Activated clotting time test alone is inadequate to optimize therapeutic heparin dosage adjustment during post-cardiopulmonary resuscitational extracorporeal membrane oxygenation (e-CPR)

Yie, Kilsoo; Chon, Soon-Ho; Na, Chan-Young

doi:10.1177/0267659115604710

Cited by 18 publications

(8 citation statements)

References 36 publications

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“…6 Currently, ELSO guidelines recommend any combination of ACT, aPTT, anti-Xa, and TEG, but if ACT is selected, other tests should be used as a supplement given the shortcomings of ACT measurements in patients with anemia, hypofibrinogenemia, thrombocytopenia, coagulation factor deficiencies, dilution, and hypothermia. 23,24 Although the ELSO guidelines state that most centers that utilize anti-Xa protocols target 0.3 to 0.7 U/mL, based on our early experience with anti-Xa, our institution uses lower targets to try and minimize bleeding. This approach is consistent with the Sieg et al 19 data in which 2 heparin intensities were developed (anti-Xa 0.15-0.25 and anti-Xa 0.3-0.4) to mitigate bleeding in axillary Impella and percutaneous temporary LVAD patients.…”

Section: Discussionmentioning

confidence: 99%

Heparin Monitoring with an Anti-Xa Protocol Compared to Activated Clotting Time in Patients on Temporary Mechanical Circulatory Support

et al. 2021

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Background: Temporary mechanical circulatory support (tMCS) devices are used for patients with severe cardiac or respiratory failure; however, these patients are at high risk for clotting and bleeding. The best method to monitor heparin in these patients has not been established. Objective: To determine the risks for bleeding and clotting while monitoring heparin with either anti-Xa or activated clotting time (ACT) in tMCS patients. Methods: A retrospective cohort study was conducted on tMCS patients who received heparin adjusted according to an anti-Xa or ACT protocol. The primary outcome was incidence of major bleeding. Pertinent secondary outcomes were individual components of the primary outcome, clotting events, and time to therapeutic range. Results: There were 103 patients included in the study: 53 in the ACT group and 50 in the anti-Xa group. Overall, there were 30 (56.6%) patients with major bleeding in the ACT group, compared with 16 (32%) patients in the anti-Xa group ( P = 0.017). An anti-Xa–based protocol was associated with a decreased hazard of major bleeding (hazard ratio = 0.388 [0.215-0.701]; P = 0.002) in the univariate analysis. In the multivariable analysis, an anti-Xa protocol remained associated with a significantly lower hazard of bleeding. Findings were similar when broken down into more discrete subgroups of the entire cohort, extracorporeal membrane oxygenation life support (ECMO), and non-ECMO groups. Conclusion and Relevance: Anti-Xa monitoring was associated with a lower hazard of bleeding during tMCS compared to an ACT-based protocol. Further studies should evaluate if anti-Xa monitoring should be preferentially used in tMCS.

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Section: Discussionmentioning

confidence: 99%

Heparin Monitoring with an Anti-Xa Protocol Compared to Activated Clotting Time in Patients on Temporary Mechanical Circulatory Support

et al. 2021

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“…However, when viewing the large variety of tests used, it is not surprising that results are conflicting. While in some investigations a good correlation between both tests was found, a weak correlation was reported in some other investigations (19)(20)(21).…”

Section: Monitoring Of Anticoagulation With Ufhmentioning

confidence: 84%

Traditional and non-traditional anticoagulation management during extracorporeal membrane oxygenation

Koster¹,

Ljajikj²,

Faraoni³

2019

Ann. Cardiothorac. Surg.

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Unfractionated heparin (UFH) is the anticoagulant of choice during extracorporeal membrane oxygenation (ECMO) support. Despite its favorable pharmacologic properties, management of heparin anticoagulation during ECMO remains a major challenge. To date, little is known about the optimal monitoring strategy or the heparin dose offering the best safety/efficacy profile. Therefore, it remains unclear if the heparin dose should be adapted to target a specific "clotting time" [e.g., activated clotting time (ACT) or activated partial thromboplastin time (aPTT)] or a heparin concentration, measured by coagulation factor anti-Xa assay. In addition, no study has compared the relevance of modern viscoelastic coagulation tests over the single value of a clotting time or heparin concentration value. Although guidelines for anticoagulation during ECMO support have been published, the absence of evidence limits the quality of the recommendations provided, which explains the major intra-and inter-institutional variability observed. Large prospective multicenter trials are urgently needed to investigate the optimal anticoagulation management strategy during ECMO support.

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“…These studies continue to demonstrate a poor correlation between the ACT and aPTT in patients receiving heparin on ECMO, 4-6 with 2 of them also indicating the superiority of the aPTT compared to the ACT with regard to the HID. 4,6 Another study demonstrated a poor correlation between the ACT and anti-factor Xa and a moderate correlation between the aPTT and anti-factor Xa level. 7 This important work confirms our opinion and validates our efforts in creating a multipronged approach using variables that may be more indicative of the efficacy of the HID.…”

Section: Authors' Responsementioning

confidence: 98%

Authors’ Response

Kessel

Sweberg

2018

J Intensive Care Med

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Activated clotting time test alone is inadequate to optimize therapeutic heparin dosage adjustment during post-cardiopulmonary resuscitational extracorporeal membrane oxygenation (e-CPR)

Abstract: Our study demonstrates that the ACT test alone does not seem to be enough to optimize therapeutic heparin dosage adjustment during e-CPR.

Cited by 18 publications

References 36 publications

Heparin Monitoring with an Anti-Xa Protocol Compared to Activated Clotting Time in Patients on Temporary Mechanical Circulatory Support

Heparin Monitoring with an Anti-Xa Protocol Compared to Activated Clotting Time in Patients on Temporary Mechanical Circulatory Support

Traditional and non-traditional anticoagulation management during extracorporeal membrane oxygenation

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