Systematic review and meta-analysis of the clinical effectiveness of point-of-care testing for anticoagulation management during ECMO.

Abstract

STUDY OBJECTIVE\nViscoelastic point-of-care (POC) tests are commonly used to provide prompt diagnosis of coagulopathy and allow targeted treatments in bleeding patients on ECMO. We evaluated the clinical effectiveness of point-of-care (POC) testing for anticoagulation management in patients on extracorporeal membrane oxygenation (ECMO).\n\n\nDESIGN\nSystematic review and meta-analysis. Eligible studies evaluating the use of thromboelastography- or thromboelastometry-guided algorithms, anti-factor Xa and platelet function testing were selected after screening the literature from July 1975 to January 2020.\n\n\nSETTING\nPatients on ECMO support.\n\n\nPATIENTS\nAnticoagulation management on ECMO patients.\n\n\nINTERVENTIONS\nRotational thromboelastometry, thromboelastography, alone or combined with platelet function testing. Trials monitoring the anticoagulation effects during ECMO using an anti-factor Xa assay were included in the systematic review.\n\n\nMEASUREMENTS\nThe primary outcomes were bleeding events, surgical revisions, thrombosis events and ECMO circuit change/failure. Secondary outcomes were blood-product transfusions, cerebrovascular accidents, mortality on ECMO, ECMO duration, intensive care unit and hospital discharge rates, and in-hospital mortality.\n\n\nMAIN RESULTS\nThirty-one trials enrolling 1684 participants were included in the systematic review. Four trials enrolling 547 subjects were included in the meta-analysis. The use of a POC testing device resulted in improved detection of surgical bleeding (RR: 0.68, 95% CI 0.49 to 0.94, I2\xa0=\xa00%; χ2 test for heterogeneity, P\xa0=\xa00.02). The use of POC-guided algorithms did not affect bleeding (RR:0.78, 95% CI 0.58 to 1.04, I2\xa0=\xa047%; χ2 test for heterogeneity, P\xa0=\xa00.09), thrombosis events (RR:1.35, 95% CI 0.86 to 2.12, I2\xa0=\xa037%; χ2 test for heterogeneity, P\xa0=\xa00.19), or ECMO circuit/change (RR:0.90, 95% CI 0.48 to 1.71, I2\xa0=\xa028%; χ2 test for heterogeneity, P\xa0=\xa00.75).\n\n\nCONCLUSION\nRoutine use of POC tests did not improve the main clinical outcomes beyond suggesting a diagnosis of surgical bleeding in ECMO patients.