Safety and efficacy of nafamostat mesilate as an anticoagulant for extracorporeal membrane oxygenation circuit
CCCF ePoster library. Sueishi T. 11/01/16; 150947; 67
Takayuki Sueishi
Takayuki Sueishi
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Topic: Retrospective or Prospective Cohort Study

Safety and efficacy of nafamostat mesilate as an anticoagulant for extracorporeal membrane oxygenation circuit

Takayuki, Sueishi; Osamu, Saito; Yuki, Nagai; Ichiro, Watanabe; Makoto, Motomura; Takehiro, Niitsu; Naoki, Shimizu
Paediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children’s Medical Centre, Tokyo, Japan


Background and objectives: Anticoagulants are required to maintain extracorporeal membrane oxygenation (ECMO) circuit for long period. However, bleeding complication during ECMO is one of the most fatal complications. Unfractionated heparin (UFH) has been thought to be the gold standard for anticoagulation. We reported low incidence of intracranial bleeding in neonatal ECMO with the combination protocol with UFH and nafamostat mesilate (NM) (JSICM 2016). In this study, we are determining if combination with UFH and NM (UFH/NM) is showing fewer hemorrhagic complications, fewer clot formations, and longer circuit life than those with UFH only or not.
Methods: During the period of from 2010 till 2016, 80 paediatric ECMO cases were included in our institution. Age, gender, duration of ECMO, incidence of hemorrhage, circuit life, length of ICU stay, and survival from ECMO were reviewed retrospectively. Multiple trauma (1), use of thrombolytics (1), intracranial hemorrhage preECMO or during ECPR (3) were excluded.
Results: Within 75 cases (15 neonatal, 60 paediatric), etiology was 27 respiratory, 24 cardiac, and 24 ECPR; mode was 10 VV, 56 VA, 9 VV-VA conversion. Almost all cases (71/75, 96%) received continuous renal replacement therapy. Median age of patients was 6.0 months, body weight 5.0 kg, period of ECMO 198 hours, length of stay 27.3 days, overall survival 70% respectively.
Within 75 cases, UFH/NM combined protocol was used in 63 cases, NM was used solely in 12 cases. Median dose of UFH was 10 U/kg/hr in UFH/NM combined protocol. The occurrence of cannula site bleeding and haematoma needed surgical removal was seen only in 2 cases with central cannulation during ECPR. Median ECMO circuit life was 156 hours. 7 out of 75 ECMO cases had evidence of neurologic injury in this cohort, 1 of those developed brain arrest. Mortality was higher in patients with neurologic complications compared to those without (22% vs. 78%; p=0.03). In neonatal cases, only 1 out of 15 had neurologic injury.
Discussion: Neurologic complications are thought to be common in paediatric ECMO and are associated with increased mortality in our report. Neonatal cases with neurologic injury (1/15, 6.6%) was fewer than other reports such as Extracorporeal Life Support Organization (ELSO). Circuit life with UFH/NM combined protocol was equivalent to those with UFH only, while blood flow was low and clot formations were frequent in paediatric ECMO in general. We are planing to assess further including economical aspects.
Conclusion: For neonate, UFH/NM combined protocol with relatively smaller doses of UFH showed fewer hemorrhagic complications, equivalent ECMO circuit life comparing with UFH only.

1. ELSO guidelines 2013,
2. ECLS Registry Report International Summary 2015,
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4. Neurologic injury in neonates with congenital heart disease during extracorporeal membrane oxygenation: an analysis of extracorporeal life support organization registry data. Polito A et al. ASAIO J. 2015 Jan-Feb;61(1):43-8.
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8. The use of an extracorporeal membrane oxygenation anticoagulation laboratory protocol is associated with decreased blood product use, decreased hemorrhagic complications, and increased circuit life. Northrop MS et al. Pediatr Crit Care Med. 2015 Jan;16(1):66-74

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