Anticoagulation and Transfusion Management During Neonatal and Pediatric Extracorporeal Membrane Oxygenation: A Survey of Medical Directors in the United States*

Ozment, Caroline; Scott, Briana; Bembea, Melania M.; Spinella, Philip C.

doi:10.1097/pcc.0000000000002696

Cited by 60 publications

(82 citation statements)

References 48 publications

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“…Surveys showed large differences among institutions, both in anticoagulation protocols and in transfusion triggers. 6,8,16 These differences are also revealed in our review, which are most likely explained by the lack of evidence for the optimal test and target ranges to monitor and titrate the coagulation status and the lack of evidence to guide transfusion thresholds in pediatric ECMO patients. Standardization of anticoagulation and transfusion management among centers will permit comparison of testing regimens between centers.…”

Section: Discussionmentioning

confidence: 91%

“…In addition, description of the anticoagulation protocol and transfusion thresholds was lacking in almost 40% and 60% of studies, respectively. Surveys showed large differences among institutions, both in anticoagulation protocols and in transfusion triggers 6,8,16 …”

Section: Discussionmentioning

confidence: 99%

“…In most studies, however, the population size is limited or comprises a specific group of patients. Moreover, there is a large variability in ECMO indications, coagulation protocols, ECMO circuitry, cannulation techniques, and transfusion thresholds 6‐8 9 .…”

Section: Introductionmentioning

confidence: 99%

“…Moreover, there is a large variability in ECMO indications, coagulation protocols, ECMO circuitry, cannulation techniques, and transfusion thresholds. 6 , 7 , 8 To compare results and differences between these studies, clear documentation of the study population, outcome definitions, and ECMO‐, coagulation‐, and transfusion‐related parameters is essential. 9 In the absence of a clear description of these variables, the comparability of research to other studies or the applicability to individual centers remains uncertain.…”

Section: Introductionmentioning

confidence: 99%

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Coagulation in pediatric extracorporeal membrane oxygenation: A systematic review of studies shows lack of standardized reporting

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Monagle

et al. 2022

Research and Practice in Thrombosis and Haemostasis

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Objectives Extracorporeal membrane oxygenation (ECMO) involves complex coagulation management and frequent hemostatic complications. ECMO practice between centers is variable. To compare results between coagulation studies, standardized definitions and clear documentation of ECMO practice is essential. We assessed how study population, outcome definitions, and ECMO‐, coagulation‐, and transfusion‐related parameters were described in pediatric ECMO studies. Data sources Embase, Medline, Web of Science, Cochrane Library and Google Scholar. Study selection English original studies of pediatric ECMO patients describing hemostatic tests or outcome. Data extraction Eligibility was assessed following PRISMA guidelines. Study population, outcome and ECMO‐, coagulation, and transfusion parameters were summarized. Data synthesis A total of 107 of 1312 records were included. Study population parameters most frequently included (gestational) age (79%), gender (60%), and (birth) weight (59%). Outcomes, including definitions of bleeding (29%), thrombosis (15%), and survival (43%), were described using various definitions. Description of pump type, oxygenator and cannulation mode occurred in 49%, 45%, and 36% of studies, respectively. The main coagulation test (53%), its reference ranges (49%), and frequency of testing (24%) were the most prevalent reported coagulation parameters. The transfusion thresholds for platelets, red blood cells, and fibrinogen were described in 27%, 18%, and 18% of studies, respectively. Conclusions This systematic review demonstrates a widespread lack of detail or standardization of several parameters in coagulation research of pediatric ECMO patients. We suggest several parameters that might be included in future coagulation studies. We encourage the ECMO community to adopt and refine this list of parameters and to use standardized definitions in future research.

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Section: Discussionmentioning

confidence: 91%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Coagulation in pediatric extracorporeal membrane oxygenation: A systematic review of studies shows lack of standardized reporting

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Helm

Monagle

et al. 2022

Research and Practice in Thrombosis and Haemostasis

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“…Consensus regarding optimal anticoagulation and monitoring strategies are lacking, despite multiple retrospective and observational studies (3)(4)(5)(6)(7)(8)(9). Center level variability in choice of anticoagulant, monitoring assays and associated therapeutic targets has been documented in surveys of ECMO center directors (3,10). The Bleeding and Thrombosis on ECMO (BATE) prospective observational study examined risk factors for bleeding and thrombosis in pediatric patients supported with ECMO.…”

Section: Introductionmentioning

confidence: 99%

Risk Factors Associated With Bleeding in Children With Cardiac Disease Receiving Extracorporeal Membrane Oxygenation: A Multi-Center Data Linkage Analysis

Ankola

Bailly

Reeder

et al. 2022

Front. Cardiovasc. Med.

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Background: Bleeding is a common complication of extracorporeal membrane oxygenation (ECMO) for pediatric cardiac patients. We aimed to identify anticoagulation practices, cardiac diagnoses, and surgical variables associated with bleeding during pediatric cardiac ECMO by combining two established databases, the Collaborative Pediatric Critical Care Research Network (CPCCRN) Bleeding and Thrombosis in ECMO (BATE) and the Extracorporeal Life Support Organization (ELSO) Registry.Methods: All children (<19 years) with a primary cardiac diagnosis managed on ECMO included in BATE from six centers were analyzed. ELSO Registry criteria for bleeding events included pulmonary or intracranial bleeding, or red blood cell transfusion >80 ml/kg on any ECMO day. Bleeding odds were assessed on ECMO Day 1 and from ECMO Day 2 onwards with multivariable logistic regression.Results: There were 187 children with 114 (61%) bleeding events in the study cohort. Biventricular congenital heart disease (94/187, 50%) and cardiac medical diagnoses (75/187, 40%) were most common, and 48 (26%) patients were cannulated directly from cardiopulmonary bypass (CPB). Bleeding events were not associated with achieving pre-specified therapeutic ranges of activated clotting time (ACT) or platelet levels. In multivariable analysis, elevated INR and fibrinogen were associated with bleeding events (OR 1.1, CI 1.0–1.3, p = 0.02; OR 0.77, CI 0.6–0.9, p = 0.004). Bleeding events were also associated with clinical site (OR 4.8, CI 2.0–11.1, p < 0.001) and central cannulation (OR 1.75, CI 1.0–3.1, p = 0.05) but not with cardiac diagnosis, surgical complexity, or cannulation from CPB. Bleeding odds on ECMO day 1 were increased in patients with central cannulation (OR 2.82, 95% CI 1.15–7.08, p = 0.023) and those cannulated directly from CPB (OR 3.32, 95% CI 1.02–11.61, p = 0.047).Conclusions: Bleeding events in children with cardiac diagnoses supported on ECMO were associated with central cannulation strategy and coagulopathy, but were not modulated by achieving pre-specified therapeutic ranges of monitoring assays.

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Pharmacokinetic Modeling Using Real‐World Data to Optimize Unfractionated Heparin Dosing in Pediatric Patients on Extracorporeal Membrane Oxygenation and Evaluate Target Achievement–Clinical Outcomes Relationship

Salem

Smith

Wilkes

et al. 2023

The Journal of Clinical Pharma

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Unfractionated heparin (UFH) is a commonly used anticoagulant for pediatric patients undergoing extracorporeal membrane oxygenation (ECMO) but evidence is lacking on the ideal dosing. We aimed to: (i) develop a population pharmacokinetic (PK) model for UFH, measured through anti‐factor Xa assay, (ii) optimize UFH starting infusions and dose titrations through simulations, and (iii) explore UFH exposure‐clinical outcomes relationship. Data from 218 patients admitted to Utah's Primary Children's Hospital were retrospectively collected. A one‐compartment PK model with time‐varying clearance (CL) adequately described UFH PK. Weight on CL and volume of distribution and, ECMO circuit change on CL were significant covariates. The typical estimates for initial CL and first‐order rate constant to reach steady‐state CL were 0.57 L/(h·10 kg) and 0.02 h−1. Comparable to non‐ECMO patients, the typical steady‐state CL was 0.81 L/(h·10 kg). Simulations showed that a 75 IU/kg UFH bolus dose followed by starting infusions of 25 & 20 IU/h/kg for patients < 6 & ≥ 6 years, respectively, achieved the therapeutic target in 56.6% of all patients while only 3.1% exceeded the target. The proposed UFH titration schemes achieved the target in > 90% of patients while < 0.63% were above the target after 24 and 48 hours of treatment. The median intensive care unit survival time in patients within and below the target at 24 hours was 136 and 66 hours, respectively. In conclusion, PK model of UFH was developed for pediatric patients on ECMO. The proposed UFH dosing scheme attained the anti‐factor Xa target rapidly and safely.This article is protected by copyright. All rights reserved

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Anticoagulation and Transfusion Management During Neonatal and Pediatric Extracorporeal Membrane Oxygenation: A Survey of Medical Directors in the United States*

Abstract: To compare current practices within the United States of anticoagulation management and blood transfusion in neonatal and pediatric extracorporeal membrane oxygenation patients with a 2013 international report.

Cited by 60 publications

References 48 publications

Coagulation in pediatric extracorporeal membrane oxygenation: A systematic review of studies shows lack of standardized reporting

Coagulation in pediatric extracorporeal membrane oxygenation: A systematic review of studies shows lack of standardized reporting

Risk Factors Associated With Bleeding in Children With Cardiac Disease Receiving Extracorporeal Membrane Oxygenation: A Multi-Center Data Linkage Analysis

Pharmacokinetic Modeling Using Real‐World Data to Optimize Unfractionated Heparin Dosing in Pediatric Patients on Extracorporeal Membrane Oxygenation and Evaluate Target Achievement–Clinical Outcomes Relationship

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