Performance Assessment of a Multifaceted Unfractionated Heparin Dosing Protocol in Adult Patients on Extracorporeal Membrane Oxygenator.

BACKGROUND: The use of extracorporeal membrane oxygenator (ECMO) support devices are associated with complications, including bleeding and thrombosis. Unfractionated heparin (UFH) is the gold standard anticoagulant in ECMO patients. Clinically, UFH is monitored through activated clotting time (ACT), activated partial thromboplastin time (aPTT), and anti-factor Xa assay. It is unknown which assay best predicts anticoagulation effects in adults. OBJECTIVE: To assess the correlation of UFH dosing and monitoring using an established protocol. METHODS: A pilot, prospective cohort, historically controlled study was conducted at a tertiary care hospital. Patients ≥18 years-old who received ECMO on the multifaceted anticoagulation protocol were included and compared with those on the conventional method of anticoagulation. The primary end point was to assess the correlation between UFH dose and different monitoring methods throughout 72 hours using the new protocol guided by ACT and anti-factor Xa assay. RESULTS: In each arm, 20 patients were enrolled. The study revealed that anti-factor Xa assay had the largest number of "strong" correlations 11/20 (55%), followed by both aPTT and aPTT ratio 10/20 (50%), and, finally, ACT 2/20 (10%). Concordance between anti-factor Xa assay and the other monitoring parameters in the prospective arm was generally low: 31% with aPTT ratio, 26% with ACT, and 23% with aPTT. CONCLUSION AND RELEVANCE: The adaption of a multifaceted anticoagulation protocol using anti-factor Xa assay may provide a better prediction of heparin dosing in adults ECMO patients compared with the conventional ACT-based protocol. Further studies are needed to assess the safety and different monitoring modalities.

Impact of a medication reconciliation program on cardiac surgery patients.

Background Cardiac surgery patients are at high risk of medication errors. Resumption of home medications reduces the significance and number of medication errors. This could be achieved by implementing a medication reconciliation program. Patients and Methods Patients were eligible for inclusion in this prospective study if they were admitted, transferred, and/or discharged under cardiac surgery team care from September 2015 to March 2016. The primary outcome was the number and proportion of unintentional medication discrepancies. Secondary outcomes included the number of interventions to resolve discrepancies and their clinical significance, and the medication regimen complexity index and its correlation with discrepancies. Results There were 374 patients included and 1000 encounters tracked. Four-hundred and seventy (47%) of the included encounters were for adult patients. Of the 260 medication discrepancies detected, 181 (69.61%) were detected during admission. Discrepancies among adults were 0.913, 0.307, and 0.176 on admission, transfer, and discharge, respectively. Two-hundred (76.92%) of the interventions recommended by the pharmacy residents were accepted by the medical team, and the remaining were accepted with modifications, with no rejections. One-hundred and sixty-six (83%) of the accepted interventions were of high clinical significance. There was a significant correlation between the number of medication discrepancies and medication regimen complexity index on admission ( p < 0.0001, r = 0.34), transfer, and discharge. Conclusion Implementation of a medication reconciliation program in cardiac surgery units and its step-down units can be a powerful mean of identifying medication errors in post-cardiac surgery patients at admission and throughout the transition of care.