We read with interest the paper published by Repressé and colleagues [1]. Coagulation management is a challenge during extracorporeal membrane oxygenation (ECMO) due to complex hemostatic and inflammatory responses associated with the underlying conditions that include infection, sepsis, surgery, and/or traumatic injury [2]. Repressé and colleagues present the first algorithm-based approach to bleeding in ECMO patients. However, additional perspectives are important to consider.
First, activated partial thromboplastin time or antiactivated factor × monitoring are routinely used to monitor heparin therapy in ECMO patients, despite intraindividual and inter-individual variability [3]. Rotational thromboelastometry (ROTEM®; TEM® International GmbH, Munich, Germany) is also increasingly used in the ICU to rapidly assess the coagulation status, including clotting factors, fibrinogen levels, and whole blood clotting [4]. Moreover, this test also facilitates fibrinolytic pathway evaluation, which cannot be easily explored by routine laboratory tests. We believe ROTEM® could be used to design an algorithm-based approach to bleeding in ECMO patients and follow fibrinogen consumption associated with hyperfibrinolysis, an important cause of bleeding. For this reason, anti-fibrinolytic agents should be considered in the multimodal approach (Figure 1), an important point the authors omitted in their algorithm.
Figure 1.
Hyperfibrinolysis diagnosed in a bleeding extracorporeal membrane oxygenation patient. (a) Baseline EXTEM, (b) baseline FIBTEM, (c) EXTEM and (d) FIBTEM thromboelastometry tests after the administration of tranexamic acid (TXA; 10 mg/kg) and fibrinogen concentrates (2 g).
Second, adverse events including 32% venous thrombosis and a 2.5% incidence of fatal pulmonary embolism have already been reported in ECMO patients [5]. In another series, Combes and colleagues reported a 10% incidence of femoral vein and 7% incidence vena cava thrombosis [6]. Recombinant activated factor VII is associated with thromboembolic events [7] and should be used with caution until additional data help us evaluate the benefit-to-risk administration in bleeding ECMO patients.
Abbreviations
ECMO: extracorporeal membrane oxygenation; ROTEM: rotational thromboelastometry.
Competing interests
The authors declare that they have no competing interests.
See related research by Repressé et al., http://ccforum.com/content/17/2/R55
Contributor Information
David Faraoni, Email: davidfaraoni@me.com.
Jerrold H Levy, Email: lerrold.levy@duke.edu.
References
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