Page 42 - ANZCP Gazette MAY 2014

IMPROVING OUTCOMES FROM
ADULT VENOARTERIAL ECMO
A/Prof Graeme MacLaren National University Heart Centre, Singapore
Venoarterial ECMO is regarded as a standard of care in adult cardiogenic shock refractory to conventional therapy. However, at least 50% of patients treated with ECMO for this indication do not survive. A number of recent advances may change this.
The talk will focus on a number of key areas which may improve outcomes: patient selection, team training, medical management, anticipating complications, and bridging strategies.
RISK FACTORS FOR ANTICOAGULATION RELATED COMPLICATIONS ON PAEDIATRIC EXTRACORPOREAL LIFE SUPPORT:
A SINGLE INSTITUTION EXPERIENCE
Christian Stocker MD FCICM, Emma Haisz, Paul Holmes, Molly Olden, Sylvio Provenzano, Andreas Schibler Queensland Paediatric ECLS Service, Mater Children’s Hospital, Raymond Tce, South Brisbane Qld 4101, Australia
Background
ECLS providers have learnt to circulate, oxygenate, and ventilate blood outside the body, but its biological domestication remains a problem.
Objectives
To describe institutional rates of bleeding/clotting complications during paediatric Extracorporeal Life Support (ECLS), benchmark against international experience, and identify potential risk factors.
Methods
Case-control study from 2008 through 2012. Data on potential predictors within 6 hours prior to a complication event, and event times from initiation of ECLS were recorded. Matching in event time, virtual events were created from patients with complication-free runs. Potential risk factors were examined for any association with bleeding/clotting complications.
Findings
44 clotting events were observed in 17, 20 bleeding events in 14 runs. The Extracorporeal Life Support Organisation (ELSO) database reveals increasing bleeding/clotting complication rates. Our complication rate is declining, but runs and deaths with reported complications match ELSO’s. In ‘bleeders’, compared to controls, there were significantly more post-cardiac-surgical patients, longer activated partial thromboplastin times (aPTT), lower maximal amplitudes (heparinised thromboelastography, TEG), more fluid and blood products infused, higher flows and more frequent use of dialysis on pump. In ‘clotters’, the aPTTs and anti-FactorXa-activity were shorter/lower, more platelets and antifibrinolytics administered, ultrafiltrate volumes higher with dialysis also more frequently used.
Conclusion
Problems with anticoagulation and its complications on paediatric ECLS are global. In our institution, recommended ACT based anticoagulation management does not work, while aPTT, anti-FactorXa-activity, and selected TEG features may do. Care should be taken with administration of fluid and blood products, while ultradiafiltration makes anticoagulation harder to manage.
40 MAY 2014 | www.anzcp.org