Algorithm-based management of bleeding in patients with extracorporeal membrane oxygenation

نویسندگان

  • David Faraoni
  • Jerrold H Levy
چکیده

and colleagues [1]. Coagulation management is a challenge during extracorporeal membrane oxygenation (ECMO) due to complex hemostatic and infl ammatory responses associated with the underlying conditions that include infection, sepsis, surgery, and/or traumatic injury [2]. Repressé and colleagues present the fi rst algorithmbased approach to bleeding in ECMO patients. However, additional perspectives are important to consider. First, activated partial thromboplastin time or antiacti vated factor X monitoring are routinely used to monitor heparin therapy in ECMO patients, despite intraindividual and inter-individual variability [3]. Rotational thromboelasto metry (ROTEM®; TEM® International GmbH, Munich, Germany) is also increasingly used in the ICU to rapidly assess the coagulation status, including clotting factors, fi brinogen levels, and whole blood clotting [4]. Moreover, this test also facilitates fi brinolytic pathway evaluation, which cannot be easily explored by routine laboratory tests. We believe ROTEM® could be used to design an algorithm-based approach to bleeding in ECMO patients and follow fi brinogen consumption associated with hyperfi brinolysis, an important cause of bleeding. For this reason, anti-fi brinolytic agents should be considered in the multimodal approach (Figure 1), an important point the authors omitted in their algorithm. Second, adverse events includin g 32% venous thrombosis and a 2.5% incidence of fatal pulmonary embolism have already been reported in ECMO patients [5]. In another series, Combes and colleagues reported a 10% incidence of femoral vein and 7% incidence vena cava thrombosis [6]. Recombinant activated factor VII is associated with thromboembolic events [7] and should be used with caution until additional data help us evaluate the benefi t-to-risk administration in bleeding ECMO patients.

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عنوان ژورنال:

دوره 17  شماره 

صفحات  -

تاریخ انتشار 2013