From the Anesthesia, Intensive Care, and Emergency Department, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy (A.P., M.P.) Department of Anesthesia and Intensive Care Units, Humanitas Clinical and Research Center, Milan, Italy (G.E.I.) Department of Medical and Surgical Neonatology, Ospedale IRCCS Pediatrico Bambino Gesù, Rome, Italy (M.D.N.) Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany (L.G.).
Anesthesiology. 2020 Mar;132(3):562-570. doi: 10.1097/ALN.0000000000003044.
There is a lack of consensus on how to manage anticoagulation during veno-venous extracorporeal membrane oxygenation, including antithrombin monitoring and supplementation. The authors' aim was to determine current practice in a large number of extracorporeal membrane oxygenation centers around the world.
This was an electronic survey disseminated in 2018 to directors and coordinators of extracorporeal membrane oxygenation centers as well as to extracorporeal membrane oxygenation experts. Participating centers were classified according to some covariates that may affect practice, including 2017 gross national income per capita, primary patient population, and annual extracorporeal membrane oxygenation patient volume.
The authors analyzed 273 unique responses from 50 countries. Systemic anticoagulation was routinely prescribed in 264 (96.7%) centers, with unfractionated heparin being the drug of choice in 255 (96.6%) of them. The preferred method to monitor anticoagulation was activated partial thromboplastin time in 114 (41.8%) centers, activated clotting time in 82 (30.0%) centers, and anti-factor Xa activity in 62 (22.7%) centers. Circulating antithrombin activity was routinely monitored in 133 (48.7%) centers. Antithrombin supplementation was routinely prescribed in 104 (38.1%) centers. At multivariable analyzes, routine antithrombin supplementation was associated with national income, being less likely in lower- than in higher-income countries (odds ratio, 0.099 [95% CI, 0.022 to 0.45]; P = 0.003); with primary patient population being more frequent in mixed (odds ratio, 2.73 [1.23 to 6.0]; P = 0.013) and pediatric-only centers (odds ratio, 6.3 [2.98 to 13.2]; P < 0.001) than in adult-only centers; but not with annual volume of extracorporeal membrane oxygenation cases, being similarly common in smaller and larger centers (odds ratio, 1.00 [0.48 to 2.08]; P = 0.997).
There is large practice variation among institutions regarding anticoagulation management and antithrombin supplementation during veno-venous extracorporeal membrane oxygenation. The paucity of prospective studies and differences across institutions based on national income and primary patient population may contribute to these findings.
在静脉-静脉体外膜肺氧合（venous-venous extracorporeal membrane oxygenation，VV-ECMO）期间，如何管理抗凝治疗，包括抗凝血酶监测和补充，目前尚未达成共识。作者的目的是确定全球大量体外膜肺氧合中心的当前实践情况。
这是一项 2018 年向体外膜肺氧合中心主任和协调员以及体外膜肺氧合专家分发的电子调查。参与的中心根据可能影响实践的一些协变量进行分类，包括 2017 年人均国民总收入、主要患者人群和每年体外膜肺氧合患者数量。
作者分析了来自 50 个国家的 273 份独特回复。264 个（96.7%）中心常规开具全身抗凝治疗，其中 255 个（96.6%）中心首选普通肝素。114 个（41.8%）中心首选监测抗凝的方法是活化部分凝血活酶时间，82 个（30.0%）中心是活化凝血时间，62 个（22.7%）中心是抗因子 Xa 活性。133 个（48.7%）中心常规监测循环抗凝血酶活性。104 个（38.1%）中心常规开具抗凝血酶补充治疗。多变量分析显示，常规抗凝血酶补充治疗与国家收入相关，收入较低的国家较收入较高的国家更不可能（比值比，0.099[95%CI，0.022 至 0.45]；P=0.003）；主要患者人群为混合人群（比值比，2.73[1.23 至 6.0]；P=0.013）和儿科患者（比值比，6.3[2.98 至 13.2]；P<0.001）的中心较仅成年患者的中心更常见，但与体外膜肺氧合年病例量无关，在较小和较大的中心中同样常见（比值比，1.00[0.48 至 2.08]；P=0.997）。
在 VV-ECMO 期间，抗凝治疗管理和抗凝血酶补充方面，各机构之间的实践差异很大。这种情况可能是由于缺乏前瞻性研究以及基于国家收入和主要患者人群的机构之间的差异造成的。
