Chen Jiale, Chen Guoquan, Zhao Wenyi, Peng Wenxing
Department of Pharmacy, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, China.
Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
Pharmacotherapy. 2023 Oct;43(10):1084-1093. doi: 10.1002/phar.2859. Epub 2023 Aug 11.
Extracorporeal membrane oxygenation (ECMO) plays an important role in providing temporary life support for patients with severe cardiac or pulmonary failure, but requires strict anticoagulation and monitoring. This network meta-analysis systematically explored the most effective anticoagulation and monitoring strategies for patients receiving ECMO.
MEDLINE, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials were searched up to January 31, 2023, for studies comparing unfractionated heparin (UFH), argatroban (Arg), bivalirudin (Biv), and/or nafamostat mesylate (NM) in patients receiving ECMO. The primary outcomes included device-related thrombosis, patient-related thrombosis, and major bleeding events. The secondary outcomes included ECMO survival, ECMO duration, and in-hospital mortality.
A total of 2522 patients from 23 trials were included in the study. Biv was associated with a decreased risk of device-related thrombosis (odd ratio [OR] 0.51, 95% confidence interval [CI]: 0.33-0.84) compared with UFH, whereas NM (OR 2.2, 95% CI: 0.24-65.0) and Arg (OR 0.92, 95% CI: 0.43-2.0) did not reduce the risk of device-related thrombosis compared with UFH. Biv was superior to Arg in decreasing the risk of device-related thrombosis (OR 0.14, 95% CI: 0.03-0.51). Biv reduced the risk of patient-related thrombosis compared with UFH (OR 0.44, 95% CI: 0.18-0.85); NM (OR 0.65, 95% CI: 0.14-3.3) and Arg (OR 3.1, 95% CI: 0.94-12.0) did not decrease risk of patient-related thrombosis compared with UFH. No significant difference was observed in the risk of major bleeding between three alternatives and UFH: Biv (OR 0.54, 95% CI: 0.23-1.3), Arg (OR 1.3, 95% CI: 0.34-5.8), and NM (OR 0.60, 95% CI: 0.13-2.6). NM showed a reduced risk of in-hospital mortality compared with UFH (OR 0.27, 95% CI: 0.091-0.77), whereas Arg (OR 0.43, 95% CI: 0.15-1.2) and Biv (OR 0.75, 95% CI: 0.52-1.1) did not decrease risk of in-hospital mortality.
Compared with UFH and Arg, Biv reduces the risk of thrombosis and appears to be a better choice for patients requiring ECMO. NM was associated with a reduced risk of in-hospital mortality.
体外膜肺氧合（ECMO）在为严重心功能或肺功能衰竭患者提供临时生命支持方面发挥着重要作用，但需要严格的抗凝和监测。这项网状荟萃分析系统地探讨了接受ECMO治疗的患者最有效的抗凝和监测策略。
检索MEDLINE、Embase、Web of Science和Cochrane对照试验中心注册库，截至2023年1月31日，查找比较接受ECMO治疗的患者使用普通肝素（UFH）、阿加曲班（Arg）、比伐卢定（Biv）和/或甲磺酸萘莫司他（NM）的研究。主要结局包括与设备相关的血栓形成、与患者相关的血栓形成和大出血事件。次要结局包括ECMO存活、ECMO持续时间和住院死亡率。
该研究共纳入了来自23项试验的2522例患者。与UFH相比，Biv与降低与设备相关的血栓形成风险相关（比值比[OR]0.51，95%置信区间[CI]：0.33-0.84），而与UFH相比，NM（OR 2.2，95% CI：0.24-65.0）和Arg（OR 0.92，95% CI：0.43-2.0）并未降低与设备相关的血栓形成风险。在降低与设备相关的血栓形成风险方面，Biv优于Arg（OR 0.14，95% CI：0.03-0.51）。与UFH相比，Biv降低了与患者相关的血栓形成风险（OR 0.44，95% CI：0.18-0.85）；与UFH相比，NM（OR 0.65，95% CI：0.14-3.3）和Arg（OR 3.1，95% CI：0.94-12.0）并未降低与患者相关的血栓形成风险。三种替代药物与UFH在大出血风险方面未观察到显著差异：Biv（OR 0.54，95% CI：0.23-1.3）；Arg（OR 1.3，95% CI：0.34-5.8）；NM（OR 0.60，95% CI：0.13-2.6）。与UFH相比，NM显示出住院死亡率降低（OR 0.27，95% CI：0.091-0.77），而Arg（OR 0.43，95% CI：0.15-1.2）和Biv（OR 0.75，95% CI：0.52-1.1）并未降低住院死亡率。
与UFH和Arg相比，Biv降低了血栓形成风险，似乎是需要ECMO的患者的更好选择。NM与降低住院死亡率相关。
