在使用体外膜氧合(ECMO)的支持下,患者会发生凝血病,尽管使用了全身性抗凝治疗,但仍可能是出血性和/或血栓形成。本研究的目的是检查肝素和直接凝血酶抑制剂(DTI)在COVID-19急性呼吸窘迫综合征(ARDS)患者中的应用。根据疾病状态进行子集分析。IRB批准后,在2020年5月至2021年12月期间,对静脉静脉ECMO成年患者的570条连续记录进行了审查。患者按抗凝剂的使用进行分组:仅肝素(n=373),仅限DTI(bivalirudin或argatroban,n=90),或肝素后的DTI(n=107)。使用贝叶斯混合效应逻辑回归对年龄进行调整,评估抗凝分组的效果。体重指数(BMI),性别,在ECMO之前进行机械通气的天数,指示ECMO支持,肝肾衰竭,ECMO上的几个小时,停药数小时,凝血监测目标,和医院。主要终点是需要改变的回路衰竭,次要终点是器官衰竭和死亡率。经回归调整的回路改变概率如下:肝素患者后的DTI-32.7%,95%可信区间[16.1-51.9%];仅DTI患者-23.3%[7.5-40.8%];仅肝素患者-19.8%[8.1-31.3%]。肝素与肝素后DTI组间差异的后验概率最强仅肝素(97.0%),肝素后DTI的中度与仅限DTI(88.2%),和弱的DTI与仅肝素(66.6%)。仅DTI和肝素后DTI患者肝肾功能衰竭的发生率高于仅肝素患者。肝素后DTI的未调整死亡率最高(64.5%),其次是仅DTI(56.7%),和仅肝素(50.1%,p=0.027)。肝素后的DTI与电路改变的可能性增加相关。未调整的肝功能衰竭,肾功能衰竭,DTI患者的死亡率高于仅肝素患者。
Coagulopathies develop in patients supported with the use of extracorporeal membrane oxygenation (ECMO) and can be hemorrhagic and/or thrombophilic in spite of the use of systemic anticoagulation. The purpose this study was to examine the use of heparin and direct thrombin inhibitors (DTI) in COVID-19 patients with acute respiratory distress syndrome (ARDS) on ECMO, with a subset analysis by disease state. Following IRB approval, 570 consecutive records were reviewed of adult patients on venovenous ECMO between May 2020 and December 2021. Patients were grouped by anticoagulant use: Heparin Only (n = 373), DTI Only (bivalirudin or argatroban, n = 90), or DTI after Heparin (n = 107). The effect of anticoagulant grouping was assessed using Bayesian mixed-effects logistic regression adjusting for age, body mass index (BMI), gender, days of mechanical ventilation prior to ECMO, indication for ECMO support, hepatic and renal failure, hours on ECMO, hours off anticoagulation, coagulation monitoring target, and hospital. The primary endpoint was circuit failure requiring change-out with secondary endpoints of organ failure and mortality. Regression-adjusted probability of circuit change-outs were as follows: DTI after Heparin patients-32.7%, 95% Credible Interval [16.1-51.9%]; DTI Only patients-23.3% [7.5-40.8%]; and Heparin Only patients-19.8% [8.1-31.3%]. The posterior probability of difference between groups was strongest for DTI after Heparin vs. Heparin Only (97.0%), moderate for DTI after Heparin vs. DTI Only (88.2%), and weak for DTI Only vs. Heparin only (66.6%). The occurrence of both hepatic and renal failure for DTI Only and DTI after Heparin patients was higher than that of Heparin Only patients. Unadjusted mortality was highest for DTI after Heparin (64.5%) followed by DTI Only (56.7%), and Heparin Only (50.1%, p = 0.027). DTI after Heparin was associated with an increased likelihood of circuit change-out. Unadjusted hepatic failure, renal failure, and mortality were more frequent among DTI patients than Heparin Only patients.