Anticoagulation Monitoring during Pediatric Extracorporeal Membrane Oxygenation

Bembea, Melania M.; Schwartz, Jamie McElrath; Shah, Nilay; Colantuoni, Elizabeth; Lehmann, Christoph U.; Kickler, Thomas S.; Pronovost, Peter J.; Strouse, John J.

doi:10.1097/mat.0b013e318279854a

Cited by 118 publications

(124 citation statements)

References 18 publications

(26 reference statements)

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“…Therefore, the antiXa assay will be relatively unrelated to heparin effect. 9 However, this had led to confusion in the literature of anticoagulation in ECLS because the some investigators have proposed using antiXa levels to titrate heparin. As explained above, heparin (and AT) is titrated to achieve a constant level of anticoagulation, so the antiXa level does not correlate with direct measures of heparin effect (ACT and aPTT).…”

Section: Heparinmentioning

confidence: 99%

“…This becomes especially important in infants with who have developmental hemostasis and lower levels of AT. 9 Fresh frozen plasma infusion often does not generate adequate concentrations of AT (1 U/ml), therefore AT concentrate is the preferred replacement(1,000-2,000 U/ concentrate infusion). 10 Monitoring of UNFH effect can be accomplished in a variety of ways.…”

Section: Heparinmentioning

confidence: 99%

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Anticoagulation for Extracorporeal Life Support

Coughlin

Bartlett

2015

ASAIO Journal

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Since its introduction to bedside clinical practice over 40 years ago, extracorporeal life support (ECLS) has been continually changing and improving as a life-saving technology. Extracorporeal life support disrupts the normal finely maintained balance of coagulation and fibrinolysis by exposing large amounts of blood to nonendothelial surfaces. This leads to an inflammatory response with activation of the coagulation cascade and the need for systemic anticoagulation. Unfractionated heparin (UNFH) is currently the standard anticoagulant in ECLS. Alternative anticoagulants have been recently developed with improved safety profiles and reliable monitoring. Within this group of agents are the direct thrombin inhibitors (DTIs) bivalirudin and argatroban. The purpose of this article is to compare these DTIs to the current standard of UNFH anticoagulation during ECLS, to evaluate the current literature surrounding the use of these drugs in ECLS, and finally to propose therapeutic guidelines for their use in ECLS.

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Section: Heparinmentioning

confidence: 99%

Section: Heparinmentioning

confidence: 99%

Anticoagulation for Extracorporeal Life Support

Coughlin

Bartlett

2015

ASAIO Journal

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“…

In this issue of the journal, Bembea et al 1 continue the ECMO community's collective search for the holy grail of anticoagulation monitoring for patients on extracorporeal membrane oxygenation (ECMO) in hopes of minimizing the arguably excessive complications of bleeding and thrombosis experienced internationally. 2 Despite many limitations of their prospective observational study, including small numbers and dramatic heterogeneity of their patient populations, one cannot argue with their demonstration of the lack of correlation between our bedside activated clotting time (ACT) testing and more specific measures of anticoagulation, such as anti-Factor Xa.

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mentioning

confidence: 97%

Anticoagulation Monitoring During Pediatric Extracorporeal Membrane Oxygenation

Hines¹

2013

ASAIO Journal

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In this issue of the journal, Bembea et al. 1 continue the ECMO community's collective search for the holy grail of anticoagulation monitoring for patients on extracorporeal membrane oxygenation (ECMO) in hopes of minimizing the arguably excessive complications of bleeding and thrombosis experienced internationally. 2 Despite many limitations of their prospective observational study, including small numbers and dramatic heterogeneity of their patient populations, one cannot argue with their demonstration of the lack of correlation between our bedside activated clotting time (ACT) testing and more specific measures of anticoagulation, such as anti-Factor Xa. However, what do we make of it all? Does the lack of correlation directly contribute to their relatively high rates of both thrombotic and hemorrhagic complications?Extracorporeal membrane oxygenation clinicians have long recognized the limitations of the global test for anticoagulation upon which we have long relied: the activated clotting time. Quick, relatively cheap and readily available, and reasonably reliable in most patients, it has become our mainstay of management. But we also recognize that when it is off, it can be way off, effected by a variety of factors, including sepsis, D-dimers, hypothermia, and, perhaps most commonly on ECMO, thrombocytopenia. Thus, we seek more specific determinants of preventing circuit thrombosis and patient hemorrhage. Unfortunately, in our desire to find a better monitor, we may be creating a system of "overmeasure and overtreat," with increasing use Department of Pediatric Surgery, Division of Cardiovascular Surgery antithrombin III, and platelets in all patients, in our attempt to reduce the complications in the minority. For example, in this study, the use of AT was discretionary and the use of FFP common. However, in the absence of sepsis and true disseminated intravascular coagulopathy (DIC), I personally have found little use for routine FFP, and rarely give AT III, despite using Amicar fairly liberally, yet I have experienced less

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“…In contrast to the ACT and APTT, the anti-Xa assay is specific to the anticoagulant effect of UNFH and is not influenced by coagulopathy, thrombocytopenia, or dilution. A number of studies in extracorporeal life support (ECLS) patients have shown superior correlation of the anti-Xa assay to UNFH dose and poor correlation of anti-Xa assay to ACT (8,9). The anticoagulant effect of UNFH is mediated by its interaction with two endogenous anticoagulants: AT and tissue factor pathway inhibitor.…”

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confidence: 99%

Monitoring of Anticoagulation in Extracorporeal Membrane Oxygenation

Lequier

Massicotte

2015

Pediatric Critical Care Medicine

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T he indications for the use of extracorporeal membrane oxygenation (ECMO) have expanded significantly from the early years of predominantly neonatal respiratory failure decades ago to current severe neonatal and pediatric cardiac and/or respiratory failure. Considerable advances in the materials and components used and the techniques used for the provision of extracorporeal support have been made over that same time period. However, the inability to completely control the interaction between blood and the biomaterials of the extracorporeal circuit, along with the subsequent inflammatory and coagulation response, still results in bleeding and thrombotic complications (1). Although a patient is receiving ECMO support, there is continuous contact between circulating blood and foreign surface of the extracorporeal circuit. As a result of this, the normal physiologic hemostatic balance is shifted to a hypercoagulable state, with patients, extracorporeal circuits and components at risk for thrombosis. In order to suppress hemostatic activation and prevent thrombosis, administration of antithrombotic therapy is necessary. Ideally, when using antithrombotic therapy for ECMO, platelet and coagulation factor activation should be inhibited enough to minimize clot formation in the ECMO circuit while maintaining enough endogenous procoagulant activity to avoid bleeding in the patient. However, this can be a difficult balance to sustain, and as a consequence, bleeding and thrombotic complications are not only some of the most common complications encountered during the provision of ECMO support but, more importantly, also associated with increased overall mortality (2-4).Unfractionated heparin (UNFH) is an antithrombotic agent and is the most widely used systemic anticoagulant during the provision of ECMO support. The activated clotting time (ACT) has been used for decades to monitor UNFH therapy in extracorporeal applications and remains the most commonly used test during ECMO to dictate UNFH dosage. The ACT is a low cost, point-of-care test (POCT), available 24 hours per day in most centers. Because of some potential shortcomings of UNFH and the ACT alone, including the effects of hemodilution, hypothermia, and the fact that different ACT devices can yield divergent results, it may be useful to complement regular whole blood ACT measurements, intermittently, with more elaborate tests of UNFH anticoagulation. To this end, alongside the technological evolution in extracorporeal life support, the methods for monitoring UNFH activity have also become more sophisticated, adding additional layers of complexity with a goal of creating an ideal safe protocol for anticoagulation during extracorporeal life support (5). In fact, a recent report of a survey of ECMO medical directors and coordinators at Extracorporeal Life Support Organization (ELSO) member centers revealed that although ACT was still the predominant method used to titrate UNFH for ECMO applications, there was concomitant use of other measures of UNFH anticoagulation, i...

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Anticoagulation Monitoring during Pediatric Extracorporeal Membrane Oxygenation

Cited by 118 publications

References 18 publications

Anticoagulation for Extracorporeal Life Support

Anticoagulation for Extracorporeal Life Support

Anticoagulation Monitoring During Pediatric Extracorporeal Membrane Oxygenation

Monitoring of Anticoagulation in Extracorporeal Membrane Oxygenation

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