Antithrombin III infusion improves anticoagulation in congenital diaphragmatic hernia patients on extracorporeal membrane oxygenation.

PURPOSE: Achieving effective anticoagulation during neonatal extracorporeal membrane oxygenation (ECMO) without increasing the risk of hemorrhage remains challenging. The use of antithrombin III (AT-III) for this purpose has been examined, but studies have been limited to intermittent bolus dosing. We aimed to evaluate the efficacy and safety of an institutionally developed AT-III continuous infusion protocol in neonates receiving ECMO for the treatment of congenital diaphragmatic hernia (CDH). METHODS: In this single center, retrospective study, all neonates with a CDH who received ECMO support during the study period were included. Data on anticoagulation labs and therapy, life-threatening bleeding, and circuit changes were analyzed. RESULTS: Eleven patients were divided into two groups: patients with AT-III continuous infusion (n = 5) and without (n = 6). There were no differences in the gestational age (p = 0.29), sex (p = 1.00), ECMO duration (p = 0.59), or initial AT-III levels (p = 0.76) between groups. Patients in the AT-III infusion group had on average 18.5% higher AT-III levels (p < 0.0001). Patients receiving continuous AT-III infusions spent a significantly higher percentage of ECMO time within the therapeutic range, measured using anti-Factor Xa levels (64.9±4.2% vs. 29.1±8.57%, p = 0.008), and required fewer changes to the heparin infusion rate (6.48±0.88 vs 2.38±0.36 changes/day changes/day, p = 0.005). Multivariate analysis revealed continuous infusion of AT-III did not increase the rate of intracranial or surgical bleeding (p = 0.27). CONCLUSION: AT-III as a continuous infusion in CDH neonates on ECMO provides a decreased need to modify heparin infusion and more consistent therapeutic anticoagulation without increasing the risk of life-threatening bleeding.

Impact of simulation-based extracorporeal membrane oxygenation training in the simulation laboratory and clinical environment.

INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) is a high-risk, complex therapy. Opportunities to develop teamwork skills and expertise to mitigate risks are few. Our objective was to assess whether simulation would improve technical and nontechnical skills in dealing with ECMO circuit emergencies and allow transfer of skills from the simulated setting to clinical environment. METHODS: Subjects were ECMO circuit providers who performed scenarios utilizing an infant simulator and functional ECMO circuit, followed immediately by video-assisted debriefings. Within the simulation laboratory, outcomes were timed responses, percentage of correct actions, teamwork, safety knowledge, and attitudes. Identification of latent safety threats (LSTs) was the focus of debriefings. Within the clinical setting, translation of learned skills was assessed by measuring circuit readiness and compliance with a cannulation initiation checklist. RESULTS: Nineteen subjects performed 96 simulations during enrollment. In the laboratory, there was no improvement in timed responses or percent correct actions. Teamwork (P = 0.001), knowledge (P = 0.033), and attitudes (P = 0.001) all improved compared with baseline. Debriefing identified 99 LSTs. Clinically, 26 cannulations occurred during enrollment. Median time from blood available to circuit readiness was 17 minutes (range, 5-95), with no improvement during the study. Compliance with the initiation checklist improved compared with prestudy baseline (P < 0.0001). CONCLUSIONS: Simulation-based training is an effective method to improve safety knowledge, attitudes, and teamwork surrounding ECMO emergencies. On-going training is feasible and allows identification of LSTs. Further work is needed to assess translation of learned skills and behaviors into the clinical environment.