Unfractionated Heparin Versus Subcutaneous Nadroparin in Adults Supported With Venovenous Extracorporeal Membrane Oxygenation: a Retrospective, Multicenter Study

Abstract

Extracorporeal membrane oxygenation (ECMO) requires constant management of coagulation. Whereas unfractionated heparin remains the anticoagulant of choice, experienced centers report high bleeding rates. Biocompatibility of the extracorporeal circuit enables management of anticoagulation with subcutaneous low-molecular-weight heparins only. The aim of this study was to evaluate the safety and feasibility of anticoagulation with subcutaneous nadroparin compared with unfractionated heparin during respiratory ECMO in patients. We assessed for thrombotic complications and number of bleeding and life-threatening bleeding events. Additionally, we evaluated the change in resistance to flow in the oxygenator and the number of transfused blood products. Nadroparin and unfractionated heparin were comparable in terms of number of bleeding (34 vs. 53%; p = 0.12), life-threatening bleeding (2.8 vs. 9.3%; p = 0.26) events, and daily red blood cell transfusion rates (0.79 units/patient/day vs. 0.71 units/patient/day in nadroparin group; p = 0.87) during respiratory ECMO. The relative change in resistance to flow in the oxygenator was similar between groups (8.03 vs. 11.6%; p = 0.27). Nadroparin seemed equivalent to unfractionated heparin in the number of thrombotic and hemorrhagic events as well as in the daily red blood cell transfusion rates during venovenus-ECMO.

Subcutaneous Enoxaparin for Systemic Anticoagulation of COVID-19 Patients During Extracorporeal Life Support

“…Only two direct comparisons are currently available on the safety and efficacy of low-molecular-weight vs. unfractionated heparin during extracorporeal oxygenation. While Piwowarczyk et al ( 15 ) noted similar rates of thromboembolic events and bleeding complications for nadroparin and unfractionated heparin, these findings might not be directly relatable to ours, since the comparability of enoxaparin and nadroparin has been questioned ( 32 ). Our own study group observed, in perioperative settings of lung transplantation, bleeding events with enoxaparin in 12.5% and with unfractionated heparin in 22.7% of patients ( p = 0.31) ( 13 ).…”

“…Current guidelines recommend the use of unfractionated heparin for anticoagulation during extracorporeal membrane oxygenation (ECMO) (12). Standardized protocols using low-molecularweight heparin have yet to find their way into routine clinical practice, even though promising data have been presented for enoxaparin and nadroparin (13)(14)(15). There are also reports on major advantages of low-molecular-weight over unfractionated heparin like reduced bleeding complications or heparin-induced thrombocytopenia (16,17).…”

Anticoagulation on Extracorporeal Support: An Alternative Strategy

“…Despite paucity of literature related to anticoagulation management based on LMWH only during ECMO support, [2][3][4] we decided to introduce this approach since the second wave of Coronavirus disease 2019 (COVID-19) pandemic, to simplify and standardize anticoagulation management, reducing the strain on the team members, particularly on most recently recruited, and less experienced ones, involved to expand ECMO capacity.…”

Challenges and pitfalls of extracorporeal membrane oxygenation in critically-ill pregnant and peripartum women with COVID-19: a retrospective case series

“…According to our center’s experience before the COVID-19 pandemic, anti-Xa guided subcutaneous nadroparin was used for anticoagulation during ECMO support. 13 This mode of anticoagulation during ECMO, although performed by less than 4% of centers, has been reported to be feasible and safe in observational trials and case series. 14 , 15 …”