Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD.
Department of Pharmacy, Duke University Hospital, Durham, NC.
J Cardiothorac Vasc Anesth. 2022 Sep;36(9):3561-3569. doi: 10.1053/j.jvca.2022.05.012. Epub 2022 May 13.
To evaluate the effect of anticoagulation targets and intensity on bleeding events, thrombotic events, and transfusion requirements in patients with acute respiratory distress syndrome (ARDS) receiving venovenous extracorporeal membrane oxygenation (ECMO) and continuous-infusion heparin.
A retrospective cohort study.
At a single-center, large academic medical center.
One hundred thirty-six critically ill patients.
The following three therapeutic targets were implemented over time and evaluated: (1) no protocol (September 2013-August 2016): no standardized anticoagulation protocol or transfusion thresholds; (2) <50 seconds (September 2016-January 2018): standardized activated partial thromboplastin time (aPTT) goal of <50 seconds, maximum heparin infusion rate of 1,200 units/h, transfusion threshold of hemoglobin (Hgb) <8 g/dL; and (3) 40-to-50 seconds (February 2018-December 2019): aPTT goal of 40-to-50 sec, no maximum heparin infusion rate, transfusion threshold of Hgb <7 g/dL.
Continuous variables were compared using the Kruskal-Wallis test, and categorical variables were compared using Fisher exact tests. The primary endpoint, an incidence of at least 1 bleeding event, was highest in the no-protocol group though not statistically different among groups (39.3% v 26.7% v 34%, p = 0.5). Thrombotic complications were similar. The median units of packed red blood cells transfused were highest in the no-protocol group (3 v 2 v 0.5, p < 0.001).
Anticoagulation protocols standardizing aPTT goals to <50 or 40-to-50 seconds may be a reasonable strategy for patients receiving venovenous ECMO for ARDS. More restrictive hemoglobin transfusion thresholds, in combination with lower aPTT targets, may be associated with a reduction in transfusion requirements.
评估急性呼吸窘迫综合征（ARDS）患者接受静脉-静脉体外膜肺氧合（ECMO）和持续输注肝素时抗凝目标和强度对出血事件、血栓事件和输血需求的影响。
回顾性队列研究。
在一个单一中心的大型学术医疗中心。
136 名危重症患者。
随着时间的推移，实施了以下三个治疗目标并进行了评估：（1）无方案（2013 年 9 月至 2016 年 8 月）：无标准化抗凝方案或输血阈值；（2）<50 秒（2016 年 9 月至 2018 年 1 月）：标准化激活部分凝血活酶时间（aPTT）目标<50 秒，最大肝素输注率 1200 单位/小时，血红蛋白（Hgb）<8 g/dL 的输血阈值；和（3）40-50 秒（2018 年 2 月至 2019 年 12 月）：aPTT 目标为 40-50 秒，无最大肝素输注率，Hgb<7 g/dL 的输血阈值。
连续变量采用 Kruskal-Wallis 检验进行比较，分类变量采用 Fisher 确切检验进行比较。主要终点，即至少发生 1 次出血事件的发生率，在无方案组最高，但各组之间无统计学差异（39.3%比 26.7%比 34%，p=0.5）。血栓并发症相似。无方案组输注的浓缩红细胞单位数最高（3 比 2 比 0.5，p<0.001）。
为 ARDS 患者行静脉-静脉 ECMO 治疗时，将 aPTT 目标标准化至<50 或 40-50 秒的抗凝方案可能是合理的策略。更严格的血红蛋白输血阈值与较低的 aPTT 目标相结合，可能与减少输血需求有关。
