Sanfilippo Filippo, Currò Jessica Marika, La Via Luigi, Dezio Veronica, Martucci Gennaro, Brancati Serena, Murabito Paolo, Pappalardo Federico, Astuto Marinella
Department of Anaesthesia and Intensive Care, A.O.U. "Policlinico-San Marco", Catania, Italy.
School of Anaesthesia and Intensive Care, University "Magna Graecia", Catanzaro, Italy.
Artif Organs. 2022 Dec;46(12):2371-2381. doi: 10.1111/aor.14276. Epub 2022 May 9.
Extracorporeal membrane oxygenation (ECMO) represents an advanced option for supporting refractory respiratory and/or cardiac failure. Systemic anticoagulation with unfractionated heparin (UFH) is routinely used. However, patients with bleeding risk and/or heparin-related side effects may necessitate alternative strategies: among these, nafamostat mesilate (NM) has been reported.
We conducted a systematic literature search (PubMed and EMBASE, updated 12/08/2021), including all studies reporting NM anticoagulation for ECMO. We focused on reasons for starting NM, its dose and the anticoagulation monitoring approach, the incidence of bleeding/thrombosis complications, the NM-related side effects, ECMO weaning, and mortality.
The search revealed 11 relevant findings, all with retrospective design. Of these, three large studies reported a control group receiving UFH, the other were case series (n = 3) or case reports (n = 5). The main reason reported for NM use was an ongoing or high risk of bleeding. The NM dose varied largely as did the anticoagulation monitoring approach. The average NM dose ranged from 0.46 to 0.67 mg/kg/h, but two groups of authors reported larger doses when monitoring anticoagulation with ACT. Conflicting findings were found on bleeding and thrombosis. The only NM-related side effect was hyperkalemia (n = 2 studies) with an incidence of 15%-18% in patients anticoagulated with NM. Weaning and survival varied across studies.
Anticoagulation with NM in ECMO has not been prospectively studied. While several centers have experience with this approach in high-risk patients, prospective studies are warranted to establish the optimal space of this approach in ECMO.
体外膜肺氧合（ECMO）是支持难治性呼吸和/或心力衰竭的一种先进选择。常规使用普通肝素（UFH）进行全身抗凝。然而，有出血风险和/或肝素相关副作用的患者可能需要替代策略：其中，甲磺酸萘莫司他（NM）已被报道。
我们进行了系统的文献检索（PubMed和EMBASE，更新于2021年8月12日），纳入所有报道NM用于ECMO抗凝的研究。我们关注开始使用NM的原因、剂量和抗凝监测方法、出血/血栓形成并发症的发生率、与NM相关的副作用、ECMO撤机情况及死亡率。
检索发现11项相关研究结果，均为回顾性设计。其中，三项大型研究报告了接受UFH的对照组，其他为病例系列（n = 3）或病例报告（n = 5）。报道的使用NM的主要原因是持续出血或出血风险高。NM剂量差异很大，抗凝监测方法也各不相同。NM的平均剂量范围为0.46至0.67mg/kg/h，但两组作者报告在使用活化凝血时间（ACT）监测抗凝时使用了更大剂量。关于出血和血栓形成的研究结果相互矛盾。唯一与NM相关的副作用是高钾血症（n = 2项研究），在接受NM抗凝的患者中发生率为15% - 18%。不同研究中的撤机情况和生存率各不相同。
尚未对ECMO中使用NM进行前瞻性研究。虽然几个中心在高危患者中使用这种方法有经验，但仍需要进行前瞻性研究以确定该方法在ECMO中的最佳应用范围。
