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Hofmaenner, Daniel A.; Furfaro, David; Wild, Lennart C.; Wendel-Garcia, Pedro David; Baedorf Kassis, Elias; Pannu, Ameeka; Welte, Tobias; Erlebach, Rolf; Stahl, Klaus; Grandin, Edward Wilson; Putensen, Christian; Schuepbach, Reto A.; Shaefi, Shahzad; David, Sascha; Seeliger, Benjamin; Bode, Christian

Reduced anticoagulation strategy is associated with a lower incidence of intracerebral hemorrhage in COVID-19 patients on extracorporeal membrane oxygenation

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  • Media type: E-Article
  • Title: Reduced anticoagulation strategy is associated with a lower incidence of intracerebral hemorrhage in COVID-19 patients on extracorporeal membrane oxygenation
  • Contributor: Hofmaenner, Daniel A.; Furfaro, David; Wild, Lennart C.; Wendel-Garcia, Pedro David; Baedorf Kassis, Elias; Pannu, Ameeka; Welte, Tobias; Erlebach, Rolf; Stahl, Klaus; Grandin, Edward Wilson; Putensen, Christian; Schuepbach, Reto A.; Shaefi, Shahzad; David, Sascha; Seeliger, Benjamin; Bode, Christian
  • Published: Springer Science and Business Media LLC, 2023
  • Published in: Intensive Care Medicine Experimental, 11 (2023) 1
  • Language: English
  • DOI: 10.1186/s40635-023-00525-3
  • ISSN: 2197-425X
  • Origination:
  • Footnote:
  • 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.
  • Access State: Open Access