Anticoagulation and Transfusions Management in Veno-Venous Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome: Assessment of Factors Associated With Transfusion Requirements and Mortality

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Abstract

Purpose: We describe an approach for anticoagulation and transfusions in veno-venous–extracorporeal membrane oxygenation (VV-ECMO), evaluating factors associated with higher transfusion requirements, and their impact on mortality. Methods: Observational study on consecutive adults supported with VV-ECMO for acute respiratory distress syndrome (ARDS). We targeted an activated partial thromboplastin time of 40 to 50 seconds and a hematocrit of 24% to 30%. Univariate and multiple analyses were done to evaluate factors associated with transfusion requirements and the influence of increasing transfusions on mortality during ECMO. Results: In a cohort of 82 VV-ECMO patients (PRedicting dEath for SEvere ARDS on VV-ECMO [PRESERVE] score: 4, Interquartile range [IQR]: 3-5, Respiratory Extracorporeal Membrane Oxygenation Survival Prediction [RESP] score: 2, IQR: 2-4), 76 (92.7%) patients received at least 1 unit of packed red blood cells (PRBCs) during the intensive care unit stay related to ECMO (median PRBC/d 156 mL, IQR: 93-218; median ECMO duration 14 days, IQR: 8-22). A higher requirement of PRBC transfusions was associated with pre-ECMO hematocrit, and with the following conditions during ECMO: platelet nadir, antithrombin III (ATIII), and stage 3 of acute kidney injury (all P <.05). Sixty-two (75.6%) patients survived ECMO. Pre-ECMO hospital stay, PRBC transfusion, and septic shock were associated with mortality (all P <.05). The adjusted odds ratio for each 100mL/d increase in PRBC transfusion was 1.9 (95% confidence interval [CI]: 1.1-3.2, P =.01); for the development of septic shock it was 15.4 (95% CI: 1.7-136.8, P =.01), and for each day of pre-ECMO stay it was 1.1 (95% CI: 1-1.2, P =.04). Conclusion: Implementation of a comprehensive protocol for anticoagulation and transfusions in VV-ECMO for ARDS resulted in a low PRBC requirement, and an ECMO survival comparable to data in the literature. Lower ATIII emerged as a factor associated with increased need for transfusions. Higher PRBC transfusions were associated with ECMO mortality. Further investigations are needed to better understand the right level of anticoagulation in ECMO, and the factors to take into account in order to manage personalized transfusion practice in this select setting.

Original languageEnglish
JournalJournal of Intensive Care Medicine
DOIs
Publication statusPublished - Jan 1 2017

Fingerprint

Erythrocyte Transfusion
Extracorporeal Membrane Oxygenation
Adult Respiratory Distress Syndrome
Antithrombin III
Mortality
Erythrocytes
Confidence Intervals
Septic Shock
Hematocrit
Severe Acute Respiratory Syndrome
Survival
Partial Thromboplastin Time
Acute Kidney Injury
Observational Studies
Intensive Care Units
Length of Stay
Blood Platelets
Odds Ratio
Membranes

Keywords

  • anticoagulation
  • antithrombin III
  • blood management
  • critically ill patients
  • ECMO
  • hemoglobin
  • intensive care unit
  • red blood cell transfusion

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine

Cite this

@article{e7bc40466b9e473c98ebcb6f7b275d2a,
title = "Anticoagulation and Transfusions Management in Veno-Venous Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome: Assessment of Factors Associated With Transfusion Requirements and Mortality",
abstract = "Purpose: We describe an approach for anticoagulation and transfusions in veno-venous–extracorporeal membrane oxygenation (VV-ECMO), evaluating factors associated with higher transfusion requirements, and their impact on mortality. Methods: Observational study on consecutive adults supported with VV-ECMO for acute respiratory distress syndrome (ARDS). We targeted an activated partial thromboplastin time of 40 to 50 seconds and a hematocrit of 24{\%} to 30{\%}. Univariate and multiple analyses were done to evaluate factors associated with transfusion requirements and the influence of increasing transfusions on mortality during ECMO. Results: In a cohort of 82 VV-ECMO patients (PRedicting dEath for SEvere ARDS on VV-ECMO [PRESERVE] score: 4, Interquartile range [IQR]: 3-5, Respiratory Extracorporeal Membrane Oxygenation Survival Prediction [RESP] score: 2, IQR: 2-4), 76 (92.7{\%}) patients received at least 1 unit of packed red blood cells (PRBCs) during the intensive care unit stay related to ECMO (median PRBC/d 156 mL, IQR: 93-218; median ECMO duration 14 days, IQR: 8-22). A higher requirement of PRBC transfusions was associated with pre-ECMO hematocrit, and with the following conditions during ECMO: platelet nadir, antithrombin III (ATIII), and stage 3 of acute kidney injury (all P <.05). Sixty-two (75.6{\%}) patients survived ECMO. Pre-ECMO hospital stay, PRBC transfusion, and septic shock were associated with mortality (all P <.05). The adjusted odds ratio for each 100mL/d increase in PRBC transfusion was 1.9 (95{\%} confidence interval [CI]: 1.1-3.2, P =.01); for the development of septic shock it was 15.4 (95{\%} CI: 1.7-136.8, P =.01), and for each day of pre-ECMO stay it was 1.1 (95{\%} CI: 1-1.2, P =.04). Conclusion: Implementation of a comprehensive protocol for anticoagulation and transfusions in VV-ECMO for ARDS resulted in a low PRBC requirement, and an ECMO survival comparable to data in the literature. Lower ATIII emerged as a factor associated with increased need for transfusions. Higher PRBC transfusions were associated with ECMO mortality. Further investigations are needed to better understand the right level of anticoagulation in ECMO, and the factors to take into account in order to manage personalized transfusion practice in this select setting.",
keywords = "anticoagulation, antithrombin III, blood management, critically ill patients, ECMO, hemoglobin, intensive care unit, red blood cell transfusion",
author = "Gennaro Martucci and Giovanna Panarello and Giovanna Occhipinti and Veronica Ferrazza and Fabio Tuzzolino and Diego Bellavia and Filippo Sanfilippo and Cristina Santonocito and Alessandro Bertani and Patrizio Vitulo and Michele Pilato and Antonio Arcadipane",
year = "2017",
month = "1",
day = "1",
doi = "10.1177/0885066617706339",
language = "English",
journal = "Journal of Intensive Care Medicine",
issn = "0885-0666",
publisher = "SAGE Publications Inc.",

}

TY - JOUR

T1 - Anticoagulation and Transfusions Management in Veno-Venous Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome

T2 - Assessment of Factors Associated With Transfusion Requirements and Mortality

AU - Martucci, Gennaro

AU - Panarello, Giovanna

AU - Occhipinti, Giovanna

AU - Ferrazza, Veronica

AU - Tuzzolino, Fabio

AU - Bellavia, Diego

AU - Sanfilippo, Filippo

AU - Santonocito, Cristina

AU - Bertani, Alessandro

AU - Vitulo, Patrizio

AU - Pilato, Michele

AU - Arcadipane, Antonio

PY - 2017/1/1

Y1 - 2017/1/1

N2 - Purpose: We describe an approach for anticoagulation and transfusions in veno-venous–extracorporeal membrane oxygenation (VV-ECMO), evaluating factors associated with higher transfusion requirements, and their impact on mortality. Methods: Observational study on consecutive adults supported with VV-ECMO for acute respiratory distress syndrome (ARDS). We targeted an activated partial thromboplastin time of 40 to 50 seconds and a hematocrit of 24% to 30%. Univariate and multiple analyses were done to evaluate factors associated with transfusion requirements and the influence of increasing transfusions on mortality during ECMO. Results: In a cohort of 82 VV-ECMO patients (PRedicting dEath for SEvere ARDS on VV-ECMO [PRESERVE] score: 4, Interquartile range [IQR]: 3-5, Respiratory Extracorporeal Membrane Oxygenation Survival Prediction [RESP] score: 2, IQR: 2-4), 76 (92.7%) patients received at least 1 unit of packed red blood cells (PRBCs) during the intensive care unit stay related to ECMO (median PRBC/d 156 mL, IQR: 93-218; median ECMO duration 14 days, IQR: 8-22). A higher requirement of PRBC transfusions was associated with pre-ECMO hematocrit, and with the following conditions during ECMO: platelet nadir, antithrombin III (ATIII), and stage 3 of acute kidney injury (all P <.05). Sixty-two (75.6%) patients survived ECMO. Pre-ECMO hospital stay, PRBC transfusion, and septic shock were associated with mortality (all P <.05). The adjusted odds ratio for each 100mL/d increase in PRBC transfusion was 1.9 (95% confidence interval [CI]: 1.1-3.2, P =.01); for the development of septic shock it was 15.4 (95% CI: 1.7-136.8, P =.01), and for each day of pre-ECMO stay it was 1.1 (95% CI: 1-1.2, P =.04). Conclusion: Implementation of a comprehensive protocol for anticoagulation and transfusions in VV-ECMO for ARDS resulted in a low PRBC requirement, and an ECMO survival comparable to data in the literature. Lower ATIII emerged as a factor associated with increased need for transfusions. Higher PRBC transfusions were associated with ECMO mortality. Further investigations are needed to better understand the right level of anticoagulation in ECMO, and the factors to take into account in order to manage personalized transfusion practice in this select setting.

AB - Purpose: We describe an approach for anticoagulation and transfusions in veno-venous–extracorporeal membrane oxygenation (VV-ECMO), evaluating factors associated with higher transfusion requirements, and their impact on mortality. Methods: Observational study on consecutive adults supported with VV-ECMO for acute respiratory distress syndrome (ARDS). We targeted an activated partial thromboplastin time of 40 to 50 seconds and a hematocrit of 24% to 30%. Univariate and multiple analyses were done to evaluate factors associated with transfusion requirements and the influence of increasing transfusions on mortality during ECMO. Results: In a cohort of 82 VV-ECMO patients (PRedicting dEath for SEvere ARDS on VV-ECMO [PRESERVE] score: 4, Interquartile range [IQR]: 3-5, Respiratory Extracorporeal Membrane Oxygenation Survival Prediction [RESP] score: 2, IQR: 2-4), 76 (92.7%) patients received at least 1 unit of packed red blood cells (PRBCs) during the intensive care unit stay related to ECMO (median PRBC/d 156 mL, IQR: 93-218; median ECMO duration 14 days, IQR: 8-22). A higher requirement of PRBC transfusions was associated with pre-ECMO hematocrit, and with the following conditions during ECMO: platelet nadir, antithrombin III (ATIII), and stage 3 of acute kidney injury (all P <.05). Sixty-two (75.6%) patients survived ECMO. Pre-ECMO hospital stay, PRBC transfusion, and septic shock were associated with mortality (all P <.05). The adjusted odds ratio for each 100mL/d increase in PRBC transfusion was 1.9 (95% confidence interval [CI]: 1.1-3.2, P =.01); for the development of septic shock it was 15.4 (95% CI: 1.7-136.8, P =.01), and for each day of pre-ECMO stay it was 1.1 (95% CI: 1-1.2, P =.04). Conclusion: Implementation of a comprehensive protocol for anticoagulation and transfusions in VV-ECMO for ARDS resulted in a low PRBC requirement, and an ECMO survival comparable to data in the literature. Lower ATIII emerged as a factor associated with increased need for transfusions. Higher PRBC transfusions were associated with ECMO mortality. Further investigations are needed to better understand the right level of anticoagulation in ECMO, and the factors to take into account in order to manage personalized transfusion practice in this select setting.

KW - anticoagulation

KW - antithrombin III

KW - blood management

KW - critically ill patients

KW - ECMO

KW - hemoglobin

KW - intensive care unit

KW - red blood cell transfusion

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DO - 10.1177/0885066617706339

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JO - Journal of Intensive Care Medicine

JF - Journal of Intensive Care Medicine

SN - 0885-0666

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