Antithrombin Levels and Heparin Responsiveness during Venoarterial Extracorporeal Membrane Oxygenation: A Prospective Single-center Cohort Study.

IF 9.1 1区 医学 Q1 ANESTHESIOLOGY Anesthesiology Pub Date : 2024-06-01 DOI:10.1097/ALN.0000000000004920
Alexandre Mansour, Mathilde Berahou, Joscelyn Odot, Adeline Pontis, Alessandro Parasido, Florian Reizine, Yoann Launey, Ronan Garlantézec, Erwan Flecher, Thomas Lecompte, Nicolas Nesseler, Isabelle Gouin-Thibault
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Abstract

Background: Unfractionated heparin, administered during venoarterial extracorporeal membrane oxygenation to prevent thromboembolic events, largely depends on plasma antithrombin for its antithrombotic effects. Decreased heparin responsiveness seems frequent on extracorporeal membrane oxygenation; however, its association with acquired antithrombin deficiency is poorly understood. The objective of this study was to describe longitudinal changes in plasma antithrombin levels during extracorporeal membrane oxygenation support and evaluate the association between antithrombin levels and heparin responsiveness. The hypothesis was that extracorporeal membrane oxygenation support would be associated with acquired antithrombin deficiency and related decreased heparin responsiveness.

Methods: Adults receiving venoarterial extracorporeal membrane oxygenation were prospectively included. All patients received continuous intravenous unfractionated heparin using a standardized protocol (target anti-Xa 0.3 to 0.5 IU/ml). For each patient, arterial blood was withdrawn into citrate-containing tubes at 11 time points (from hour 0 up to day 7). Anti-Xa (without dextran or antithrombin added) and antithrombin levels were measured. The primary outcome was the antithrombin plasma level. In the absence of consensus, antithrombin deficiency was defined as a time-weighted average of antithrombin less than or equal to 70%. Data regarding clinical management and heparin dosage were collected.

Results: Fifty patients, including 42% postcardiotomy, were included between April 2020 and May 2021, with a total of 447 samples. Median extracorporeal membrane oxygenation duration was 7 (interquartile range, 4 to 12) days. Median antithrombin level was 48% (37 to 60%) at baseline. Antithrombin levels significantly increased throughout the follow-up. Time-weighted average of antithrombin levels was 63% (57 to 73%) and was less than or equal to 70% in 32 (64%) of patients. Overall, 45 (90%) patients had at least one antithrombin value less than 70%, and 35 (70%) had at least one antithrombin value less than 50%. Antithrombin levels were not significantly associated with heparin responsiveness evaluated by anti-Xa assay or heparin dosage.

Conclusions: Venoarterial extracorporeal membrane oxygenation support was associated with a moderate acquired antithrombin deficiency, mainly during the first 72 h, that did not correlate with heparin responsiveness.

Editor’s perspective:

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静脉-动脉体外膜氧合过程中的抗凝血酶水平和肝素反应性:一项前瞻性单中心队列研究。
背景:在静脉-动脉体外膜氧合过程中为防止血栓栓塞事件而施用的非分数肝素,其抗血栓作用主要依赖于血浆抗凝血酶。体外膜氧合过程中肝素反应性降低似乎很常见,但其与获得性抗凝血酶缺乏症的关系却鲜为人知。我们的目的是描述体外膜氧合支持过程中血浆抗凝血酶水平的纵向变化,并评估抗凝血酶水平与肝素反应性之间的关联。我们假设体外膜氧合支持与获得性抗凝血酶缺乏和肝素反应性降低有关:我们对接受静脉-动脉体外膜氧合的成人进行了前瞻性研究。所有患者均采用标准化方案(目标抗 Xa 值为 0.3-0.5 IU.mL -1 )持续静脉注射非分数肝素。每位患者在 11 个时间点(从 H0 到第 7 天)抽取动脉血至含枸橼酸盐的试管中。测量抗 Xa(未添加右旋糖酐或抗凝血酶)和抗凝血酶水平。主要结果是抗凝血酶血浆水平。在缺乏共识的情况下,抗凝血酶缺乏的定义是抗凝血酶的时间加权平均值≤70%。收集了有关临床治疗和肝素用量的数据:2020 年 4 月至 2021 年 5 月期间,共纳入 50 名患者,其中 42% 为开胸手术后患者,共采集 447 份样本。体外膜氧合时间中位数为 7 天(四分位数间距为 4-12 天)。H0时抗凝血酶水平中位数为48(37-60)%。在整个随访过程中,抗凝血酶水平明显升高。抗凝血酶水平的时间加权平均值为 63(57-73)%,32(64%)名患者的抗凝血酶水平低于 70%。总体而言,45(90%)名患者至少有一次抗凝血酶值低于 70%,35(70%)低于 50%。抗凝血酶水平与抗 Xa 检测法评估的肝素反应性或肝素剂量无明显关联:结论:静脉-动脉体外膜氧合支持与中度获得性抗凝血酶缺乏有关,主要是在最初的 72 小时内,与肝素反应性无关。
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来源期刊
Anesthesiology
Anesthesiology 医学-麻醉学
CiteScore
10.40
自引率
5.70%
发文量
542
审稿时长
3-6 weeks
期刊介绍: With its establishment in 1940, Anesthesiology has emerged as a prominent leader in the field of anesthesiology, encompassing perioperative, critical care, and pain medicine. As the esteemed journal of the American Society of Anesthesiologists, Anesthesiology operates independently with full editorial freedom. Its distinguished Editorial Board, comprising renowned professionals from across the globe, drives the advancement of the specialty by presenting innovative research through immediate open access to select articles and granting free access to all published articles after a six-month period. Furthermore, Anesthesiology actively promotes groundbreaking studies through an influential press release program. The journal's unwavering commitment lies in the dissemination of exemplary work that enhances clinical practice and revolutionizes the practice of medicine within our discipline.
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