Correlation of thromboelastography with standard tests of anticoagulation in paediatric patients receiving extracorporeal life support

Alexander, David C.; Butt, Warwick; Best, James D.; Donath, Susan; Monagle, Paul; Shekerdemian, Lara

doi:10.1016/j.thromres.2009.07.001

Cited by 72 publications

(58 citation statements)

References 20 publications

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“…Nevertheless, Brealey et al (10) reported that mitochondrial function is impaired in skeletal muscle biopsy specimens obtained from patients with ultimately lethal sepsis. Similar findings were subsequently reported by Fredriksson et al (11). Interestingly, these findings were not confirmed by Protti et al (12).…”

supporting

confidence: 81%

“…The thromboelastogram (TEG) is a whole blood POCT of the viscoelastic properties of clot formation that measures the integrity of the coagulation cascade from the time of fibrin formation to clot lysis and importantly includes the contribution of cells: red cells, white cells, and platelets. TEG/ROTEM provides information relating to multiple phases of coagulation in whole blood, which is extremely relevant to ECLS patients since there may be more than one reason for coagulation abnormalities (11).…”

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confidence: 99%

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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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supporting

confidence: 81%

mentioning

confidence: 99%

Monitoring of Anticoagulation in Extracorporeal Membrane Oxygenation

Lequier

Massicotte

2015

Pediatric Critical Care Medicine

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“…R is typically associated with soluble clotting factors, thus representing the intrinsic pathway of coagulation 38. Some TEG studies have reported good correlation between R and PT or aPTT 39, 40, 41. Similarly in a canine study using rotational thromboelastometry, PT was significantly correlated with coagulation time (similar to R), clot formation time (equivalent to K), α angle, and maximum clot firmness (similar to MA), but aPTT was not.…”

Section: Discussionmentioning

confidence: 80%

Effect of Synthetic Colloid Administration on Coagulation in Healthy Dogs and Dogs with Systemic Inflammation

Gauthier

Holowaychuk

Kerr

et al. 2015

Veterinary Internal Medicne

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BackgroundSynthetic colloids are often used during fluid resuscitation and affect coagulation.ObjectiveTo compare the effects of an isotonic crystalloid and synthetic colloid on coagulation in healthy dogs and dogs with systemic inflammation.AnimalsSixteen adult purpose‐bred Beagles.MethodsRandomized, placebo‐controlled, blinded study. Dogs were randomized into one of two groups receiving fluid resuscitation with either 40 mL/kg IV 0.9% NaCl or tetrastarch after administration of lipopolysaccharide or an equal volume of placebo. After a 14‐day washout period, the study was repeated such that dogs received the opposite treatment (LPS or placebo) but the same resuscitation fluid. Blood samples were collected at 0, 1, 2, 4, and 24 hours for measurement of coagulation variables.ResultsAdministration of either fluid to healthy dogs and dogs with systemic inflammation resulted in similar increases in prothrombin time and activated clotting time. In comparison to saline administration, tetrastarch administration resulted in significantly decreased R (P = .017) in healthy dogs, as well as significantly increased activated partial thromboplastin time (P ≤ .016), CL30% (P ≤ .016), and K (P < .001) and significantly decreased platelet count (P = .019), α (P ≤ .001), MA (P < .001), and von Willebrand factor antigen (P < .001) and collagen binding activity (P ≤ .003) in both healthy dogs and dogs with systemic inflammation.Conclusions and Clinical ImportanceTetrastarch bolus administration to dogs with systemic inflammation resulted in a transient hypocoagulability characterized by a prolonged activated partial thromboplastin time, decreased clot formation speed and clot strength, and acquired type 1 von Willebrand disease.

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“…Various laboratory tests exist that measure specific components of the hemostatic system, including anti-Xa, activated thromboplastin time (aPTT), prothrombin time (PT), and international normalized ratio (INR), but none of these gives a complete picture of hemostasis[7,10-12]. Thromboelastography (TEG) has been proposed to more accurately demonstrate the in vivo state of hemostasis[13,14].…”

Section: Introductionmentioning

confidence: 99%

Utility and correlation of known anticoagulation parameters in the management of pediatric ventricular assist devices

Bhatia¹,

Yabrodi²,

Carroll³

et al. 2017

WJC

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AIMTo assess utility and correlation of known anticoagulation parameters in the management of pediatric ventricular assist device (VAD).METHODSRetrospective study of pediatric patients supported with a Berlin EXCOR VAD at a single pediatric tertiary care center during a single year.RESULTSWe demonstrated associations between activated thromboplastin time (aPTT) and R-thromboelastography (R-TEG) values (rs = 0.65, P < 0.001) and between anti-Xa assay and R-TEG values (rs = 0.54, P < 0.001). The strongest correlation was seen between aPTT and anti-Xa assays (rs = 0.71, P < 0.001). There was also a statistically significant correlation between platelet counts and the maximum amplitude of TEG (rs = 0.71, P < 0.001). Importantly, there was no association between dose of unfractionated heparin and either measure of anticoagulation (aPTT, anti-Xa or R-TEG value).CONCLUSIONThis study suggests that while there is strong correlation between aPTT, anti-Xa assay and R-TEG values for patients requiring VAD support, there is a lack of relevant correlation between heparin dose and degree of effect. This raises concern as various guidelines continue to recommend using these parameters to titrate heparin therapy.

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Correlation of thromboelastography with standard tests of anticoagulation in paediatric patients receiving extracorporeal life support

Cited by 72 publications

References 20 publications

Monitoring of Anticoagulation in Extracorporeal Membrane Oxygenation

Monitoring of Anticoagulation in Extracorporeal Membrane Oxygenation

Effect of Synthetic Colloid Administration on Coagulation in Healthy Dogs and Dogs with Systemic Inflammation

Utility and correlation of known anticoagulation parameters in the management of pediatric ventricular assist devices

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