PMID- 21057061 OWN - NLM STAT- MEDLINE DCOM- 20110414 LR - 20101223 IS - 1477-111X (Electronic) IS - 0267-6591 (Linking) VI - 26 IP - 1 DP - 2011 Jan TI - Improvement in long-term ECMO by detailed monitoring of anticoagulation: a case report. PG - 59-64 LID - 10.1177/0267659110385513 [doi] AB - INTRODUCTION: The use of unfractionated heparin (UFH) as an anticoagulant during long-term extracorporeal support presents a unique challenge for the clinician in balancing the amount of anticoagulant to maintain adequate anticoagulation without causing excessive bleeding. Activated clotting times (ACT) and activated partial thromboplastin times (aPTT) are the most common modality to monitor UFH on extracorporeal membrane oxygenation (ECMO). Limitations to these tests include consumptive coagulopathies, clotting factor deficiencies, platelet dysfunction, and fibrinolysis. The following case report describes the use of alternative monitoring strategies to assess more accurately anticoagulation during ECMO. CASE REPORT: A 20-month-old female presented to the emergency department with a 5-6 day history of cough, fever, tachypnea, and respiratory distress. She was diagnosed with influenza A and B with pneumonia. The patient was placed on veno-venous ECMO (V-V ECMO) after mechanical ventilation failed. On ECMO day eight, the patient developed a thrombus in her inferior vena cava and pleural effusions, obstructing cannula flow. Laboratory tests revealed the ACT was within range, yet the aPTT was dropping, despite increased heparin. Heparin levels were low and antithrombin-III (AT) concentrations were 40%. Recombinant AT was given and subsequent aPTTs were within the therapeutic range. Later, the aPTT decreased to <50 sec, heparin levels were within the therapeutic range, while fibrinogen was >475 mg/ dL, and Factor VIII >150 IU/dL, suggesting an acute phase reaction or ongoing systemic inflammation, increasing the risk for thrombosis. We maintained heparin assays between 0.5-0.7 IU/mL and AT >60% to assure heparin's effect. The patient showed no signs of excess bleeding, blood product administration, or clots in the circuit, suggesting proper anticoagulation. The patient was successfully weaned on day 33 and is currently alive and at home. CONCLUSION: Monitoring of anti-Xa UFH and AT proved effective for measuring anticoagulation and detecting inconsistencies in other anticoagulation parameters, leading to steady levels of heparin without further complications. FAU - Sievert, Alicia AU - Sievert A AD - Medical University of South Carolina, Charleston, SC, USA. sievera@musc.edu FAU - Uber, Walter AU - Uber W FAU - Laws, Stacey AU - Laws S FAU - Cochran, Joel AU - Cochran J LA - eng PT - Case Reports PT - Journal Article DEP - 20101105 PL - England TA - Perfusion JT - Perfusion JID - 8700166 RN - 0 (Anticoagulants) RN - 0 (Heparin, Low-Molecular-Weight) SB - IM MH - Anticoagulants/*therapeutic use MH - Blood Coagulation Tests MH - *Drug Monitoring MH - *Extracorporeal Membrane Oxygenation MH - Female MH - Heparin, Low-Molecular-Weight/*therapeutic use MH - Humans MH - Infant MH - Partial Thromboplastin Time EDAT- 2010/11/09 06:00 MHDA- 2011/04/16 06:00 CRDT- 2010/11/09 06:00 PHST- 2010/11/09 06:00 [entrez] PHST- 2010/11/09 06:00 [pubmed] PHST- 2011/04/16 06:00 [medline] AID - 0267659110385513 [pii] AID - 10.1177/0267659110385513 [doi] PST - ppublish SO - Perfusion. 2011 Jan;26(1):59-64. doi: 10.1177/0267659110385513. Epub 2010 Nov 5.