1.
Comparison of anticoagulation monitoring strategies for adults supported on extracorporeal membrane oxygenation: A systematic review
Sun J, Ma Y, Su W, Miao H, Guo Z, Chen Q, Zhang Y, Ma X, Chen S, Ding R
Heart & lung : the journal of critical care. 2023;61:72-83
Abstract
BACKGROUND Anticoagulation is critical in patients supported on extracorporeal membrane oxygenation (ECMO). The appropriate monitoring strategies for heparin remain unclear. OBJECTIVES This systematic review aimed to compare the accuracy and safety of various monitoring strategies for patients supported on ECMO. METHODS The PubMed and Web of Science databases were searched for articles in March 2023 without restrictions on publication date. Anticoagulation monitoring strategies for adults supported on ECMO were compared across all included studies. The incidence of bleeding, thrombosis, mortality, blood transfusion, correlation between tests and heparin dose, and the discordance between different tests were discussed in the included studies. The risk of bias was assessed using the Newcastle-Ottawa Scale and Cochrane Collaboration's tool. RESULTS Twenty-six studies, including a total of 1,684 patients, met the inclusion criteria. The monitoring of anticoagulation by activated partial thromboplastin time (aPTT) resulted in less blood product transfusion than that by activated clotting time (ACT). Moreover, the monitoring of anticoagulation by anti-factor Xa (Anti-Xa) resulted in a more stable anticoagulation than that by aPTT. Anti-Xa and aPTT correlated with heparin dose better than ACT, and the discordance between different monitoring tests was common. Finally, combined monitoring showed some advantages in reducing mortality and blood product transfusion. CONCLUSION Anti-Xa and aPTT are more suitable for anticoagulation monitoring for patients supported on ECMO than ACT. Thromboelastography and combination strategies are less applied. Most of the studies were retrospective, and their sample sizes were relatively small; thus, more appropriate monitoring strategies and higher quality research are needed.
2.
[Application of goal-oriented fluid replacement therapy in volume management of postpartum hemorrhage during cesarean section]
Yu Y, Zhang Y, Zhu X, Zhang C, Tong C, Zhao Y
Zhonghua wei zhong bing ji jiu yi xue. 2021;33(3):305-310
Abstract
OBJECTIVE To observe the effect of fluid therapy on volume and coagulation function in patients with severe postpartum hemorrhage during cesarean section of placenta accreta under the guidance of inferior vena cava diameter (IVCD) and inferior vena cava collapse index (IVC-CI). METHODS A prospective randomized controlled study was conducted in 60 pregnant women with severe postpartum hemorrhage (blood loss ≥ 1 000 mL) who were hospitalized for delivery or referred for delivery in the Peking University Third Hospital from December 2018 to July 2019. The patients were divided into routine fluid replacement group and goal-oriented fluid resuscitation group (goal-oriented fluid replacement therapy was given) according to the different ways of fluid replacement. The hemodynamics, blood gas analysis, coagulation function, total fluid replacement, urine volume, prognosis, intraoperative vasoactive drugs utilization rate and postoperative adverse events were recorded before skin incision, after the fetus delivered, postpartum hemorrhage and at the end of operation, and the differences of these indices between the two groups were compared. RESULTS (1) Hemodynamics: the heart rate (HR) of the two groups were reached the peak during postpartum hemorrhage, but there was no significant difference in HR at each time point between the two groups. The mean arterial pressure (MAP) was decreased at first and then increased in both groups, and reached the trough at postpartum hemorrhage, but the MAP in the goal-oriented fluid resuscitation group was significantly higher than that in the routine fluid replacement group [mmHg (1 mmHg = 0.133 kPa): 75.6±10.7 vs. 69.2±8.9, P < 0.05]. In the goal-oriented fluid resuscitation group, the central venous pressure (CVP) was increased slightly after the fetus delivered and then stabilized, while in the routine fluid replacement group, the CVP was increased at first and then decreased, and reached the peak in postpartum hemorrhage. During postpartum hemorrhage, CVP in the goal-oriented fluid resuscitation group was significantly lower than that in the routine fluid replacement group [cmH(2)O (1 cmH(2)O = 0.098 kPa): 9.5±3.9 vs. 11.4±3.4, P < 0.05]. (2) Arterial blood gas: partial pressure of oxygen (PaO(2)) and partial pressure of carbon dioxide (PaCO(2)) in arterial blood at the end of operation in both groups were higher than those in postpartum hemorrhage. There was no significant difference in PaO(2) at the end of operation between the goal-oriented fluid resuscitation group and routine fluid replacement group (mmHg: 189.3±100.5 vs. 240.2±126.3, P > 0.05). The PaCO(2) in the goal-oriented fluid resuscitation group was significantly lower than that in the routine fluid replacement group (mmHg: 34.6±4.6 vs. 36.8±4.1, P < 0.05). The lactic acid (Lac) at the end of operation of the goal-oriented fluid resuscitation group was significantly lower than that of the routine fluid replacement group (mmol/L: 2.2±0.6 vs. 2.6±1.1, P < 0.05). (3) Liquid intake and output volume: the total infusion volume, crystal fluid infusion volume and suspended red blood cell infusion volume in the goal-oriented fluid resuscitation group were significantly less than those in the routine fluid replacement group [total infusion volume (mL): 3 385.9±1 144.1 vs. 4 448.3±1 194.4, crystal infusion volume (mL): 2 635.6±789.7 vs. 3 160.0±860.3, suspended red blood cell input volume (mL): 695.6±366.2 vs. 911.1±284.7, all P < 0.05], and the utilization rate of vasoactive drugs in the goal-oriented fluid resuscitation group was decreased significantly during operation [13.3% (4/30) vs. 60.0% (18/30), P < 0.05]. The amount of bleeding in the goal-oriented fluid resuscitation group was also significantly less than that in the routine fluid replacement group (mL: 1 451.7±373.8 vs. 1 725.9±372.8, P < 0.05), but there was no significant difference in urine volume between the goal-oriented fluid resuscitation group and the routine fluid replacement group (mL: 369.0±262.7 vs. 485.0±286.8, P > 0.05). (4) Coagulation function: at the end of operation, the prothrombin time (PT) in the goal-oriented fluid resuscitation group was significantly shorter than that in the routine fluid replacement group (s: 10.9±0.6 vs. 11.2±0.6), and the fibrinogen (Fib) in the goal-oriented fluid resuscitation group was significantly higher than that in the routine fluid replacement group (g/L: 3.7±0.5 vs. 2.9±0.8), and the differences were statistically significant (both P < 0.05). (5) Prognostic index: compared with the routine fluid replacement group, the proportion of patients transferred to intensive care unit (ICU) at the end of operation in the goal-oriented fluid resuscitation group was significantly lower [16.7% (5/30) vs. 66.7% (20/30), P < 0.05], and ICU length-of-stay was significantly shorter [hours: 0 (0, 24) vs. 24 (0, 24), P < 0.05], but there was no significant difference in the incidence of disseminated intravascular coagulation (DIC), acute renal injury (AKI) or hysterectomy between the goal-oriented fluid resuscitation group and the routine fluid replacement group [the incidence of DIC: 0% (0/30) vs. 6.7% (2/30), the incidence of AKI: 0% (0/30) vs. 3.3% (1/30), the hysterectomy rate: 10.0% (3/30) vs. 26.7% (8/30), all P > 0.05]. CONCLUSIONS Fluid resuscitation guided by IVC-CI can effectively reduce the volume of blood and fluid transfusion and blood loss in patients with severe postpartum hemorrhage and improve their blood coagulation function.