BACKGROUND: Anticoagulation during extracorporeal membrane oxygenation (ECMO) might still lead to severe bleeding complications. Heparin is the most frequently used anticoagulant, but novel drugs could be promising. Argatroban is a new alternative to heparin. To date, no robust studies have confirmed the clear superiority of argatroban (AG) over heparin, although it has some advantages and may be safer. STUDY DESIGN AND METHODS: An observational study was conducted in all adult veno-venous ECMO patients with COVID-19-associated acute respiratory distress syndrome admitted to the University Hospital Ostrava (n = 63). They were anticoagulated with heparin in the first period and with AG in the second period, targeting the same activated partial thromboplastin time (aPTT; 45-60 s). Bleeding complications requiring transfusion and life-threatening bleeding events were evaluated. The primary objective was to compare heparin and AG in terms of bleeding, transfusion requirements and mortality-related bleeding. RESULTS: The total time on ECMO per patient was 16 days with an in-hospital mortality of 55.6%. The red blood cell consumption in the AG group (median 2.7 transfusions/week) was significantly lower than in the heparin group (median 4.2 transfusions/week, p = 0.011). Life-threatening bleeding complications were higher in the heparin group compared to the AG group (35.7% vs. 10.2%, p = 0.035), and mortality-related bleeding complications were also higher in the heparin group (21.4% vs. 2.0%, p = 0.032). DISCUSSION: Argatroban is an interesting alternative to heparin with less bleeding, less need for red blood cell transfusions and improved safety of ECMO with less mortality-related bleeding.
- MeSH
- antikoagulancia * škodlivé účinky terapeutické užití MeSH
- arginin * analogy a deriváty MeSH
- COVID-19 komplikace MeSH
- dospělí MeSH
- heparin * škodlivé účinky MeSH
- krvácení * chemicky indukované terapie MeSH
- kyseliny pipekolové * terapeutické užití aplikace a dávkování MeSH
- lidé středního věku MeSH
- lidé MeSH
- mimotělní membránová oxygenace * MeSH
- mortalita v nemocnicích MeSH
- SARS-CoV-2 MeSH
- senioři MeSH
- sulfonamidy * MeSH
- syndrom dechové tísně terapie MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- pozorovací studie MeSH
- srovnávací studie MeSH
Unfractionated heparin has long been considered the standard anticoagulation in ECMO, despite some pitfalls such as heparin resistance, heparin induced thrombocytopenia (HIT), etc Recently, some centres started to increasingly use argatroban for this purpose, typically using activated partial thromboplastin time (aPTT) for its monitoring. Direct monitoring of the efficacy of argatroban using Anti-IIa is not yet an established method, although it might be more appropriate as it targets the same pathway.An observational study was performed in adult veno-venous ECMO patients hospitalized with SARS-CoV-2 infection anticoagulated with argatroban to an aPTT target of 40-60 s and Anti-IIa target of 0.4-0.6 μg/mL. Bleeding and thrombotic complications were monitored.Forty-four VV ECMO patients were included, with an overall hospital mortality of approx. 50%. No life-threatening thrombotic events were recorded. The risk of bleeding complications significantly increased with aPTT above 52.7 s and with Anti-IIa values over 0.78 μg/mL. Using the above cut-offs for both the aPTT and Anti-IIa and their combination, the negative predictive value for bleeding was approximately 90%.It seems that the generally recommended limits for Anti-IIa of 1.5 μg/mL may be high. However, further data are needed to confirm lower limits.Trial Registration:retrospectively registered in ClinicalTrials.gov, NCT06038682.
- MeSH
- antikoagulancia * terapeutické užití škodlivé účinky aplikace a dávkování MeSH
- arginin analogy a deriváty MeSH
- COVID-19 * krev terapie mortalita komplikace MeSH
- dospělí MeSH
- farmakoterapie COVID-19 * MeSH
- krvácení chemicky indukované MeSH
- kyseliny pipekolové * terapeutické užití aplikace a dávkování škodlivé účinky MeSH
- lidé středního věku MeSH
- lidé MeSH
- mimotělní membránová oxygenace * metody MeSH
- monitorování léčiv metody MeSH
- parciální tromboplastinový čas MeSH
- SARS-CoV-2 MeSH
- senioři MeSH
- sulfonamidy MeSH
- trombóza prevence a kontrola etiologie MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- pozorovací studie MeSH
Umělá plicní ventilace (UPV) patří mezi zavedené metody orgánové podpory na jednotkách intenzivní péče. U pacientů s plicním postižením, zejména pak s jejich těžšími formami, může UPV působit takovými silami, že mohou vést k dalšímu poškození nemocných plic. Mechanická energie (ME) je parametr představující celkovou energii, kterou UPV působí na plíce (případně na plíce, dýchací cesty a hrudník). Vyšší hodnoty ME jsou spojené s vyšším rizikem plicního postižení indukovaného ventilátorem (VILI). ME je možné vypočítat z ventilačních parametrů pomocí rovnic, z nichž některé umožňují výpočet přímo u lůžka nemocného na běžné kalkulačce. Úpravou jednotlivých parametrů, pak můžeme ME snížit ve snaze snížení rizika VILI. Ze vzorců lze rovněž odvodit jak se jednotlivé parametry podílejí na celkové ME a můžeme se tak rozhodnout, který parametr je vhodné upravit. Tento přehledový článek přináší ucelený pohled na současné postavení ME jako ventilačního parametru asociovaného s rizikem VILI. Jsou zde uvedeny rovnice pro výpočet ME pro jednotlivé ventilační režimy s kritickým hodnocením přesnosti jednotlivých možností výpočtu a využití konceptu ME v běžné denní praxi u lůžka pacienta na UPV.
Mechanical ventilation (MV) is one of the established methods of organ support in intensive care units. In patients with lung disease, especially in its more severe forms, MV can act with such forces that it can lead to further damage to the diseased lungs. Mechanical energy (ME) is a parameter representing the total energy that the MV exerts on the lungs (or lungs, airways, and chest). Higher ME values are associated with a higher risk of ventilator-induced lung injury (VILI). ME can be calculated from ventilation parameters using equations, some of which allow calculation directly at the patient's bedside on a regular calculator. By adjusting individual parameters, we can then reduce the ME to reduce the risk of VILI. From the formulas, it is also possible to derive how the individual parameters contribute to the overall ME, and we can thus decide which parameter should be adjusted. This review article provides a comprehensive view of the current knowledge of ME as a ventilatory parameter associated with the risk of VILI. Equations for calculating ME for individual ventilation modes are presented here, with a critical assessment of the accuracy of individual calculation options and the use of the ME concept in routine daily practice at the patient's bed on MV.
- Klíčová slova
- mechanická energie,
- MeSH
- lidé MeSH
- mechanické ventilátory škodlivé účinky MeSH
- poškození plic mechanickou ventilací prevence a kontrola MeSH
- přenos energie MeSH
- syndrom dechové tísně etiologie terapie MeSH
- umělé dýchání * metody škodlivé účinky MeSH
- ventilace umělá s výdechovým přetlakem metody MeSH
- Check Tag
- lidé MeSH
Mechanical ventilation (MV) provides basic organ support for patients who have acute hypoxemic respiratory failure, with acute respiratory distress syndrome as the most severe form. The use of excessive ventilation forces can exacerbate the lung condition and lead to ventilator-induced lung injury (VILI); mechanical energy (ME) or power can characterize such forces applied during MV. The ME metric combines all MV parameters affecting the respiratory system (ie, lungs, chest, and airways) into a single value. Besides evaluating the overall ME, this parameter can be also related to patient-specific characteristics, such as lung compliance or patient weight, which can further improve the value of ME for characterizing the aggressiveness of lung ventilation. High ME is associated with poor outcomes and could be used as a prognostic parameter and indicator of the risk of VILI. ME is rarely determined in everyday practice because the calculations are complicated and based on multiple equations. Although low ME does not conclusively prevent the possibility of VILI (eg, due to the lung inhomogeneity and preexisting damage), individualization of MV settings considering ME appears to improve outcomes. This article aims to review the roles of bedside assessment of mechanical power, its relevance in mechanical ventilation, and its associations with treatment outcomes. In addition, we discuss methods for ME determination, aiming to propose the most suitable method for bedside application of the ME concept in everyday practice.
- MeSH
- agrese MeSH
- dýchání MeSH
- hrudník MeSH
- lidé MeSH
- poškození plic mechanickou ventilací * MeSH
- syndrom dechové tísně * MeSH
- umělé dýchání MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- přehledy MeSH
Although extracorporeal life support is an expensive method with serious risks of complications, it is nowadays a well-established and generally accepted method of organ support. In patients with severe respiratory failure, when conventional mechanical ventilation cannot ensure adequate blood gas exchange, veno-venous extracorporeal membrane oxygenation (ECMO) is the method of choice. An improvement in oxygenation or normalization of acid-base balance by itself does not necessarily mean an improvement in the outcome but allows us to prevent potential negative effects of mechanical ventilation, which can be considered a crucial part of complex care leading potentially to an improvement in the outcome. The disconnection from ECMO or discharge from the intensive care unit should not be viewed as the main goal, and the long-term outcome of the ECMO-surviving patients should also be considered. Approximately three-quarters of patients survive the veno-venous ECMO, but various (both physical and psychological) health problems may persist. Despite these, a large proportion of these patients are eventually able to return to everyday life with relatively little limitation of respiratory function. In this review, we summarize the available knowledge on long-term mortality and quality of life of ECMO patients with respiratory failure.
- Publikační typ
- časopisecké články MeSH
- přehledy MeSH
Extracorporeal membrane oxygenation (ECMO) has been established as a life-saving technique for patients with the most severe forms of respiratory or cardiac failure. It can, however, be associated with severe complications. Anticoagulation therapy is required to prevent ECMO circuit thrombosis. It is, however, associated with an increased risk of hemocoagulation disorders. Thus, safe anticoagulation is a cornerstone of ECMO therapy. The most frequently used anticoagulant is unfractionated heparin, which can, however, cause significant adverse effects. Novel drugs (e.g., argatroban and bivalirudin) may be superior to heparin in the better predictability of their effects, functioning independently of antithrombin, inhibiting thrombin bound to fibrin, and eliminating heparin-induced thrombocytopenia. It is also necessary to keep in mind that hemocoagulation tests are not specific, and their results, used for setting up the dosage, can be biased by many factors. The knowledge of the advantages and disadvantages of particular drugs, limitations of particular tests, and individualization are cornerstones of prevention against critical events, such as life-threatening bleeding or acute oxygenator failure followed by life-threatening hypoxemia and hemodynamic deterioration. This paper describes the effects of anticoagulant drugs used in ECMO and their monitoring, highlighting specific conditions and factors that might influence coagulation and anticoagulation measurements.
- MeSH
- hrudník diagnostické zobrazování MeSH
- lidé MeSH
- plíce diagnostické zobrazování MeSH
- ultrasonografie * metody MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- přehledy MeSH
