- Letter
- Published:
Algorithm-based management of bleeding in patients with extracorporeal membrane oxygenation
Critical Care volume 17, Article number: 432 (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.
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.
References
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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.
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. 10.1097/CCM.0b013e31816f7cf7
Levy JH, Faraoni D, Sniecinski RM: Perioperative coagulation management in the intensive care unit. Curr Opin Anaesthesiol 2013, 26: 65-70. 10.1097/ACO.0b013e32835b82df
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Faraoni, D., Levy, J.H. Algorithm-based management of bleeding in patients with extracorporeal membrane oxygenation. Crit Care 17, 432 (2013). https://doi.org/10.1186/cc12682
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DOI: https://doi.org/10.1186/cc12682