Citations

ABSTRACT Background The Extracorporeal Life Support Organization recommends daily antithrombin monitoring and supplementation to achieve > 50%–80% activity during extracorporeal membrane oxygenation (ECMO). Evidence supporting this practice is uncertain, and whether it confers clinical benefit or harm is unclear. Methods This was a systematic review with meta‐analysis to evaluate the safety and efficacy of antithrombin supplementation during ECMO. We systematically searched databases and registers for studies comparing patients on ECMO who received antithrombin supplementation to those who did not. Random effects meta‐analysis was performed. Risk of bias was independently assessed by two investigators. A priori subgroup and sensitivity analyses were performed to explore reasons for heterogeneity. Results A total of 11 studies were identified. In the pooled meta‐analysis, antithrombin supplementation resulted in no difference in bleeding events (OR 1.38, 95% CI, 0.88–2.17, p = 0.16), thrombotic events (OR 1.57, 95% CI, 0.84–2.90, p = 0.15), or mortality (OR 1.21, 95% CI, 0.81–1.81, p = 0.35) when compared to those who did not receive antithrombin. Subgroup analysis revealed no difference in bleeding events or mortality in pediatric or adult patients; however, pediatric patients that received antithrombin were more likely to experience a thrombotic event (OR 1.70, 95% CI, 1.51–1.91). Sensitivity analysis in only low risk of bias studies confirmed these findings. Conclusions Antithrombin supplementation was not associated with differences in mortality or hemostatic outcomes during ECMO support and may be associated with harm in pediatric patients on ECMO.

Abstract Background Posaconazole immediate release (IR) suspension is the standard product for enteral feeding tube (EFT) administration but has erratic pharmacokinetic behaviour, often resulting in subtherapeutic concentrations. Limited evidence suggests that posaconazole oral delayed-release (DR) tablets may be crushed. Methods This was a retrospective cohort study of hospitalized adults who received EFT administration of posaconazole IR suspension or crushed DR tablets between 2018 and 2024. Patients were eligible if they had at least one serum drug concentration drawn ≥5 days after posaconazole initiation. The primary outcome was attainment of therapeutic drug concentrations. Secondary outcomes included time to therapeutic serum concentration, adverse drug events, and frequency of occluded EFT. Results Of the included patients, 48 received IR suspension and 100 received DR tablets. Baseline characteristics and severity of illnesses were well balanced. Among IR suspension and crushed DR tablet recipients, 39% and 80% achieved therapeutic concentrations, respectively (P = 0.002). After adjusting for age, sex, BMI, drug interactions, posaconazole indication and malabsorptive conditions, crushed DR tablets were significantly more likely than IR suspension to achieve therapeutic posaconazole concentrations within 30 days (HR 5.22, 95% CI 2.35–11.61). Occluded EFTs were more frequent among crushed DR tablet recipients (27% versus 10%, P = 0.022), while no differences were observed in the occurrence of hepatotoxicity or hypokalaemia. Conclusions With EFT administration, crushed posaconazole DR tablets were associated with a greater likelihood of achieving therapeutic concentrations compared with IR suspension. The optimal technique for administering crushed DR tablets to prevent EFT complications warrants investigation.

Refractory anaphylaxis is rare but carries high mortality, particularly when complicated by severe bronchospasm and respiratory failure. We present a 32-year-old individual with food-induced anaphylaxis and profound bronchospasm unresponsive to first- and second-line therapies, resulting in severe hypoxemic and hypercapnic respiratory failure despite mechanical ventilation. Peripheral venovenous extracorporeal membrane oxygenation (VV-ECMO) was emergently initiated, leading to rapid stabilization and full recovery. This case demonstrates the successful use of VV-ECMO as a life-saving bridge in anaphylaxis-induced respiratory failure. This is one of the few reported cases of successful use of VV-ECMO for refractory bronchospasm secondary to anaphylaxis.