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Objective:To evaluate the safety and efficacy of argatroban applied as alternative anticoagulant in critical illness patients underwent extracorporeal membrane oxygenation (ECMO) with contraindications of unfractionated heparin (UFH), and to further explore the effective dose of argatroban.Methods:From July 1, 2013 to February 28, 2022, there were 14 patients who admitted in the respiratory intensive care unit (RICU) of Beijing Chao-Yang Hospital received ECMO and used argatroban for anticoagulation (argatroban group). Two of them received argatroban as the initial anticoagulant. The remaining 12 patients used UFH at first, and then switched to argatroban. UFH group included 28 patients who received UFH for anticoagulation after matching the demographic characteristics. Primary endpoint was the prevalence of ECMO-related thrombotic events. Secondary endpoints included the type of thrombotic events, prevalence of ECMO-related major bleeding events, bleeding sites, ICU mortality, mortality during ECMO, liver and kidney function, thrombelastogram, blood transfusion, dosage of argatroban, the dynamic changes of coagulation variables 4 days before and 7 days after argatroban treatment.Results:In argatroban group, there were 8 patients received veno-venous ECMO (VV-ECMO), 2 patients with veno-arterial ECMO (VA-ECMO), and 4 patients with veno-arterio-venous ECMO (VAV-ECMO). In UFH group, VV-ECMO was applied in 23 patients, VA-ECMO and VAV ECMO was established in 3 patients and 2 patients, respectively. In endpoint events, the incidence of ECMO related thrombotic events in argatroban group was slightly higher than that in UFH group (28.6% vs. 21.4%). The ECMO running time in argatroban group was slightly longer than that in UFH group [days: 16 (7, 21) vs. 13 (8, 17)]. The incidence of ECMO-related bleeding events (28.6% vs. 32.1%) and mortality during ECMO (35.7% vs. 46.4%) in argatroban group were slightly lower than those in UFH group. However, the differences were not statistically significant (all P < 0.05). The platelet transfusion in argatroban group was significantly higher than that in UFH group [U: 7.7 (0, 10.0) vs. 0.8 (0, 1.0)]. The coagulation reaction time (R value) in thrombelastography in argatroban group was significantly longer than that in UFH group [minutes: 9.3 (7.2, 10.8) vs. 8.8 (6.3, 9.7)]. The maximum width value [MA value, mm: 48.4 (40.7, 57.9) vs. 52.6 (45.4, 61.5)] and blood clot generation rate [α-Angle (deg): 54.1 (45.4, 62.0) vs. 57.9 (50.2, 69.0)] in the argatroban group were significantly lower than those in the UFH group (all P < 0.05). The activated partial thromboplastin time (APTT) was prolonged after changing from UFH to argatroban in the argatroban group [seconds: 63.5 (58.4, 70.6) vs. 56.7 (53.1, 60.9)]. The PLT level showed a decreasing trend during UFH anticoagulation therapy, and gradually increased after changing to argatroban. D-dimer level was 19.1 (7.0, 28.7) mg/L after switching to argatroban, and then no longer showed an increasing trend. The level of fibrinogen (FIB) showed a decreasing trend during the anticoagulant therapy of UFH (the lowest was 23.6 g/L), and fluctuated between 16.8 and 26.2 g/L after changing to argatroban. The median initial dose of argatroban was 0.049 (0.029, 0.103) μg·kg -1·min -1, which the highest dose was in VV-ECMO patients of [0.092 (0.049, 0.165) μg·kg -1·min -1]. The initial dose of VAV-ECMO was the lowest [0.026 (0.013, 0.041) μg·kg -1·min -1], but without significant difference ( P > 0.05). The maintenance dose of argatroban was 0.033 (0.014, 0.090) μg·kg -1·min -1, VV-ECMO patients was significantly higher than those in VA-ECMO and VAV-ECMO patients [μg·kg -1·min -1: 0.102 (0.059, 0.127) vs. 0.036 (0.026, 0.060), 0.013 (0.004, 0.022), both P < 0.05]. Conclusion:Argatroban appears to be a feasible, effective and safety alternative anticoagulant for patients with contraindications to UFH who undergoing ECMO support.
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BackgroundCOVID-19 pandemic has developed rapidly and the ability to stratify the most vulnerable patients is vital. However, routinely used severity scoring systems are often low on diagnosis, even in non-survivors. Therefore, clinical prediction models for mortality are urgently required. MethodsWe developed and internally validated a multivariable logistic regression model to predict inpatient mortality in COVID-19 positive patients using data collected retrospectively from Tongji Hospital, Wuhan (299 patients). External validation was conducted using a retrospective cohort from Jinyintan Hospital, Wuhan (145 patients). Nine variables commonly measured in these acute settings were considered for model development, including age, biomarkers and comorbidities. Backwards stepwise selection and bootstrap resampling were used for model development and internal validation. We assessed discrimination via the C statistic, and calibration using calibration-in-the-large, calibration slopes and plots. FindingsThe final model included age, lymphocyte count, lactate dehydrogenase and SpO2 as independent predictors of mortality. Discrimination of the model was excellent in both internal (c=0{middle dot}89) and external (c=0{middle dot}98) validation. Internal calibration was excellent (calibration slope=1). External validation showed some over-prediction of risk in low-risk individuals and under-prediction of risk in high-risk individuals prior to recalibration. Recalibration of the intercept and slope led to excellent performance of the model in independent data. InterpretationCOVID-19 is a new disease and behaves differently from common critical illnesses. This study provides a new prediction model to identify patients with lethal COVID-19. Its practical reliance on commonly available parameters should improve usage of limited healthcare resources and patient survival rate. FundingThis study was supported by following funding: Key Research and Development Plan of Jiangsu Province (BE2018743 and BE2019749), National Institute for Health Research (NIHR) (PDF-2018-11-ST2-006), British Heart Foundation (BHF) (PG/16/65/32313) and Liverpool University Hospitals NHS Foundation Trust in UK. Research in contextO_ST_ABSEvidence before this studyC_ST_ABSSince the outbreak of COVID-19, there has been a pressing need for development of a prognostic tool that is easy for clinicians to use. Recently, a Lancet publication showed that in a cohort of 191 patients with COVID-19, age, SOFA score and D-dimer measurements were associated with mortality. No other publication involving prognostic factors or models has been identified to date. Added value of this studyIn our cohorts of 444 patients from two hospitals, SOFA scores were low in the majority of patients on admission. The relevance of D-dimer could not be verified, as it is not included in routine laboratory tests. In this study, we have established a multivariable clinical prediction model using a development cohort of 299 patients from one hospital. After backwards selection, four variables, including age, lymphocyte count, lactate dehydrogenase and SpO2 remained in the model to predict mortality. This has been validated internally and externally with a cohort of 145 patients from a different hospital. Discrimination of the model was excellent in both internal (c=0{middle dot}89) and external (c=0{middle dot}98) validation. Calibration plots showed excellent agreement between predicted and observed probabilities of mortality after recalibration of the model to account for underlying differences in the risk profile of the datasets. This demonstrated that the model is able to make reliable predictions in patients from different hospitals. In addition, these variables agree with pathological mechanisms and the model is easy to use in all types of clinical settings. Implication of all the available evidenceAfter further external validation in different countries the model will enable better risk stratification and more targeted management of patients with COVID-19. With the nomogram, this model that is based on readily available parameters can help clinicians to stratify COVID-19 patients on diagnosis to use limited healthcare resources effectively and improve patient outcome.
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Objective:To analyze the relationship and clinical value between serum matrix metalloproteinases-3 (MMP-3) and rheumatoid arthritis (RA).Methods:By using retrospective study to collect 123 patients with RA diagnosed in our hospital from January 2019 to January 2020 as the RA group. Among the patients, there are 25 males and 98 females, the median age is 60 years old. During the same term, 53 healthy people were selected as the control group, with 12 males and 41 females, the median age is 55 years old. MMP-3, erythrocyte sedimentation rate (ESR), high sensitivity C-reactive protein (hs-CRP), rheumatoid facotrs (RF), anti-cyclocitrulline factor (ACCP) in peripheral blood of all subjects were detected. Disease activity score of 28 joints (DAS28) were collected. This research used T test, Spearman correlation analysis and receiver operating characteristic curve (ROC curve) to analyze the relationship between MMP-3 and other clinical biochemical indices, and the efficacy of MMP-3 in the diagnosis of RA.Results:Compared with the control group (26.30±14.83)ng/ml, the levels of serum MMP-3 in the RA group (79.71±123.54) ng/ml had significantly increased ( t=-4.95, P<0.001). The serum concentration of MMP-3 in RA patients was significantly correlated with ESR, hs-CRP and DAS28 ( r value were 0.521, 0.372, 0.405 respectively, P<0.001). The area under the curve (AUC) of MMP-3 to diagnose RA was 0.765, and the sensitivity was 64.44%, and the specificity was 75.76%, cut-off of MMP-3 were 32.50 ng/ml. Conclusions:The levels of serum MMP-3 in the RA group had significantly increased. MMP-3 and the disease activity were highly correlated. MMP-3 can be used as an indicator of RA disease activity, also can significantly improve the diagnostic efficacy, treatment and warning of early RA.
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Objective:To discuss how to avoid the occurrence of adverse events and provides basis for improving the extracorporeal membrane oxygenation (ECMO) transport safety management to formulate the corresponding preventive measures through analyzing the causes and characteristics of adverse events in transport of ECMO.Methods:By using a self-designed ECMO transport observation table to collect data, with a retrospective study of adverse events in patients with ECMO transport in ECMO center of Beijing Chaoyang Hospital from January 2013 to June 2017, carrying out classification and analysis according to the causes of adverse events and the potential risks of the patients, thus put forward the feasible preventive measures.Results:There were 53 cases of ECMO transport in study period, with 18 cases (33.96%) of adverse events, among which the incidence of adverse events in inner-hospital transport was 34.21% (13/38) and that in inter-hospital transport was 33.33% (5/15). There was no patient died in ECMO transport. In the adverse events of ECMO transport, the main causes were related to transport staff, transport equipment and patient, which accounting for 1/3 of each. Among them, the most prominent was 4 cases (22.22%) of equipment lacking and 3 cases of battery and power supply (16.67%). In classification according to the risk degree of patients, 6 cases (33.33%) of third grade risk were found.Conclusions:It is safe and feasible to carry out ECMO transport in inner-hospital transport and inter-hospital transport based on ECMO transport team and transport process of this hospital. However the unexpected events of high risk or crisis of life is inevitable in ECMO transport. Through standardized training for ECMO team, with full assessment before transport, by the use of ECMO checklist and strict implementation of various transport processes and specifications, the incidence of adverse events in ECMO transport may be reduced.
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Extracorporeal membrane oxygenation (ECMO) is a novel mechanical system that provides respiratory and/or hemodynamic support to patients with severe respiratory or cardiac failure.These patients generally develop a state of increased metabolic activity accompanied by elevated catabolism of protein and negative nitrogen balance.Moreover,provision of adequate nutritional therapy is hard to achieve due to various factors.Nutrition support for these patients is hence a critical issue.This article provides a brief overview of the current literature regarding nutritional support during ECMO in adult patients,as no current guidelines address this issue.
