Clinical Measures of Heparin’s Effect and Thrombin Inhibitor Levels in Pediatric Patients with Congenital Heart Disease

Guzzetta, Nina A.; Miller, Bruce E.; Todd, Kathy; Szlam, Fania; Moore, Reneé H.; Brosius, Keith K.; Wilson, Elizabeth; Cohen, Anna; Tosone, Steven R.

doi:10.1213/01.ane.0000247963.40082.8b

Cited by 28 publications

(4 citation statements)

References 26 publications

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“…Pediatric heart surgery produces parameters that must be considered when looking at adequate anticoagulation and reaching target ACTs: CPB influences, pediatric physiology, and heparin weight-based dosing deduced from adult protocols. As a result of changes in blood viscosity, plasma clotting factor concentrations, platelet function, and hypothermic temperature on CPB, a falsely high ACT could be measured (1,(6)(7)(8)(9)(10)(11). Additionally, the developing immune system of neonates reacts with a variety of CPB contact activation factors such as factor XII, factor XI, prekallikrein, and high-molecularweight kininogen, which can also lead to misinterpreting prolonged ACTs.…”

Section: Discussionmentioning

confidence: 99%

“…Additionally, the developing immune system of neonates reacts with a variety of CPB contact activation factors such as factor XII, factor XI, prekallikrein, and high-molecularweight kininogen, which can also lead to misinterpreting prolonged ACTs. Another factor to consider when looking at the neonatal population is the recognition of congenital heart defects and the administration of prostaglandin E1, an inhibitor of platelet aggregation, may prolong the ACT (1,9). Overall, the influences of CPB and physiology can lead to a prolongation of ACT, which could result in error and risks of inadequate anticoagulation (1,(6)(7)(8)(9).…”

Section: Discussionmentioning

confidence: 99%

“…Another factor to consider when looking at the neonatal population is the recognition of congenital heart defects and the administration of prostaglandin E1, an inhibitor of platelet aggregation, may prolong the ACT (1,9). Overall, the influences of CPB and physiology can lead to a prolongation of ACT, which could result in error and risks of inadequate anticoagulation (1,(6)(7)(8)(9).…”

Section: Discussionmentioning

confidence: 99%

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Effect of New Heparin Potency on Activated Clotting Time during Pediatric Cardiac Surgery: A Retrospective Chart Review

Thompson¹,

Alred²,

Deyo³

et al. 2014

J Extra Corpor Technol

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In 2009, the U.S Food and Drug Administration (FDA) announced a two-phase change in unfractionated heparin to reduce contamination and create a new potency reference. The FDA announced the change would bring about a 10% decrease in potency from the old heparin (OH) to new heparin (NH). The purpose of this article is to compare heparin in pediatric patients undergoing cardiac surgery before and after the FDA changes. After Institutional Review Board approval, a retrospective chart review was conducted with pediatric patients (n = 266) undergoing cardiac surgery. All patients received a heparin loading dose of 400 IU/kg and data collected included patient demographics, baseline activated clotting time (ACT), ACT after initial heparin dose, and heparin dose–response. These data were then further broken down into age blocks consisting of neonates (<1 month), 1–12 months, 1–5 years old, and older than 5 years old. In 17.3% of cases in the NH group, the ACT after the initial heparin dose did not reach the critical value of 400 seconds necessary for initiation of cardiopulmonary bypass (CPB). This is significantly higher than the 8.9% of cases in the OH group (p < .05). There was an overall trend among age groups that the NH was less potent than OH. However, only the 1–5 years of age group showed significance at p < .05. Given the median ACTs 591 seconds for OH and 484 seconds for NH, the calculated percentage difference was 18.1%. The results from this retrospective pediatric chart review indicate that the change in heparin potency greatly deviates from the 10% change reported by the FDA. In conclusion, NH has a trend of lower potency and frequent monitoring is necessary to maintain a safe level of anticoagulation during CPB.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Effect of New Heparin Potency on Activated Clotting Time during Pediatric Cardiac Surgery: A Retrospective Chart Review

Thompson¹,

Alred²,

Deyo³

et al. 2014

J Extra Corpor Technol

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“…Studies suggest that using AT supplementation to maintain normal AT activity levels may attenuate the consumption of coagulation factors, platelets, and potentially the associated inflammatory response that occurs secondary to inadequate anticoagulation (7)(8)(9). Additionally, neonates have reduced AT activity levels that do not reach those of healthy adults until 3-6 months of age (10,11). Coupled with data demonstrating deteriorating AT activity levels over time while supported on ECMO, these factors have led some to suggest that pediatric patients on ECMO may benefit from AT supplementation (12,13).…”

mentioning

confidence: 99%

Initial Experience with Recombinant Antithrombin to Treat Antithrombin Deficiency in Patients on Extracorporeal Membrane Oxygenation

Niimi¹,

Fanning²

2014

J Extra Corpor Technol

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Acquired antithrombin (AT) deficiency has been associated with patients on extracorporeal membrane oxygenation (ECMO) as a result of hemodilution, blood coagulation activation, and the use of heparin. Replacement of AT has been typically utilized through the use of fresh-frozen plasma or AT concentrate. Antithrombin alfa (ATryn®) is a recombinant form of AT (rAT) with an identical amino acid sequence as that of plasma-derived antithrombin. The primary objective of this study is to examine the relationship of rAT dose to measured plasma antithrombin activity in a small series of patients who received rAT while on ECMO. A retrospective chart review was performed of all patients at Medical City Children’s Hospital who received ATryn while supported on ECMO between December 2011 and April 2012. Five patients were identified and the patients’ weight, bolus dose of ATryn, drip rate of ATryn, and AT blood levels were collected for analysis. The median age of these patients was 1 month (range, 1 day to 3.75 years). Because no dosing guidelines exist for pediatric ECMO, a starting dose of ATryn was chosen based on the manufacturer’s labeled indication (prevention of thromboembolic events in patients with AT hereditary deficiency). The median dose of rAT was 368 IU/kg/day (range, 104–520 IU/kg/day) to obtain AT activity level of 80–120%. The average time to reach the targeted AT activity level (80–120%) was 12.7 hours (range, 11–17 hours). Our findings suggest that the published ATryn dose may be inadequate to reach desired AT activity concentrations for pediatric patients on ECMO. Difference in patient population, use of extracorporeal circuits, and the use of heparin are likely explanations for this finding. We would also recommend frequent checking of AT levels while delivering this drug because making timely adjustments is necessary for achieving and maintaining the target AT activity level.

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Management of Pediatric Cardiopulmonary Bypass

Berkowitz

Gaynor

2012

Pediatric Cardiac Surgery

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Clinical Measures of Heparin’s Effect and Thrombin Inhibitor Levels in Pediatric Patients with Congenital Heart Disease

Cited by 28 publications

References 26 publications

Effect of New Heparin Potency on Activated Clotting Time during Pediatric Cardiac Surgery: A Retrospective Chart Review

Effect of New Heparin Potency on Activated Clotting Time during Pediatric Cardiac Surgery: A Retrospective Chart Review

Initial Experience with Recombinant Antithrombin to Treat Antithrombin Deficiency in Patients on Extracorporeal Membrane Oxygenation

Management of Pediatric Cardiopulmonary Bypass

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