Downloaded 63 times
Uploaded byInternational Fluid Academy
4. anticoagulation during ecmo #beach2019 (peperstraete)
The document discusses anticoagulation management during veno-venous and venoarterial extracorporeal membrane oxygenation (ECMO), highlighting the balance between bleeding and thromboembolic events. It presents various anticoagulation strategies, including unfractionated heparin, low-molecular-weight heparin, and direct thrombin inhibitors, along with monitoring parameters like ACT, APTT, and anti-Xa levels. The review emphasizes the importance of tailored anticoagulation practices to minimize complications during ECMO therapy.
More Related Content
Similar to 4. anticoagulation during ecmo #beach2019 (peperstraete)
More from International Fluid Academy
![CTEV [ clubfoot] DR ARUN LAL ,DR MOHAMED ASHRAF travancore medical college k...](https://cdn.slidesharecdn.com/ss_thumbnails/ctevclubfootdrarunlaldrmohamedashraftravancoremedicalcollegekollamkeralaindia-260208063247-18fc466c-thumbnail.jpg?width=640&height=640&fit=bounds)
4. anticoagulation during ecmo #beach2019 (peperstraete)
- 1. Harlinde Peperstraete MD GhentUniversity Hospital Harlinde.peperstraete@ugent.be Anticoagulation
- 2.
- 3.
- 4.
- 5. albumin fibrinogen albumin fibrinogen Trombospondin Fibronectin VWF IgE TF VIIa VIIa VIIa VIIa TF TF TF TF VIIa And so coagulationis initiated... Leading to activation of factor X and a burst of thrombin formation Important role for Ca2+
- 6.
- 7. 3 actions of bradykinin •Activation of intrinsic coagulation pathway • Activation of complement system > inflammation > activated endothelium > TF • Inflammatory reaction by the kallikrein system Leading to SIRS and vasoplegic state
- 8. Hemolysis Plasma free Hbenhances interaction between vWF and platelets
- 9. Delicate balance betweencoagulation and fibrinolysis • TFPI-system (Tissue Factor Pathway Inhibitor) • Intact endothelial cells: ADPase, eNO, PGI2, t-PA • Intact endothelial cells: heparansulfate • Protein C-system (VIIIa & Va) • Protein S • Antithrombin (± heparin) via XIIa, XIa, IXa, Xa & IIa • Fibrinolytic system through fibrinogen & fibrin
- 10. Unfractionated heparin • Standardin most centers • Low cost • Antidote= protamin • Familiarity • Monitoring: • ACT (140-220) • APTT (40-80sec or 1.5-2.5 ratio) • Anti-Xa (0.3-0.7) • Viscoelastic tests
- 11. UFH binds AT Structuralchange in AT Inhibitory power is accelerated 1:1 Xa & IIa Variability in effect: UFH binds pos charged proteins !AFP
- 12. Antithrombin • Drop inlevels during the first days of ECMO therapy • Indicated in heparin resistance • Daily...? • Cut off for substitution...
- 13. Low- Molecular- Weight Heparin • Anti Xamonitoring (1h before and 4h after administering) • Mainly renal clearance, most ECMO pts have AKI
- 14. (parental) Direct Thrombin Inhibitors • Bivalirudin • Agratoban •Short half-lives (30 min and 40 min) • No antidotes
- 15. Bivalirudin • Direct trombininhibitor • HIT pts • Best monitored with Diluted Thrombin Time • aPTT 50-90sec (ceiling effect), ACT • Bolus: 0.5-0.75 mg/kg • Infusion: 1.75 mg/kg/h • Mainly renal clearance
- 16. Argatroban • Direct trombininhibitor • HIT pts • Best monitored with Diluted Thrombin Time • aPTT • Can interfere with PT • Mainly hepatic clearance
- 17. Antiplatelet drugs • Inhibit coagulationat the starting point • Might reduce platelet consumption • iNO on oxygenator
- 18. No anticoagulation • First 24-48hto 7days • TBI, major bleeding, Disseminated Intravascular Coagulation • Waiting for resolution of shock • Lubnow M et al. Technical complications during veno-venous extracorporeal membrane oxygenation and their relevance predicting a system-exchange—retrospective analysis of 265 cases. J Crit Care 2014;29:473.e1–473.e5.
- 19. VV ECMO: anticovs no antico (n=646) Overall: major bleeding 16%, thrombosis 53% ACT alone target: 62% major bleeding, 62% thrombosis aPTT guided 19% bleeding, 27% thrombosis aPTT<60 8% bleeding, 34% thrombosis aPTT >60 56% major bleeding, 7% thrombosis Thrombosis: mainly circuit clotting Anticoagulation Practices during Venovenous Extracorporeal Membrane Oxygenation for Respiratory Failure. A Systematic Review; MC Sklar e.a. AnnalsATS Volume 13 Number 12; 2242-2250
- 20. VA ECMO: anticovs no antico (n=1496) Overall 27% bleeding, 8% Trombo-embolic events ACT< 180sec 13%, 12% TE ACT>180sec 28%, 9% TE APTT target 50%, 3%TE Mixture of methods for monitoring 24% bleeding; 6 % TE 43% bleeding if no antico, 24% TE events Anticoagulation practices and the prevalence of major bleeding, thromboembolic events, and mortality in venoarterial extracorporeal membrane oxygenation: A systematic review and meta-analysis. E. Sy e.a. Journal of Critical Care; Volume 39, June 2017, Pages 87-9
- 21. Monitoring coagulation Combination of ACT,aPTT, anti Xa with ATIII Platelet count / function Fibrinogen Viscoelastic test (How fast- how strong- for how long?) NO SINGLE TEST may be considered adequate to guide (UFH) management
- 22.
Editor's Notes
- #7 Activated factor XII cleaves PK to kallikrein, which in turn splits bradykinin from HMWK
- #20 Clinical relevance of circuit clotting reported in the different papers Most included studies were descriptive and retrospective in design, thereby limiting quantitative analyses of anticoagulation modalities and strategies. The frequency and type of complications may be underreported in this review.