Observational study of thrombosis and bleeding in COVID-19 VV ECMO patients

Ripoll, Brianda; Rubino, Antonio; Besser, Martin; Patvardhan, Chinmay; Thomas, William; Sheares, Karen; Shanahan, Hilary; Agrawal, Bobby; Webb, Stephen T.; Vuylsteke, Alain

doi:10.1177/0391398821989065

Cited by 23 publications

(29 citation statements)

References 9 publications

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“…The results were similar when the sample was limited to patients with COVID-19 who were characterised as having ARDS. Our results are also consistent with previously reported survival rates in acute hypoxaemic respiratory failure, supporting current recommendations that centres experienced in ECMO should consider its use in refractory COVID-19-related respiratory failure [13,80].…”

Section: Immuno-thrombosis and Anticoagulation Therapysupporting

confidence: 92%

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Risk Management and Treatment of Coagulation Disorders Related to COVID-19 Infection

Zanza

Racca

Longhitano

et al. 2021

IJERPH

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Coronavirus disease 2019 (COVID-19) is an emerging infectious disease. Bilateral pneumonia, acute respiratory failure, systemic inflammation, endothelial dysfunction and coagulation activation are key features of severe COVID-19. Fibrinogen and D-dimer levels are typically increased. The risk for venous thromboembolism is markedly increased, especially in patients in the intensive care unit despite prophylactic dose anticoagulation. Pulmonary microvascular thrombosis has also been described and the risk for arterial thrombotic diseases also appears to be increased while bleeding is less common than thrombosis, but it can occur. Evaluation for venous thromboembolism may be challenging because symptoms of pulmonary embolism overlap with COVID-19, and imaging studies may not be feasible in all cases. The threshold for evaluation or diagnosis of thromboembolism should be low given the high frequency of these events. Management and treatment are new challenges due to the paucity of high-quality evidence regarding efficacy and safety of different approaches to prevent or treat thromboembolic complications of the disease. All inpatients should receive thromboprophylaxis unless contraindicated. Some institutional protocols provide more aggressive anticoagulation with intermediate or even therapeutic dose anticoagulation for COVID-19 patients admitted to ICU. Therapeutic dose anticoagulation is always appropriate to treat deep venous thrombosis or pulmonary embolism, unless contraindicated. This article reviews evaluation and management of coagulation abnormalities in individuals with COVID-19.

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Section: Immuno-thrombosis and Anticoagulation Therapysupporting

confidence: 92%

“…This review provides practical information for evaluation and management of coagulation abnormalities in individuals with COVID-19 [12,13].…”

Section: Introductionmentioning

confidence: 99%

Risk Management and Treatment of Coagulation Disorders Related to COVID-19 Infection

Zanza

Racca

Longhitano

et al. 2021

IJERPH

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“…Bleeding may be more prominent in patients with COVID-19. 11 ECMO centers must have an approach to when such bleeding occurs. It has been our experience that traditional therapies to control pulmonary bleeding may be inadequate.…”

Section: Discussionmentioning

confidence: 99%

Cryotherapy: A Safe Approach to Pulmonary Hemorrhage During VV-ECMO

Green

Puri

Kouch

et al. 2022

Journal of Investigative Medicine High Impact Case Reports

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The number of hospitals with veno-venous extracorporeal membrane oxygenation (VV-ECMO) capabilities is expanding. To support an ECMO program, centers must be equipped to handle associated complications such as pulmonary hemorrhage. We describe a case series of 4 patients with life-threatening pulmonary bleeding and central airway obstruction. A therapeutic approach of anticoagulation cessation coupled with cryoextraction via flexible bronchoscopy led to successful restoration of airway patency without any adverse events. A low threshold to stop anticoagulation with a strong consideration of bronchoscopy with cryotherapy for pulmonary toilet should be done in patients with pulmonary hemorrhage during VV-ECMO.

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“…Previous reports of ECMO in COVID-19 demonstrated thrombotic events of 41% to 43% utilizing systemic heparin therapy. 30-32 In our cohort, systemic clotting events occurred in 6.1% (n = 1). Only 1 DVT and 1 PE developed during ECMO receipt.…”

Section: Discussionmentioning

confidence: 81%

Evaluation of Bivalirudin as the Primary Anticoagulant in Patients Receiving Extracorporeal Membrane Oxygenation for SARS-CoV-2–Associated Acute Respiratory Failure

et al. 2021

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Background Extracorporeal membrane oxygenation (ECMO) is a potential option for the management of severe acute respiratory failure secondary to COVID-19. Conflicting the use of this therapy is the known coagulopathy within COVID-19, leading to an incidence of venous thrombotic events of 25% to 49%. To date, limited guidance is available on optimal anticoagulation strategies in this population. Objective The purpose of this study was to evaluate the utilization of a pharmacist-driven bivalirudin dosing protocol for anticoagulation in the setting of ECMO for COVID-19–associated respiratory failure. Methods This was a single-center retrospective chart review over a 9-month period of patients receiving bivalirudin while on ECMO. All patients with acute respiratory failure requiring ECMO with a positive SARS-CoV-2 polymerase chain reaction were included. Bivalirudin was dosed via aPTT monitoring after a starting dose of 0.2 or 0.3 mg/kg/h. Results There were 33 patients included in this study, all receiving mechanical ventilation. The most common starting dose of bivalirudin was 0.2 mg/kg/h, with an average time to therapeutic range of 20 hours. Compared to previous reports, rates of bleeding were low at 15.1%, and 6.1% of patients developed a new venous thromboembolic event while on ECMO. ECMO survival was 51.5%, with an ICU mortality rate of 48.5%. Conclusion and Relevance In the first published report of its use within this population, bivalirudin was found to be a viable choice for anticoagulation in those patients on ECMO for severe respiratory failure secondary to COVID-19.

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Observational study of thrombosis and bleeding in COVID-19 VV ECMO patients

Cited by 23 publications

References 9 publications

Risk Management and Treatment of Coagulation Disorders Related to COVID-19 Infection

Risk Management and Treatment of Coagulation Disorders Related to COVID-19 Infection

Cryotherapy: A Safe Approach to Pulmonary Hemorrhage During VV-ECMO

Evaluation of Bivalirudin as the Primary Anticoagulant in Patients Receiving Extracorporeal Membrane Oxygenation for SARS-CoV-2–Associated Acute Respiratory Failure

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