Anticoagulation and Pediatric Extracorporeal Membrane Oxygenation: Impact of Activated Clotting Time and Heparin Dose on Survival

Baird, Christopher W.; Zurakowski, David; Robinson, Barbara L.; Gandhi, Sanjiv K.; Burdis-Koch, Leighann; Tamblyn, Joseph; Muñoz, Ricardo; Fortich, Karol; Pigula, Frank A.

doi:10.1016/j.athoracsur.2006.09.054

Cited by 136 publications

(116 citation statements)

References 31 publications

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“…A large retrospective study of pediatric ECMO patients found no relationship between ACT values and survival but noted an association between increased heparin infusion doses and improved survival [8]. Other investigators have noted the poor association between ACT measurements and heparin concentrations as measured by anti-Factor Xa concentration [9,11].…”

Section: Discussionmentioning

confidence: 99%

“…The ACT gained acceptance as the primary measurement of heparin effect in ECMO supported patients based on its ready bedside availability, rapid results, and ability to measure clotting time in whole blood. The use of ACT measurement in ECMO support evolved from its use during cardiopulmonary bypass and was never implemented on the basis of prospective investigations [6-8]. However, recent studies suggest that basing ECMO anticoagulation strategy on ACT measurement alone leads to sub-optimal anticoagulation in these patients [8-14].…”

Section: Introductionmentioning

confidence: 99%

“…The circuit/membrane oxygenator change procedure itself may be associated with an increased risk of complications and increased costs in an already critically ill patient. Furthermore, sub-optimal anticoagulation and increased clot formation in the extracorporeal circuit has been suggested to be associated with microembolic injury to end-organs and increased morbidity and mortality [8,15]. It has been proposed that additional monitoring of anticoagulation using anti-Factor Xa levels, a direct measurement of the plasma concentration of UFH and long considered the “gold standard” measure of heparin activity, may be warranted [9,16].…”

Section: Introductionmentioning

confidence: 99%

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Unfractionated Heparin Activity Measured by Anti-Factor Xa Levels Is Associated With the Need for Extracorporeal Membrane Oxygenation Circuit/Membrane Oxygenator Change

Irby

Swearingen

Byrnes

et al. 2014

Pediatric Critical Care Medicine

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Rationale Traditional measures of anticoagulation, including activated clotting time (ACT), have been poorly correlated with circuit thrombosis in pediatric patients supported with extracorporeal membrane oxygenation (ECMO). Objective Investigate whether anti-Factor Xa levels are associated with the need for change of circuit/membrane oxygenator secondary to thrombus formation in pediatric patients. Design and Settings Retrospective single institution study. Patients and Methods Retrospective record review of 62 pediatric patients supported with ECMO from 2009-2011. Data on standard demographic characteristics, indications for ECMO, duration of ECMO, ACT measurements, anti-Factor Xa measurements, and heparin infusion rate (HIR) were collected. Generalized linear models were used to associate anti-Factor Xa concentrations and need for change of either entire circuit/membrane oxygenator secondary to thrombus formation. Measurements and Main Results Sixty two patients met study inclusion criteria. No circuit change was required in 45/62 (Group NC). 17/62 patients required change of circuit/membrane oxygenator due to thrombus formation (Group CC). Multivariate analysis of daily anti-Factor Xa measurements throughout duration of ECMO support estimated a mean anti-Factor Xa concentration of 0.20 IU/ml [95% CI: (0.16, 0.24)] in Group NC that was significantly higher than the estimated 0.13 IU/ml [95% CI: (0.12, 0.14)] in Group CC (p = 0.001). A 0.01 IU/ml decrease in anti-Factor Xa increased odds of need for circuit/membrane oxygenator change by 5% (OR = 1.105 95% CI: 1.00, 1.10), p=0.044). Based upon the observed anti-Factor Xa concentrations, Group CC had 41% increased odds for requiring circuit/ membrane oxygenator change compared to Group NC (OR=1.41, 95% CI: 1.01, 1.96, p = 0.044). Mean daily ACT measurement (p = 0.192) was not different between groups, but mean daily HIR (p <0.001) was significantly different between the two groups. Conclusion Higher anti-Factor Xa concentrations were associated with freedom from circuit/membrane oxygenator change due to thrombus formation in pediatric patients during ECMO support. ACT measurements did not differ significantly between groups with or without circuit/membrane oxygenator change. This is the first study to link anti-Factor Xa concentrations with a clinically relevant measure of thrombosis in pediatric patients during ECMO support. Further prospective study is warranted.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Unfractionated Heparin Activity Measured by Anti-Factor Xa Levels Is Associated With the Need for Extracorporeal Membrane Oxygenation Circuit/Membrane Oxygenator Change

Irby

Swearingen

Byrnes

et al. 2014

Pediatric Critical Care Medicine

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“…494 It has been generally accepted that for patients on ECMO, a lower level of anticoagulation is necessary compared with patients undergoing surgery using CPB, but a recent study suggested improved survival for patients on ECMO with higher heparin doses. 498 The typical anticoagulation protocol includes a loading dose of 100 U/kg heparin before ECMO cannulation and a continuous infusion of heparin to maintain the ACT between 180 and 220 seconds. The ACT is checked every hour during extracorporeal support, and the heparin infusion is adjusted to maintain the target ACT.…”

Section: Anticoagulation For Cardiac Ecmo In Children With Chdmentioning

confidence: 99%

Prevention and Treatment of Thrombosis in Pediatric and Congenital Heart Disease

Giglia¹,

Massicotte²,

Tweddell³

et al. 2013

Circulation

282

245

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“…An ACT level of 300 sec is widely accepted as sufficient anticoagulation for heparin-coated ECLS circuits. 2 The tubing set of the ECLS circuit consisted of suspension polyvinyl chloride (sPVC) from Raumedic ® (Aalen, Germany) which is phthalate free (no DOP) and coated with Rheoparin ® (Medos Medizintechnik AG, Stolberg, Germany). In order to allow for longer extracorporeal support, a Hilite ® 7000 LT (Medos, Germany) oxygenator and a Levitronix ® CentriMag ® (Thoratec Corp., Pleasanton, CA, USA) centrifugal pump were used.…”

Section: Case Reportmentioning

confidence: 99%

Emergency oxygenator change-out after massive fat embolism

2012

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Anticoagulation and Pediatric Extracorporeal Membrane Oxygenation: Impact of Activated Clotting Time and Heparin Dose on Survival

Cited by 136 publications

References 31 publications

Unfractionated Heparin Activity Measured by Anti-Factor Xa Levels Is Associated With the Need for Extracorporeal Membrane Oxygenation Circuit/Membrane Oxygenator Change

Unfractionated Heparin Activity Measured by Anti-Factor Xa Levels Is Associated With the Need for Extracorporeal Membrane Oxygenation Circuit/Membrane Oxygenator Change

Prevention and Treatment of Thrombosis in Pediatric and Congenital Heart Disease

Emergency oxygenator change-out after massive fat embolism

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