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01-12-2020 | Heparin | Review

Clinical controversies in anticoagulation monitoring and antithrombin supplementation for ECMO

Authors: Meghan M. Chlebowski, Sirine Baltagi, Mel Carlson, Jerrold H. Levy, Philip C. Spinella

Published in: Critical Care | Issue 1/2020

Abstract

During extracorporeal membrane oxygenation (ECMO), a delicate balance is required to titrate systemic anticoagulation to prevent thrombotic complications within the circuit and prevent bleeding in the patient. Despite focused efforts to achieve this balance, the frequency of both thrombotic and bleeding events remains high. Anticoagulation is complicated to manage in this population due to the complexities of the hemostatic system that are compounded by age-related developmental hemostatic changes, variable effects of the etiology of critical illness on hemostasis, and blood-circuit interaction. Lack of high-quality data to guide anticoagulation management in ECMO patients results in marked practice variability among centers. One aspect of anticoagulation therapy that is particularly challenging is the use of antithrombin (AT) supplementation for heparin resistance. This is especially controversial in the neonatal and pediatric population due to the baseline higher risk of bleeding in this cohort. The indication for AT supplementation is further compounded by the potential inaccuracy of the diagnosis of heparin resistance based on the standard laboratory parameters used to assess heparin effect. With concerns regarding the adverse impact of bleeding and thrombosis, clinicians and institutions are faced with making difficult, real-time decisions aimed at optimizing anticoagulation in this setting. In this clinically focused review, the authors discuss the complexities of anticoagulation monitoring and therapeutic intervention for patients on ECMO and examine the challenges surrounding AT supplementation given both the historical and current perspectives summarized in the literature on these topics.

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Oliver WC. Anticoagulation and coagulation management for ECMO. Semin Cardiothorac Vasc Anesth. 2009;13(3):154–75.PubMed

Bembea MM, Annich G, Rycus P, Oldenburg G, Berkowitz I, Pronovost P. Variability in anticoagulation management of patients on extracorporeal membrane oxygenation: an international survey. Pediatr Crit Care Med. 2013;14(2):e77–84.PubMedPubMedCentral

Hessel EA 2nd. A brief history of cardiopulmonary bypass. Semin Cardiothorac Vasc Anesth. 2014;18(2):87–100.PubMed

Monagle P, Chan AKC, Goldenberg NA, Ichord RN, Journeycake JM, Nowak-Gottl U, Vesely SK. Antithrombotic therapy in neonates and children: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e737S–801S.PubMedPubMedCentral

Garvin S, Muehlschlegel JD, Perry TE, Chen J, Liu KY, Fox AA, Collard CD, Aranki SF, Shernan SK, Body SC. Postoperative activity, but not preoperative activity, of antithrombin is associated with major adverse cardiac events after coronary artery bypass graft surgery. Anesth Analg. 2010;111(4):862–9.PubMed

Iapichino GE, Protti A, Andreis DT, Panigada M, Artoni A, Novembrino C, Pesenti A, Gattinoni L. Antithrombin during extracorporeal membrane oxygenation in adults: national survey and retrospective analysis. ASAIO J. 2019;65(3):257–63.PubMed

Bingham KR, Riley JB, Schears GJ. Anticoagulation management during first five days of infant-pediatric extracorporeal life support. J Extra Corpor Technol. 2018;50(1):30–7.PubMedPubMedCentral

Niebler RA, Christensen M, Berens R, Wellner H, Mikhailov T, Tweddell JS. Antithrombin replacement during extracorporeal membrane oxygenation. Artif Organs. 2011;35(11):1024–8.PubMed

Thiagarajan RR, Barbaro RP, Rycus PT, McMullan DM, Conrad SA, Fortenberry JD, Paden ML, centers Em. Extracorporeal life support organization registry international report 2016. ASAIO J. 2017;63(1):60–7.PubMed

10.

Barbaro RP, Paden ML, Guner YS, Raman L, Ryerson LM, Alexander P, Nasr VG, Bembea MM, Rycus PT, Thiagarajan RR, et al. Pediatric extracorporeal life support organization registry international report 2016. ASAIO J. 2017;63(4):456–63.PubMedPubMedCentral

11.

Reed RC, Rutledge JC. Laboratory and clinical predictors of thrombosis and hemorrhage in 29 pediatric extracorporeal membrane oxygenation nonsurvivors. Pediatr Dev Pathol. 2010;13(5):385–92.PubMed

12.

Dalton HJ, Reeder R, Garcia-Filion P, Holubkov R, Berg RA, Zuppa A, Moler FW, Shanley T, Pollack MM, Newth C, et al. Factors associated with bleeding and thrombosis in children receiving extracorporeal membrane oxygenation. Am J Respir Crit Care Med. 2017;196(6):762–71.PubMedPubMedCentral

13.

Esper SAWI, Subramaniam K, John Wallisch W, Levy JH, et al. Adult extracorporeal membrane oxygenation: an international survey of transfusion and anticoagulation techiques. Vox Sang. 2017;112(5):443–52.PubMed

14.

Rastan AJ, Lachmann N, Walther T, Doll N, Gradistanac T, Gommert JF, Lehmann S, Wittekind C, Mohr FW. Autopsy findings in patients on postcardiotomy extracorporeal membrane oxygenation (ECMO). Int J Artif Organs. 2006;29(12):1121–31.PubMed

15.

Saini A, Spinella PC. Management of anticoagulation and hemostasis for pediatric extracorporeal membrane oxygenation. Clin Lab Med. 2014;34(3):655–73.PubMed

16.

Doyle AJ, Hunt BJ. Current understanding of how extracorporeal membrane oxygenators activate haemostasis and other blood components. Front Med (Lausanne). 2018;5:352.

17.

Vincent F, Rauch A, Loobuyck V, Robin E, Nix C, Vincentelli A, Smadja DM, Leprince P, Amour J, Lemesle G, et al. Arterial pulsatility and circulating von Willebrand factor in patients on mechanical circulatory support. J Am Coll Cardiol. 2018;71(19):2106–18.PubMed

18.

Koster A, Ljajikj E, Faraoni D. Traditional and non-traditional anticoagulation management during extracorporeal membrane oxygenation. Ann Cardiothorac Surg. 2019;8(1):129–36.PubMedPubMedCentral

19.

Dzik WH. The James Blundell Award Lecture 2006: transfusion and the treatment of haemorrhage: past, present and future. Transfus Med. 2007;17(5):367–74.PubMed

20.

Hoffman M, Monroe DM. Coagulation 2006: a modern view of hemostasis. Hematol Oncol Clin North Am. 2007;21(1):1–11.PubMed

21.

Spinella PC. The blind physicians and the elephant on extracorporeal membrane oxygenation. Pediatr Crit Care Med. 2013;14(2):231–3.PubMed

22.

Spinler SA, Wittkowsky AK, Nutescu EA, Smythe MA. Anticoagulation monitoring part 2: unfractionated heparin and low-molecular-weight heparin. Ann Pharmacother. 2005;39(7–8):1275–85.PubMed

23.

Ammar T, Fisher CF, Sarier K, Coller BS. The effects of thrombocytopenia on the activated coagulation time. Anesth Analg. 1996;83(6):1185–8.PubMed

24.

Finley A, Greenberg C. Review article: heparin sensitivity and resistance: management during cardiopulmonary bypass. Anesth Analg. 2013;116(6):1210–22.PubMed

25.

Lawson DS, Walczak R, Lawson AF, Shearer IR, Ing R, Schulman S, Kern F, Jaggers J. North American neonatal extracorporeal membrane oxygenation (ECMO) devices: 2002 survey results. J Extra Corpor Technol. 2004;36(1):16–21.PubMed

26.

Despotis GJ, Summerfield AL, Joist JH, Goodnough LT, Santoro SA, Spitznagel E, Cox JL, Lappas DG. Comparison of activated coagulation time and whole blood heparin measurements with laboratory plasma anti-Xa heparin concentration in patients having cardiac operations. J Thorac Cardiovasc Surg. 1994;108(6):1076–82.PubMed

27.

Colby CE, Sheehan A, Benitz W, Van Meurs K, Halamek LP, Moss RL. Maintaining adequate anticoagulation on extracorporeal membrane oxygenation therapy: hemochron junior low range versus hemochron 400. J Extra Corpor Technol. 2003;35(1):35–8.PubMed

28.

Chan AK, Leaker M, Burrows FA, Williams WG, Gruenwald CE, Whyte L, Adams M, Brooker LA, Adams H, Mitchell L, et al. Coagulation and fibrinolytic profile of paediatric patients undergoing cardiopulmonary bypass. Thromb Haemost. 1997;77(2):270–7.PubMed

29.

Owings JT, Pollock ME, Gosselin RC, Ireland K, Jahr JS, Larkin EC. Anticoagulation of children undergoing cardiopulmonary bypass is overestimated by current monitoring techniques. Arch Surg. 2000;135(9):1042–7.PubMed

30.

Nankervis CA, Preston TJ, Dysart KC, Wilkinson WD, Chicoine LG, Welty SE, Nelin LD. Assessing heparin dosing in neonates on venoarterial extracorporeal membrane oxygenation. ASAIO J. 2007;53(1):111–4.PubMed

31.

Khaja WA, Bilen O, Lukner RB, Edwards R, Teruya J. Evaluation of heparin assay for coagulation management in newborns undergoing ECMO. Am J Clin Pathol. 2010;134(6):950–4.PubMed

32.

Bembea MM, Schwartz JM, Shah N, Colantuoni E, Lehmann CU, Kickler T, Pronovost P, Strouse JJ. Anticoagulation monitoring during pediatric extracorporeal membrane oxygenation. ASAIO J. 2013;59(1):63–8.PubMedPubMedCentral

33.

Liveris A, Bello RA, Friedmann P, Duffy MA, Manwani D, Killinger JS, Rodriquez D, Weinstein S. Anti-factor Xa assay is a superior correlate of heparin dose than activated partial thromboplastin time or activated clotting time in pediatric extracorporeal membrane oxygenation*. Pediatr Crit Care Med. 2014;15(2):e72–9.PubMed

34.

Atallah S, Liebl M, Fitousis K, Bostan F, Masud F. Evaluation of the activated clotting time and activated partial thromboplastin time for the monitoring of heparin in adult extracorporeal membrane oxygenation patients. Perfusion. 2014;29(5):456–61.PubMed

35.

Sklar MC, Sy E, Lequier L, Fan E, Kanji HD. Anticoagulation practices during venovenous extracorporeal membrane oxygenation for respiratory failure. A systematic review. Ann Am Thorac Soc. 2016;13(12):2242–50.PubMed

36.

Ranucci M, Baryshnikova E, Cotza M, Carboni G, Isgro G, Carlucci C, Ballotta A, Group for the S, Clinical Outcome R. Coagulation monitoring in postcardiotomy ECMO: conventional tests, point-of-care, or both? Minerva Anestesiol. 2016;82(8):858–66.PubMed

37.

Conlan MG, Folsom AR, Finch A, Davis CE, Sorlie P, Marcucci G, Wu KK. Associations of factor VIII and von Willebrand factor with age, race, sex, and risk factors for atherosclerosis. The Atherosclerosis Risk in Communities (ARIC) Study. Thromb Haemost. 1993;70(3):380–5.PubMed

38.

Olson JD, Arkin CF, Brandt JT, Cunningham MT, Giles A, Koepke JA, Witte DL. College of American Pathologists Conference XXXI on laboratory monitoring of anticoagulant therapy: laboratory monitoring of unfractionated heparin therapy. Arch Pathol Lab Med. 1998;122(9):782–98.PubMed

39.

Bates SM, Weitz JI, Johnston M, Hirsh J, Ginsberg JS. Use of a fixed activated partial thromboplastin time ratio to establish a therapeutic range for unfractionated heparin. Arch Intern Med. 2001;161(3):385–91.PubMed

40.

Ignjatovic V, Lai C, Summerhayes R, Mathesius U, Tawfilis S, Perugini MA, Monagle P. Age-related differences in plasma proteins: how plasma proteins change from neonates to adults. PLoS One. 2011;6(2):e17213.PubMedPubMedCentral

41.

Kostousov V, Nguyen K, Hundalani SG, Teruya J. The influence of free hemoglobin and bilirubin on heparin monitoring by activated partial thromboplastin time and anti-Xa assay. Arch Pathol Lab Med. 2014;138(11):1503–6.PubMed

42.

Delmas C, Jacquemin A, Vardon-Bounes F, Georges B, Guerrero F, Hernandez N, Marcheix B, Seguin T, Minville V, Conil JM, et al. Anticoagulation monitoring under ECMO support: a comparative study between the activated coagulation time and the anti-Xa activity assay. J Intensive Care Med. 2018. p. 885066618776937.

43.

De Luca L, Sardella G, Davidson CJ, De Persio G, Beraldi M, Tommasone T, Mancone M, Nguyen BL, Agati L, Gheorghiade M, et al. Impact of intracoronary aspiration thrombectomy during primary angioplasty on left ventricular remodelling in patients with anterior ST elevation myocardial infarction. Heart. 2006;92(7):951–7.PubMed

44.

Alexander DC, Butt WW, Best JD, Donath SM, Monagle PT, Shekerdemian LS. Correlation of thromboelastography with standard tests of anticoagulation in paediatric patients receiving extracorporeal life support. Thromb Res. 2010;125(5):387–92.PubMed

45.

Prakash S, Wiersema UF, Bihari S, Roxby D. Discordance between ROTEM(R) clotting time and conventional tests during unfractionated heparin-based anticoagulation in intensive care patients on extracorporeal membrane oxygenation. Anaesth Intensive Care. 2016;44(1):85–92.PubMed

46.

Panigada M, E Iapichino G, Brioni M, Panarello G, Protti A, Grasselli G, Occhipinti G, Novembrino C, Consonni D, Arcadipane A, et al. Thromboelastography-based anticoagulation management during extracorporeal membrane oxygenation: a safety and feasibility pilot study. Ann Intensive Care. 2018;8(1):7.PubMedPubMedCentral

47.

Hincker A, Feit J, Sladen RN, Wagener G. Rotational thromboelastometry predicts thromboembolic complications after major non-cardiac surgery. Crit Care. 2014;18(5):549.PubMedPubMedCentral

48.

Akay OM, Ustuner Z, Canturk Z, Mutlu FS, Gulbas Z. Laboratory investigation of hypercoagulability in cancer patients using rotation thrombelastography. Med Oncol. 2009;26(3):358–64.PubMed

49.

Davies NA, Harrison NK, Sabra A, Lawrence MJ, Noble S, Davidson SJ, Evans VJ, Morris RH, Hawkins K, Williams PR, et al. Application of ROTEM to assess hypercoagulability in patients with lung cancer. Thromb Res. 2015;135(6):1075–80.PubMed

50.

Thorson CM, Van Haren RM, Ryan ML, Curia E, Sleeman D, Levi JU, Livingstone AS, Proctor KG. Persistence of hypercoagulable state after resection of intra-abdominal malignancies. J Am Coll Surg. 2013;216(4):580–9 discussion 589-590.PubMed

51.

Akay OM, Karagulle M, Kus G, Mutlu FS, Gunduz E. Thrombelastographic evaluation of the influence of 2-RBC apheresis on donor's coagulation system. Transfus Apher Sci. 2013;48(3):387–90.PubMed

52.

Gorlinger KDD, Mueller-Beissenhirtz H, Paul A, et al. Thromboelastometry-based perioperative coagulation management in visceral surgery and liver transplantation: experience of 10 years and 1105 LTX. Liver Transpl. 2010;16:S86.

53.

Shimauchi T, Yamaura K, Higashi M, Abe K, Yoshizumi T, Hoka S. Fibrinolysis in living donor liver transplantation recipients evaluated using thromboelastometry: impact on mortality. Transplant Proc. 2017;49(9):2117–21.PubMed

54.

Romlin BS, Wahlander H, Berggren H, Synnergren M, Baghaei F, Nilsson K, Jeppsson A. Intraoperative thromboelastometry is associated with reduced transfusion prevalence in pediatric cardiac surgery. Anesth Analg. 2011;112(1):30–6.PubMed

55.

Straub A, Schiebold D, Wendel HP, Hamilton C, Wagner T, Schmid E, Dietz K, Ziemer G. Using reagent-supported thromboelastometry (ROTEM) to monitor haemostatic changes in congenital heart surgery employing deep hypothermic circulatory arrest. Eur J Cardiothorac Surg. 2008;34(3):641–7.PubMed

56.

Dunning J, Versteegh M, Fabbri A, Pavie A, Kolh P, Lockowandt U, Nashef SA, Audit E, Guidelines C. Guideline on antiplatelet and anticoagulation management in cardiac surgery. Eur J Cardiothorac Surg. 2008;34(1):73–92.PubMed

57.

de Lange NM, Lance MD, de Groot R, Beckers EA, Henskens YM, Scheepers HC. Obstetric hemorrhage and coagulation: an update. Thromboelastography, thromboelastometry, and conventional coagulation tests in the diagnosis and prediction of postpartum hemorrhage. Obstet Gynecol Surv. 2012;67(7):426–35.PubMed

58.

Huissoud C, Carrabin N, Audibert F, Levrat A, Massignon D, Berland M, Rudigoz RC. Bedside assessment of fibrinogen level in postpartum haemorrhage by thrombelastometry. BJOG. 2009;116(8):1097–102.PubMed

59.

Rugeri L, Levrat A, David JS, Delecroix E, Floccard B, Gros A, Allaouchiche B, Negrier C. Diagnosis of early coagulation abnormalities in trauma patients by rotation thrombelastography. J Thromb Haemost. 2007;5(2):289–95.PubMed

60.

Schochl H, Nienaber U, Hofer G, Voelckel W, Jambor C, Scharbert G, Kozek-Langenecker S, Solomon C. Goal-directed coagulation management of major trauma patients using thromboelastometry (ROTEM)-guided administration of fibrinogen concentrate and prothrombin complex concentrate. Crit Care. 2010;14(2):R55.PubMedPubMedCentral

61.

Shaz BH, Dente CJ, Nicholas J, MacLeod JB, Young AN, Easley K, Ling Q, Harris RS, Hillyer CD. Increased number of coagulation products in relationship to red blood cell products transfused improves mortality in trauma patients. Transfusion. 2010;50(2):493–500.PubMed

62.

Furukawa S, Nogami K, Ogiwara K, Yada K, Minami H, Shima M. Systematic monitoring of hemostatic management in hemophilia a patients with inhibitor in the perioperative period using rotational thromboelastometry. J Thromb Haemost. 2015;13(7):1279–84.PubMed

63.

Nogami K. The utility of thromboelastography in inherited and acquired bleeding disorders. Br J Haematol. 2016;174(4):503–14.PubMed

64.

Akay OM. The double hazard of bleeding and thrombosis in hemostasis from a clinical point of view: a global assessment by rotational thromboelastometry (ROTEM). Clin Appl Thromb Hemost. 2018;24(6):850–8.PubMedPubMedCentral

65.

Gorlinger K, Fries D, Dirkmann D, Weber CF, Hanke AA, Schochl H. Reduction of fresh frozen plasma requirements by perioperative point-of-care coagulation management with early calculated goal-directed therapy. Transfus Med Hemother. 2012;39(2):104–13.PubMedPubMedCentral

66.

Henderson N, Sullivan JE, Myers J, Wells T, Calhoun A, Berkenbosch J, Tzanetos DT. Use of thromboelastography to predict thrombotic complications in pediatric and neonatal extracorporeal membranous oxygenation. J Extra Corpor Technol. 2018;50(3):149–54.PubMedPubMedCentral

67.

Levy JH, Sniecinski RM, Welsby IJ, Levi M. Antithrombin: anti-inflammatory properties and clinical applications. Thromb Haemost. 2016;115(4):712–28.PubMed

68.

Rodgers GM. Role of antithrombin concentrate in treatment of hereditary antithrombin deficiency. An update. Thromb Haemost. 2009;101(5):806–12.PubMed

69.

Horie S, Ishii H, Kazama M. Heparin-like glycosaminoglycan is a receptor for antithrombin III-dependent but not for thrombin-dependent prostacyclin production in human endothelial cells. Thromb Res. 1990;59(6):895–904.PubMed

70.

Uchiba M, Okajima K, Murakami K, Okabe H, Takatsuki K. Effects of antithrombin III (AT III) and Trp49-modified AT III on plasma level of 6-keto-PGF1 alpha in rats. Thromb Res. 1995;80(3):201–8.PubMed

71.

Okajima K, Uchiba M. The anti-inflammatory properties of antithrombin III: new therapeutic implications. Semin Thromb Hemost. 1998;24(1):27–32.PubMed

72.

Appel IM, Grimminck B, Geerts J, Stigter R, Cnossen MH, Beishuizen A. Age dependency of coagulation parameters during childhood and puberty. J Thromb Haemost. 2012;10(11):2254–63.PubMed

73.

Williams MD, Chalmers EA, Gibson BE, Haemostasis, Thrombosis Task Force BCfSiH. The investigation and management of neonatal haemostasis and thrombosis. Br J Haematol. 2002;119(2):295–309.PubMed

74.

Tarango C, Manco-Johnson MJ. Pediatric thrombolysis: a practical approach. Front Pediatr. 2017;5:260.PubMedPubMedCentral

75.

Niimi KS, Fanning JJ. Initial experience with recombinant antithrombin to treat antithrombin deficiency in patients on extracorporeal membrane oxygenation. J Extra Corpor Technol. 2014;46(1):84–90.PubMedPubMedCentral

76.

Therapeutics G. Thrombate III prescribing information. In: Grifols US FDA; Revised; 2019.

77.

FDA LGBU: ATryn antithrombin (recombinant) prescribing information. 1999.

78.

Wong TE, Huang YS, Weiser J, Brogan TV, Shah SS, Witmer CM. Antithrombin concentrate use in children: a multicenter cohort study. J Pediatr. 2013;163(5):1329–34 e1321.PubMed

79.

FDA GU: Thrombate III (antithrombin III [human]) prescribing information. Revised 2019.

80.

Levy JH, Montes F, Szlam F, Hillyer CD. The in vitro effects of antithrombin III on the activated coagulation time in patients on heparin therapy. Anesth Analg. 2000;90(5):1076–9.PubMed

81.

Ryerson LM, Lequier LL. Anticoagulation management and monitoring during pediatric extracorporeal life support: a review of current issues. Front Pediatr. 2016;4:67.PubMedPubMedCentral

82.

Marshall AL, Levine M, Howell ML, Chang Y, Riklin E, Parry BA, Callahan RT, Okechukwu I, Ayres AM, Nahed BV, et al. Dose-associated pulmonary complication rates after fresh frozen plasma administration for warfarin reversal. J Thromb Haemost. 2016;14(2):324–30.PubMed

83.

Nelson KM, Hansen LA, Steiner ME, Fischer GA, Dehnel J, Gupta S. Continuous antithrombin III administration in pediatric veno-arterial extracorporeal membrane oxygenation. J Pediatr Pharmacol Ther. 2017;22(4):266–71.PubMedPubMedCentral

84.

O'Meara LC, Alten JA, Goldberg KG, Timpa JG, Phillips J, Laney D, Borasino S. Anti-xa directed protocol for anticoagulation management in children supported with extracorporeal membrane oxygenation. ASAIO J. 2015;61(3):339–44.PubMed

85.

Irby K, Swearingen C, Byrnes J, Bryant J, Prodhan P, Fiser R. Unfractionated heparin activity measured by anti-factor Xa levels is associated with the need for extracorporeal membrane oxygenation circuit/membrane oxygenator change: a retrospective pediatric study. Pediatr Crit Care Med. 2014;15(4):e175–82.PubMedPubMedCentral

86.

Northrop MS, Sidonio RF, Phillips SE, Smith AH, Daphne HC, Pietsch JB, Bridges BC. The use of an extracorporeal membrane oxygenation anticoagulation laboratory protocol is associated with decreased blood product use, decreased hemorrhagic complications, and increased circuit life. Pediatr Crit Care Med. 2015;16(1):66–74.PubMed

87.

Kessel AD, Kline M, Zinger M, McLaughlin D, Silver P, Sweberg TM. The impact and statistical analysis of a multifaceted anticoagulation strategy in children supported on ECMO: performance and pitfalls. J Intensive Care Med. 2017;32(1):59–67.PubMed

88.

Organization ECLS. ELSO anticoagulation guideline. The Extracorporeal Life Support Organization (ELSO). Ann Arbor; 2014. p. 2–17.

89.

Panigada M, Spinelli E, Cucino A, Cipriani E, De Falco S, Panarello G, Occhipinti G, Arcadipane A, Sales G, Fanelli V, et al. Antithrombin supplementation during extracorporeal membrane oxygenation: study protocol for a pilot randomized clinical trial. Trials. 2019;20(1):349.PubMedPubMedCentral

90.

Silva R, Grabowski EF. Flow devices to assess platelet function: historical evolution and current choices. Semin Thromb Hemost. 2019;45(3):297–301.PubMed

91.

Six KR, Devloo R, Van Aelst B, Vandekerckhove P, Feys HB, Compernolle V. A microfluidic flow chamber model for platelet transfusion and hemostasis measures platelet deposition and fibrin formation in real-time. J Vis Exp. 2017;120:1–9.

Title: Clinical controversies in anticoagulation monitoring and antithrombin supplementation for ECMO
Authors: Meghan M. Chlebowski
Sirine Baltagi
Mel Carlson
Jerrold H. Levy
Philip C. Spinella
Publication date: 01-12-2020
Publisher: BioMed Central
Keywords: Heparin
ECMO
ECMO
Published in: Critical Care / Issue 1/2020
Electronic ISSN: 1364-8535
DOI: https://doi.org/10.1186/s13054-020-2726-9

Keynote webinar | Spotlight on sleep in brain health

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Clinical controversies in anticoagulation monitoring and antithrombin supplementation for ECMO

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Keynote webinar | Spotlight on sleep in brain health

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Abstract

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