Anticoagulation Management in Severe Coronavirus Disease 2019 Patients on Extracorporeal Membrane Oxygenation

Abstract

Objective: To explore special coagulation characteristics and anticoagulation management in extracorporeal membrane oxygenation (ECMO)À assisted patients with coronavirus disease 2019 (COVID-19). Design: Single-center, retrospective observation of a series of patients. Participants: Laboratory-confirmed severe COVID-19 patients who received venovenous ECMO support from January 20ÀMay 20, 2020. Interventions: This study analyzed the anticoagulation management and monitoring strategies, bleeding complications, and thrombotic events during ECMO support. Measurements and Main Results: Eight of 667 confirmed COVID-19 patients received venovenous ECMO and had an elevated D-dimer level before and during ECMO support. An ECMO circuit pack (oxygenator and tubing) was replaced a total of 13 times in all 8 patients, and coagulation-related complications included oxygenator thrombosis (7/8), tracheal hemorrhage (5/8), oronasal hemorrhage (3/8), thoracic hemorrhage (3/ 8), bleeding at puncture sites (4/8), and cannulation site hemorrhage (2/8). Conclusions: Hypercoagulability and secondary hyperfibrinolysis during ECMO support in COVID-19 patients are common and possibly increase the propensity for thrombotic events and failure of the oxygenator. Currently, there is not enough evidence to support a more aggressive anticoagulation strategy.

Extracorporeal Membrane Oxygenation Induces Early Alterations in Coagulation and Fibrinolysis Profiles in COVID-19 Patients with Acute Respiratory Distress Syndrome

“…aPTT significantly lengthened between day 1 and day 7 only in the COVID-19 group (median difference þ18.1 seconds, p ¼ 0.011). This was related to higher UFH doses in the COVID-19 group (median 38,000 [27,,000] vs. 24,000 [19,,000] IU/24 h, p ¼ 0.0126). Heparin resistance (defined as doses of UFH greater than 35,000 IU/day to raise the target) was observed in 70% of the COVID-19 patients.…”

“…12,13 Some authors suggested that these bleeding events might result from worsening COVID-19-associated coagulopathy during ECMO support, further leading to disseminated intravascular coagulation, enhanced fibrinolysis or acquired von Willebrand syndrome, or from heparin overdose. 14 However, data on the kinetics of coagulation and fibrinolysis markers over the course of vv-ECMO in COVID-19 patients which might support this hypothesis are scarce [15][16][17][18][19] and direct comparisons with non-COVID-19 patients are lacking.…”

EACTA/SCA Recommendations for the Cardiac Anesthesia Management of Patients With Suspected or Confirmed COVID-19 Infection: An Expert Consensus From the European Association of Cardiothoracic Anesthesiology and Society of Cardiovascular Anesthesiologists With Endorsement From the Chinese Society of Cardiothoracic and Vascular Anesthesiology

“… Bleeding events are observed in 7.8% of patients with COVID-19 infection, which are sensitive to the use of escalated doses of anticoagulants ( 19 ). Point-of-care monitoring of coagulation, including thromboelastography ( 20 ) can be considered to manage hemostasis in the perioperative period. …”

The Role of Extracorporeal Membrane Oxygenation on Acute Respiratory Distress Syndrome

“…A pulmonary protective ventilator strategy was adopted after ECMO initiation (FiO2 < 40%, tidal volume 2-4 ml/kg, plateau pressure < 25 cmH2O, and respiratory rate 8-10 breaths/min. 33 The anticoagulant heparin unfractionated (UFH) was used for all patients, with a bolus dose of 50 U/kg 10 minutes before cannulation. If the activated clotting time (ACT) is < 180 seconds, the continuous intravenous infusion of UFH is increased at a rate of 2-20 U/kg/hour, with a target ACT of 180-200 seconds and an activated partial thromboplastin time (aPTT) of 50-80 seconds (or 1.5 times the baseline).…”

“…If the activated clotting time (ACT) is < 180 seconds, the continuous intravenous infusion of UFH is increased at a rate of 2-20 U/kg/hour, with a target ACT of 180-200 seconds and an activated partial thromboplastin time (aPTT) of 50-80 seconds (or 1.5 times the baseline). 33 Figure 6 shows a flowchart of ECMO initiation on ARDS. while in patients using ECMO-VV, there is no recovery of lung function after 2-3 weeks.…”