Review of anticoagulation considerations in extracorporeal membrane oxygenation support.

Since its first success in 1975, extracorporeal membrane oxygenation (ECMO) has been used with increasing frequency for pulmonary and cardiopulmonary bypass. Use in adults has increased exponentially since the early 2000s, but despite thousands of international cannulations using both veno-arterial (VA) and veno-venous (VV) ECMO, there are still significant hemocompatibility-related adverse events. Current management of anticoagulation has been based on the Extracorporeal Life Support Organization guidance published in 2014 with recent updates published in 2022. Despite this guidance, there is still limited international consensus on how to manage anticoagulation in ECMO. For this review, we completed a comprehensive search of multiple electronic databases to identify studies pertaining to anticoagulation of adult patients on VV or VA-ECMO. The highest priority was given to sources that were prospective, randomized, controlled studies, but in the absence of such resources, observational studies, retrospective uncontrolled studies, and case series/reports were considered for inclusion. This document serves to provide a comprehensive review of the current understanding of management pertaining to anticoagulation relating to ECMO.

Incidence and outcomes of critical illness-related corticosteroid insufficiency in trauma patients.

The spectrum of critical illness-related corticosteroid insufficiency (CIRCI) in trauma is not fully defined. This study describes our trauma experience with hydrocortisone-treated patients experiencing CIRCI. We conducted a 5-year retrospective analysis from a Level II trauma center using biochemical and clinical criteria for adrenal insufficiency. Seventy patients met the inclusion criteria for CIRCI. There was a 34 per cent mortality rate despite therapy. Nonsurvivors were older with larger admission base deficits and experienced higher rates of sepsis, bacteremia, and pneumonia. Nonsurvivors had prolonged vent days (mean 53 ± 64 days) when compared with survivors (mean 30 ± 22 days; P = 0.029). Renal replacement therapy was a strong predictor of mortality. Spinal cord-injured patients had high Injury Severity Scores (mean 34 ± 18), elevated baseline cortisol levels (mean 56 ± 84 vs. 18 ± 14; P = 0.004), and required prolonged duration of steroid therapy (30 ± 52 vs. 15 ± 15 days; P = 0.080) when compared with the nonspinal cord-injured group. Our data suggest that CIRCI in trauma is associated with significant mortality and morbidity even when patients are treated appropriately.

Reliability and accuracy of practitioner-calculated Acute Physiology and Chronic Health Evaluation II scores for determining the appropriateness of drotrecogin alfa (activated).

PURPOSE: The reliability and accuracy of practitioner-calculated Acute Physiology and Chronic Health Evaluation (APACHE) II scores for determining the appropriateness of drotrecogin alfa (activated) in critically ill patients were evaluated. METHODS: Three adjudicated clinical cases of sepsis were developed using composites of real patient scenarios. The patients' APACHE II scores were independently assessed by randomly selected critical care practitioners (physicians and nonphysicians). Each case contained at least one reason to consider withholding drotrecogin alfa (activated), but none had a definitive contraindication to drotrecogin alfa (activated). Intraobserver and interobserver variabilities were assessed using kappa correlation. Accuracy was assessed by comparing median scores to the adjudicated scores and evaluating correctly classified APACHE II scores. RESULTS: A total of 21 (42%) physicians and 14 (56%) nonphysicians completed all assessments. Intraobserver and interobserver variabilities were 0.16 and 0.49 for the total APACHE II score, respectively. Median calculated APACHE II scores significantly differed for case 1 (p = 0.003) and case 3 (p < 0.0001). The percentage of error in calculating the total APACHE II score approached 85%. The main reasons for administering drotrecogin alfa (activated) were an APACHE II score of >or=25 and multiple organ failures. The main reason for therapy was a high bleeding risk or an APACHE II score of <25. CONCLUSION: Weak intraobserver agreement, modest interobserver reliability, a high error rate, and low accuracy limited the clinical application of the APACHE II score by untrained practitioners, indicating that the APACHE II score should not be the only determinant for the use of drotrecogin alfa (activated).

Formulary management of recombinant factor VIIa at an academic medical center.

BACKGROUND: Recombinant human coagulation factor VIIa (rVIIa) is a procoagulant indicated for treatment of bleeding in patients with hemophilia. A large proportion of rVIIa utilization is for off-label administration in nonhemophiliac patients with acute hemorrhage. Concerns of potentially inappropriate use, safety, and cost of rVIIa led to efforts to standardize use of this agent. OBJECTIVE: To comparatively describe the utilization of rVIIa upon implementation of an evidence-based guideline at a university hospital. METHODS: With advisory direction from a multidisciplinary task force, an evidence-based guideline for use of rVIIa was developed, approved, and fully implemented. Assessment of appropriateness of use and retrospective review were required for all cases. Effects of these actions were evaluated by auditing and comparing rVIIa use in patients treated in two 6-month observation periods before and after guideline implementation. Outcomes assessed were proportions of patients deemed appropriate to receive rVIIa, compliance with dosing recommendations, and acquisition costs. RESULTS: Twenty-two and 29 patients were treated in the periods before and after guideline implementation, respectively. Patient characteristics were similar, except more cardiothoracic surgeries were performed in patients treated before implementation of the guideline. Indications for rVIIa use were judged appropriate in 21 (95.5%) before-cases and in all (100%) after-cases. The dose was compliant in 1 (4.6%) before-case and 27 (93.1%) after-cases (p < 0.001). Mean dosages of rVIIa administered were 81.8 microg/kg and 45.3 microg/kg in before- and after-cases, respectively (p < 0.001). During the respective periods of observation, amounts of rVIIa purchased monthly averaged 42.6 mg and 21.8 mg, a 49% difference. Semiannual expenditures for rVIIa decreased approximately $110,000 following guideline implementation. Patient outcomes were similar. CONCLUSIONS: A guideline based on currently available evidence can serve to sustain the clinical appropriateness of rVIIa therapy and substantially decrease costs.