Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The STEP trials

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.
ADVANCED SEARCH
Log in
Top
Annals of Intensive Care
Published in: Annals of Intensive Care 1/2018

Open Access 01-12-2018 | Research

Thromboelastography-based anticoagulation management during extracorporeal membrane oxygenation: a safety and feasibility pilot study

Authors: Mauro Panigada, Giacomo E. Iapichino, Matteo Brioni, Giovanna Panarello, Alessandro Protti, Giacomo Grasselli, Giovanna Occhipinti, Cristina Novembrino, Dario Consonni, Antonio Arcadipane, Luciano Gattinoni, Antonio Pesenti

Published in: Annals of Intensive Care | Issue 1/2018

Login to get access

Abstract

Background

There is no consensus on the management of anticoagulation during extracorporeal membrane oxygenation (ECMO). ECMO is currently burdened by a high rate of hemostatic complications, possibly associated with inadequate monitoring of heparin anticoagulation. This study aims to assess the safety and feasibility of an anticoagulation protocol for patients undergoing ECMO based on thromboelastography (TEG) as opposed to an activated partial thromboplastin time (aPTT)-based protocol.

Methods

We performed a multicenter, randomized, controlled trial in two academic tertiary care centers. Adult patients with acute respiratory failure treated with veno-venous ECMO were randomized to manage heparin anticoagulation using a TEG-based protocol (target 16–24 min of the R parameter, TEG group) or a standard of care aPTT-based protocol (target 1.5–2 of aPTT ratio, aPTT group). Primary outcomes were safety and feasibility of the study protocol.

Results

Forty-two patients were enrolled: 21 were randomized to the TEG group and 21 to the aPTT group. Duration of ECMO was similar in the two groups (9 (7–16) days in the TEG group and 11 (4–17) days in the aPTT group, p = 0.74). Heparin dosing was lower in the TEG group compared to the aPTT group (11.7 (9.5–15.3) IU/kg/h vs. 15.7 (10.9–21.3) IU/kg/h, respectively, p = 0.03). Safety parameters, assessed as number of hemorrhagic or thrombotic events and transfusions given, were not different between the two study groups. As for the feasibility, the TEG-based protocol triggered heparin infusion rate adjustments more frequently (p < 0.01) and results were less frequently in the target range compared to the aPTT-based protocol (p < 0.001). Number of prescribed TEG or aPTT controls (according to study groups) and protocol violations were not different between the study groups.

Conclusions

TEG seems to be safely used to guide anticoagulation management during ECMO. Its use was associated with the administration of lower heparin doses compared to a standard of care aPTT-based protocol.
Trial registration ClinicalTrials.gov, October 22,2014. Identifier: NCT02271126.
Appendix
Available only for authorised users
Literature
1.
Urlesberger B, Zobel G, Zenz W, et al. Activation of the clotting system during extracorporeal membrane oxygenation in term newborn infants. J Pediatr. 1996;129:264–8.CrossRefPubMed
2.
Panigada M, Artoni A, Passamonti SM, et al. Hemostasis changes during veno-venous extracorporeal membrane oxygenation for respiratory support in adults. Minerva Anestesiol. 2016;82:170–9.PubMed
3.
4.
5.
Millar JE, Fanning JP, McDonald CI, et al. The inflammatory response to extracorporeal membrane oxygenation (ECMO): a review of the pathophysiology. Crit Care. 2016;20(1):387.CrossRefPubMedPubMedCentral
6.
Levi M, Schultz MJ. What do sepsis-induced coagulation test result abnormalities mean to intensivists? Intensive Care Med. 2017;43:581–3.CrossRefPubMed
7.
Annich GM. Extracorporeal life support: the precarious balance of hemostasis. J Thromb Haemost. 2015;13(Suppl 1):S336–42.CrossRefPubMed
8.
Bembea MM, Annich G, Rycus P, et al. Variability in anticoagulation management of patients on extracorporeal membrane oxygenation: an international survey. Pediatr Crit Care Med. 2013;14:e77–84.CrossRefPubMedPubMedCentral
9.
Esper SA, Levy JH, Waters JH, et al. Extracorporeal membrane oxygenation in the adult: a review of anticoagulation monitoring and transfusion. Anesth Analg. 2014;118:731–43.CrossRefPubMed
10.
11.
Oliver WC. Anticoagulation and coagulation management for ECMO. Semin Cardiothorac Vasc Anesth. 2009;13:154–75.CrossRefPubMed
12.
13.
Lee BY, Taha S, Trainor FS, et al. Monitoring heparin therapy with thromboelastography and activated partial thromboplastin time. World J Surg. 1980;4:323–30.CrossRefPubMed
14.
Tekkesin N, Tekkesin M, Kaso G. Thromboelastography for the monitoring of the antithrombotic effect of low-molecular-weight heparin after major orthopedic surgery. Anatol J Cardiol. 2015;15:932–7.CrossRefPubMed
15.
McLaughlin CM, Marks SL, Dorman DC, et al. Thromboelastographic monitoring of the effect of unfractionated heparin in healthy dogs. J Vet Emerg Crit Care (San Antonio). 2016;27:71–81.CrossRef
16.
Panigada M, Iapichino G, L’Acqua C, et al. Prevalence of “flat-line” thromboelastography during extracorporeal membrane oxygenation for respiratory failure in adults. ASAIO J. 2016;62:302–9.CrossRefPubMed
17.
Aubron C, DePuydt J, Belon F, et al. Predictive factors of bleeding events in adults undergoing extracorporeal membrane oxygenation. Ann Intensive Care. 2016;6:97.CrossRefPubMedPubMedCentral
18.
Combes A, Brodie D, Chen Y-S, et al. The ICM research agenda on extracorporeal life support. Intensive Care Med. 2017;43:1306–18.CrossRefPubMed
19.
Mehran R, Rao SV, Bhatt DL, et al. Standardized bleeding definitions for cardiovascular clinical trials: a consensus report from the Bleeding Academic Research Consortium. In: Circulation; 2011. pp. 2736–2747.
20.
Julious SA. Sample size of 12 per group rule of thumb for a pilot study. Pharmaceut Stat. 2005;4:287–91.CrossRef
21.
Rabe-Hesketh S, Skrondal A. Multilevel and longitudinal modeling using stata, 2nd edn. College Station, Texas: A Stata Press Publication, StataCorp LP; 2008.
22.
Bolliger D, Szlam F, Molinaro RJ, et al. Finding the optimal concentration range for fibrinogen replacement after severe haemodilution: an in vitro model. Br J Anaesth. 2009;102:793–9.CrossRefPubMed
23.
24.
Irby K, Swearingen C, Byrnes J, et al. 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:e175–82.CrossRefPubMedPubMedCentral
25.
Agerstrand CL, Burkart KM, Abrams DC, et al. Blood conservation in extracorporeal membrane oxygenation for acute respiratory distress syndrome. Ann Thorac Surg. 2015;99:590–5.CrossRefPubMed
26.
Yeo HJ, Kim DH, Jeon D, et al. Low-dose heparin during extracorporeal membrane oxygenation treatment in adults. Intensive Care Med. 2015;41(11):2020–1.CrossRefPubMed
27.
Krueger K, Schmutz A, Zieger B, et al. Venovenous extracorporeal membrane oxygenation with prophylactic subcutaneous anticoagulation only: an observational study in more than 60 patients. Artif Organs. 2016;41:186–92.CrossRefPubMed
28.
29.
Klein SM, Slaughter TF, Vail PT, et al. Thromboelastography as a perioperative measure of anticoagulation resulting from low molecular weight heparin: a comparison with anti-Xa concentrations. Anesth Analg. 2000;91:1091–5.CrossRefPubMed
30.
Basu D, Gallus A, Hirsh J, et al. A prospective study of the value of monitoring heparin treatment with the activated partial thromboplastin time. N Engl J Med. 1972;287:324–7.CrossRefPubMed
31.
Chiu HM, Hirsh J, Yung WL, et al. Relationship between the anticoagulant and antithrombotic effects of heparin in experimental venous thrombosis. Blood. 1977;49:171–84.PubMed
Metadata
Title
Thromboelastography-based anticoagulation management during extracorporeal membrane oxygenation: a safety and feasibility pilot study
Authors
Mauro Panigada
Giacomo E. Iapichino
Matteo Brioni
Giovanna Panarello
Alessandro Protti
Giacomo Grasselli
Giovanna Occhipinti
Cristina Novembrino
Dario Consonni
Antonio Arcadipane
Luciano Gattinoni
Antonio Pesenti
Publication date
01-12-2018
Publisher
Springer International Publishing
Published in
Annals of Intensive Care / Issue 1/2018
Electronic ISSN: 2110-5820
DOI
https://doi.org/10.1186/s13613-017-0352-8

Other articles of this Issue 1/2018

Annals of Intensive Care 1/2018 Go to the issue

Review

Renal failure in critically ill patients, beware of applying (central venous) pressure on the kidney

Research

Plasma microRNAs levels are different between pulmonary and extrapulmonary ARDS patients: a clinical observational study

Research

Characteristics and outcome of patients with newly diagnosed advanced or metastatic lung cancer admitted to intensive care units (ICUs)

Research

Ischemic and hemorrhagic brain injury during venoarterial-extracorporeal membrane oxygenation

Research

Acute kidney injury epidemiology, risk factors, and outcomes in critically ill patients 16–25 years of age treated in an adult intensive care unit

Review

Data-driving methods: More than merely trendy buzzwords?