Scholarly article on topic 'Using anti-platelet therapy to prevent extracorporeal membrane oxygenator thrombosis without heparin resistance and with thrombocytopenia'

Using anti-platelet therapy to prevent extracorporeal membrane oxygenator thrombosis without heparin resistance and with thrombocytopenia Academic research paper on "Clinical medicine"

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Academic research paper on topic "Using anti-platelet therapy to prevent extracorporeal membrane oxygenator thrombosis without heparin resistance and with thrombocytopenia"

He et al. Critical Care 2014, 18:595 http://ccforum.com/content/18/5/595

CRITICAL CARE

LETTER

Using anti-platelet therapy to prevent extracorporeal membrane oxygenator thrombosis without heparin resistance and with thrombocytopenia

Huai-Wu He, Xiang Zhou, Yun Long, Xiao-ting Wang, Qing Zhang, Hua Zhao, Hong-min Zhang, Wen-zhao Chai and Da-Wei Liu*

Anticoagulation is widely used for preventing membrane oxygenator thrombosis during extracorporeal membrane oxygenation (ECMO) therapy while anti-platelets are rarely used, especially in patients with thrombocytopenia [1]. Here we report a case of successfully using anti-platelet treatment to prevent recurrent extracorporeal membrane oxygenator thrombosis in a fulminant myocarditis (FM) patient.

A 32-year-old man was admitted to our hospital with FM, with 10% left ventricular ejection fraction. After his arrival, he had a sudden onset of ventricular fibrillation and developed cardiac arrest, so cardiopulmonary resuscitation was performed. With high doses of vasoactive medications, he was transferred to the ICU, where venoarterial ECMO was initiated. Continuous infusion of heparin was used for anticoagulation, and activated partial thromboplastin time (aPTT) was titrated up to about 70 seconds. The rotational speed of the pump was about 4,500 rpm, and the blood flow of the pump was 3.9 L/minute. On the second day of ECMO therapy, the membrane oxygenator developed thrombosis, so we replaced it with a new one. Furthermore, we intensified the systemic anticoagulation with a higher aPTT target, about 70 to 90 seconds. However, the membrane oxygenator still developed thrombosis on the fourth day of ECMO initiation, and the oxygenator was replaced again. In addition, there was no clinical evidence of hemolysis or thrombosis at other body sites, and the platelet count decreased to 31,000/mm3. Thus, we inferred that the membrane oxygenator may have abnormally activated the platelets, resulting in thrombotic clot formation. As a result we combined the anti-platelet

* Correspondence: tjmuhhw@163.com

Department of CriticalCare Medicine, Peking Union MedicalCollege Hospital, Chinese Academy of MedicalSciences, 1 shuaifuyuan, Dongcheng District, 100730 Beijing, China

Bio Med Central

treatment (aspirin administered with a first dose of 300 mg and then 100 mg per day) with heparin therapy. After that, oxygenator thrombosis did not occur again, and the platelet count gradually increased to 123,000/mm3 without bleeding complications. The patient was weaned from ECMO 15 days after his admission. The related data for coagulation and anti-platelet treatment are summarized in Table 1.

Ranucci and colleagues [2] reported that inadequate thrombin suppression by heparin may induce intravascular and extravascular thrombosis, which would result in coagulation factors and platelet consumption, and cause more bleeding and require larger transfusions. However, there was no evidence of insufficient anticoagulation and heparin resistance in our case presented here. Moreover, a higher target of anticoagulation was not effective for preventing oxygenator thrombosis, and the recurrent thrombosis happened only in the oxygenator but not at other sites of the body. Therefore, it seemed that the combination of anti-platelet treatment would be appropriate. However, thrombopenia is another dilemma. In our opinion, the primary cause of oxygenator thrombosis and thrombopenia was abnormal activation of the platelets in the membrane oxygenator, which deserved medical intervention. Lehot and colleagues [3] recently showed that oxygenator thrombosis occurred without heparin resistance in coronary artery bypass graft surgery with normothermic extracorporeal circulation in polycytemia vera. To the best of our knowledge, this is the first case report of the use of anti-platelet therapy to prevent oxygenator thrombosis without heparin resistance and with thrombopenia in FM.

© 2014 He et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

He et al. Critical Care 2014, 18:595 http://ccforum.eom/content/18/5/595

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Table 1 Related data for anticoagulation and anti-platelet therapy during extracorporeal membrane oxygenation

D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13

Plt 202 113 63 36 31 37 39 40 54 66 73 92 123

aPTT 77 68 91 97 65 58 56 61 60 79 77 74 64

Aspirin - - - 300 100 100 100 100 100 100 100 100 100

Event Ex-* Ex-*

D1 is the first day of extracorporeal membrane oxygenation initiation. Plt, platelet count (x103/ml3); Aspirin, aspirin dose (mg); aPTT, activated partial thromboplastin time (seconds); Ex-*, oxygenator exchanged.

Abbreviations

aPTT: activated partial thromboplastin time; ECMO: extracorporeal membrane oxygenation; FM: fulminant myocarditis.

Competing interests

The authors declare that they have no competing interests. Acknowledgments

Written informed consent was obtained from the patient for publication of his individual details in this manuscript. The consent form is held in the patients' clinical notes and is available for review by the Editor-in-Chief. The authors thank Jing Zhang for her contribution in reviewing the manuscript for spelling and grammar.

Published online: 30 October 2014

References

1. Gorlinger K, Bergmann L, Dirkmann D: Coagulation management in patients undergoing mechanical circulatory support. Best Pract Res Clin Anaesthesiol 2012, 26:179-198.

2. Ranucci M, Ballotta A, Kandil H, Isgro G, Carlucci C, Baryshnikova E, Pistuddi V, Surgical and Clinical Outcome Research Group: Bivalirudin-based versus conventional heparin anticoagulation for postcardiotomy extracorporeal membrane oxygenation. Crit Care 2011,15:R275.

3. Lehot JJ, Was B, Dendeleu L, Jegaden O: Oxygenator thrombosis without heparin resistance in polycythemia vera. Ann FrAnesth Reanim 2012, 31:S14-S17.

doi:10.1186/s13054-014-0595-9

Cite this article as: He et al.: Using anti-platelet therapy to prevent extracorporeal membrane oxygenator thrombosis without heparin resistance and with thrombocytopenia. Critical Care 2014 18:595.