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A Journal on Anesthesiology, Resuscitation, Analgesia and Intensive Care
Minerva Anestesiologica 2016 August;82(8):858-66
Coagulation monitoring in postcardiotomy ECMO: conventional tests, point-of-care, or both?
Marco RANUCCI, Ekaterina BARYSHNIKOVA, Mauro COTZA, Giovanni CARBONI, Giuseppe ISGRÒ, Concetta CARLUCCI, Andrea BALLOTTA, for the Surgical and Clinical Outcome Research (SCORE) Group
Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
BACKGROUND: The aim of this study was to assess the association of the coagulation point-of-care (POC) tests activated clotting time (ACT) and thromboelastography-derived parameters reaction time (R-time) and maximum amplitude (MA) with the standard coagulation tests during postcardiotomy extracorporeal membrane oxygenation (ECMO), finding adequate values predictive for the target range of the standard coagulation tests.
METHODS: Thirty-one patients undergoing postcardiotomy ECMO with heparin anticoagulation were analyzed. Paired data of the POC tests and standard coagulation tests were analyzed for association and positive predictive value (PPV).
RESULTS: The following target range values for standard coagulation test were settled: activated partial thromboplastin time (aPTT) 50-70 seconds; international normalized ratio (INR) 1.5-2.5; platelet count >50,000 cells/µL; fibrinogen >150 mg/dL. The best predictor for the desired aPTT range was an ACT of 162-185 seconds. A combination of an ACT<162 seconds with an R-time <10 minutes had an 83% PPV for a short aPTT. A combination of an ACT>185 seconds with an R-time >27 minutes had a 71% PPV for a long aPTT. No predictive ability of the POC tests was found in terms of the optimal INR range. An MA value <41 mm had a 75% PPV for a low platelet count or fibrinogen level.
CONCLUSIONS: Diagnostic-therapeutic algorithms based on coagulation POC-tests may be useful to manage anticoagulation during postcardiotomy ECMO. The best PPV for prompting therapeutic decision is provided by a combination of ACT and visco-elastic tests.