Department of Pediatrics, Division of Pediatric Cardiology, Cardiovascular Intensive Care Unit, Cincinnati Children's Hospital/University of Cincinnati College of Medicine, 3333 Burnet Ave, Cincinnati, OH, 45229, USA.
Department of Pediatrics, Division of Critical Care Medicine, St. Joseph's Children's Hospital/University of Pittsburg School of Medicine, Tampa, FL, USA.
Crit Care. 2020 Jan 20;24(1):19. doi: 10.1186/s13054-020-2726-9.
During extracorporeal membrane oxygenation (ECMO), a delicate balance is required to titrate systemic anticoagulation to prevent thrombotic complications within the circuit and prevent bleeding in the patient. Despite focused efforts to achieve this balance, the frequency of both thrombotic and bleeding events remains high. Anticoagulation is complicated to manage in this population due to the complexities of the hemostatic system that are compounded by age-related developmental hemostatic changes, variable effects of the etiology of critical illness on hemostasis, and blood-circuit interaction. Lack of high-quality data to guide anticoagulation management in ECMO patients results in marked practice variability among centers. One aspect of anticoagulation therapy that is particularly challenging is the use of antithrombin (AT) supplementation for heparin resistance. This is especially controversial in the neonatal and pediatric population due to the baseline higher risk of bleeding in this cohort. The indication for AT supplementation is further compounded by the potential inaccuracy of the diagnosis of heparin resistance based on the standard laboratory parameters used to assess heparin effect. With concerns regarding the adverse impact of bleeding and thrombosis, clinicians and institutions are faced with making difficult, real-time decisions aimed at optimizing anticoagulation in this setting. In this clinically focused review, the authors discuss the complexities of anticoagulation monitoring and therapeutic intervention for patients on ECMO and examine the challenges surrounding AT supplementation given both the historical and current perspectives summarized in the literature on these topics.
在体外膜肺氧合（ECMO）过程中，需要精细地调整全身抗凝，以防止回路内的血栓形成并发症，并防止患者出血。尽管为了达到这种平衡付出了集中的努力，但血栓形成和出血事件的频率仍然很高。由于止血系统的复杂性，再加上与年龄相关的发育性止血变化、严重疾病对止血的影响的可变性以及血液回路相互作用，这种人群的抗凝管理变得复杂。缺乏高质量的数据来指导 ECMO 患者的抗凝管理，导致中心之间的实践差异显著。抗凝治疗中一个特别具有挑战性的方面是使用抗凝血酶 (AT) 来补充肝素抵抗。由于在这一队列中出血的基线风险较高，这在新生儿和儿科人群中尤其具有争议。AT 补充的指征进一步受到基于用于评估肝素效果的标准实验室参数来诊断肝素抵抗的潜在不准确性的影响。由于担心出血和血栓形成的不良影响，临床医生和机构面临着在这种情况下优化抗凝的困难、实时决策。在这篇临床重点综述中，作者讨论了 ECMO 患者抗凝监测和治疗干预的复杂性，并研究了在这些主题的文献中总结的历史和当前观点的背景下，AT 补充的挑战。
