Antithrombin Replacement During Extracorporeal Membrane Oxygenation

Niebler, Robert A.; Christensen, Melissa; Berens, Richard J.; Wellner, Heidi; Mikhailov, Theresa A.; Tweddell, James S.

doi:10.1111/j.1525-1594.2011.01384.x

Cited by 99 publications

(79 citation statements)

References 21 publications

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“…18 Niebler et al reviewed AT use in 28 pediatric patients receiving ECMO support with AT activity levels less than 80% and reported increases in AT activity but no difference in heparin infusion rate, ACTs, chest tube output, or red blood cell transfusion volume. 19 The results of our study add evidence that suggest intermittent daily doses of AT concentrate in critically ill adult patients does not reduce heparin infusion rates or affect clinically significant bleeding.…”

Section: Discussionsupporting

confidence: 54%

Antithrombin Administration During Intravenous Heparin Anticoagulation in the Intensive Care Unit: A Single-Center Matched Retrospective Cohort Study

Beyer

Schoeppler

Zanotti

et al. 2016

Clin Appl Thromb Hemost

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Unfractionated heparin (UFH) is a frequently utilized indirect anticoagulant that induces therapeutic effect by enhancing antithrombin (AT)-mediated procoagulant enzyme inhibition. In suspected heparin resistance (HR) during cardiopulmonary bypass, AT activity may be decreased and AT supplementation helps restore UFH responsiveness. The benefit of AT supplementation in HR over longer durations of UFH therapy is unclear. The objective of this study was to describe and evaluate the use of AT III concentrate in the intensive care units (ICUs) at our institution for improving UFH therapy response over 72 hours. A total of 44 critically ill patients were included in the analysis-22 patients received at least 1 dose of AT and 22 patients received no AT. Thirty (68.2%) of the 44 patients were receiving mechanical circulatory support. Baseline characteristics were similar between groups. The average AT activity prior to AT supplementation was 57.9% in the treatment group, and the median cumulative dose of AT was 786.5 U (9.26 U/kg) per patient. There were no significant differences observed in proportion of time spent in therapeutic range (31.9% vs 35.2%, P ¼ .65), time to therapeutic goal (16.5 vs 15.5 hours, P ¼ .97), or patients who experienced a bleeding event (5 vs 5, P ¼ .99) between groups. In conclusion, AT supplementation had minimal impact on anticoagulant response in this cohort of ICU patients with mild to moderate HR receiving a prolonged UFH infusion. Additional research is needed to define AT activity targets and to standardize AT supplementation practices in patients receiving prolonged heparin infusion.

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Section: Discussionsupporting

confidence: 54%

Antithrombin Administration During Intravenous Heparin Anticoagulation in the Intensive Care Unit: A Single-Center Matched Retrospective Cohort Study

Beyer

Schoeppler

Zanotti

et al. 2016

Clin Appl Thromb Hemost

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“…The authors concluded that there were no clinically relevant acute major bleeding or clinically relevant bleeding episodes that were not related to the underlying condition. 8 Niebler et al 6 performed a retrospective review of AT III doses administered to infants and children receiving ECMO. The AT III doses administered were determined by the treating physician and, at times, were rounded to full vial sizes.…”

Section: Discussionmentioning

confidence: 99%

“…1,2 Also, when a patient is treated with extracorporeal membrane oxygenation (ECMO), increased endogenous AT III consumption occurs from blood exposure to the ECMO circuit. [5][6][7] Increased excretion may result from nephrotic syndrome, protein-losing enteropathy, inflammatory bowel disease, and chylothoraces. Druginduced mechanisms that cause AT III consumption include l-asparaginase, estrogen, and heparin.…”

Section: Introductionmentioning

confidence: 99%

“…2 Continuous heparin infusion is a common method of anticoagulation in patients receiving ECMO or continuous renal replacement therapy (CRRT). [5][6][7]9 Patients treated with ECMO and CRRT have potential for developing antithrombin deficiency due to both heparin administration and blood exposure to the artificial surface of the ECMO circuit. 5 Exogenous AT III is often administered to patients with AT III deficiency who are receiving heparin infusions in an effort to increase efficacy of heparin, thus lowering the heparin infusion rates required to achieve therapeutic partial thromboplastin time or activated clotting time.…”

Section: Introductionmentioning

confidence: 99%

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Antithrombin III Doses Rounded to Available Vial Sizes in Critically Ill Pediatric Patients

Stockton¹,

Padilla-Tolentino²,

Ragsdale³

2017

The Journal of Pediatric Pharmacology and Therapeutics

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OBJECTIVESChildren have decreased levels of antithrombin III (AT III) compared to adults. These levels may be further decreased during acute illness. Administration of exogenous AT III can increase anticoagulant efficacy. The objective of this study was to evaluate AT III doses rounded to available vial sizes compared to partial vial doses in critically ill pediatric patients, including patients receiving extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT).METHOD This retrospective review evaluated pediatric patients 0-18 years of age admitted to a 24-bed medical/surgical pediatric intensive care unit between June 1, 2012, and December 31, 2014, who received plasma-derived AT III. Patients received unfractionated heparin, low-molecular-weight heparin, or no anticoagulation. This review included patients who received ECMO and CRRT.RESULTS Eighty doses of AT III were administered to 24 patients (38 full vial size doses and 42 partial vial size doses). The AT III level following dose administration was ≥80% for 26 full vial doses (70%) and 16 partial vial doses (41%; p = 0.010). For patients who received multiple doses of AT III, the median time between doses was 45 hours following full vial doses, and 23 hours following partial vial doses (p = 0.011). Seven patients (29%) had documentation of new or increased bleeding. The median waste prevented from rounding doses to full vial sizes was 363 units.CONCLUSIONS After receiving AT III doses rounded to full vial sizes, patients were more likely to have a therapeutic AT III level and a longer interval between administrations. Rounding AT III doses to full vial sizes reduces waste and can result in cost savings.

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“…Most are severely underpowered, lacking sufficient events for efficacy analysis. However, those that are published do indicate that AT increases heparin levels in the blood and reduces the heparin dose in ECMO patients, and that AT can be safely administered to patients on ECMO without increased risk of bleeding [67][68][69]70]. There have been reports of increased failure rates of ECMO circuits in patients receiving AT, but this may be due primarily to sub-therapeutic heparin effect (for which AT is being given) [68].…”

Section: Antithrombinmentioning

confidence: 99%

ECMO Biocompatibility: Surface Coatings, Anticoagulation, and Coagulation Monitoring

Maul¹,

Massicotte²,

Wearden³

2016

Extracorporeal Membrane Oxygenation: Advances in Therapy

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The interaction between the patient and the ECMO (extracorporeal membrane oxygenation) circuit initiates a significant coagulation and inflammatory response due to the large surface area of foreign material contained within the circuit. This response can be blunted with the appropriate mix of biocompatible materials and anticoagulation therapy. The use of anticoagulants, in turn, requires appropriate laboratory testing to determine whether the patient is appropriately anticoagulated. Physicians must balance the risks of bleeding with the risks of thrombosis; the proper interpretation of these tests is often shrouded in mystery. It is the purpose of this chapter to help demystify the coagulation system, anticoagulants, biocompatible surfaces, and coagulation testing so that ECMO practitioners can make informed decisions about their patients and to spur coordinated efforts for future research to improve our understanding of these complex processes.

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Antithrombin Replacement During Extracorporeal Membrane Oxygenation

Cited by 99 publications

References 21 publications

Antithrombin Administration During Intravenous Heparin Anticoagulation in the Intensive Care Unit: A Single-Center Matched Retrospective Cohort Study

Antithrombin Administration During Intravenous Heparin Anticoagulation in the Intensive Care Unit: A Single-Center Matched Retrospective Cohort Study

Antithrombin III Doses Rounded to Available Vial Sizes in Critically Ill Pediatric Patients

ECMO Biocompatibility: Surface Coatings, Anticoagulation, and Coagulation Monitoring

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