Dorsey Michael, Phillips Katherine, James Les, Kelley Emily, Duff Erica, Lewis Tyler, Merchan Cristian, Menghani Neil, Chan Justin, Chang Stephanie, Geraci Travis, Moazami Nader, Smith Deane
Department of Cardiothoracic Surgery, NYU Langone Health, New York, NY.
Transplant Institute, NYU Langone Health, New York, NY.
JTCVS Open. 2024 Dec 8;23:199-209. doi: 10.1016/j.xjon.2024.11.019. eCollection 2025 Feb.
Anticoagulation monitoring in patients supported on extracorporeal membrane oxygenation is challenging given the risks of both bleeding and thrombotic complications. Based on our early clinical experience, we revised our heparin protocol by reducing our target anti-factor Xa assay from 0.3 to 0.7 U/mL to 0.15 to 0.5 U/mL, while instituting a partial thromboplastin time cutoff of 70 seconds. We evaluated the impact of this change on bleeding/thrombotic complications.
A single-center retrospective study of adult patients on extracorporeal membrane oxygenation support was conducted from January 2015 to August 2022. Patients were stratified into groups based on protocol revision: Pre-Revision (2015-2018) or Post-Revision (2019-2022). Our primary end point was the incidence of bleeding/thrombotic complications. Time in therapeutic range was calculated to determine protocol adherence. Poisson regression was performed to correlate time in therapeutic range with the likelihood of complication.
A total of 302 patients were supported on extracorporeal membrane oxygenation during the study period: 67 Pre-Revision and 235 Post-Revision, median age 57 years. Post-Revision, patients experienced longer extracorporeal membrane oxygenation durations with an increase in the percentage of venovenous extracorporeal membrane oxygenation configurations. The incidence of bleeding complications decreased for all categories, reaching significance for surgical site bleeds (5% vs 14%, 013) and gastrointestinal hemorrhage (2% vs 6%, 049). Likewise, thrombotic complications decreased for all categories except fasciotomy, which was unchanged. Time in therapeutic range for anti-factor Xa assay and partial thromboplastin time were similar across time periods. On Poisson regression, the Post-Revision anti-factor Xa assay range significantly correlated with decreases in bleeding (023) and a composite of bleeding/thrombotic complications (008).
A modified heparin monitoring protocol defined by a lower therapeutic anti-factor Xa assay target and a set partial thromboplastin time cutoff correlated with decreases in bleeding/thrombotic complications in patients on extracorporeal membrane oxygenation.
对于接受体外膜肺氧合支持的患者，抗凝监测颇具挑战性，因为存在出血和血栓形成并发症的风险。基于我们早期的临床经验，我们修订了肝素方案，将目标抗Xa因子测定值从0.3至0.7 U/mL降至0.15至0.5 U/mL，同时设定部分凝血活酶时间临界值为70秒。我们评估了这一变化对出血/血栓形成并发症的影响。
对2015年1月至2022年8月期间接受体外膜肺氧合支持的成年患者进行了一项单中心回顾性研究。根据方案修订情况将患者分为几组：修订前（2015 - 2018年）或修订后（2019 - 2022年）。我们的主要终点是出血/血栓形成并发症的发生率。计算治疗范围内的时间以确定方案依从性。进行泊松回归以关联治疗范围内的时间与并发症发生的可能性。
在研究期间，共有302例患者接受了体外膜肺氧合支持：67例修订前患者和235例修订后患者，中位年龄57岁。修订后，患者的体外膜肺氧合持续时间更长，静脉 - 静脉体外膜肺氧合配置的百分比增加。所有类型的出血并发症发生率均下降，手术部位出血（5%对14%，P = 0.013）和胃肠道出血（2%对6%，P = 0.049）达到显著水平。同样，除筋膜切开术外，所有类型的血栓形成并发症均下降，筋膜切开术的并发症情况未变。不同时间段的抗Xa因子测定和部分凝血活酶时间在治疗范围内的时间相似。在泊松回归分析中，修订后的抗Xa因子测定范围与出血减少（P = 0.023）以及出血/血栓形成并发症的综合发生率降低（P = 0.008）显著相关。
由较低的治疗性抗Xa因子测定目标和设定的部分凝血活酶时间临界值定义的改良肝素监测方案，与接受体外膜肺氧合患者的出血/血栓形成并发症减少相关。
