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Rivista di Anestesia, Rianimazione, Terapia Antalgica e Terapia Intensiva
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.