Algorithm-based management of bleeding in patients with extracorporeal membrane oxygenation

  • David Faraoni1Email author and

    Affiliated with

    • Jerrold H Levy2

      Affiliated with

      Critical Care201317:432

      DOI: 10.1186/cc12682

      Published: 8 May 2013

      We read with interest the paper published by Repressé and colleagues [1]. Coagulation management is a challenge during extracorporeal membrane oxygenation (ECMO) due to complex hemostatic and inflammatory responses associated with the underlying conditions that include infection, sepsis, surgery, and/or traumatic injury [2]. Repressé and colleagues present the first algorithm-based approach to bleeding in ECMO patients. However, additional perspectives are important to consider.

      First, activated partial thromboplastin time or antiactivated factor × monitoring are routinely used to monitor heparin therapy in ECMO patients, despite intraindividual and inter-individual variability [3]. Rotational thromboelastometry (ROTEM®; TEM® International GmbH, Munich, Germany) is also increasingly used in the ICU to rapidly assess the coagulation status, including clotting factors, fibrinogen levels, and whole blood clotting [4]. Moreover, this test also facilitates fibrinolytic pathway evaluation, which cannot be easily explored by routine laboratory tests. We believe ROTEM® could be used to design an algorithm-based approach to bleeding in ECMO patients and follow fibrinogen consumption associated with hyperfibrinolysis, an important cause of bleeding. For this reason, anti-fibrinolytic agents should be considered in the multimodal approach (Figure 1), an important point the authors omitted in their algorithm.
      http://static-content.springer.com/image/art%3A10.1186%2Fcc12682/MediaObjects/13054_2013_1729_Fig1_HTML.jpg
      Figure 1

      Hyperfibrinolysis diagnosed in a bleeding extracorporeal membrane oxygenation patient. (a) Baseline EXTEM, (b) baseline FIBTEM, (c) EXTEM and (d) FIBTEM thromboelastometry tests after the administration of tranexamic acid (TXA; 10 mg/kg) and fibrinogen concentrates (2 g).

      Second, adverse events including 32% venous thrombosis and a 2.5% incidence of fatal pulmonary embolism have already been reported in ECMO patients [5]. In another series, Combes and colleagues reported a 10% incidence of femoral vein and 7% incidence vena cava thrombosis [6]. Recombinant activated factor VII is associated with thromboembolic events [7] and should be used with caution until additional data help us evaluate the benefit-to-risk administration in bleeding ECMO patients.

      Abbreviations

      ECMO: 

      extracorporeal membrane oxygenation

      ROTEM: 

      rotational thromboelastometry.

      Declarations

      Authors’ Affiliations

      (1)
      Department of Anesthesiology, Queen Fabiola Children’s University Hospital
      (2)
      Department of Anesthesiology and Intensive Care, Duke University School of Medicine

      References

      1. Repressé X, Au SM, Brechot N, Trouillet J, Leprince P, Chastre J, Combes A, Luyt CE: Recombinant factor VIIa for uncontrollable bleeding in patients with extracorporeal membrane oxygenation: report on 15 cases and literature review. Crit Care 2013, 17:R55.View Article
      2. Peek GJ, Firmin RK: The inflammatory and coagulative response to prolonged extracorporeal membrane oxygenation. ASAIO J 1999, 45:250–263.PubMedView Article
      3. Dempfle CE, Elmas E, Link A, Suvajac N, Liebe V, Janes J, Borggrefe M: Endogenous plasma activated protein C levels and the effect of enoxaparin and drotrecogin alfa (activated) on markers of coagulation activation and fibrinolysis in pulmonary embolism. Crit Care 2011, 15:R23.PubMedView Article
      4. Bischof D: Thrombelastography in the surgical patient. Minerva Anestesiol 2010, 76:131–137.PubMed
      5. Rastan AJ, Lachmann N, Walther T, Doll N, Gradistanac T, Gommert JF, Lehmann S, Wittekind C, Mohr FW: Autopsy findings in patients on postcardiotomy extracorporeal membrane oxygenation (ECMO). Int J Artif Organs 2006, 29:1121–1131.PubMed
      6. Combes A, Leprince P, Luyt CE, Bonnet N, Trouillet JL, Leger P, Pavie A, Chastre J: Outcomes and long-term quality-of-life of patients supported by extracorporeal membrane oxygenation for refractory cardiogenic shock. Crit Care Med 2008, 36:1404–1411.PubMedView Article
      7. Levy JH, Faraoni D, Sniecinski RM: Perioperative coagulation management in the intensive care unit. Curr Opin Anaesthesiol 2013, 26:65–70.PubMedView Article

      Copyright

      © BioMed Central Ltd 2013

      Advertisement