐ egy
Settings and participants We conducted a retrospective cohort study including patients with severe ARF receiving veno-venous extracorporeal membrane oxygenation (VV-ECMO) support between April 2015 and February 2020 at two German university hospitals with extensive ECMO experience. Both centres routinely used unfractionated heparin (UFH)-based anticoagulation, but with different intensity, enabling us to compare a low-dose heparinization strategy aiming for a partial thromboplastin time (PTT) between 35 and 40 s with a high-dose heparinization strategy aiming for an activated clotting time (ACT) between 140 and 180 s

Summary

Introduction

In refractory acute respiratory failure (ARF), implementation of veno-venous extracorporeal membrane oxygenation (VV-ECMO) as a rescue strategy may be life-saving and is increasingly applied [1]. ECMO support is associated with potentially life-threatening complications, mostly related to either bleeding events or thromboembolic complications [2,3,4]. To minimize such events, most centres use unfractionated heparin (UFH)based anticoagulation adjusted by partial thromboplastin time (PTT), usually within 40–80 s or by activated clotting time (ACT) within 140–180 s [5]. Extracorporeal membrane oxygenation (ECMO) support in acute respiratory failure may be lifesaving, but bleeding and thromboembolic complications are common. The optimal anticoagulation strategy balancing these factors remains to be determined This retrospective study compared two institutional anticoagulation management strategies focussing on oxygenator changes and both bleeding and thromboembolic events

Methods

Results

Conclusion