4. anticoagulation during ecmo #beach2019 (peperstraete)
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This workshop will outline the basic principles of extracorporeal life support made easy by key-experts in the field. During the course delegates will gain a good understanding of ECMO in the following areas: Theoretical concepts, basic physiology and pathophysiology, cardiac and respiratory support and monitoring, alarm settings and monitoring, role of cardiac ultrasound during ECMO, newest technologies, circuits and devices, practical hands-on sessions and simulations.
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4. anticoagulation during ecmo #beach2019 (peperstraete)
- 1. Harlinde Peperstraete MD Ghent University Hospital Harlinde.peperstraete@ugent.be Anticoagulation
- 5. albumin fibrinogen albumin fibrinogen Trombospondin Fibronectin VWF IgE TF VIIa VIIa VIIa VIIa TF TF TF TF VIIa And so coagulation is initiated... Leading to activation of factor X and a burst of thrombin formation Important role for Ca2+
- 7. 3 actions of bradykinin • Activation of intrinsic coagulation pathway • Activation of complement system > inflammation > activated endothelium > TF • Inflammatory reaction by the kallikrein system Leading to SIRS and vasoplegic state
- 8. Hemolysis Plasma free Hb enhances interaction between vWF and platelets
- 9. Delicate balance between coagulation and fibrinolysis • TFPI-system (Tissue Factor Pathway Inhibitor) • Intact endothelial cells: ADPase, eNO, PGI2, t-PA • Intact endothelial cells: heparansulfate • Protein C-system (VIIIa & Va) • Protein S • Antithrombin (± heparin) via XIIa, XIa, IXa, Xa & IIa • Fibrinolytic system through fibrinogen & fibrin
- 10. Unfractionated heparin • Standard in most centers • Low cost • Antidote= protamin • Familiarity • Monitoring: • ACT (140-220) • APTT (40-80sec or 1.5-2.5 ratio) • Anti-Xa (0.3-0.7) • Viscoelastic tests
- 11. UFH binds AT Structural change in AT Inhibitory power is accelerated 1:1 Xa & IIa Variability in effect: UFH binds pos charged proteins !AFP
- 12. Antithrombin • Drop in levels during the first days of ECMO therapy • Indicated in heparin resistance • Daily...? • Cut off for substitution...
- 13. Low- Molecular- Weight Heparin • Anti Xa monitoring (1h before and 4h after administering) • Mainly renal clearance, most ECMO pts have AKI
- 14. (parental) Direct Thrombin Inhibitors • Bivalirudin • Agratoban • Short half-lives (30 min and 40 min) • No antidotes
- 15. Bivalirudin • Direct trombin inhibitor • HIT pts • Best monitored with Diluted Thrombin Time • aPTT 50-90sec (ceiling effect), ACT • Bolus: 0.5-0.75 mg/kg • Infusion: 1.75 mg/kg/h • Mainly renal clearance
- 16. Argatroban • Direct trombin inhibitor • HIT pts • Best monitored with Diluted Thrombin Time • aPTT • Can interfere with PT • Mainly hepatic clearance
- 17. Antiplatelet drugs • Inhibit coagulation at the starting point • Might reduce platelet consumption • iNO on oxygenator
- 18. No anticoagulation • First 24-48h to 7days • TBI, major bleeding, Disseminated Intravascular Coagulation • Waiting for resolution of shock • Lubnow M et al. Technical complications during veno-venous extracorporeal membrane oxygenation and their relevance predicting a system-exchange—retrospective analysis of 265 cases. J Crit Care 2014;29:473.e1–473.e5.
- 19. VV ECMO: antico vs no antico (n=646) Overall: major bleeding 16%, thrombosis 53% ACT alone target: 62% major bleeding, 62% thrombosis aPTT guided 19% bleeding, 27% thrombosis aPTT<60 8% bleeding, 34% thrombosis aPTT >60 56% major bleeding, 7% thrombosis Thrombosis: mainly circuit clotting Anticoagulation Practices during Venovenous Extracorporeal Membrane Oxygenation for Respiratory Failure. A Systematic Review; MC Sklar e.a. AnnalsATS Volume 13 Number 12; 2242-2250
- 20. VA ECMO: antico vs no antico (n=1496) Overall 27% bleeding, 8% Trombo-embolic events ACT< 180sec 13%, 12% TE ACT>180sec 28%, 9% TE APTT target 50%, 3%TE Mixture of methods for monitoring 24% bleeding; 6 % TE 43% bleeding if no antico, 24% TE events Anticoagulation practices and the prevalence of major bleeding, thromboembolic events, and mortality in venoarterial extracorporeal membrane oxygenation: A systematic review and meta-analysis. E. Sy e.a. Journal of Critical Care; Volume 39, June 2017, Pages 87-9
- 21. Monitoring coagulation Combination of ACT, aPTT, anti Xa with ATIII Platelet count / function Fibrinogen Viscoelastic test (How fast- how strong- for how long?) NO SINGLE TEST may be considered adequate to guide (UFH) management
- 22. By Adam Morcom
Notas del editor
- Activated factor XII cleaves PK to kallikrein, which in turn splits bradykinin from HMWK
- Clinical relevance of circuit clotting reported in the different papers Most included studies were descriptive and retrospective in design, thereby limiting quantitative analyses of anticoagulation modalities and strategies. The frequency and type of complications may be underreported in this review.