Factor XIII Activity Might Already Be Impaired before Veno-Venous ECMO in ARDS Patients: A Prospective, Observational Single-Center Cohort Study

Abstract

Direct complications in patients receiving extracorporeal (veno-venous) membrane oxygenation (vvECMO) are mainly either due to bleeding or thromboembolism. We aimed to evaluate the course of routine coagulation parameters and the activity of different coagulation factors—with special focus on factor XIII (F XIII)—before, during and after vvECMO in acute respiratory distress syndrome (ARDS) patients. The activity of coagulation factors and rotational thrombelastometry were analyzed in 20 ECMO patients before (T-1) and 6 h (T0), one (T1), three (T3) and seven days (T7) after the implantation, as well as one and three days after the termination of ECMO. F XIII activity was already severely decreased to 37% (30/49) before ECMO. F XIII activity was the only coagulation factor continuously declining during vvECMO, being significantly decreased at T3 (31% (26/45) vs. 24% (18/42), p = 0.0079) and T7 (31% (26/45) vs. 23% (17/37), p = 0.0037) compared to T0. Three days after termination of vvECMO, platelet count and fibrinogen nearly doubled and factors II, V, XI and XIII showed spontaneous significant increases. Severe ARDS patients showed a considerably diminished factor XIII activity before vvECMO initiation and its activity continuously declined later on. Thus, incorporation of F XIII monitoring into the regular hemostaseologic routine during vvECMO therapy seems advisable. Due to the potential development of a hypercoagulatory state after the termination of vvECMO, tight hemostasiologic monitoring should persist in the initial phase after ECMO termination.

Contraindications to the Initiation of Veno-Venous ECMO for Severe Acute Respiratory Failure in Adults: A Systematic Review and Practical Approach Based on the Current Literature

“…An analysis of the ELSO registry revealed a survival rate to discharge of 61% in trauma patients [ 200 ]. Extended advanced monitoring is suggested to detect early deterioration, ideally as a baseline before initiation of ECMO to prevent potentially deleterious bleeding or thromboembolic complications [ 201 , 202 ]. Using extracorporeal lung assist has been reported in various circuit compositions, with all of these reports describing feasibility without an increased risk of bleeding and survival benefits, as well as high survival rates [ 161 , 162 , 203 , 204 , 205 , 206 , 207 , 208 , 209 , 210 , 211 , 212 , 213 , 214 , 215 , 216 , 217 ].…”

Monitoring of Unfractionated Heparin Therapy in the Intensive Care Unit Using a Point-of-Care aPTT: A Comparative, Longitudinal Observational Study with Laboratory-Based aPTT and Anti-Xa Activity Measurement

“…We also assessed the variables that could explain differences between POCT-APTT and lab-APTT and found that CRP, fibrinogen, factor XII levels, and LA positivity could explain differences between the two tests. Recent studies found that FXII and FXIII show a significant decrease during ECMO, FXIII even showing reduced levels hours before its initiation [ 39 , 40 ]. Low coagulation FXII activity has been associated with less thromboembolic complications [ 40 ], and was beneficial in an animal model, as its inhibition prevented fibrin deposition and thrombosis in the extracorporeal circuit [ 41 ].…”

The impact of acquired coagulation factor XIII deficiency in traumatic bleeding and wound healing

“…A recent review has described three pools of FXIII within the circulation, in plasma, and within the cellular compartments of platelets and monocytes/macrophages, providing additional insights into the complex roles of FXIII in these physiological processes [78]. Although beyond the scope of this review, studies have indicated that FXIII levels/activity are impaired before and during extracorporeal membrane oxygenation [79][80][81]. Moreover, acquired coagulopathy and reduced FXIII levels have been reported in patients with COVID-19 [82][83][84].…”