Panigada Mauro, Iapichino Giacomo, L'Acqua Camilla, Protti Alessandro, Cressoni Massimo, Consonni Dario, Mietto Cristina, Gattinoni Luciano
From the *Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy; and †Epidemiology Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy.
ASAIO J. 2016 May-Jun;62(3):302-9. doi: 10.1097/MAT.0000000000000325.
We evaluated the prevalence of a thromboelastography reaction time (R time) >90 min ("flat-line") reversible with heparinase during extracorporeal membrane oxygenation (ECMO). We evaluated the association between "flat-line" thromboelastography, other coagulation tests, and risk of bleeding during ECMO. Thirty-two consecutive patients on ECMO were included. Anticoagulation was provided by continuous infusion of unfractionated heparin to maintain an activated partial thromboplastin time (aPTT) ratio between 1.5 and 2.0. Activated clotting times (ACTs) thromboelastography without and with heparinase were measured. Occurrence of bleeding was recorded. Median heparin infusion rate was 16 (12-20) IU/kg/h, aPTT ratio was 1.67 (1.48-1.96), and ACT was 173 (161-184) sec. One hundred forty-five (46%) of 316 paired thromboelastography samples were "flat lines" all reversed with heparinase. Patients with "flat-line" thromboelastography received more heparin (p = 0.001) but had similar platelet count (p = 0.164) and fibrinogen level (p = 0.952) than those without. Activated partial thromboplastin time, ACT, and R time without heparinase weakly correlated between each other (Spearman correlation ≤0.36) with poor agreement (Cohen's κ ≤0.10). Major bleeding occurred in seven (22%) patients. Bleeding during ECMO was not predicted by any of the used test. In conclusion, adjusting heparin infusion to maintain aPTT ratio between 1.5 and 2.0 frequently resulted in "flat-line" thromboelastography.
我们评估了体外膜肺氧合（ECMO）期间血栓弹力图反应时间（R时间）>90分钟（“平线”）且可被肝素酶逆转的发生率。我们评估了“平线”血栓弹力图、其他凝血试验与ECMO期间出血风险之间的关联。纳入了32例连续接受ECMO治疗的患者。通过持续输注普通肝素进行抗凝，以维持活化部分凝血活酶时间（aPTT）比值在1.5至2.0之间。测量了有无肝素酶时的活化凝血时间（ACT）和血栓弹力图。记录出血的发生情况。肝素输注的中位速率为16（12 - 20）IU/kg/h，aPTT比值为1.67（1.48 - 1.96），ACT为173（161 - 184）秒。316对血栓弹力图样本中有145个（46%）为“平线”，均被肝素酶逆转。与无“平线”血栓弹力图的患者相比，有“平线”血栓弹力图的患者接受了更多的肝素（p = 0.001），但血小板计数（p = 0.164）和纤维蛋白原水平（p = 0.952）相似。无肝素酶时的活化部分凝血活酶时间、ACT和R时间彼此之间弱相关（Spearman相关性≤0.36），一致性较差（Cohen's κ≤0.10）。7例（22%）患者发生了大出血。所使用的任何一项检查均未预测到ECMO期间的出血情况。总之，调整肝素输注以维持aPTT比值在1.5至2.0之间经常会导致血栓弹力图出现“平线”。
