1. ELSO-EURO Rome June Oral abstract presentation ECMO Circuit Efficacy and Complications in patients on ECMO Without systemic Anticoagulation : a Case series in Asian population
Department of Intensive Care Unit
Queen Mary Hospital
The University of Hong Kong
Sin WC , Ngai CW , Chan WM

2. Background (1)
The ELSO guideline suggested continuous infusion of heparin during ECLS despite the surface of some extracorporeal circuit and devices are heparin coated
However, bleeding in ECLS resulted in significant morbidity and mortality

3. Background (2) Asian tends to bleed and Caucasian tends to clot
Lower incidence of deep vein thrombosis in Chinese
Absence of factor V gene mutation and prothrombin gene mutation in Chinese 1
Higher incidence of intracranial bleeding after warfarinzation for atrial fibrillation in Asian
Differences in gene encoding vitamin K epoxide reductase complex
haplotypes predictive of low maintenance dose of warfarin in 89% of Asian but 35% in Caucasian 2
Bleeding risk further increase in patients with underlying/ ongoing coagulopathy and platelet dysfunction
Hong Kong Med Journal 2002
JACC 2007

4. Objectives
to review circuit efficacy, safety and patient outcomes in ECLS without systemic anticoagulation in Asian population

5. ECLS for cardiopulmonary support since Nov 2010 14 cases recruited
6 without systemic anticoagulation
heparin coated circuit and membrane oxygenation (Cardiohelp HLS set advanced 7.0 Bioline coating oxygenator; MAQUET, Germany)
Percutaneous peripheral cannulation with seldinger technique

6. Protocol MAP 65-95 mmHg Conventional heparin for anticoagulation
Blood flow 50-80ml/kg/min
Gas flow 1:1 to blood flow
SpO2 95% (VA) , 85-92% (VV)
PaCO mmHg
Pre-oxygenator oxygenation> 65%
Routine reperfusion catheter in superficial femoral artery
Lung rest ventilator strategy
MAP mmHg
Conventional heparin for anticoagulation
ACT sec
APTT times of normal
Platelet > 100,000/mm3
Hb~10 g/dl pH

7. Six patients were considered to be at high risk of bleeding and systemic anticoagulation was not given
They included
2 patients with ongoing bleeding
Haemorrhagic gastritis
Haemorrhagic cystitis
4 patients with underlying severe thrombocytopenia ± coagulopathy

8. Demographics Disease With anticoagulation Without anticoagulation
VV ECMO
Human swine flu x3
Viral pneumonitis
Pneumocystis infection
VA ECMO
Viral myocarditis x2
Chemo- cardiomyopathy
1) Post BMT BOOP
2)Lymphoma CMV pneumonitis
3)Post BMT respiratory failure of unknown cause
4)Pneumonia, post renal transplant
1)VT storm
2) Decompensated DCMP

9. Demographics With anticoagulation (n=8) , IQR Without anticoagulation
P value
Age (year)
48(36-54)
54 (46-59)
0.21
Gender (M)
4 (50%)
3 (50%)
0.69
Weight (kg)
70.0 ( )
58.5 ( )
0.19
APACHE II
18 (16-27)
23 (19-28)
0.46
Mode of ECMO
(VA/VV)
3/5
2/4
0.54

10. Clinical parameters during ECMO
With anticoagulation
Without anticoagulation
p valve
At presentation
Hb (g/dL)
Hct
Platelet count (109/L)
APTT (sec)
PT (sec)
INR (sec)
12 ( )
0.35 ( )
231( )
27.7 ( )
12.6( )
1.1 ( )
8.9 ( )
0.26 ( )
66 (16-138)
31(25-37)
20 (12-36)
1.4 ( )
0.02
0.34
0.18
0.08
Average during ECMO
9.5 ( )
0.26 ( )
180 (76-246)
49( 45-54)
13(12-14)
1.2 ( )
9.9 ( )
0.28 ( )
51 (32-54)
38 (31-42)
15 (12-45)
1.4 ( )
0.86
0.87
0.003
0.002
0.36
0.26

11. Transfusion requirement and complications
With anticoagulation
(n=8)
Without anticoagulation
(n=6)
P value
Transfusion
Packed cell (units)
Platelet (units)
FFP (units)
3 (2-4.7)
1( 0-7)
0 (0-3)
4(0.75—6.5)
32 (8-45)
4(0-13.5)
0.68
0.008
0.351
CNS
Ischaemia
Bleeding
0 (0%)
1 (12.5%)
1 (16%) minor stroke
1.0
GI bleeding
wound bleeding
4 (66%) without surgical intervention
0.55
Limb complications
DVT
0(0%)
1(12.5%)
1(16%) mechanical complication
RRT
2 (25%)
4 (66%)
0.30
Intracardiac clot
Hemolysis

12. Circuit efficacy With anticoagulation (n=8) Without anticoagulation
Circuit function
With anticoagulation
(n=8)
Without anticoagulation
(n=6)
P valve
Duration of ECMO support (hr)
155 (34-239)
184 (61-418)
0.63
ECMO flow (L/min)
3.07 ( )
3.08 ( )
TMP (mmHg)
24hr
48hr
72 hr
144hr (6 days)
212hr (9 days)
288 hr (12 days)
360 hr (15 days)
12 (6-20)
13 (10-19)
14.5 ( )
12 ( )
12 (4.5-12)
No data
13 (9-16)
16 ( )
16 ( )
13.5 ( ) 11 13 15
0.49
0.95
0.87
0.79
0.31
Thrombus in circuit (n%)
0 (0%)
1 (16%)
0.43
Plasma leakage (n%)
Change of oxygenator (n%)
1(16%)

13. Empirical change of oxygenator
No abnormality in TMPD and oxygenation function

14. Outcomes With anticoagulation (n=8) Without anticoagulation (n=6)
P value
Survival
Overall
VA ECMO
VV ECMO
7(88%)
4(50%)
3(37.5%)
2(33%)
1(16%)
0.09
ICU LOS (days)
13 (8-20)
20 (12-24)
0.49
Hospital LOS (days)
33 (17-58)
50 (21-85)
0.41

15. Conclusion  Discussion
Early experience
Similar circuit efficacy
No excessive clinical complications
Trend toward higher mortality may be due to higher proportion of immunosuppressed patients
Platelet transfusion
Intrinsic defect in patients with hematological disease
Excessive platelet transfusion cause oxygenator failure
Packed cell transfusion
Similar vs. anticoagulation free group
Much lower vs. international reported data
? Peripheral , seldinger cannulation

16. Advance in technology
PVC uncoated
Bioline coating

17. Multifactorial Clot Red blood cell (Anaemia) Clotting factors Platelet
(Ethnic difference)
Coagulopathy
Anti-thrombotic agent
Platelet
(Thrombocytopenia)
Quantity and function
Antiplatelet agent

18. Reasonable to lower the target of anticoagulation in patients with high bleeding risk

19. Thank You

20. Thromboelastogram

21. Comparison Kanji 2010 (peripheral VA ECMO with heparin) Lamarche 2010
(Central and peripheral VA ECMO – heparin free)
Present cohort
(VA + VV ECMO- heparin free)
RC transfusion
7.9
18 unit
4(0.75—6.5)
FFP
1.2
14±20
4(0-13.5)
Platelet
4.4
5±9
32 (8-45)
Limb ischaemia
18%
16%
CVA
14%
N/A
Oxygenator change 9%
Intra-cardiac clot 6% 0%
survival
52%
44%
33%

22. Transfusion requirement

23. Ethnic difference DVT post op in HK , Taiwan and Singapore

24. Causade score anticoaguation 27 (20-47) No anticoagulation 60 (56-72)
p value
0.028
ESC guideline 2011

25. ESC guideline 2011