Kalbhenn J, Wittau N, Schmutz A, Zieger B, Schmidt R
Department of Anaesthesiology and Critical Care Medicine, Freiburg University Medical Centre, Freiburg, Germany
Department of Anaesthesiology, Critical Care and Emergency Medicine, St. Josef's Hospital Freiburg, Germany.
Perfusion. 2015 Nov;30(8):675-82. doi: 10.1177/0267659115579714. Epub 2015 Mar 30.
Intracranial haemorrhage is a redoubtable complication during extracorporeal membrane oxygenation (ECMO) therapy. The underlying mechanisms of haemorrhagic diathesis are still not completely understood. This study was performed to evaluate a coagulation protocol for the regular analysis of acquired coagulation disorders and the systematic substitution of coagulation factors to reach predefined target values. We hypothesised that using this strategy would lead to the identification of acquired bleeding disorders which cannot be monitored with standard coagulation tests and that substitution of the respective factors in a target-controlled approach could have an impact on the incidence and severity of intracranial haemorrhage.
A protocol for the analysis of acquired coagulation disorders and the subsequent administration of associated factor concentrates was introduced. Previously, coagulation management was mainly based on clinical bleeding signs as the trigger for the administration of blood products. In this investigation, nineteen consecutive patients before (control group) and twenty consecutive patients after the implementation of the protocol (intervention group) have been included in the study.
Eighty-eight percent of the patients developed factor XIII deficiency, 79% acquired von Willebrand syndrome, 40% fibrinogen deficiency and 54% of the patients showed a decline in platelet count >20% within the first 24 hours of ECMO therapy. In 6 out of 19 (31%) patients in the control group and in 2 patients out of 20 (10%) in the intervention group, intracranial haemorrhage was detected. Whilst 5 of 6 patients in the control group died because of fatal bleeding, both of the patients in the intervention group recovered with a favourable neurologic outcome.
Veno-venous ECMO therapy leads to thrombocytopenia, factor XIII and fibrinogen deficiency as well as acquired von Willebrand syndrome. The implementation of a coagulation protocol including a standardized determination and target-controlled substitution of coagulation factors may have a beneficial impact on the incidence and severity of intracranial haemorrhage.
颅内出血是体外膜肺氧合（ECMO）治疗期间一种可怕的并发症。出血素质的潜在机制仍未完全明了。本研究旨在评估一种凝血方案，用于定期分析获得性凝血障碍以及系统地替代凝血因子以达到预定目标值。我们假设采用该策略将有助于识别无法通过标准凝血试验监测的获得性出血性疾病，并且以目标控制的方式替代相应因子可能会对颅内出血的发生率和严重程度产生影响。
引入了一种用于分析获得性凝血障碍并随后给予相关因子浓缩物的方案。此前，凝血管理主要基于临床出血迹象作为输注血液制品的触发因素。在本研究中，纳入了19例实施该方案前的连续患者（对照组）和20例实施该方案后的连续患者（干预组）。
88%的患者出现因子XIII缺乏，79%出现获得性血管性血友病综合征，40%出现纤维蛋白原缺乏，54%的患者在ECMO治疗的头24小时内血小板计数下降>20%。对照组19例患者中有6例（31%）、干预组20例患者中有2例（10%）检测到颅内出血。对照组6例患者中有5例因致命性出血死亡，而干预组的2例患者均康复且神经功能预后良好。
静脉-静脉ECMO治疗会导致血小板减少、因子XIII和纤维蛋白原缺乏以及获得性血管性血友病综合征。实施包括标准化测定和目标控制的凝血因子替代的凝血方案可能会对颅内出血的发生率和严重程度产生有益影响。
