Viscoelastic Testing in Pediatric Mechanical Circulatory Support

Regling, Katherine; Saini, Arun; Cashen, Katherine

doi:10.3389/fmed.2022.854258

Cited by 3 publications

(5 citation statements)

References 91 publications

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“…No correlation was found between ROTEM parameters and bleeding complications (128). Clot formation time on INTEM and HEPTEM was found to have a moderate-strong correlation with aPTT and HaPTT for children receiving bivalirudin for anticoagulation (123).…”

Section: Thromboelastography and Rotational Thromboelastometrymentioning

confidence: 87%

“…Rotational thromboelastometry and thromboelastography provide the same information, even with different parameter names, although the results are not interchangeable as they use different methodology and laboratory assays (123).…”

Section: Thromboelastography and Rotational Thromboelastometrymentioning

confidence: 99%

“…Therefore, anticoagulation management is usually based on R or CT time, comparing the values obtained with or without heparinase (123).…”

Section: Thromboelastography and Rotational Thromboelastometrymentioning

confidence: 99%

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Hemostasis in neonatal ECMO

et al. 2022

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Extracorporeal membrane oxygenation (ECMO) is a life-saving support for cardio-respiratory function. Over the last 50 years, the extracorporeal field has faced huge technological progress. However, despite the improvements in technique and materials, coagulation problems are still the main contributor to morbidity and mortality of ECMO patients. Indeed, the incidence and survival rates of the main hemorrhagic and thrombotic complications in neonatal respiratory ECMO are relevant. The main culprit is related to the intrinsic nature of ECMO: the contact phase activation. The exposure of the human blood to the non-endothelial surface triggers a systemic inflammatory response syndrome, which chronically activates the thrombin generation and ultimately leads to coagulative derangements. Pre-existing illness-related hemostatic dysfunction and the peculiarity of the neonatal clotting balance further complicate the picture. Systemic anticoagulation is the management's mainstay, aiming to prevent thrombosis within the circuit and bleeding complications in the patient. Although other agents (i.e., direct thrombin inhibitors) have been recently introduced, unfractionated heparin (UFH) is the standard of care worldwide. Currently, there are multiple tests exploring ECMO-induced coagulopathy. A combination of the parameters mentioned above and the evaluation of the patient's underlying clinical context should be used to provide a goal-directed antithrombotic strategy. However, the ideal algorithm for monitoring anticoagulation is currently unknown, resulting in a large inter-institutional diagnostic variability. In this review, we face the features of the available monitoring tests and approaches, mainly focusing on the role of point-of-care (POC) viscoelastic assays in neonatal ECMO. Current gaps in knowledge and areas that warrant further study will also be addressed.

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Section: Thromboelastography and Rotational Thromboelastometrymentioning

confidence: 87%

Section: Thromboelastography and Rotational Thromboelastometrymentioning

confidence: 99%

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Hemostasis in neonatal ECMO

et al. 2022

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“…In critical care settings, global hemostatic tests can guide diagnosis, management, and outcome prediction in various conditions like cardiac surgery, mechanical circulatory support, and DIC (38–40). Specifically, in pediatric DIC cases, two case reports used CWA to monitor hemostatic changes, and one case report demonstrated thromboelastometry-guided surgery in a girl with neuroblastoma and DIC (31, 32, 41).…”

Section: Discussionmentioning

confidence: 99%

Rotational Thromboelastometry and Clot Waveform Analysis as Point-of-Care Tests for Diagnosis of Disseminated Intravascular Coagulation in Critically Ill Children in Thailand*

Chanthong,

Choed-Amphai,

Manowong

et al. 2024

Pediatric Critical Care Medicine

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Objectives: This study aimed to determine the test performances of rotational thromboelastometry (ROTEM) and activated partial thromboplastin time-based clot waveform analysis (aPTT-CWA) compared with the International Society on Thrombosis and Hemostasis disseminated intravascular coagulation (ISTH-DIC) score for diagnosis of overt disseminated intravascular coagulation (ODIC) in critically ill children. Prognostic indicators of DIC complications were also evaluated. Design: A prospective cross-sectional observational study was conducted. ROTEM and aPTT-CWA were assessed alongside standard parameters based on the ISTH-DIC score and natural anticoagulants. Both conventional and global hemostatic tests were repeated on days 3–5 for nonovert DIC. Setting: PICU of the Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand. Subjects: Infants and children who were admitted to PICU with underlying diseases predisposed to DIC, such as sepsis, malignancy, major surgery, trauma, or severe illness, were included in the study between July 1, 2021, and November 30, 2022. Interventions: None. Measurements and Main Results: Sixty-four children were enrolled in this study. The prevalence of ODIC was 20.3%. Regarding ROTEM parameters, using EXTEM clot formation time (CFT) cutoff of greater than 102 seconds provided sensitivity and specificity of 90.9% and 80.9%, respectively, for diagnosing ODIC, with the area under the curve (AUC) of 0.86. In the case of aPTT-CWA performance, no biphasic waveform was observed, whereas both maximum coagulation acceleration (Min2) of less than 0.35%/s2 and maximum coagulation deceleration of less than 0.25%/s2 demonstrated identical sensitivities of 76.9% and specificities of 79.6%. Combining two global hemostatic tests significantly improved the diagnostic performance (INTEM CFT + EXTEM CFT + Min2 AUC 0.92 [95% CI, 0.80–1.00] vs. EXTEM CFT AUC 0.86 [95% CI, 0.75–0.96], p = 0.034). Bleeding was the most common consequence. In multivariable logistic regression analysis, Min2 of less than 0.36%/s2 was an independent risk factor for bleeding complications, with an adjusted odds ratio of 15.08 (95% CI, 1.08–211.15, p = 0.044). Conclusions: ROTEM and aPTT-CWA were valuable diagnostic tools in critically ill children who might require point-of-care tests. Min2 showed significant clinical implications for predicting bleeding events in this population.

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“…It is important to ascertain the recent increase in the evidence to support the use of viscoelastic tests thromboelastogram (TEG)/rotatory thromboelastometry (ROTEM) to evaluate and optimise coagulopathy in the paediatric surgical population, especially, cardiac surgery (CPB), craniosynostosis surgery, patients on mechanical circulatory support and trauma 120–122 …”

Section: Perioperative Pbmmentioning

confidence: 99%

Transfusion therapy of neonatal and paediatric patients: They are not just little adults

Gammon

Al‐Mozain

Aurón

et al. 2022

Transfusion Medicine

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Patient blood management (PBM) strategies are needed in the neonate and paediatric population, given that haemoglobin thresholds used are often higher than recommended by evidence, with exposure of children to potential complications without meaningful benefit. A literature review was performed on the following topics: evidence-based transfusions of blood components and pharmaceutical agents. Other topics reviewed included perioperative coagulation assessment and perioperative PBM. The Transfusion and Anaemia Expertise Initiative (TAXI) consortium published a consensus statement addressing haemoglobin (Hb) transfusion threshold in multiple subsets of patients. A multicentre trial (PlaNeT-2) reported a higher risk of bleeding and death or serious new bleeding among infants who received platelet transfusion at a higher (50 000/μl) compared to a lower (25 000/μl) threshold. Recent data support the use of a restrictive transfusion threshold of 25 000/μl for prophylactic platelet transfusions in preterm neonates. The TAXI-CAB consortium mentioned that in critically ill paediatric patients undergoing invasive procedures outside of the operating room, platelet transfusion might be considered when the platelet count is less than or equal to 20 000/μl and there is no benefit of platelet transfusion when the platelet count is more than 50 000/μl. There are limited controlled studies in paediatric and neonatal population regarding plasma transfusion. Blood conservation strategies to minimise allogenic blood exposure are essential to positive patient outcomes neonatal and paediatric transfusion practices have changed significantly in recent years since randomised controlled trials were published to guide practice. Additional studies are needed in order to provide practice change recommendations.

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Viscoelastic Testing in Pediatric Mechanical Circulatory Support

Cited by 3 publications

References 91 publications

Hemostasis in neonatal ECMO

Hemostasis in neonatal ECMO

Rotational Thromboelastometry and Clot Waveform Analysis as Point-of-Care Tests for Diagnosis of Disseminated Intravascular Coagulation in Critically Ill Children in Thailand*

Transfusion therapy of neonatal and paediatric patients: They are not just little adults

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