Intensive Care Unit 13i2, Department of Medicine I, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
Department of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, NC, USA.
Med Klin Intensivmed Notfmed. 2024 Jul;119(Suppl 2):78-84. doi: 10.1007/s00063-024-01116-0. Epub 2024 Mar 8.
Anticoagulation is an essential component of optimal extracorporeal membrane oxygenation (ECMO) management. Unfractionated heparin is still the anticoagulant of choice in most centers due to longstanding familiarity with the agent. Disadvantages include alterations in drug responses due to its capability to bind multiple heparin-binding proteins that compete with antithrombin and the potential for heparin-induced thrombocytopenia. In such cases, direct thrombin inhibitors are the treatment of choice but pose difficulties in monitoring due to the limited experience and target ranges for non-aPTT-guided management (aPTT: activated partial thromboplastin time). The current trend toward low-dose anticoagulation, especially for venovenous ECMO, is supported by data associating bleeding complications with mortality but not thromboembolic events, which include circuit thrombosis. However, only prospective data will provide appropriate answers to how to individualize anticoagulation, transfusions, and bleeding management which is currently only supported by expert opinion. Empiric therapy for ECMO patients based on laboratory coagulation alone should always be critically questioned. In summary, only collaboration and future studies of coagulation management during ECMO will help us to make this life-saving therapy that has become part of daily life of the intensivist even safer and more effective. Until then, a fundamental understanding of coagulation and bleeding management, as well as pearls and pitfalls of monitoring, is essential to optimize anticoagulation during ECMO. This article is freely available.
抗凝是体外膜肺氧合（ECMO）管理的重要组成部分。由于长期以来对该药物的熟悉，未分级肝素仍然是大多数中心的首选抗凝剂。其缺点包括由于其能够与抗凝血酶结合的多种肝素结合蛋白而改变药物反应，以及肝素诱导的血小板减少症的潜在风险。在这种情况下，直接凝血酶抑制剂是首选治疗方法，但由于非 aPTT 指导管理的经验有限和靶范围（aPTT：激活部分凝血活酶时间），监测存在困难。目前，低剂量抗凝的趋势，特别是对于静脉-静脉 ECMO，得到了数据的支持，这些数据表明出血并发症与死亡率相关，而与血栓栓塞事件（包括回路血栓形成）无关。然而，只有前瞻性数据才能提供关于如何个体化抗凝、输血和出血管理的适当答案，目前这仅得到专家意见的支持。仅基于实验室凝血的 ECMO 患者的经验性治疗应始终受到质疑。总之，只有在 ECMO 期间进行凝血管理的合作和未来研究才能帮助我们使这种挽救生命的治疗方法更安全、更有效，而这种治疗方法已经成为重症监护医生日常生活的一部分。在那之前，对凝血和出血管理的基本理解，以及监测的要点和陷阱，对于在 ECMO 期间优化抗凝至关重要。本文是免费提供的。
