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

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.

Figure 1
figure1

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.

References

  1. 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. 10.1186/cc12581

    Article  Google Scholar 

  2. 2.

    Peek GJ, Firmin RK: The inflammatory and coagulative response to prolonged extracorporeal membrane oxygenation. ASAIO J 1999, 45: 250-263. 10.1097/00002480-199907000-00003

    CAS  Article  PubMed  Google Scholar 

  3. 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. 10.1186/cc9968

    PubMed Central  Article  PubMed  Google Scholar 

  4. 4.

    Bischof D: Thrombelastography in the surgical patient. Minerva Anestesiol 2010, 76: 131-137.

    CAS  PubMed  Google Scholar 

  5. 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.

    CAS  PubMed  Google Scholar 

  6. 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. 10.1097/CCM.0b013e31816f7cf7

    Article  PubMed  Google Scholar 

  7. 7.

    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

    CAS  Article  PubMed  Google Scholar 

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Correspondence to David Faraoni.

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The authors declare that they have no competing interests.

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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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Keywords

  • Pulmonary Embolism
  • Fibrinogen
  • Extracorporeal Membrane Oxygenation
  • Routine Laboratory Test
  • Heparin Therapy