Division of Cardiothoracic Surgery, Oregon Health & Science University, Portland, Oregon.
Department of Medicine, Rush University Medical Center, Chicago, Illinois.
J Heart Lung Transplant. 2019 Apr;38(4):433-439. doi: 10.1016/j.healun.2019.01.1313. Epub 2019 Jan 31.
Bleeding and need for blood products are major complications associated with extracorporeal membrane oxygenation (ECMO) use. This study evaluated bleeding complications with low and standard heparinization protocols in the maintenance of venoarterial (VA)-ECMO.
A retrospective comparison was performed of 2 methods of heparinization in a contemporaneous series of adult patients supported with VA-ECMO at Rush University Medical Center, between November 2011 and November 2016. CentriMag (Thoratec, Pleasanton, CA) pumps, Quadrox (Maquet, Wayne, NJ) oxygenators, and heparin-bonded circuitry were used in all patients. Group 1 was a control group of 50 patients who had ECMO support with an initiation dose of 5,000 U of heparin, followed by standard heparinization at a goal activated clotting time of 180 to 220 seconds. Group 2 comprised 52 adult patients supported with a "low heparin protocol" ECMO, receiving a standard heparin bolus of 5,000 U for cannulation but without subsequent, ongoing heparin administration. Acuity of illness was similar in both groups as assessed by the Mortality Probability Model (59% in Group 1 vs 62.9% in Group 2, p = 0.08). Data were submitted to the Extracorporeal Life Support Organization prospectively. Clots in the circuit, limb ischemia, oxygenator failure, and embolic complications were recorded.
Weaning off ECMO was successful in 26 patients (50%) in Group 2 compared with 18 (36%) in Group 1 (p = 0.05). Hemorrhage from the cannulation site occurred in 11 (21%) in Group 2 vs 21 (42%) in Group 1 and from the surgical site in 11 (21%) in Group 2 vs 18 (36%) in Group 1. Severe bleeding complications were higher in the control group (Group 1, 32%) compared with Group 2 (11.5%; p = 0.012).
Maintenance with low heparin is safe in patients supported by VA-ECMO. This strategy may reduce risk of severe bleeding and associated complications.
出血和对血制品的需求是与体外膜肺氧合（ECMO）使用相关的主要并发症。本研究评估了低剂量和标准肝素化方案在维持静脉-动脉（VA）-ECMO 中的出血并发症。
回顾性比较了 2011 年 11 月至 2016 年 11 月在拉什大学医学中心接受 VA-ECMO 支持的成年患者的两种肝素化方法。所有患者均使用 CentriMag（Thoratec，Pleasanton，CA）泵、Quadrox（Maquet，Wayne，NJ）氧合器和肝素结合电路。第 1 组为 50 例患者的对照组，他们在 ECMO 支持下接受 5000U 肝素的起始剂量，然后以 180-220 秒的目标激活凝血时间进行标准肝素化。第 2 组包括 52 名接受“低肝素方案”ECMO 支持的成年患者，他们在插管时接受标准肝素 5000U 推注，但随后不再持续给予肝素。两组的疾病严重程度相似，根据死亡率预测模型评估（第 1 组为 59%，第 2 组为 62.9%，p=0.08）。数据被提交给体外生命支持组织进行前瞻性评估。记录了回路中的血栓、肢体缺血、氧合器故障和栓塞并发症。
第 2 组中有 26 例（50%）成功脱机 ECMO，而第 1 组有 18 例（36%）（p=0.05）。第 2 组有 11 例（21%）插管部位出血，第 1 组有 21 例（42%），第 2 组有 11 例（21%）手术部位出血，第 1 组有 18 例（36%）。对照组（第 1 组，32%）严重出血并发症发生率高于第 2 组（11.5%；p=0.012）。
VA-ECMO 支持的患者使用低剂量肝素维持是安全的。这种策略可能会降低严重出血和相关并发症的风险。
