Anticoagulation and Bleeding during Veno-Venous Extracorporeal Membrane Oxygenation: Insights from the PROTECMO Study

• DOI: 10.1164/rccm.202305-0896oc
• Publication Date: 2023-11-09T14:25:31Z
• Authors: Gennaro Martucci; Marco Giani; Matthieu Schmidt; Kenichi Tanaka; Ali Tabatabai; Fabio Tuzzolino; Cara Agerstrand; Jordi Riera; Raj Ramanan; Giacomo Grasselli; Ali Ait Hssain; Whitney D. Gannon; Sara Buabbas; Vojka Gorjup; Brian Trethowan; Monica Rizzo; Vito Fanelli; Kyeongman Jeon; Gennaro De Pascale; Alain Combes; Marco V. Ranieri; Thibault Duburcq; Giuseppe Foti; Juan I. Chico; Martin Balik; Lars Mikael Broman; Peter Schellongowski; Hergen Buscher; Roberto Lorusso; Daniel Brodie; Antonio Arcadipane; Matteo Brioni; Antonio Pesenti; Luca Montini; Linda Bosa; Luca Brazzi; Pierfrancesco Curcio; Eugenio Garofalo; Luis Martin-Villen; Raquel Garcìa-Álv...; Marta Lopez Sanchez; Nuno Principe; Violeta Chica Saez; Santiago Freita; Joaquin Colomina-...; Andres F. Pacheco; Julien Goutay; Konstanty Szułdrz...; Mariusz Kowalewski; Philipp Eller; Elisabeth Lobmeyr; Silvia Mariani; Pavel Suk; Michal Maly; Jakob Forestier; Nicolò Rizzitello; Marco Barbara; Tyler Holsworth; Alexis Serra; Yiorgos A. Cavayas; Jay Menaker; Samuel Galvagno; Todd W. Rice; Wilson E. Grandin; Jose Nunez; Collette Cheplic; Harikesh Subramanian; Ryan Rivosecchi; Young-Jae Cho; Ming Chit Kwan; Hend Sallam; Joy A. Villanueva; Jeffrey Aliudin; Kota Hoshino; Yoshitaka Hara; Kollengode Ramana...; Graeme Maclaren; Hergen Buscher
• Keywords: heparin; bivalirudin; argatroban; nafamostat; bleeding; antithrombin; nafamostat; bivalirudin; antithrombin; fibrinogen; hemorrhage; thrombin; tranexamic acid; argatroban; fibrinogen; hemorrhage; heparin; bleeding; thrombin; tranexamic acid

Definitive guidelines for anticoagulation management during veno-venous extracorporeal membrane oxygenation (VV ECMO) are lacking, while bleeding complications continue to pose major challenges.To describe anticoagulation modalities and bleeding events in adults receiving VV ECMO.International prospective observational study in 41 centers, from December 2018 to February 2021. Anticoagulation was recorded daily in terms of type, dosage, and monitoring strategy. Bleeding events were reported according to site, severity, and impact on mortality.The study cohort included 652 patients, and 8471 days on ECMO were analyzed. Unfractionated heparin (UFH) was the initial anticoagulant in 77% of patients, and the most used anticoagulant during the ECMO course (6221 days, 73%). Activated partial thromboplastin time (aPTT) was the most common test for monitoring coagulation (86% of days): the median value was 52 seconds (39-61), but dropped by 5.3 seconds after the first bleeding event (95% CI -7.4 to -3.2, p< 0.01). Bleeding occurred on 1202 days (16.5 %). Overall, 342 patients (52.5 %) experienced at least one bleeding event (one episode every 215 hours on ECMO), of which 10 (1.6%) were fatal. In a multiple penalized Cox proportional hazard model, higher aPTT was a potentially modifiable risk factor for the first episode of bleeding (for 20 seconds increase, hazard ratio 1.07).Anticoagulation during VV ECMO was a dynamic process, with frequent stopping in cases of bleeding, and restart according to the clinical picture. Future studies might explore lower aPTT targets to reduce the risk of bleeding.