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Benegni S, Giorni C, Raggi V, Garisto C, Iodice FG, Rizza A, Marinari E, Favia I, Piga S, Buonomo C, Di Chiara L, Atti MLCD, Ricci Z. Diagnostic Agreement Between TEG5000 and TEG6S in the Assessment of Hemostasis in Pediatric Cardiac Surgery: A Prospective Non-inferiority Study. Pediatr Cardiol 2023:10.1007/s00246-023-03311-w. [PMID: 37787785 DOI: 10.1007/s00246-023-03311-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 09/25/2023] [Indexed: 10/04/2023]
Abstract
Thromboelastography (TEG) is a point-of-care test (POCT) used to analyze the hemostatic properties of whole blood. TEG® 5000and TEG® 6s (Haemonetics Corp, USA) measure the same parameters describing clot viscoelasticity using different methodologies. The purpose of this study was to evaluate agreement between TEG5000 and TEG6s measurements. We analyzed prospectively collected tests resulting from paired blood samples in cardiac surgery pediatric patients at one hour (T0) and 24 h (T1) postoperatively. Each citrated sample was utilized for TEG® 5000 and TEG ®6s. Six specific TEG parameters were analyzed and compared: R kaolin time (RK), R kaolin heparinase (RKH) time, K kaolin time (KK), K kaolin heparinase time KH (KKH), Maximum Amplitude kaolin (MAK), Maximal Amplitude Kaolin Heparinase (MAKH). We enrolled 30 patients. Median (interquartile range) patients' age was 206 (20-597) days. All surgical patients underwent correction except 5 who were palliated. At T0, RK and RKH showed an average (standard deviation) % bias of 15.8 (31) and 16.1 (28), respectively, with similar results at T1. A % bias of -6 (23) and - 6 [15] in MAK was found at T0 and T1, respectively. Similarly, MAKH % bias was 1.5 (22) and 7.6 (29) at T0 and T1, respectively. At both timepoints, low % biases (< ± 6%) were demonstrated in KK and KKH. All parameters showed improved coagulation from T0 to T1, but without significant interaction between type of device and time. Analysis of the entire pool of 60 paired samples showed no agreement in diagnostic performance (within the range vs. outside the range) in 12 (20%), 5 (9.8%), 1 (1.7%), 4 (7.8%), 9 (15%), and 5 (9.8%) cases for RK, RKH, MAK, MAKH, KK and KKH, respectively. We observed substantial agreement in MAK and KK in a cohort of pediatric patients undergoing uncomplicated cardiac surgery. Our findings suggest that TEG®5000 and TEG®6s are interchangeable for assessing these parameters.
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Affiliation(s)
- Simona Benegni
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Piazza S.Onofrio 4, Rome, 00165, Italy.
| | - Chiara Giorni
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Piazza S.Onofrio 4, Rome, 00165, Italy
| | - Valeria Raggi
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Piazza S.Onofrio 4, Rome, 00165, Italy
| | - Cristiana Garisto
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Piazza S.Onofrio 4, Rome, 00165, Italy
| | - Francesca Giovanna Iodice
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Piazza S.Onofrio 4, Rome, 00165, Italy
| | - Alessandra Rizza
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Piazza S.Onofrio 4, Rome, 00165, Italy
| | - Eleonora Marinari
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Piazza S.Onofrio 4, Rome, 00165, Italy
| | - Isabella Favia
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Piazza S.Onofrio 4, Rome, 00165, Italy
| | - Simone Piga
- Clinical Epidemiology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Chiara Buonomo
- Department of Anesthesia and Critical Care, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Luca Di Chiara
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Piazza S.Onofrio 4, Rome, 00165, Italy
| | | | - Zaccaria Ricci
- Pediatric Intensive Care Unit, Meyer Children's University Hospital, IRCCS, Florence, Italy
- Department of Health Sciences, Section of Anesthesiology and Intensive Care, University of Florence, Florence, Italy
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Maroney SA, Peterson JA, Zwifelhofer W, Martinez ND, Yan K, Bercovitz RS, Woods RK, Mast AE. Plasma Proteolytic Cascade Activation during Neonatal Cardiopulmonary Bypass Surgery. Thromb Haemost 2018; 118:1545-1555. [PMID: 30086574 DOI: 10.1055/s-0038-1667198] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Neonates undergoing cardiopulmonary bypass (CPB) surgery to correct congenital heart defects often experience excessive bleeding. Exposure of blood to artificial materials during CPB may activate coagulation, complement and inflammatory pathways. In addition, the surgical stress placed on the haemostatic system may result in cross-activation of other plasma proteolytic cascades, which could further complicate physiological responses to the surgical procedure and post-operative recovery. Plasma protease inhibitors undergo distinct conformational changes upon interaction with proteases, and, thereby, can serve as endogenous biosensors to identify activation of the different proteolytic cascades. We tested the hypothesis that changes in the concentration and conformation of protease inhibitors regulating plasma proteolytic cascades during neonatal CPB are associated with post-operative bleeding. PATIENTS AND METHODS Plasma samples from 44 neonates were obtained at four time points across the surgical procedure. Anti-thrombin, antitrypsin, anti-chymotrypsin, anti-plasmin, C1-inhibitor and tissue factor pathway inhibitor (TFPI) concentrations and conformations were evaluated by enzyme-linked immunosorbent assay, transverse urea gradient gel electrophoresis and sodium dodecyl sulphate-polyacrylamide gel electrophoresis. RESULTS/CONCLUSION The most striking changes were observed following heparin administration and were associated with the appearance of inactive forms of anti-thrombin and an increase in the plasma concentration of TFPI. Changes in anti-thrombin and TFPI remained evident throughout surgery and into the post-operative period but were not different between patients with or without post-operative bleeding. The concentration of antitrypsin decreased across surgery, but there was no significant accumulation of inactive conformations of any inhibitor besides anti-thrombin, indicating that widespread cross-activation of other plasma proteolytic cascades by coagulation proteases did not occur.
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Affiliation(s)
- Susan A Maroney
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, Wisconsin, United States
| | - Julie A Peterson
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, Wisconsin, United States
| | - Wes Zwifelhofer
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, Wisconsin, United States
| | - Nicholas D Martinez
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, Wisconsin, United States
| | - Ke Yan
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - Rachel S Bercovitz
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, Wisconsin, United States.,Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, United States.,Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - Ronald K Woods
- Division of Pediatric Cardiothoracic Surgery, Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, United States.,Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - Alan E Mast
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, Wisconsin, United States.,Department of Cell Biology, Neurobiology and Anatomy, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
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Hanslik A, Kitzmüller E, Tran US, Thom K, Karapetian H, Prutsch N, Voitl J, Michel-Behnke I, Newall F, Male C. Anti-activated factor II assay for monitoring unfractionated heparin in children: results of the HEARTCAT study. J Thromb Haemost 2017; 15:38-46. [PMID: 27736032 DOI: 10.1111/jth.13539] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Indexed: 11/30/2022]
Abstract
Essentials Unfractionated heparin has variable effects in children and therefore, monitoring is essential. A randomized controlled trial substudy investigating an anti-IIa assay in children was conducted. Anti-IIa values are lower in younger children, an effect more pronounced at low-dose heparin. Heparin effect on Xa and IIa is not equal, particularly in infants and after high-dose heparin. SUMMARY Background Unfractionated heparin (UFH) is used for the prophylaxis and treatment of thrombosis in children. Laboratory monitoring of UFH is needed to prevent over-anticoagulation or under-anticoagulation. Objectives To investigate the association between UFH dose and UFH effect as monitored with the anti-activated factor II (FIIa) assay, the relationship between anti-FIIa and anti-activated factor X (FXa) effects, and the influence of patient age and other factors on UFH effect. Patients and methods This was a randomized controlled trial in children during cardiac catheterization, comparing high-dose UFH (100 units kg-1 bolus) with low-dose UFH (50 units kg-1 bolus). Blood samples were drawn at baseline, and after 30 min, 60 min, and 90 min. For the purpose of this study, 49 children and 117 blood samples were evaluated. Results The anti-FIIa assay discriminated well between high-dose and low-dose UFH. Multiple regression demonstrated significant influences of UFH dose and age on anti-FIIa levels. Younger children had lower anti-FIIa levels than older children, an effect that was more pronounced with low-dose UFH. Anti-FXa/anti-FIIa ratios were equal with low-dose UFH. However, anti-FXa levels were relatively increased over anti-FIIa levels in infants and after high-dose UFH bolus administration. Conclusion The UFH effect on anti-FIIa levels is lower in infants than in older children. This influence of age appears to be dose-dependent, being more pronounced with low-dose UFH. Anti-FXa and anti-FIIa levels are not equal, particularly in infants and after high-dose UFH. Monitoring UFH solely with anti-FXa assays may not be sufficient in children, and the anti-FIIa assay may provide important complementary information.
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Affiliation(s)
- A Hanslik
- Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - E Kitzmüller
- Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - U S Tran
- School of Psychology, University of Vienna, Vienna, Austria
| | - K Thom
- Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - H Karapetian
- Anesthesia and Intensive Care Medicine, Sozialmedizinisches Zentrum Ost, Vienna, Austria
| | - N Prutsch
- Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - J Voitl
- Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - I Michel-Behnke
- Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - F Newall
- Clinical Haematology & Nursing Research, Royal Children's Hospital, Melbourne, Australia
- Haematology Research Group, Murdoch Children's Research Institute and Departments of Paediatrics and Nursing, The University of Melbourne, Melbourne, Australia
| | - C Male
- Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
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Manlhiot C, Brandão LR, Schwartz SM, Sivarajan VB, Williams S, Collins TH, McCrindle BW. Management and Outcomes of Patients with Occlusive Thrombosis after Pediatric Cardiac Surgery. J Pediatr 2016; 169:146-53. [PMID: 26589345 DOI: 10.1016/j.jpeds.2015.10.046] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 08/24/2015] [Accepted: 10/13/2015] [Indexed: 01/08/2023]
Abstract
OBJECTIVES To evaluate management and outcomes of thrombosis after pediatric cardiac surgery and stratify thrombi according to risk of short- and long-term complications to better guide therapeutic choices. STUDY DESIGN Retrospective review was performed of 513 thrombi (400 occlusive) diagnosed after 213 pediatric cardiac operations. Long-term outcomes over time were assessed with the use of parametric hazard regression models. RESULTS Serious complications and/or high-intensity treatment occurred with 17%-24% of thrombi depending on location, most commonly in thrombi affecting the cardiac and cerebral circulation. Bleeding complications affected 13% of patients; associated factors included thrombolytics (OR 8.7, P < .001), greater daily dose of unfractionated heparin (OR 1.25 per 5 U/kg/day, P = .03), and extracorporeal support (OR 4.5, P = .007). Radiologic thrombus persistence was identified in 30% ± 3% at 12 months; associated factors included extracorporeal support (hazard ratio [HR] 1.9, P = .003), venous (HR 1.7, P = .003), and occlusive thrombi at presentation (HR 1.8, P = .001); greater oxygen saturation before surgery (HR 1.13/10%, P = .05) and thrombi in femoral veins (HR 1.9, P = .001) were associated with increased hazard of resolution. Freedom from postthrombotic syndrome was 83% ± 4% at 6 years, greater number of persistent vessel segment occlusions (HR 1.8/vessel, P = .001) and greater fibrinogen at diagnosis (HR 1.1 per g/L, P = .02) were associated with increased hazard. CONCLUSIONS Thrombosis outcomes after pediatric cardiac surgery remain suboptimal. Given that more intensive treatment would likely increase the risk of bleeding, the focus should be on both thrombosis-prevention strategies, as well as in tailoring therapy according to a thrombosis outcome risk stratification approach.
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Affiliation(s)
- Cedric Manlhiot
- Labatt Family Heart Centre, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada
| | - Leonardo R Brandão
- Division of Hematology/Oncology, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada
| | - Steven M Schwartz
- Labatt Family Heart Centre, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada
| | - V Ben Sivarajan
- Labatt Family Heart Centre, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada
| | - Suzan Williams
- Division of Hematology/Oncology, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada
| | - Tanveer H Collins
- Labatt Family Heart Centre, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada
| | - Brian W McCrindle
- Labatt Family Heart Centre, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada.
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Monitoring unfractionated heparin in children: a parallel-cohort randomized controlled trial comparing 2 dose protocols. Blood 2015; 126:2091-7. [PMID: 26239090 DOI: 10.1182/blood-2015-06-651661] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 07/30/2015] [Indexed: 11/20/2022] Open
Abstract
Monitoring unfractionated heparin (UFH) is crucial to prevent over- or under-anticoagulation. However, the optimal parameters for monitoring UFH in children are not well established. The study objectives were to investigate (1) the relationship between UFH dose and its anticoagulant effect as assessed by anti-Xa, activated partial thromboplastin time (aPTT) and activated clotting time (ACT); (2) other factors influencing UFH effect; (3) the agreement between the assays; and (4) the association between UFH effect and clinical outcome. HEARTCAT was a parallel-cohort randomized controlled trial comparing high-dose (100 U/kg bolus followed by age-based continuous infusion in randomized children) vs low-dose UFH (50 U/kg bolus) during cardiac catheterization in children. Blood samples were drawn before and after UFH administration at 30, 60, and 90 minutes. Four-hundred and two samples of 149 patients were evaluable. Anti-Xa, aPTT, and ACT all showed good discrimination between UFH doses. Regression models demonstrated the following determinants of UFH effect: UFH dose, age, baseline antithrombin (for anti-Xa), and baseline levels of aPTT and ACT, respectively. UFH effects were lower in infants compared with older children, which was more pronounced at low-dose than at high-dose UFH. Agreement between the 3 assays was poor. Most aPTT values were above therapeutic range or beyond measuring limit and thus of limited value for UFH monitoring. No association of UFH dose or effect with clinical outcome could be observed. In conclusion, all assays reflected a significant UFH dose-effect relationship, however, with poor agreement between the respective tests. The age-dependency of UFH effect was confirmed. Notably, the influence of age on UFH effect was dose-dependent.
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Giglia TM, DiNardo J, Ghanayem NS, Ichord R, Niebler RA, Odegard KC, Massicotte MP, Yates AR, Laussen PC, Tweddell JS. Bleeding and Thrombotic Emergencies in Pediatric Cardiac Intensive Care. World J Pediatr Congenit Heart Surg 2012; 3:470-91. [DOI: 10.1177/2150135112460866] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Children in the cardiac intensive care unit (CICU) with congenital or acquired heart disease are at risk for hematologic complications, both hemorrhage and thrombosis. The overall incidence of hematologic complications in the CICU is unknown, but risk factors and target groups have been identified where the essential physiologic balance between bleeding and clotting has been disrupted. Although the best management of life-threatening bleeding and clotting is prevention, the cardiac intensivist is often faced with managing life-threatening hematologic events involving patients from within the unit or those who present from outside. Part I of this review deals with the propensity of children with congenital and acquired heart disease to complications of both bleeding and clotting, and includes discussions of perioperative bleeding, thromboses in single-ventricle patients, clotting of Blalock-Taussig shunts and thrombotic complications of mechanical valves. Part II deals with the subject of stroke in children with heart disease. Part III reviews monitoring the effectiveness of anticoagulation and thrombolysis in the CICU. Currently available diagnostics modalities, medications and management strategies are reviewed and future directions discussed.
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Affiliation(s)
- Therese M. Giglia
- Division of Cardiology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - James DiNardo
- Division of Cardiac Anesthesia, Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Nancy S. Ghanayem
- Division of Critical Care, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Rebecca Ichord
- Division of Neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Robert A. Niebler
- Division of Critical Care, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Kirsten C. Odegard
- Division of Cardiovascular Critical Care, Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - M. Patricia Massicotte
- Department of Pediatrics, Stoller Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Andrew R. Yates
- Sections of Cardiology and Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Peter C. Laussen
- Division of Cardiovascular Critical Care, Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - James S. Tweddell
- Division of Critical Care, Children's Hospital of Wisconsin, Milwaukee, WI, USA
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Attard C, Cini C, Monagle P, Ignjatovic V. The impact of cardiopulmonary bypass on factor XIII levels in children. Thromb Res 2012; 130:e238-9. [PMID: 22939429 DOI: 10.1016/j.thromres.2012.08.298] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Revised: 08/08/2012] [Accepted: 08/14/2012] [Indexed: 11/30/2022]
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Ignjatovic V, Newall F, Monagle P. Heparin concentrations in neonates during cardiopulmonary bypass: a rebuttal. J Thromb Haemost 2012; 10:1972. [PMID: 22642367 DOI: 10.1111/j.1538-7836.2012.04796.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Ignjatovic V, Chandramouli A, Than J, Summerhayes R, Newall F, Horton S, Cochrane A, Monagle P. Plasmin generation and fibrinolysis in pediatric patients undergoing cardiopulmonary bypass surgery. Pediatr Cardiol 2012; 33:280-5. [PMID: 21965124 DOI: 10.1007/s00246-011-0122-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Accepted: 09/12/2011] [Indexed: 11/27/2022]
Abstract
This prospective, single-centre cohort study aimed to evaluate plasmin generation and fibrinolysis during and after cardiopulmonary bypass (CPB) surgery in a cohort of children up to 6 years of age. Blood samples were drawn at eight time points: after induction of anesthesia, before unfractionated heparin (UFH), after UFH, after initiation of bypass, before protamine, after protamine, after chest closure, and 6 h after chest closure. The study identified an increase in fibrinolysis during CPB and particularly up to 6 h afterward in children. This could be the mechanism for the significant bleeding events observed in this young population after CPB. This study establishes the foundation for future studies in this area, particularly those focusing on clinical outcomes after CPB surgery.
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