Fausat Bello Perfusion Technology Rush University PEDIATRIC ECMO: A SURVEY OF ANTICOAGULATION...
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Transcript of Fausat Bello Perfusion Technology Rush University PEDIATRIC ECMO: A SURVEY OF ANTICOAGULATION...
Fausat BelloPerfusion TechnologyRush University
PEDIATRIC ECMO: A SURVEY OF ANTICOAGULATION MONITORING PRACTICES
Disclosures I have no disclosures
Why am I here? The objective of this talk is to review:
The history of pediatric ECMO and ACT usage.Review the literature on monitoring modalities of
pediatric anticoagulation. Reveal the preliminary results of my survey.
Extracorporeal Membrane Oxygenation
ECMO Complications Patient Related
AnticoagulationNeurologicalInfectiousEnd Organ Damage
Device Related
Blood Surface Interfacing
Annich, G., & Adachi, I. (2013). Anticoagulation for pediatric mechanical circulatory support. Pediatric Critical Care Medicine : A Journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies, 14(5 Suppl 1), S37-42.
Coagulation Cascade
David Lillicrap; Nigel Key; Michael Makris; Denise O'Shaughnessy (2009). Practical Hemostasis and Thrombosis. Wiley-Blackwell. pp. 1–5.
Pediatric HemostasisProcoagulants
ClotInhibitors
Fibrinolytic
Degradation
Inhibitors
2macroglobulinProtein C,S***antithrombin
thrombin
PAI
II, VII,IX,X,XI,XII
***plasminogen tPA
Platelets
ECMO Complications
Neonatal Pediatric Adult 0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Circuit ClotsDIC
Baird, C. W., Zurakowski, D., Robinson, B., Gandhi, S., Burdis-Koch, L., Tamblyn, J., et al. (2007). Anticoagulation and pediatric extracorporeal membrane oxygenation: Impact of activated clotting time and heparin dose on survival. The Annals of Thoracic Surgery, 83(3), 912-9; discussion 919-20.
Anticoagulants Heparin is the primary anticoagulant of choice for
pediatric patients undergoing extracorporeal membrane oxygenation.
Mechanism of action: Indirect thrombin inhibitor that couple and potentiates the action of antithrombin III
Limitations• Narrow therapeutic window of adequate
anticoagulation without bleeding• Highly variable dose-response
Solution?
Monitoring patterns for Anticoagulation
93%
34%
28%76%78%
54% 45%
ACTD-DimerAnti- XAFibrinogenATIICBCaPTT
Baird, C. W., Zurakowski, D., Robinson, B., Gandhi, S., Burdis-Koch, L., Tamblyn, J., et al. (2007). Anticoagulation and pediatric extracorporeal membrane oxygenation: Impact of activated clotting time and heparin dose on survival. The Annals of Thoracic Surgery, 83(3), 912-9; discussion 919-20.
Phase 1Monitoring Practices1966-2006
Activated Clotting Time Described by Hattersly
1966 Proven correlation with
weight normalized heparin dosing….in adults
Factors affecting ACT results Patient Related Factors
Platelet countFibrinogenAntithrombin III levelsHemodilution
Technically Related Factors Agitator and timersLack of a single sample
precisionVenous vs. Arterial bloodSmaller sample volumesTemperature and timing of
ACT levels Uncertainty of results for
ACT levels less than 250
ACT tests alone cannot provide proper titration of heparin and thus be the test used to monitor anticoagulation alone.
Phase 2Monitoring Practices2007-
TEG
Anti-Factor Xa
10 20 30 40 500
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
Anti-Xa vs Heparin Dose
Heparin
An
ti--
Xa
10 20 30 40 5020
40
60
80
100
120
140
PTT vs Heparin Dose
Heparin
PT
T
10 20 30 40 50100
200
300
400
ACT vs Heparin Dose
Heparin
Act
ivat
ed C
lott
ing
Tim
e
Phase 3? Multi-modality testing...
Anti-Xa
ACT
PTT
TEG
AT-III
Objective The objective of my study is to examine:
Current status of anticoagulation monitoring practices Relationship between monitoring modalities, heparin
dosing and the perfusionist role in the solution.
Yes95%
No5%
Do you employ extracorporeal membrane oxygenation (ECMO) for patients between the ages of 0-18? (n=65)
Yes86%
No14%
Does your institution have a written anticoagulation management (frequency of testing and/or guidelines for heparin dosing) protocols for ECMO? (n=65)
If Yes, is your institution’s protocol specific to the population under the age of 18? (n=65)
Yes49%No
51%
Check all monitoring modalities used to asses proper anticoagulation at your institution. (n=65)
ACT33%
aPTT28%
Ant-Xa24%
TEG16%
Select the single test one should use in the absence of all other tests to monitor and measure anticoagulation for pediatric ECMO patients. (n=65)
ACT37%
aPTT12%
Anti-Xa39%
TEG5%
Other7%
How satisfied are you with your institutions monitoring protocol in decreasing hemorrhagic/thrombotic complications. (n=65)
Very Satisfied8%
Gener-ally Sat-is-
fied10%
Indifferent40%
Generally dissatisfied43%
Conclusion