A role for nebulized tranexamic acid in veno‐venous ECMO patients

Cabanilla, M. Gabriela; Villalobos, Nicholas; Ahmed, Shozab

doi:10.1111/jcpt.13463

Cited by 7 publications

(5 citation statements)

References 4 publications

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“…Outside of the perioperative period, no pediatric literature exists to guide management of thoracic bleeding in pediatric ECMO patients. A single case series describes nebulized tranexamic acid via endotracheal tube in three adults with pulmonary hemorrhage while on VV ECMO ( 51 ). Each patient had control of bleeding and was ultimately decannulated from ECMO successfully.…”

Section: Resultsmentioning

confidence: 99%

Management of Bleeding and Thrombotic Complications During Pediatric Extracorporeal Membrane Oxygenation: The Pediatric Extracorporeal Membrane Oxygenation Anticoagulation CollaborativE Consensus Conference

Rintoul,

McMichael,

Bembea

et al. 2024

Pediatric Critical Care Medicine

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OBJECTIVES: To derive systematic-review informed, modified Delphi consensus regarding the management of bleeding and thrombotic complications during pediatric extracorporeal membrane oxygenation (ECMO) for the Pediatric ECMO Anticoagulation CollaborativE Consensus Conference. DATA SOURCES: A structured literature search was performed using PubMed, EMBASE, and Cochrane Library (CENTRAL) databases from January 1988 to May 2021. STUDY SELECTION: The management of bleeding and thrombotic complications of ECMO. DATA EXTRACTION: Two authors reviewed all citations independently, with a third independent reviewer resolving conflicts. Twelve references were used for data extraction and informed recommendations. Evidence tables were constructed using a standardized data extraction form. DATA SYNTHESIS: Risk of bias was assessed using the Quality in Prognosis Studies tool. The evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation system. Forty-eight experts met over 2 years to develop evidence-based recommendations and, when evidence was lacking, expert-based consensus statements for the management of bleeding and thrombotic complications in pediatric ECMO patients. A web-based modified Delphi process was used to build consensus via the Research And Development/University of California Appropriateness Method. Consensus was defined as greater than 80% agreement. Two good practice statements, 5 weak recommendations, and 18 consensus statements are presented. CONCLUSIONS: Although bleeding and thrombotic complications during pediatric ECMO remain common, limited definitive data exist to support an evidence-based approach to treating these complications. Research is needed to improve hemostatic management of children supported with ECMO.

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Section: Resultsmentioning

confidence: 99%

Management of Bleeding and Thrombotic Complications During Pediatric Extracorporeal Membrane Oxygenation: The Pediatric Extracorporeal Membrane Oxygenation Anticoagulation CollaborativE Consensus Conference

Rintoul,

McMichael,

Bembea

et al. 2024

Pediatric Critical Care Medicine

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“…All three patients received tracheostomies and were eventually decannulated from ECMO successfully. 9 In five of the 10 patients with isolated pulmonary hemorrhage in our cohort, endobronchial TXA (500 mg for one or two total doses) was directly instilled during bronchoscopy, which offers another more targeted delivery modality for more anatomically difficult pulmonary bleeding management in addition to nebulization. We also saw that direct application of TXA to tracheostomy sites was common.…”

Section: Discussionmentioning

confidence: 99%

“…7 In this regard, considerable clinical experience has been gained with the use of TXA in a diverse array of bleeding indications and targeted treatment approaches. Despite the increasing use of TXA in the ECMO population, 8,9 there remains a relative paucity of literature to describe its optimal dosing, administration, and monitoring strategies as well as patient outcome and safety data. The aims of this current investigation were to describe the multifarious uses of TXA as an adjunct for bleeding management in the setting of ECMO as well as associated hemostatic and clinical outcomes in patients who received this therapy.…”

mentioning

confidence: 99%

Tranexamic Acid for Bleeding Management in Adult Patients on Extracorporeal Membrane Oxygenation

Jakowenko,

Seelhammer,

Nabzdyk

et al. 2023

ASAIO Journal

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This study described the outcomes of patients receiving topical, nebulized, endobronchial, or systemic tranexamic acid (TXA) for bleeding events while on extracorporeal membrane oxygenation (ECMO). We performed a single-center case series including adult patients >18 years old supported on either venovenous (VV) or venoarterial (VA) ECMO from January 1, 2014, to April 21, 2021. The primary outcome was hemostatic control defined as a composite of initial cessation of therapeutic interventions to mitigate bleeding or resumption of anticoagulation if previously held. Secondary outcomes included changes in transfusion requirements and lysis at 30-minute (LY30) values, venous thromboembolism (VTE) events, and seizures. In total, 47 patients were included for full analysis. There were 19 patients with surgical bleeds, 18 patients with medical bleeds, and 10 patients with multiple bleeds. Overall, initial hemostatic control was achieved in 79%, 67%, and 90% of patients, respectively. Pre- and post-TXA transfusion requirements were not significantly different (p = 0.2), although the intraindividual change in median LY30 was −5.1% compared with baseline (95% confidence interval [CI], −12.4% to −1.5%, p = 0.005). The occurrence of VTE and seizures was relatively low and similar among patient bleeding groups. Tranexamic acid provided initial hemostatic control in roughly three quarters of patients with bleeding events on ECMO and side effects were infrequent.

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“…9,10,20 Other fields have attempted to balance bleeding versus prothrombic states encountered during ECMO use through the administration of tranexamic acid, either preoperatively as prophylaxis 26 or administered through a nebulizer as a “direct-to-site” treatment for pulmonary hemorrhage while on device. 27 While promising, the use of tranexamic acid in ECMO is understudied. Outside the setting of TBI, there is considerable neurologic risk associated with ECMO.…”

Section: Discussionmentioning

confidence: 99%

Utilization and Outcomes of Extracorporeal Membrane Oxygenation Following Traumatic Brain Injury in the United States

Hatfield

Ohnuma

Soto

et al. 2022

J Intensive Care Med

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Objectives: Describe contemporary ECMO utilization patterns among patients with traumatic brain injury (TBI) and examine clinical outcomes among TBI patients requiring ECMO. Design: Retrospective cohort study. Setting: Premier Healthcare Database (PHD) between January 2016 to June 2020. Subjects: Adult patients with TBI who were mechanically ventilated and stratified by exposure to ECMO. Results: Among patients exposed to ECMO, we examined the following clinical outcomes: hospital LOS, ICU LOS, duration of mechanical ventilation, and hospital mortality. Of our initial cohort (n = 59,612), 118 patients (0.2%) were placed on ECMO during hospitalization. Most patients were placed on ECMO within the first 2 days of admission (54.3%). Factors associated with ECMO utilization included younger age (OR 0.96, 95% CI (0.95–0.97)), higher injury severity score (ISS) (OR 1.03, 95% CI (1.01–1.04)), vasopressor utilization (2.92, 95% CI (1.90–4.48)), tranexamic acid utilization (OR 1.84, 95% CI (1.12–3.04)), baseline comorbidities (OR 1.06, 95% CI (1.03–1.09)), and care in a teaching hospital (OR 3.04, 95% CI 1.31–7.05). A moderate degree (ICC = 19.5%) of variation in ECMO use was explained at the individual hospital level. Patients exposed to ECMO had longer median (IQR) hospital and ICU length of stay (LOS) [26 days (11–36) versus 9 days (4–8) and 19.5 days (8–32) versus 5 days (2–11), respectively] and a longer median (IQR) duration of mechanical ventilation [18 days (8–31) versus 3 days (2–8)]. Patients exposed to ECMO experienced a hospital mortality rate of 33.9%, compared to 21.2% of TBI patients unexposed to ECMO. Conclusions: ECMO utilization in mechanically ventilated patients with TBI is rare, with significant variation across hospitals. The impact of ECMO on healthcare utilization and hospital mortality following TBI is comparable to non-TBI conditions requiring ECMO. Further research is necessary to better understand the role of ECMO following TBI and identify patients who may benefit from this therapy.

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A role for nebulized tranexamic acid in veno‐venous ECMO patients

Cited by 7 publications

References 4 publications

Management of Bleeding and Thrombotic Complications During Pediatric Extracorporeal Membrane Oxygenation: The Pediatric Extracorporeal Membrane Oxygenation Anticoagulation CollaborativE Consensus Conference

Management of Bleeding and Thrombotic Complications During Pediatric Extracorporeal Membrane Oxygenation: The Pediatric Extracorporeal Membrane Oxygenation Anticoagulation CollaborativE Consensus Conference

Tranexamic Acid for Bleeding Management in Adult Patients on Extracorporeal Membrane Oxygenation

Utilization and Outcomes of Extracorporeal Membrane Oxygenation Following Traumatic Brain Injury in the United States

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