Background:
Heparin is the widely used anti-coagulation strategy for patients on extracorporeal membrane oxygenation (ECMO). Nevertheless, heparin-induced thrombocytopenia (HIT) and acquired ...anti-thrombin (AT) deficiency preclude the use of heparin requiring utilization of an alternative anticoagulant agent. Direct thrombin inhibitors are being proposed as potential alternatives with argatroban as one of the main agents. We aimed to review the evidence with regard to safety and efficacy of argatroban as a potential definitive alternative to heparin in the adult patient population undergoing ECMO support.
Methods:
A web-based systematic literature search was performed in Medline (PubMed) and Embase from inception until June 18, 2020.
Results:
The search identified 13 publications relevant to the target (4 cohort studies and 9 case series). Case reports and case series with less than 3 cases were not included in the qualitative synthesis. The aggregate number of argatroban treated patients on ECMO was n = 307. In the majority of studies argatroban was used as a continuous infusion without loading dose. Starting doses on ECMO varied between 0.05 and 2 μg/kg/min and were titrated to achieve the chosen therapeutic target range. The activated partial thormboplastin time (aPTT) was the anticoagulation parameter used for monitoring purposes in most studies, whereas some utilized the activated clotting time (ACT). Optimal therapeutic targets varied between 43-70 and 60-100 seconds for aPTT and between 150-210 and 180-230 seconds for ACT. Bleeding and thromboembolic complication rates were comparable to patients treated with unfractionated heparin (UFH).
Conclusions:
Argatroban infusion rates and anticoagulation target ranges showed substantial variations. The rational for divergent dosing and monitoring approaches are discussed in this paper. Argatroban appears to be a potential alternative to UFH in patients requiring ECMO. To definitively establish its safety, efficacy and ideal dosing strategy, larger prospective studies on well-defined patient populations are warranted.
Background:
Extracorporeal membrane oxygenation (ECMO) offers therapeutic options in refractory respiratory and/or cardiac failure. Systemic anticoagulation with heparin is routinely administered. ...However, in patients with heparin-induced thrombocytopenia or heparin resistance, the direct thrombin inhibitor bivalirudin is a valid option and has been increasingly used for ECMO anticoagulation. We aimed at evaluating its safety and its optimal dosing for ECMO.
Methods:
Systematic web-based literature search of PubMed and EMBASE performed via National Health Service Library Evidence and manually, updated until January 30, 2016.
Results:
The search revealed 8 publications relevant to the topic (5 case reports). In total, 58 patients (24 pediatrics) were reported (18 received heparin as control groups). Bivalirudin was used with or without loading dose, followed by infusion at different ranges (lowest 0.1-0.2 mg/kg/h without loading dose; highest 0.5 mg/kg/h after loading dose). The strategies for monitoring anticoagulation and optimal targets were dissimilar (activated partial thromboplastin time 45-60 seconds to 42-88 seconds; activated clotting time 180-200 seconds to 200-220 seconds; thromboelastography in 1 study).
Conclusion:
Bivalirudin loading dose was not always used; infusion range and anticoagulation targets were different. In this systematic review, we discuss the reasons for this variability. Larger studies are needed to establish the optimal approach with the use of bivalirudin for ECMO.
Extracorporeal membrane oxygenation (ECMO) is a widely used technique to provide circulatory and/or respiratory support in critically ill patients. ECMO treatment usually necessitates systemic ...anticoagulation. Unfractionated Heparin (UFH) is a commonly used anticoagulant in patients on ECMO support. In situations where UFH is contraindicated, alternative anticoagulation strategies can be applied, such as the use of direct thrombin inhibitors (DTI). Bivalirudin and argatroban are the most widely used DTIs. In this report we give account of the current evidence regarding dosing, monitoring and complications associated with the use of these agents in ECMO dependent patients.
Background. Burnout syndrome has reached epidemic levels among physicians (reported around 50%). Anesthesiology is among the most stressful medical disciplines but there is paucity of literature as ...compared with others. Analysis of burnout is essential because it is associated with safety and quality of care. We summarize evidence on burnout in anesthesiology. Methods. We conducted a systematic review (MEDLINE up to 30.06.2017). We included studies reporting burnout in anesthesiology with no restriction on role or screening test used. Results. Fifteen surveys/studies described burnout in anesthesiology, including different workers profiles (nurses, residents, consultants, and directors). All studies used the Maslach Burnout Inventory test but with significant differences for risk stratification. Burnout prevalence greatly varied across studies (10%–41% high risk, up to 59% at least moderate risk). Factors most consistently associated with burnout were strained working pattern, working as younger consultant, and having children. There was no consistent relationship between burnout and hospital characteristics, gender, or marital status. Conclusions. Burnout prevalence among anesthesiologists is relatively high across career stages, and some risk factors are reported frequently. However, the small number of studies as well as the large differences in their methodology and in reporting approach warrants further research in this field.
A systematic review of the role of extracorporeal life support (ECLS) in pediatric patients with burn and smoke inhalation injury was undertaken. A systematic search of the literature according to a ...specific combination of keywords to ascertain the effectiveness of this treatment strategy was conducted. A total of 14 articles out of 266 were considered suitable for the analysis in pediatric patients. The PICOS approach and PRISMA flow chart were followed for the purpose of this review. Despite the limited number of studies on the subject, ECMO in burn and smoke inhalation injury provides an additional level of support in pediatric patients leading to positive outcomes. V-V ECMO demonstrated the best overall survival of all configurations, with similar outcomes to non-burned patients. Prolonged mechanical ventilation prior to ECMO decreases survival and increases mortality by 12% with each additional day off ECMO. Good outcomes have been described for scald burns, dressing changes, and pre-ECMO cardiac arrest.
The ProtekDuo, single site dual lumen cannula can be used in a multitude of configurations. In the medical literature, the ProtekDuo is described as right ventricular assist device (RVAD), as left ...ventricular assist device (LVAD), as biventricular assist device (BiVAD) when combined with an Impella device or other LVAD’s, as double lumen drainage cannula on cardiopulmonary bypass (CPB), as RVAD with oxygenator, in veno-pulmonary (V-P) ECMO configuration, venovenous-pulmonary (VV-P) ECMO configuration with additional drainage cannula, and in veno-venopulmonary (V-VP) ECMO configuration as double lumen return cannula. Improvements in flow and oxygenation have been recognized in various settings and need further scientific evaluation. We summarized the above-mentioned configurations, technical aspects, and the present literature available for the ProtekDuo.
We sought to review the role of extracorporeal membrane oxygenation (ECMO) for the management of burn and smoke inhalation injury in the adult patient population. Therefore, we conducted a systematic ...search of the literature according to specific combination of key words to ascertain the effectiveness of this support strategy. A total of 26 articles were filtered out of 269 and considered suitable for this study. The PICOS approach and PRISMA flow chart were followed for the purposes of our review. Although there is growing evidence supporting the role of ECMO as an option for burn injury in the adult patient population, this strategy should be considered if a likely successful outcome is expected.
Assessing the outcome of Veno-Venous Extracorporeal Membrane Oxygenation (V-V ECMO) support remains challenging as plasma lactate (pLA), the widely used tool for this purpose, has been shown ...unreliable. We hypothesized that plasma oncostatin M (pOSM), a sensitive marker of leukocyte activation in infection and inflammation, could address this deficiency.
Plasma OSM levels were measured by ELISA in 30 Acute Respiratory Distress Syndrome (ARDS) patients, prior to cannulation (baseline) and decannulation.
Based on the absolute pOSM levels at presentation, patients were separated into two groups, A and B. Patients in group A had low pOSM levels (Mean ± SD; Median, 1.1 ± 3.8; 0 pg/mL), whereas group B had high pOSM levels (1548 ± 1999; 767 pg/mL) t-test: p < 0.01. The percentage of pOSM levels at decannulation relative to baseline OSM levels was significantly higher in those who died (116.8 ± 68.0; 85.3%) than those who survived (47.6 ± 25.5; 48.9%) t-test: p = 0.02; Mann-Whitney U Test: p = 0.01. Conversely, no significant difference was observed in the percentage of pLA levels between those who died (142.9 ± 179.9; 89.8%) and those who survived (79.3 ± 34.3; 81.8%) t-test: p = 0.31; Mann-Whitney U Test: p = 0.63.
These early findings suggested critical value of absolute and relative pOSM to characterize the inflammatory burden of ARDS patients and the outcome of their V-V ECMO support.
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