Jessica Cercone, PharmD
Critical Care Pharmacist
University of Maryland Medical Center, United States
Disclosure information not submitted.
Shawn Kram, PharmD, BCPS, BCCCP (he/him/his)
Clinical Pharmacist, Cardiothoracic Surgery ICU
Duke University Hospital
Durham
Disclosure information not submitted.
Morgan Trammel, PharmD, BCCCP
Clinical Pharmacist
Duke University Hospital, United States
Disclosure information not submitted.
Craig Rackley, MD
Physician
Duke University Hospital, United States
Disclosure information not submitted.
.jpg "Bridgette Kram, BCCCP, BCPS, PharmD photo")
Bridgette Kram, BCCCP, BCPS, PharmD
MICU Clinical Pharmacist
Duke University Hospital
Durham, North Carolina
Disclosure information not submitted.
Title: Anticoagulation Targets in Patients with ARDS Receiving Extracorporeal Membrane Oxygenation
Introduction: The risk of bleeding and thrombotic complications must be balanced when administering systemic anticoagulation to patients receiving venovenous extracorporeal membrane oxygenation (VV-ECMO). Due to lack of data supporting standardized anticoagulant monitoring, therapeutic targets may vary across institutions. The purpose of this study is to describe the impact of different anticoagulation targets on bleeding complications in patients receiving VV-ECMO for acute respiratory distress syndrome (ARDS).
Methods: This retrospective, single center, observational cohort study included patients 18 years and older who received VV-ECMO for ARDS from September 2013 to December 2019. Included patients received continuous infusion heparin and had at least two activated partial thromboplastin times (aPTT) resulted during heparin therapy. Patients were evaluated in three treatment groups based on the aPTT goal at the time of cannulation: aPTT < 50 seconds (sec), aPTT 40-50 sec, or no protocol group. In the no protocol and aPTT < 50 sec groups, transfusion requirements targeted a hemoglobin ≥ 8 g/dL, but this was changed to target a hemoglobin ≥ 7 g/dL in the aPTT 40-50 sec group. The primary endpoint was any bleeding event while receiving heparin as defined by the ELSO criteria for major bleeding.
Results: A total of 136 patients were included. The incidence of bleeding event was highest in the no protocol group (39.3%, 95% CI 28.3 to 51.1%), followed by the 40-50 sec group (34%, 95% CI 23 to 46.5%), and the < 50 sec group (26.7%, 95% CI 14 to 43%); however, the differences were not statistically significant (p=0.5). The no protocol group required a slightly increased median number of units of packed red blood cells than the < 50 and 40-50 sec groups (3 vs. 2 vs. 0.5, respectively). The median time to first bleeding event was less than 48 hours in all groups. Overall, thrombotic events occurred in 39 (28.7%) patients, and the incidence was comparable between groups.
Conclusions: Anticoagulation protocols targeting an aPTT of < 50 or 40-50 sec may be a safe and reasonable strategy for patients receiving VV- ECMO for ARDS. More restrictive hemoglobin transfusion thresholds in combination with lower aPTT targets may be associated with a reduction in transfusion requirements.