PMID- 37302996 OWN - NLM STAT- PubMed-not-MEDLINE LR - 20230614 IS - 2197-425X (Print) IS - 2197-425X (Electronic) IS - 2197-425X (Linking) VI - 11 IP - 1 DP - 2023 Jun 12 TI - Reduced anticoagulation strategy is associated with a lower incidence of intracerebral hemorrhage in COVID-19 patients on extracorporeal membrane oxygenation. PG - 38 LID - 10.1186/s40635-023-00525-3 [doi] LID - 38 AB - BACKGROUND: Optimal anticoagulation strategies for COVID-19 patients with the acute respiratory distress syndrome (ARDS) on venovenous extracorporeal membrane oxygenation (VV ECMO) remain uncertain. A higher incidence of intracerebral hemorrhage (ICH) during VV ECMO support compared to non-COVID-19 viral ARDS patients has been reported, with increased bleeding rates in COVID-19 attributed to both intensified anticoagulation and a disease-specific endotheliopathy. We hypothesized that lower intensity of anticoagulation during VV ECMO would be associated with a lower risk of ICH. In a retrospective, multicenter study from three academic tertiary intensive care units, we included patients with confirmed COVID-19 ARDS requiring VV ECMO support from March 2020 to January 2022. Patients were grouped by anticoagulation exposure into higher intensity, targeting anti-factor Xa activity (anti-Xa) of 0.3-0.4 U/mL, versus lower intensity, targeting anti-Xa 0.15-0.3 U/mL, cohorts. Mean daily doses of unfractionated heparin (UFH) per kg bodyweight and effectively measured daily anti-factor Xa activities were compared between the groups over the first 7 days on ECMO support. The primary outcome was the rate of ICH during VV ECMO support. RESULTS: 141 critically ill COVID-19 patients were included in the study. Patients with lower anticoagulation targets had consistently lower anti-Xa activity values over the first 7 ECMO days (p < 0.001). ICH incidence was lower in patients in the lower anti-Xa group: 4 (8%) vs 32 (34%) events. Accounting for death as a competing event, the adjusted subhazard ratio for the occurrence of ICH was 0.295 (97.5% CI 0.1-0.9, p = 0.044) for the lower anti-Xa compared to the higher anti-Xa group. 90-day ICU survival was higher in patients in the lower anti-Xa group, and ICH was the strongest risk factor associated with mortality (odds ratio [OR] 6.8 [CI 2.1-22.1], p = 0.001). CONCLUSIONS: For COVID-19 patients on VV ECMO support anticoagulated with heparin, a lower anticoagulation target was associated with a significant reduction in ICH incidence and increased survival. CI - (c) 2023. The Author(s). FAU - Hofmaenner, Daniel A AU - Hofmaenner DA AD - Institute of Intensive Care Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland. FAU - Furfaro, David AU - Furfaro D AD - Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA. FAU - Wild, Lennart C AU - Wild LC AD - Department of Anesthesia and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany. FAU - Wendel-Garcia, Pedro David AU - Wendel-Garcia PD AD - Institute of Intensive Care Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland. FAU - Baedorf Kassis, Elias AU - Baedorf Kassis E AD - Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA. FAU - Pannu, Ameeka AU - Pannu A AD - Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA. FAU - Welte, Tobias AU - Welte T AD - Department of Respiratory Medicine, Hannover Medical School and Member of the German Centre for Lung Research, Biomedical Research in End-Stage and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany. FAU - Erlebach, Rolf AU - Erlebach R AD - Institute of Intensive Care Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland. FAU - Stahl, Klaus AU - Stahl K AD - Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany. FAU - Grandin, Edward Wilson AU - Grandin EW AD - Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA. FAU - Putensen, Christian AU - Putensen C AD - Department of Anesthesia and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany. FAU - Schuepbach, Reto A AU - Schuepbach RA AD - Institute of Intensive Care Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland. FAU - Shaefi, Shahzad AU - Shaefi S AD - Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA. FAU - David, Sascha AU - David S AUID- ORCID: 0000-0002-8231-0461 AD - Institute of Intensive Care Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland. sascha.david@usz.ch. FAU - Seeliger, Benjamin AU - Seeliger B AD - Department of Respiratory Medicine, Hannover Medical School and Member of the German Centre for Lung Research, Biomedical Research in End-Stage and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany. FAU - Bode, Christian AU - Bode C AD - Department of Anesthesia and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany. CN - BonHanZA study group LA - eng PT - Journal Article DEP - 20230612 PL - Germany TA - Intensive Care Med Exp JT - Intensive care medicine experimental JID - 101645149 PMC - PMC10257972 OTO - NOTNLM OT - Acute respiratory distress syndrome OT - Anticoagulants OT - Bleeding OT - COVID-19 OT - Endothelium OT - Extracorporeal membrane oxygenation OT - Hemorrhage OT - Vascular COIS- The authors declare that they have no competing interests. EDAT- 2023/06/12 00:42 MHDA- 2023/06/12 00:43 PMCR- 2023/06/12 CRDT- 2023/06/11 23:04 PHST- 2023/03/03 00:00 [received] PHST- 2023/05/18 00:00 [accepted] PHST- 2023/06/12 00:43 [medline] PHST- 2023/06/12 00:42 [pubmed] PHST- 2023/06/11 23:04 [entrez] PHST- 2023/06/12 00:00 [pmc-release] AID - 10.1186/s40635-023-00525-3 [pii] AID - 525 [pii] AID - 10.1186/s40635-023-00525-3 [doi] PST - epublish SO - Intensive Care Med Exp. 2023 Jun 12;11(1):38. doi: 10.1186/s40635-023-00525-3.