J Extra Corpor Technol 2024 , 56 , 108 – 113 Ó The Author ( s ), published by EDP Sciences , 2024 https :// doi . org / 10.1051 / ject / 2024022
Available online at : ject . edpsciences . org
ORIGINAL ARTICLE
Increased white blood cell count is associated with an increased demand for unfractionated heparin during veno-arterial extracorporeal oxygenation in lung transplantation
Koichi Kashiwa ( CCP , Ph . D ) 1 ,* , Hideo Kurosawa ( CCP ) 1 , Kazuki Fujishiro ( CCP , BS ) 1 , Hitoshi Kubo ( CCP ) 1 , Ryota Inokuchi ( MD , Ph . D ) 1 , Masahiko Bougaki ( MD , Ph . D ) 2 , Gaku Kawamura ( MD , Ph . D ) 2 , Masaaki Sato ( MD , Ph . D ) 3 , Chihiro Konoeda ( MD , Ph . D ) 3 , Jun Nakajima ( MD , Ph . D ) 3 , and Kent Doi ( MD , Ph . D ) 1
1 Department of Clinical Engineering , The University of Tokyo Hospital , 7-3-1 , Hongo , Bunkyo-city , Tokyo 113-8655 , Japan 2 Department of Anesthesiology , The University of Tokyo Hospital , 7-3-1 , Hongo , Bunkyo-city , Tokyo 113-8655 , Japan 3 Department of Thoracic Surgery , The University of Tokyo Hospital , 7-3-1 , Hongo , Bunkyo-city , Tokyo 113-8655 , Japan
Received 8 April 2024 , Accepted 22 July 2024
Abstract – Background : This retrospective observational study aimed to examine whether clinical inflammatory parameters were associated with the requirement dosage of unfractionated heparin ( UFH ) to maintain the range of ACT in veno-arterial extracorporeal membrane oxygenation ( V-A ECMO ) during lung transplantation surgery . Methods : Among all patients who underwent lung transplantation using V-A ECMO from January 2021 to May 2022 , 27 patients were included . These patients were divided into two groups based on whether the infusion rate of UFH was increased from the initial infusion rate ( 7 – 8 units / kg / h ) ( increased group , n = 10 ) or the infusion rate was maintained or decreased ( non-increased group , n = 17 ). The infusion rate was adjusted with an activated clotting time ( ACT ) target of 160 – 200 s . Results : At1 – 2h after starting ECMO , ACT was significantly lower ( 179.0 ( 166.5 – 188.5 ) versus 224.0 ( 193.0 – 242.0 ) sec , p = 0.006 ) and white blood cell ( WBC ) counts were higher in the increased group ( 12.6 ± 3.3 versus 9.5 ± 4.0 10 3 / lL , p = 0.046 ). The UFH infusion rates were higher in the increased group during the surgery . The cutoff value of WBC count at 1 – 2 h after starting ECMO for discriminating the need for increasing the UFH dosage was determined as 10.2 10 3 / lL ( sensitivity 90.0 %, specificity 58.8 %, area under the curve 0.712 ) and discrimination of this cut-off value was confirmed as statistically significant ( p = 0.018 ). Conclusion : These data suggested that WBC count was associated with the requirement of an increase in the UFH infusion rate of V-A ECMO during lung transplantation surgery . Further evaluation is necessary to clarify the role of WBC count in determining the optimal UFH dosage .
Key words : Veno-arterial extracorporeal membrane oxygenation , Lung transplantation , Unfractionated heparin , White blood cell .
Introduction
Veno-arterial extracorporeal membrane oxygenation ( V-A ECMO ) is mainly used during lung transplantation when both circulatory and respiratory supports are required because of pulmonary hypertension or difficulty in maintaining oxygenation , ventilation , and circulation [ 1 , 2 ]. Appropriate anticoagulant therapy is required during V-A ECMO , and unfractionated heparin ( UFH ) is most used as an anticoagulant in ECMO [ 3 , 4 ]. The dosage of anticoagulants for V-A ECMO performed in the ICU is determined based on parameters such as activated partial thromboplastin time ( APTT ), activated clotting time ( ACT ), and anti-Xa activity [ 5 – 7 ].
* Corresponding author : kashiwak-sup @ h . u-tokyo . ac . jp
It is widely recognized that inflammation has a significant effect on the blood coagulation system [ 8 – 10 ]. Therefore , it is necessary to pay close attention to the changes in the data associated with inflammatory reactions during ECMO . Indeed , in the ICU settings , many reports indicate issues that should be noted in the management of ECMO such as inflammatory status [ 11 , 12 ]. However , few reports suggested specific anticoagulant strategies for ECMO during lung transplantation . In this retrospective study , we hypothesized that UFH dosage would increase with the increase of white blood cell ( WBC ) count because of the interaction between inflammation and coagulation disorder . We clinically adjusted the UFH infusion rate in V-A ECMO during lung transplantation based on the results of ACT with the target value of 160 – 200 s . The purpose of this study was to examine whether clinical inflammatory parameters
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