Anticoagulation and Transfusions Management in Veno-Venous Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome: Assessment of Factors Associated With Transfusion Requirements and Mortality
Anticoagulation and Transfusions Management in Veno-Venous Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome: Assessment of Factors Associated With Transfusion Requirements and Mortality
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DOI：
10.1177/0885066617706339
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发表时间：
2019-08-01
影响因子：
3.1
通讯作者：
Arcadipane, Antonio
中科院分区：
文献类型：
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作者：
Martucci, Gennaro;Panarello, Giovanna;Arcadipane, Antonio
目的：我们描述了静脉-静脉-体外膜肺氧合（VV-ECMO）中抗凝和输血的方法，评估了与更高输血要求相关的因素及其对死亡率的影响。方法：对连续成人急性呼吸窘迫综合征（ARDS）患者行VV-ECMO支持的观察性研究。我们的目标是活化部分凝血活酶时间为40至50秒，红细胞压积为24%至30%。进行单变量和多变量分析，以评估与输血需求相关的因素以及增加输血对ECMO期间死亡率的影响。结果如下：在82例VV-ECMO患者的队列中，（VV-ECMO [PRESERVE]评分：4，四分位数间距[IQR]：3 - 5，呼吸道膜外氧合生存预测[RESP]评分：2，IQR：2 - 4），76（92.7%）患者在ECMO相关重症监护室住院期间接受了至少1个单位的浓缩红细胞（PRBC）（PRBC/d中位数156 mL，IQR：93 - 218; ECMO持续时间中位数14天，IQR：8 - 22）。更高的PRBC输注需求与ECMO前的红细胞压积相关，与ECMO期间的以下情况相关：血小板最低值、抗凝血酶III（ATIII）和急性肾损伤3期（所有P <0.05）。62例（75.6%）患者在ECMO下存活。ECMO前住院时间、PRBC输血和感染性休克与死亡率相关（均P <0.05）。PRBC输注量每增加100 mL/d的调整优势比为1.9（95%置信区间[CI]：1.1 - 3.2，P = 0.01）;对于脓毒性休克的发生，（95% CI：1.7 - 136.8，P = 0.01），ECMO前每一天的平均值为1.1（95% CI：1 - 1.2，P = 0.04）。结论：在VV-ECMO中实施全面的抗凝和输血方案治疗ARDS，导致PRBC要求较低，ECMO生存率与文献中的数据相当。较低的ATIII是与输血需求增加相关的一个因素。较高的PRBC输血与ECMO死亡率相关。需要进一步的研究来更好地了解ECMO中抗凝的正确水平，以及在这种选择环境中管理个性化输血实践需要考虑的因素。
Purpose: We describe an approach for anticoagulation and transfusions in veno-venous-extracorporeal membrane oxygenation (VV-ECMO), evaluating factors associated with higher transfusion requirements, and their impact on mortality. Methods: Observational study on consecutive adults supported with VV-ECMO for acute respiratory distress syndrome (ARDS). We targeted an activated partial thromboplastin time of 40 to 50 seconds and a hematocrit of 24% to 30%. Univariate and multiple analyses were done to evaluate factors associated with transfusion requirements and the influence of increasing transfusions on mortality during ECMO. Results: In a cohort of 82 VV-ECMO patients (PRedicting dEath for SEvere ARDS on VV-ECMO [PRESERVE] score: 4, Interquartile range [IQR]: 3-5, Respiratory Extracorporeal Membrane Oxygenation Survival Prediction [RESP] score: 2, IQR: 2-4), 76 (92.7%) patients received at least 1 unit of packed red blood cells (PRBCs) during the intensive care unit stay related to ECMO (median PRBC/d 156 mL, IQR: 93-218; median ECMO duration 14 days, IQR: 8-22). A higher requirement of PRBC transfusions was associated with pre-ECMO hematocrit, and with the following conditions during ECMO: platelet nadir, antithrombin III (ATIII), and stage 3 of acute kidney injury (all P < .05). Sixty-two (75.6%) patients survived ECMO. Pre-ECMO hospital stay, PRBC transfusion, and septic shock were associated with mortality (all P < .05). The adjusted odds ratio for each 100mL/d increase in PRBC transfusion was 1.9 (95% confidence interval [CI]: 1.1-3.2, P = .01); for the development of septic shock it was 15.4 (95% CI: 1.7-136.8, P = .01), and for each day of pre-ECMO stay it was 1.1 (95% CI: 1-1.2, P = .04). Conclusion: Implementation of a comprehensive protocol for anticoagulation and transfusions in VV-ECMO for ARDS resulted in a low PRBC requirement, and an ECMO survival comparable to data in the literature. Lower ATIII emerged as a factor associated with increased need for transfusions. Higher PRBC transfusions were associated with ECMO mortality. Further investigations are needed to better understand the right level of anticoagulation in ECMO, and the factors to take into account in order to manage personalized transfusion practice in this select setting.