Reduced anticoagulation strategy is associated with a lower incidence of intracerebral hemorrhage in COVID-19 patients on extracorporeal membrane oxygenation
Abstract Background Optimal anticoagulation strategies for COVID-19 patients with the acute respiratory distress syndrome (ARDS) on venovenous extracorporeal membrane oxygenation (VV ECMO) remain uncertain. A higher incidence of intracerebral hemorrhage (ICH) during VV ECMO support compared to non-C...
| Main Authors: | , , , , , , , , , , , , , , , , |
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| Format: | Article |
| Language: | English |
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SpringerOpen
2023-06-01
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| Series: | Intensive Care Medicine Experimental |
| Subjects: | |
| Online Access: | https://doi.org/10.1186/s40635-023-00525-3 |
| _version_ | 1797801639241842688 |
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| author | Daniel A. Hofmaenner David Furfaro Lennart C. Wild Pedro David Wendel-Garcia Elias Baedorf Kassis Ameeka Pannu Tobias Welte Rolf Erlebach Klaus Stahl Edward Wilson Grandin Christian Putensen Reto A. Schuepbach Shahzad Shaefi Sascha David Benjamin Seeliger Christian Bode for the BonHanZA study group |
| author_facet | Daniel A. Hofmaenner David Furfaro Lennart C. Wild Pedro David Wendel-Garcia Elias Baedorf Kassis Ameeka Pannu Tobias Welte Rolf Erlebach Klaus Stahl Edward Wilson Grandin Christian Putensen Reto A. Schuepbach Shahzad Shaefi Sascha David Benjamin Seeliger Christian Bode for the BonHanZA study group |
| author_sort | Daniel A. Hofmaenner |
| collection | DOAJ |
| description | Abstract Background Optimal anticoagulation strategies for COVID-19 patients with the acute respiratory distress syndrome (ARDS) on venovenous extracorporeal membrane oxygenation (VV ECMO) remain uncertain. A higher incidence of intracerebral hemorrhage (ICH) during VV ECMO support compared to non-COVID-19 viral ARDS patients has been reported, with increased bleeding rates in COVID-19 attributed to both intensified anticoagulation and a disease-specific endotheliopathy. We hypothesized that lower intensity of anticoagulation during VV ECMO would be associated with a lower risk of ICH. In a retrospective, multicenter study from three academic tertiary intensive care units, we included patients with confirmed COVID-19 ARDS requiring VV ECMO support from March 2020 to January 2022. Patients were grouped by anticoagulation exposure into higher intensity, targeting anti-factor Xa activity (anti-Xa) of 0.3–0.4 U/mL, versus lower intensity, targeting anti-Xa 0.15–0.3 U/mL, cohorts. Mean daily doses of unfractionated heparin (UFH) per kg bodyweight and effectively measured daily anti-factor Xa activities were compared between the groups over the first 7 days on ECMO support. The primary outcome was the rate of ICH during VV ECMO support. Results 141 critically ill COVID-19 patients were included in the study. Patients with lower anticoagulation targets had consistently lower anti-Xa activity values over the first 7 ECMO days (p < 0.001). ICH incidence was lower in patients in the lower anti-Xa group: 4 (8%) vs 32 (34%) events. Accounting for death as a competing event, the adjusted subhazard ratio for the occurrence of ICH was 0.295 (97.5% CI 0.1–0.9, p = 0.044) for the lower anti-Xa compared to the higher anti-Xa group. 90-day ICU survival was higher in patients in the lower anti-Xa group, and ICH was the strongest risk factor associated with mortality (odds ratio [OR] 6.8 [CI 2.1–22.1], p = 0.001). Conclusions For COVID-19 patients on VV ECMO support anticoagulated with heparin, a lower anticoagulation target was associated with a significant reduction in ICH incidence and increased survival. |
| first_indexed | 2024-03-13T04:53:31Z |
| format | Article |
| id | doaj.art-669d83dac4ba41ed8fef61a2c1110028 |
| institution | Directory Open Access Journal |
| issn | 2197-425X |
| language | English |
| last_indexed | 2024-03-13T04:53:31Z |
| publishDate | 2023-06-01 |
| publisher | SpringerOpen |
| record_format | Article |
| series | Intensive Care Medicine Experimental |
| spelling | doaj.art-669d83dac4ba41ed8fef61a2c11100282023-06-18T11:03:56ZengSpringerOpenIntensive Care Medicine Experimental2197-425X2023-06-0111111310.1186/s40635-023-00525-3Reduced anticoagulation strategy is associated with a lower incidence of intracerebral hemorrhage in COVID-19 patients on extracorporeal membrane oxygenationDaniel A. Hofmaenner0David Furfaro1Lennart C. Wild2Pedro David Wendel-Garcia3Elias Baedorf Kassis4Ameeka Pannu5Tobias Welte6Rolf Erlebach7Klaus Stahl8Edward Wilson Grandin9Christian Putensen10Reto A. Schuepbach11Shahzad Shaefi12Sascha David13Benjamin Seeliger14Christian Bode15for the BonHanZA study groupInstitute of Intensive Care Medicine, University Hospital ZurichDivision of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical SchoolDepartment of Anesthesia and Intensive Care Medicine, University Hospital BonnInstitute of Intensive Care Medicine, University Hospital ZurichDivision of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical SchoolDepartment of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical SchoolDepartment of Respiratory Medicine, Hannover Medical School and Member of the German Centre for Lung Research, Biomedical Research in End-Stage and Obstructive Lung Disease Hannover (BREATH)Institute of Intensive Care Medicine, University Hospital ZurichDepartment of Gastroenterology, Hepatology and Endocrinology, Hannover Medical SchoolDivision of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical SchoolDepartment of Anesthesia and Intensive Care Medicine, University Hospital BonnInstitute of Intensive Care Medicine, University Hospital ZurichDepartment of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical SchoolInstitute of Intensive Care Medicine, University Hospital ZurichDepartment of Respiratory Medicine, Hannover Medical School and Member of the German Centre for Lung Research, Biomedical Research in End-Stage and Obstructive Lung Disease Hannover (BREATH)Department of Anesthesia and Intensive Care Medicine, University Hospital BonnAbstract Background Optimal anticoagulation strategies for COVID-19 patients with the acute respiratory distress syndrome (ARDS) on venovenous extracorporeal membrane oxygenation (VV ECMO) remain uncertain. A higher incidence of intracerebral hemorrhage (ICH) during VV ECMO support compared to non-COVID-19 viral ARDS patients has been reported, with increased bleeding rates in COVID-19 attributed to both intensified anticoagulation and a disease-specific endotheliopathy. We hypothesized that lower intensity of anticoagulation during VV ECMO would be associated with a lower risk of ICH. In a retrospective, multicenter study from three academic tertiary intensive care units, we included patients with confirmed COVID-19 ARDS requiring VV ECMO support from March 2020 to January 2022. Patients were grouped by anticoagulation exposure into higher intensity, targeting anti-factor Xa activity (anti-Xa) of 0.3–0.4 U/mL, versus lower intensity, targeting anti-Xa 0.15–0.3 U/mL, cohorts. Mean daily doses of unfractionated heparin (UFH) per kg bodyweight and effectively measured daily anti-factor Xa activities were compared between the groups over the first 7 days on ECMO support. The primary outcome was the rate of ICH during VV ECMO support. Results 141 critically ill COVID-19 patients were included in the study. Patients with lower anticoagulation targets had consistently lower anti-Xa activity values over the first 7 ECMO days (p < 0.001). ICH incidence was lower in patients in the lower anti-Xa group: 4 (8%) vs 32 (34%) events. Accounting for death as a competing event, the adjusted subhazard ratio for the occurrence of ICH was 0.295 (97.5% CI 0.1–0.9, p = 0.044) for the lower anti-Xa compared to the higher anti-Xa group. 90-day ICU survival was higher in patients in the lower anti-Xa group, and ICH was the strongest risk factor associated with mortality (odds ratio [OR] 6.8 [CI 2.1–22.1], p = 0.001). Conclusions For COVID-19 patients on VV ECMO support anticoagulated with heparin, a lower anticoagulation target was associated with a significant reduction in ICH incidence and increased survival.https://doi.org/10.1186/s40635-023-00525-3Acute respiratory distress syndromeExtracorporeal membrane oxygenationCOVID-19AnticoagulantsHemorrhageBleeding |
| spellingShingle | Daniel A. Hofmaenner David Furfaro Lennart C. Wild Pedro David Wendel-Garcia Elias Baedorf Kassis Ameeka Pannu Tobias Welte Rolf Erlebach Klaus Stahl Edward Wilson Grandin Christian Putensen Reto A. Schuepbach Shahzad Shaefi Sascha David Benjamin Seeliger Christian Bode for the BonHanZA study group Reduced anticoagulation strategy is associated with a lower incidence of intracerebral hemorrhage in COVID-19 patients on extracorporeal membrane oxygenation Intensive Care Medicine Experimental Acute respiratory distress syndrome Extracorporeal membrane oxygenation COVID-19 Anticoagulants Hemorrhage Bleeding |
| title | Reduced anticoagulation strategy is associated with a lower incidence of intracerebral hemorrhage in COVID-19 patients on extracorporeal membrane oxygenation |
| title_full | Reduced anticoagulation strategy is associated with a lower incidence of intracerebral hemorrhage in COVID-19 patients on extracorporeal membrane oxygenation |
| title_fullStr | Reduced anticoagulation strategy is associated with a lower incidence of intracerebral hemorrhage in COVID-19 patients on extracorporeal membrane oxygenation |
| title_full_unstemmed | Reduced anticoagulation strategy is associated with a lower incidence of intracerebral hemorrhage in COVID-19 patients on extracorporeal membrane oxygenation |
| title_short | Reduced anticoagulation strategy is associated with a lower incidence of intracerebral hemorrhage in COVID-19 patients on extracorporeal membrane oxygenation |
| title_sort | reduced anticoagulation strategy is associated with a lower incidence of intracerebral hemorrhage in covid 19 patients on extracorporeal membrane oxygenation |
| topic | Acute respiratory distress syndrome Extracorporeal membrane oxygenation COVID-19 Anticoagulants Hemorrhage Bleeding |
| url | https://doi.org/10.1186/s40635-023-00525-3 |
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