Management of acquired coagulopathy in acute paediatrics

Abstract

Acquired coagulopathy is a relatively uncommon occurrence in acute paediatrics but when it occurs is usually associated with significant underlying pathology and often with critical illness. It can be caused by a number of disease processes but infection, blood loss, iatrogenic causes and liver dysfunction are among the commonest. The blood coagulation cascade is complex and intersects with many other physiological pathways. It is also subject to developmental changes, and 'normal' coagulation and haemostasis change considerably during early life. The diagnosis of abnormal coagulation and when treatment should be initiated is influenced both by age and developmental status and limited by the range of tests routinely available to clinicians. Treatment has predominantly involved transfusion of plasma products (usually fresh frozen plasma and cryoprecipitate) but a number of pharmaceutical and human-derived options are now available. Although plasma products are less frequently transfused than red cells or platelets, their use continues to increase and has not followed the reducing usage of other blood components. This article discusses the aetiology of coagulopathy, describes the commonly available diagnostic tests and outlines the evidence available to guide paediatricians when treating acutely ill children with acquired coagulopathy.

Bleeding and Clotting Disorders in Pediatric Liver Disease

“…The studies by Holland and Brooks in adults suggest that a dose of 21 mL/kg of body weight is needed to achieve a target INR of 1.7 from an initial INR of 3, but that it takes 50 mL/kg to achieve an INR of 1.3 from a starting INR of 3. 55 Current guidelines for FFP dosing in pediatric patients cited in a review by Morley recommend 15 mL/kg of body weight, with a range of dosing of 10-20 mL/kg of body weight, 61 which is in agreement with adult guidelines. 62 A follow-up PT is needed after the infusion of FFP to ensure that the desired correction of the INR has been achieved.…”

“…[61][62][63] Dosing of cryoprecipitate for pediatric use is typically 4-5 mL/kg of body weight, with adult dosing being 1 unit (10-20 mL)/10 kg of body weight. 61,62 A fibrinogen concentrate (Haemocomplettan P/Ria-STAP, CSL Behring) is being marketed for the treatment of congenital hypofibrinogenemia, and has been used in some European countries for the management of acquired hypofibrinogenemia. Little research is available to guide its use in acquired coagulopathy, and it cannot be recommended at present for routine treatment, except for its labeled indication to treat congenital hypofibrinogenemia.…”

“…Little research is available to guide its use in acquired coagulopathy, and it cannot be recommended at present for routine treatment, except for its labeled indication to treat congenital hypofibrinogenemia. 61 …”

“…A dose of 10 mg of vitamin K administered parenterally is recommended for adults. 64 Pediatric guidelines on acquired coagulopathy recommend that any patient suspected of having vitamin K deficiency should receive supplementation, but that if there is no response, repeated administration of large doses should be avoided 61 Pediatric dosing for vitamin K deficiency is 30 g/kg given intravenously, subcutaneously, or orally, based on guidelines for reversal of warfarin. 65 Parenteral administration of phytonadione can be accompanied by hypersensitivity reactions, anaphylaxis, and/or shock, and therefore published guidelines should be followed closely.…”

“…80 Stravitz considers it reasonable to add epsilon-aminocaproic acid to the treatment of acute liver failure in the setting of severe hypofibrinogenemia and possible hyperfibrinolysis, but Morley recommends in pediatric practice to restrict antifibrinolytic therapy to use in specific settings such as prevention of bleeding after cardiac or orthopedic surgery, severe menorrhagia, or severe epistaxis or bleeding after dental surgery. 50,61 My approach to treating bleeding in pediatric patients with liver disease, based on published data on the differences between pediatric and adult patients and pathologic conditions, is summarized in Table 3.…”