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Giorni C, Rizza A, Favia I, Amodeo A, Chiusolo F, Picardo SG, Luciani M, Di Felice G, Di Chiara L. Pediatric Mechanical Circulatory Support: Pathophysiology of Pediatric Hemostasis and Available Options. Front Cardiovasc Med 2021; 8:671241. [PMID: 34540910 PMCID: PMC8440876 DOI: 10.3389/fcvm.2021.671241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 06/17/2021] [Indexed: 01/01/2023] Open
Abstract
Pediatric mechanical circulatory support (MCS) is considered a strategy for heart failure management as a bridge to recovery and transplantation or as a destination therapy. The final outcome is significantly impacted by the number of complications that may occur during MCS. Children on ventricular assist devices (VADs) and extracorporeal membrane oxygenation (ECMO) are at high risk for bleeding and thrombotic complications that are managed through anticoagulation. The first detailed guideline in pediatric VADs (Edmonton Anticoagulation and Platelet Inhibition Protocol) was based on conventional antithrombotic drugs, such as unfractionated heparin (UFH) and warfarin. UFH is the first-line anticoagulant in pediatric MCS, although its profile is not considered optimal in pediatric setting. The broad variation in heparin doses among children is associated with frequent occurrence of cerebrovascular accidents, bleeding, and thrombocytopenia. Direct thrombin inhibitors (DTIs) have been utilized as alternative strategies to heparin. Since 2018, bivalirudin has become the chosen anticoagulant in the long-term therapy of patients undergoing MCS implantation, according to the most recent protocols shared in North America. This article provides a review of the non-traditional anticoagulation strategies utilized in pediatric MCS, focusing on pharmacodynamics, indications, doses, and monitoring aspects of bivalirudin. Moreover, it exposes the efforts and the collaborations among different specialized centers, which are committed to an ongoing learning in order to minimize major complications in this special pediatric population. Further prospective trials regarding DTIs in a pediatric MCS setting are necessary and in specific well-designed randomized control trials between UFH and bivalirudin. To conclude, based on the reported literature, the clinical use of the bivalirudin in pediatric MCS seems to be a value added in controlling and maybe reducing thromboembolic complications. Further research is necessary to confirm all the results provided by this literature review.
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Affiliation(s)
- Chiara Giorni
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Alessandra Rizza
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Isabella Favia
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Antonio Amodeo
- Mechanical Circulatory Support Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Fabrizio Chiusolo
- Department of Anesthesia and Critical Care, Anestesia Rianimazione Comparto Operatorio, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Sergio G Picardo
- Department of Anesthesia and Critical Care, Anestesia Rianimazione Comparto Operatorio, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Matteo Luciani
- Department of Oncohematology, Haemostasis and Thrombosis Center, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Giovina Di Felice
- Hemostasis Laboratory, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Luca Di Chiara
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
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2
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Challenges and Opportunities in the Pharmacological Treatment of Acute Venous Thromboembolism in Children. Paediatr Drugs 2020; 22:385-397. [PMID: 32519267 DOI: 10.1007/s40272-020-00403-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Venous thromboembolism (VTE) is an important but historically under-recognized problem in pediatrics, with an incidence concentrated in hospitalized children. A number of specific VTE diseases with discrete triggers have been described, but the most common pediatric trigger is the presence of central venous access devices. VTE diseases, though heterogenous in etiology, are linked by the common therapeutic strategies shared by their management. Historically, the most commonly used drug therapies have been unfractionated heparin, low-molecular-weight heparins, and vitamin K antagonists, based on extrapolation from adult data rather than any specific pediatric trials. Although these widely used drugs appear safe and effective in expert hands, the historical lack of pediatric data is problematic in view of the recognized significant differences between children and adults with regards to hemostatic physiology, VTE etiology, and drug pharmacokinetics. The increasing adult usage of novel VTE pharmacotherapies such as direct oral anticoagulants (DOACs) has led to considerable interest in exploring the pediatric applications of these newer drugs. This review summarizes the advantages and disadvantages of existing VTE pharmacotherapies and outlines emerging novel pediatric VTE therapies, particularly DOACs, within the context of the current pediatric trial landscape.
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3
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Yaw HP, Van Den Helm S, MacLaren G, Linden M, Monagle P, Ignjatovic V. Platelet Phenotype and Function in the Setting of Pediatric Extracorporeal Membrane Oxygenation (ECMO): A Systematic Review. Front Cardiovasc Med 2019; 6:137. [PMID: 31620448 PMCID: PMC6759781 DOI: 10.3389/fcvm.2019.00137] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 08/29/2019] [Indexed: 11/13/2022] Open
Abstract
Background: Despite increasing technical improvement and extracorporeal membrane oxygenation (ECMO)-related knowledge over the past three decades, morbidity and mortality associated with bleeding and clotting complications remain high in pediatric patients undergoing ECMO. Platelets, a key element of the coagulation system, have been proposed to be the main cause of coagulopathy in the setting of ECMO. This systematic review aims to summarize and discuss the existing knowledge of platelet phenotype and function in the pediatric ECMO population. Methods: A systematic review was conducted for the Embase, Medline, and PubMed databases following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Results: The detailed study selection process yielded a total of 765 studies and only 3 studies that fulfilled the selection criteria were included in this review. Techniques used to assess platelet function in the three existing studies included platelet aggregometry, flow cytometry, and thromboelastography-platelet mapping. The finding that is common to the three studies is reduced platelet function in pediatric patients during ECMO either compared to before the initiation of ECMO or in non-survivors compared to survivors. Two studies demonstrated reduced platelet aggregation that are irreversible by platelet transfusion during ECMO. Two studies reported bleeding events and mortality in children on ECMO and none of the studies investigated thrombotic events. Conclusions: This systematic review demonstrates the extremely limited information available for platelet phenotype and function in the pediatric ECMO population. Evidence from the existing literature suggests reduced platelet aggregation and increased platelet activation in children during ECMO. However, this needs to be interpreted with care due to the limitations associated with the techniques used for platelet function testing. Furthermore, the association between platelet dysfunction and clinical outcomes in the pediatric ECMO population remains elusive. Multiple research gaps have been identified when it comes to the knowledge of platelet phenotype and function of children on ECMO, highlighting the need for robust, well-designed studies in this setting.
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Affiliation(s)
- Hui Ping Yaw
- Department of Haematology Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| | - Suelyn Van Den Helm
- Department of Haematology Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Graeme MacLaren
- Department of Haematology Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia.,Paediatric Intensive Care Unit, The Royal Children's Hospital, Melbourne, VIC, Australia.,Cardiothoracic Intensive Care Unit, National University Health System, Singapore, Singapore
| | - Matthew Linden
- School of Biomedical Sciences, The University of Western Australia, Perth, WA, Australia
| | - Paul Monagle
- Department of Haematology Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia.,Department of Clinical Haematology, The Royal Children's Hospital, Melbourne, VIC, Australia
| | - Vera Ignjatovic
- Department of Haematology Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
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4
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Voulgarelis S, Vitola B, Lerret SM, Hong JC, Scott JP. Perioperative anticoagulation practices for pediatric liver transplantation. Pediatr Transplant 2018; 22:e13193. [PMID: 29663585 DOI: 10.1111/petr.13193] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/12/2018] [Indexed: 12/13/2022]
Abstract
Despite continued advancements in perioperative care for pediatric liver transplant (LT), graft-threatening vascular occlusion events including hepatic artery thrombosis (HAT) and portal vein thrombosis (PVT) remain a source of significant morbidity and mortality. Perioperative anticoagulation is commonly used for the prevention of HAT and PVT, but evidence-based guidelines are lacking. The goals of this survey were to determine the frequency of use of an anticoagulation protocol and to describe variation in anticoagulation practices among pediatric LT centers. The study consisted of an online survey distributed to members of SPLIT. The survey focused on institutional anticoagulation practices employed to reduce the incidence of graft and life-threatening vascular occlusion events. Responses were received from 31 of 39 SPLIT centers. All respondents report using anticoagulation after pediatric LT, and approximately 90% have institutional anticoagulation protocols. Subgroup analysis of high volume pediatric LT centers revealed similar variability in anticoagulation patterns. All participating SPLIT centers reported the use of post-transplant anticoagulation and nearly all use a protocol. However, there is marked variability in the type and dose of anticoagulation as well as the timing of initiation and duration of therapy across centers.
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Affiliation(s)
- Stylianos Voulgarelis
- Divisions of Pediatric and Adult Cardiac Anesthesiology, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Bernadette Vitola
- Division of Gastroenterology, Hepatology, and Nutrition, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Stacee M Lerret
- Division of Gastroenterology and Transplant Surgery, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Johnny C Hong
- Division of Transplant Surgery, Department of Surgery, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - John P Scott
- Divisions of Pediatric Anesthesiology and Pediatric Critical Care, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI, USA.,Pediatric Liver Transplant Anesthesia, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI, USA.,Pediatric Intensive Care Unit, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI, USA
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5
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Egan JR, Kilo T, Winlaw DS. Goldilocks meets heparin dosing-enough but not too much. J Thorac Cardiovasc Surg 2018; 156:341-342. [PMID: 29653753 DOI: 10.1016/j.jtcvs.2018.03.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 03/07/2018] [Indexed: 10/17/2022]
Affiliation(s)
- Jonathan R Egan
- Paediatric Intensive Care, The Children's Hospital at Westmead, Sydney, New South Wales, Australia; School of Child and Adolescent Health, University of Sydney, Sydney, New South Wales, Australia
| | - Tatjana Kilo
- Department of Haematology, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - David S Winlaw
- Heart Centre for Children, The Children's Hospital at Westmead, Sydney, New South Wales, Australia; School of Child and Adolescent Health, University of Sydney, Sydney, New South Wales, Australia.
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6
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Newall F, Branchford B, Male C. Anticoagulant prophylaxis and therapy in children: current challenges and emerging issues. J Thromb Haemost 2018; 16:196-208. [PMID: 29316202 DOI: 10.1111/jth.13913] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
This review is aimed at describing the unique challenges of anticoagulant prophylaxis and treatment in children, and highlighting areas for research for improving clinical outcomes of children with thromboembolic disease. The evidence presented demonstrates the challenges of advancing the evidence base informing optimal management of thromboembolic disease in children. Recent observational studies have identified risk factors for venous thromboembolism in children, but there are few interventional studies assessing the benefit-risk balance of using thromboprophylaxis in risk-stratified clinical subgroups. A risk level-based framework is proposed for administering mechanical and pharmacological thromboprophylaxis. More research is required to refine the assignment of risk levels. The anticoagulants currently used predominantly in children are unfractionated heparin, low molecular weight heparin, and vitamin K antagonists. There is a paucity of robust evidence on the age-specific pharmacology of these agents, and their efficacy and safety for prevention and treatment of thrombosis in children. The available literature is heterogeneous, reflecting age-specific differences, and the various clinical settings for anticoagulation in children. Monitoring assays and target ranges are not well established. Nevertheless, weight-based dosing appears to achieve acceptable outcomes in most indications. Given the limitations of the classical anticoagulants for children, there is great interest in the direct oral anticoagulants (DOACs), whose properties appear to be particularly suitable for children. All DOACs currently approved for adults have Pediatric Investigation Plans ongoing or planned. These are generating age-specific formulations and systematic dosing information. The ongoing pediatric studies still have to establish whether DOACs have a positive benefit-risk balance in the various pediatric indications and age groups.
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Affiliation(s)
- F Newall
- Clinical Haematology & Nursing Research, Royal Children's Hospital, Haematology Research Group, Murdoch Childrens Research Institute and Departments of Paediatrics and Nursing, The University of Melbourne, Melbourne, Australia
| | - B Branchford
- Department of Pediatrics, Section of Hematology/Oncology/Bone Marrow Transplant and the Hemophilia and Thrombosis Center, School of Medicine and Center for Cancer and Blood Disorders, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - C Male
- Haemostasis and Thrombosis Unit, Department of Paediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
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Annich GM, Zaulan O, Neufeld M, Wagner D, Reynolds MM. Thromboprophylaxis in Extracorporeal Circuits: Current Pharmacological Strategies and Future Directions. Am J Cardiovasc Drugs 2017; 17:425-439. [PMID: 28536932 DOI: 10.1007/s40256-017-0229-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The development of extracorporeal devices for organ support has been a part of medical history and progression since the late 1900s. These types of technology are primarily used and developed in the field of critical care medicine. Unfractionated heparin, discovered in 1916, has really been the only consistent form of thromboprophylaxis for attenuating or even preventing the blood-biomaterial reaction that occurs when such technologies are initiated. The advent of regional anticoagulation for procedures such as continuous renal replacement therapy and plasmapheresis have certainly removed the risks of systemic heparinization and heparin effect, but the challenges of the blood-biomaterial reaction and downstream effects remain. In addition, regional anticoagulation cannot realistically be applied in a system such as extracorporeal membrane oxygenation because of the high blood flow rates needed to support the patient. More recently, advances in the technology itself have resulted in smaller, more compact extracorporeal life support (ECLS) systems that can-at certain times and in certain patients-run without any form of anticoagulation. However, the majority of patients on ECLS systems require some type of systemic anticoagulation; therefore, the risks of bleeding and thrombosis persist, the most devastating of which is intracranial hemorrhage. We provide a concise overview of the primary and alternate agents and monitoring used for thromboprophylaxis during use of ECLS. In addition, we explore the potential for further biomaterial and technologic developments and what they could provide when applied in the clinical arena.
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Affiliation(s)
- Gail M Annich
- Department of Critical Care Medicine, The Hospital for Sick Children, University of Toronto, 555 University Avenue, M5G 1X8, Toronto, ON, Canada.
| | - Oshri Zaulan
- Department of Critical Care Medicine, The Hospital for Sick Children, University of Toronto, 555 University Avenue, M5G 1X8, Toronto, ON, Canada
| | - Megan Neufeld
- Department of Chemistry, Colorado State University, Fort Collins, Colorado, USA
| | - Deborah Wagner
- Departments of Pharmacology and Anesthesia, University of Michigan, Ann Arbor, Michigan, USA
| | - Melissa M Reynolds
- Department of Chemistry, School of Biomedical Engineering, Chemical and Biological Engineering, Colorado State University, Fort Collins, Colorado, USA
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8
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Patricia Massicotte M, Bauman ME. Developmental hemostasis and ventricular assist devices: A troubled relationship. PROGRESS IN PEDIATRIC CARDIOLOGY 2017. [DOI: 10.1016/j.ppedcard.2017.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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9
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Moynihan K, Johnson K, Straney L, Stocker C, Anderson B, Venugopal P, Roy J. Coagulation monitoring correlation with heparin dose in pediatric extracorporeal life support. Perfusion 2017; 32:675-685. [DOI: 10.1177/0267659117720494] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives: Extracorporeal Life Support (ECLS) risks thrombotic and hemorrhagic complications. Optimal anti-coagulation monitoring is controversial. We compared coagulation tests evaluating the heparin effect in pediatric ECLS. Methods: A retrospective study of children (<18yrs) undergoing ECLS over 12 months in a tertiary pediatric intensive care unit (PICU). Variables included anti-Factor Xa activity (anti-Xa), activated partial thromboplastin time (aPTT), activated clotting time (ACT) and thromboelastogram (TEG®6s) parameters: ratio and delta reaction (R) times (the ratio and difference, respectively, between R times in kaolin assays with and without heparinase). Test results were correlated with unfractionated heparin infusion rate (IU/kg/hr) at the time of sampling. Mean test results of each ECLS run were evaluated according to the presence/absence of complications. Results: Thirty-two ECLS runs (31 patients) generated 695 data-points for correlation. PICU mortality was 22% and the thrombotic complication rate was 66%. The proportion of variation in coagulation test results explained by heparin dose was 13.3% for anti-Xa, 11.9% for ratio R time, and 9.9% for delta R time, compared with <1% for ACT and aPTT. Incorporating individual variation, age and antithrombin activity in a model with heparin dose explained less than 50% of the variation in test results. Correlation varied according to age, day of ECLS run and between individuals, with parallel dose-response lines noted between patients. Significantly lower mean anti-Xa was observed in PICU non-survivors and runs with thrombosis. Conclusion: Lower anti-Xa was observed in ECLS runs with complications. Although absolute results from anti-Xa and TEG6®s showed the best correlation with heparin dose, a large proportion of variation in results was unexplained by heparin, while dose response was similar between individuals. Population pharmacokinetic/pharmacodynamic modelling is required, as well as prospective trials to delineate the superior means of adjusting heparin therapy to prevent adverse clinical outcomes.
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Affiliation(s)
- Katie Moynihan
- Pediatric Intensive Care Unit, Lady Cilento Children’s Hospital (LCCH), Brisbane, Australia
- Pediatric Critical Care Research Group, LCCH, Brisbane, Australia
- University of Queensland School of Medicine, Brisbane, Australia
| | - Kerry Johnson
- Pediatric Intensive Care Unit, Lady Cilento Children’s Hospital (LCCH), Brisbane, Australia
| | - Lahn Straney
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Christian Stocker
- Pediatric Intensive Care Unit, Lady Cilento Children’s Hospital (LCCH), Brisbane, Australia
- Pediatric Critical Care Research Group, LCCH, Brisbane, Australia
- University of Queensland School of Medicine, Brisbane, Australia
- Queensland Neonatal & Pediatric ECLS Service, LCCH, Brisbane, Australia
| | - Ben Anderson
- Queensland Neonatal & Pediatric ECLS Service, LCCH, Brisbane, Australia
| | - Prem Venugopal
- Queensland Neonatal & Pediatric ECLS Service, LCCH, Brisbane, Australia
| | - John Roy
- University of Queensland School of Medicine, Brisbane, Australia
- Pathology Queensland, Brisbane, Australia
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Cho HJ, Kim DW, Kim GS, Jeong IS. Anticoagulation Therapy during Extracorporeal Membrane Oxygenator Support in Pediatric Patients. Chonnam Med J 2017; 53:110-117. [PMID: 28584789 PMCID: PMC5457945 DOI: 10.4068/cmj.2017.53.2.110] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 04/22/2017] [Accepted: 04/28/2017] [Indexed: 02/01/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a salvage therapy for critically ill patients. Although ECMO is becoming more common, hemorrhagic and thromboembolic complications remain the major causes of death in patients undergoing ECMO treatments. These complications commence upon blood contact with artificial surfaces of the circuit, blood pump, and oxygenator system. Therefore, anticoagulation therapy is required in most cases to prevent these problems. Anticoagulation is more complicated in pediatric patients than in adults, and the foreign surface of ECMO only increases the complexity of systemic anticoagulation. In this review, we discuss the pathophysiology of coagulation, anticoagulants, and monitoring tools in pediatric patients receiving ECMO.
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Affiliation(s)
- Hwa Jin Cho
- Department of Pediatrics, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea.,Extracorporeal Life Support Organization, Asia-Pacific Chapter, Ann Arbor, MI, USA
| | - Do Wan Kim
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Gwan Sic Kim
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - In Seok Jeong
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
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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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12
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Al-Sallami H, Newall F, Monagle P, Ignjatovic V, Cranswick N, Duffull S. Development of a population pharmacokinetic-pharmacodynamic model of a single bolus dose of unfractionated heparin in paediatric patients. Br J Clin Pharmacol 2016; 82:178-84. [PMID: 26972703 DOI: 10.1111/bcp.12930] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Revised: 02/24/2016] [Accepted: 03/07/2016] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Unfractionated heparin (UFH) is the anticoagulant of choice in paediatric patients undergoing a variety of cardiac procedures. There are currently no population pharmacokinetic-pharmacodynamic (PKPD) models for UFH in paediatrics. OBJECTIVE The aim of the present study was to develop and evaluate a PKPD model of UFH in paediatrics. METHODS Data from 64 children who received 75-100 IU kg(-1) of UFH during cardiac angiography were analysed. Five blood samples were collected at baseline and at 15, 30, 45 and 120 min postdose. The UFH concentration was quantified using a protamine titration assay. The UFH effect was quantified using activated partial thromboplastin time (aPTT). A PKPD model was fitted using nonlinear mixed-effects modelling. Patient covariates such as gender, weight (WT) and fat-free mass (FFM) were tested. The final model was evaluated using the likelihood ratio test and visual predictive checks (VPCs). RESULTS A one-compartment model with linear elimination provided the best fit for the dose-concentration data. FFM was a significant covariate on clearance. A linear model provided the best fit for the concentration-effect data using aPTT as a biomarker for effect. The models performed well using VPCs. However, when used to simulate UFH infusion (at a much lower dose), the model overpredicted target aPTT responses. CONCLUSIONS A PKPD model to describe the time course of the UFH effect was developed in a paediatric population. FFM was shown to describe drug disposition well. However, when applied to smaller UFH infusion doses, the model overpredicted target aPTT responses. This unsuccessful extrapolation may be attributed to a possible nonlinear relationship for heparin PKPD.
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Affiliation(s)
| | - Fiona Newall
- Department of Paediatrics, University of Melbourne, Melbourne, Australia.,Murdoch Children's Research Institute, Melbourne, Vic, Australia.,Clinical Haematology, Royal Children's Hospital, Melbourne, Vic, Australia
| | - Paul Monagle
- Department of Paediatrics, University of Melbourne, Melbourne, Australia.,Murdoch Children's Research Institute, Melbourne, Vic, Australia.,Clinical Haematology, Royal Children's Hospital, Melbourne, Vic, Australia
| | - Vera Ignjatovic
- Department of Paediatrics, University of Melbourne, Melbourne, Australia.,Murdoch Children's Research Institute, Melbourne, Vic, Australia
| | - Noel Cranswick
- Department of Paediatrics, University of Melbourne, Melbourne, Australia.,Department of Pharmacology, University of Melbourne, Melbourne, Vic, Australia
| | - Stephen Duffull
- School of Pharmacy, University of Otago, Dunedin, New Zealand
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13
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Ryerson LM, Lequier LL. Anticoagulation Management and Monitoring during Pediatric Extracorporeal Life Support: A Review of Current Issues. Front Pediatr 2016; 4:67. [PMID: 27446890 PMCID: PMC4916162 DOI: 10.3389/fped.2016.00067] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 06/10/2016] [Indexed: 11/16/2022] Open
Abstract
Anticoagulation is an imperfect science and is even more complicated in neonates and young children. The addition of the extracorporeal life support (ECLS) foreign circuit adds an additional layer of complexity. Anticoagulation goals during ECLS are to maintain a clot-free circuit and a hemostatically balanced patient. Unfractionated heparin (UFH) is the default gold standard anticoagulant as no large studies have been performed on any other anticoagulants. This review will focus on the advantages and disadvantages of the various methods to monitor UFH anticoagulation, discuss alternative anticoagulants, and examine bleeding and thrombotic complications during ECLS.
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Affiliation(s)
- Lindsay M Ryerson
- Pediatric Critical Care, Stollery Children's Hospital , Edmonton, AB , Canada
| | - Laurence L Lequier
- Pediatric Critical Care, Stollery Children's Hospital , Edmonton, AB , Canada
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O'Brien SH, Yee DL, Lira J, Goldenberg NA, Young G. UNBLOCK: an open-label, dose-finding, pharmacokinetic and safety study of bivalirudin in children with deep vein thrombosis. J Thromb Haemost 2015; 13:1615-22. [PMID: 26180006 DOI: 10.1111/jth.13057] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 06/19/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Direct thrombin inhibitors offer potential advantages over unfractionated heparin but have been poorly studied in children. OBJECTIVES To determine appropriate dosing of bivalirudin in children and adolescents and the relationship between activated partial thromboplastin time (APTT) and plasma bivalirudin concentration. PATIENTS/METHODS The UNBLOCK (UtilizatioN of BivaLirudin On Clots in Kids) study was an open-label, single-arm, dose-finding, pharmacokinetic, safety and efficacy study of bivalirudin for the acute treatment of deep vein thrombosis (DVT) in children aged 6 months to 18 years. Drug initiation consisted of a bolus dose (0.125 mg kg(-1) ) followed by continuous infusion (0.125 mg kg h(-1) ). Dose adjustments were based on the APTT, targeting a range of 1.5-2.5 times each patient's baseline APTT. Safety was assessed by specific bleeding endpoints and efficacy by repeat imaging at 48-72 h and 25-35 days. RESULTS Eighteen patients completed the study. Following the bolus dose and the initial infusion rate, most patients' APTT values were within the target range. The infusion rate bivalirudin correlated more closely with drug concentration than the APTT. At 48-72 h, nine (50%) patients had complete or partial thrombus resolution, increasing to 16 (89%) at 25-35 days. No major and one minor bleeding event occurred. CONCLUSIONS Bivalirudin demonstrated reassuring safety and noteworthy efficacy in terms of early clot resolution in children and adolescents with DVT. Although a widely available and familiar monitoring tool, the APTT correlates poorly with plasma bivalirudin concentration, possibly limiting its utility in managing pediatric patients receiving bivalirudin for DVT.
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Affiliation(s)
- S H O'Brien
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital/The Ohio State University, Columbus, OH, USA
| | - D L Yee
- Department of Pediatrics Hematology-Oncology Section, Baylor College of Medicine, Houston, TX, USA
| | - J Lira
- Hemostasis and Thrombosis Center, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - N A Goldenberg
- Division of Hematology, Departments of Pediatrics and Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
- All Children's Research Institute, All Children's Hospital, Johns Hopkins Medicine, St Petersburg, FL, USA
| | - G Young
- Hemostasis and Thrombosis Center, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
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15
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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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16
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Stocker CF, Horton SB. Anticoagulation strategies and difficulties in neonatal and paediatric extracorporeal membrane oxygenation (ECMO). Perfusion 2015; 31:95-102. [DOI: 10.1177/0267659115590626] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: The aim of this review is to highlight an emerging problem with anticoagulation-related complications in neonatal and paediatric ECMO, to explore for flaws in the currently recommended anticoagulation management responsible for these problems and to discuss possible strategies mitigating further escalation of the issue. Data Sources: Pertinent neonatal and paediatric literature on the topic of interest and international Extracorporeal Life Support Organisation (ELSO) registry data request. Conclusions: The international ELSO registry data reveals increasing rates of anticoagulation-related complications during neonatal and paediatric ECMO worldwide. The causes are multifactorial and the proposed solution to the problem is to match anticoagulation management to the pathophysiological complexity of haemostasis on ECMO.
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Affiliation(s)
- Christian F Stocker
- Paediatric Intensive Care Medicine, Queensland Children’s Hospital, Brisbane, Queensland, Australia
| | - Stephen B Horton
- Paediatric Perfusion Unit, Royal Children’s Hospital, Melbourne, Australia
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Massicotte MP, Bauman ME, Murray J, Almond CS. Antithrombotic therapy for ventricular assist devices in children: do we really know what to do? J Thromb Haemost 2015; 13 Suppl 1:S343-50. [PMID: 26149046 DOI: 10.1111/jth.12928] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
The use of ventricular assist devices (VADs) in children is increasing. Stroke and device-related thromboembolism remain the most feared complications associated with VAD therapy in children. The presence of a VAD causes dysregulation of hemostasis due to the presence of foreign materials and sheer forces intrinsic to the device resulting in hypercoagulability and potentially life-threatening thrombosis. The use of antithrombotic therapy in adults with VADs modulates this disruption in hemostasis, decreasing the risk of thrombosis. Yet, differences in hemostasis in children (developmental hemostasis) may result in variances in dysregulation by these devices and preclude the use of adult guidelines. Consequently, pediatric device studies must include safety and efficacy estimates of device-specific antithrombotic therapy guidelines. This review will discuss mechanisms of hemostatic dysregulation as it pertains to VADs, goals of VAD antithrombotic therapy for children and adults, and emerging antithrombotic strategies for VAD use in children.
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Affiliation(s)
- M P Massicotte
- KIDCLOT Pediatric Thrombosis, Stollery Children's Hospital, Edmonton, AB, Canada
- University of Alberta, Edmonton, AB, Canada
| | - M E Bauman
- KIDCLOT Pediatric Thrombosis, Stollery Children's Hospital, Edmonton, AB, Canada
- University of Alberta, Edmonton, AB, Canada
| | - J Murray
- Division of Cardiology, Lucile Packard Children's Hospital Stanford, Stanford, CA, USA
- Stanford University, Stanford, CA, USA
| | - C S Almond
- Division of Cardiology, Lucile Packard Children's Hospital Stanford, Stanford, CA, USA
- Stanford University, Stanford, CA, USA
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18
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Trucco M, Lehmann CU, Mollenkopf N, Streiff MB, Takemoto CM. Retrospective cohort study comparing activated partial thromboplastin time versus anti-factor Xa activity nomograms for therapeutic unfractionated heparin monitoring in pediatrics. J Thromb Haemost 2015; 13:788-94. [PMID: 25740425 DOI: 10.1111/jth.12890] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 03/01/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Unfractionated heparin (UFH) is widely used to treat thromboembolic disease, but monitoring in children is challenging. Both activated partial thromboplastin time (aPTT) and anti-factor Xa activity (anti-Xa) are utilized, but a comparison of dosing nomograms has not been reported in pediatrics. OBJECTIVE To compare the performance of aPTT and anti-Xa for UFH monitoring in pediatric patients. DESIGN/METHODS A retrospective cohort study was conducted in patients ≤ 21 years old treated with UFH at Johns Hopkins Hospital from January 2009 to May 2011. For monitoring, an aPTT nomogram was used for the initial 15 months, and an anti-Xa nomogram was used for the subsequent 12 months. Clinical characteristics, laboratory data and outcomes were analyzed. RESULTS Thirty-four patients were monitored with aPTT and 26 patients with anti-Xa. There was no significant difference in median time to therapeutic range (11.6 h aPTT, 95%CI = 6.0-17.0; 9.9 h anti-Xa, 95%CI = 7.3-20.7) or per cent of patients achieving therapeutic measurements at 24 (79% aPTT, 95%CI = 62-91; 73% anti-Xa, 95%CI = 52-88) and 48 h (88% aPTT, 95%CI = 73-97; 96% anti-Xa, 95%CI = 80-100). However, anti-Xa measurements were more frequently therapeutic than aPTT (74% [95%CI = 69-78] vs. 54% [95%CI = 50-59]). Variance between anti-Xa and aPTT measurements was high (R(2) = 0.236). No significant difference was seen in bleeding incidence (9% aPTT, 95%CI = 2-24; 15% anti-Xa, 95%CI = 4-35). CONCLUSION The time to achieve therapeutic measures and bleeding outcomes were not significantly different between anti-Xa and aPTT nomograms. However, a small study size limits the power to detect clinically relevant differences. The results warrant larger prospective studies of UFH monitoring in children with thromboembolic disease.
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Affiliation(s)
- M Trucco
- Division of Pediatric Hematology, The Johns Hopkins University, Baltimore, MD, USA
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19
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Newall F, Jones S, Bauman M, Bruce A, Massicotte MP, Monagle P. Recommendations for the development of a dedicated pediatric anticoagulation service: communication from the SSC of the ISTH. J Thromb Haemost 2015; 13:155-9. [PMID: 25331069 DOI: 10.1111/jth.12763] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2014] [Accepted: 10/09/2014] [Indexed: 11/28/2022]
Affiliation(s)
- F Newall
- Clinical Haematology Department, Royal Children's Hospital, Parkville, Victoria, Australia; Nursing Research Department, Royal Children's Hospital, Parkville, Victoria, Australia; Department of Nursing, The University of Melbourne, Melbourne, Victoria, Australia; Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia; Haematology Research Group, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
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20
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Abstract
Given the rising incidence of thrombotic complications in paediatric patients, understanding of the pharmacologic behaviour of anticoagulant drugs in children has gained importance. Significant developmental differences between children and adults in the haemostatic system and pharmacologic parameters for individual drugs highlight potentially unique aspects of anticoagulant pharmacology in this special and vulnerable population. This review focuses on pharmacologic information relevant to the dosing of unfractionated heparin, low molecular weight heparin, warfarin, bivalirudin, argatroban and fondaparinux in paediatric patients. The bulk of clinical experience with paediatric anticoagulation rests with the first three of these agents, each of which requires higher bodyweight-based dosing for the youngest patients, compared with adults, in order to achieve comparable pharmacodynamic effects, likely related to an inverse correlation between age and bodyweight-normalized clearance of these drugs. Whether extrapolation of therapeutic ranges targeted for adult patients prescribed these agents is valid for children, however, is unknown and a high priority for future research. Novel oral anticoagulants, such as dabigatran, rivaroxaban and apixaban, hold promise for future use in paediatrics but require further pharmacologic study in infants, children and adolescents.
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21
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Chabrier S, Kossorotoff M, Darteyre S. Place des antithrombotiques dans l’accident vasculaire cérébral de l’enfant. Presse Med 2013; 42:1259-66. [DOI: 10.1016/j.lpm.2013.06.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Accepted: 06/12/2013] [Indexed: 02/06/2023] Open
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22
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Lebas A, Chabrier S, Fluss J, Gordon K, Kossorotoff M, Nowak-Göttl U, de Vries LS, Tardieu M. EPNS/SFNP guideline on the anticoagulant treatment of cerebral sinovenous thrombosis in children and neonates. Eur J Paediatr Neurol 2012; 16:219-28. [PMID: 22425391 DOI: 10.1016/j.ejpn.2012.02.005] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Accepted: 02/14/2012] [Indexed: 12/17/2022]
Abstract
Anticoagulation of cerebral sinovenous thrombosis (CSVT) is recommended in adults and has been also approved in the paediatric setting. Some controversies remain however between the existing paediatric professional consensus, notably about its use in children with intra-cranial haemorrhage and in neonates. The publication of further original studies prompted the French Society for Paediatric Neurology (SFNP) in association with a panel of EPNS experts, to update the level of evidence and the knowledge in this domain. A bibliographic analysis revealed that anticoagulants are widely used in paediatrics. Anticoagulation is well tolerated by children (Class I, level of evidence B) and also probably by neonates (Class IIa, level of evidence B). During the acute phase, anticoagulation is probably effective in reducing the risk of death and sequelae in children (Class IIa, level of evidence B). It is not yet possible to draw any conclusions regarding neonates (Class IIb). Anticoagulation is also effective in reducing the risk of recurrence (Class I, level of evidence B). This risk is dependent on several individual factors such as the age of the child, the cause of the thrombosis, the persistence or the recurrence of thrombogenic factors, and the speed of sinus recanalisation. The duration of anticoagulation needs therefore to be individually tailored (Class I, level of evidence B). These observations have led to the following recommendations: -In the absence of any contraindication, it is reasonable to initiate anticoagulation during the acute phase of CSVT in children. Prolonged treatment over 3-6 months is justified according to individual factors. -In the absence of any contraindication, anticoagulation may be considered individually during the acute phase of CSVT in neonates for a duration of 6-12 weeks.
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Affiliation(s)
- Axel Lebas
- CHU Rouen, Hôpital Charles-Nicolle, Service de Neurophysiologie, Rouen F-76031, France
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23
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Monagle P, Chan AKC, Goldenberg NA, Ichord RN, Journeycake JM, Nowak-Göttl U, Vesely SK. Antithrombotic therapy in neonates and children: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e737S-e801S. [PMID: 22315277 DOI: 10.1378/chest.11-2308] [Citation(s) in RCA: 950] [Impact Index Per Article: 79.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Neonates and children differ from adults in physiology, pharmacologic responses to drugs, epidemiology, and long-term consequences of thrombosis. This guideline addresses optimal strategies for the management of thrombosis in neonates and children. METHODS The methods of this guideline follow those described in the Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. RESULTS We suggest that where possible, pediatric hematologists with experience in thromboembolism manage pediatric patients with thromboembolism (Grade 2C). When this is not possible, we suggest a combination of a neonatologist/pediatrician and adult hematologist supported by consultation with an experienced pediatric hematologist (Grade 2C). We suggest that therapeutic unfractionated heparin in children is titrated to achieve a target anti-Xa range of 0.35 to 0.7 units/mL or an activated partial thromboplastin time range that correlates to this anti-Xa range or to a protamine titration range of 0.2 to 0.4 units/mL (Grade 2C). For neonates and children receiving either daily or bid therapeutic low-molecular-weight heparin, we suggest that the drug be monitored to a target range of 0.5 to 1.0 units/mL in a sample taken 4 to 6 h after subcutaneous injection or, alternatively, 0.5 to 0.8 units/mL in a sample taken 2 to 6 h after subcutaneous injection (Grade 2C). CONCLUSIONS The evidence supporting most recommendations for antithrombotic therapy in neonates and children remains weak. Studies addressing appropriate drug target ranges and monitoring requirements are urgently required in addition to site- and clinical situation-specific thrombosis management strategies.
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Affiliation(s)
- Paul Monagle
- Haematology Department, The Royal Children's Hospital, Department of Paediatrics, The University of Melbourne, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Anthony K C Chan
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Neil A Goldenberg
- Department of Pediatrics, Section of Hematology/Oncology/Bone Marrow Transplantation and Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado, Aurora, CO
| | - Rebecca N Ichord
- Department of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Janna M Journeycake
- Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas, Dallas, TX
| | - Ulrike Nowak-Göttl
- Thrombosis and Hemostasis Unit, Institute of Clinical Chemistry, University Hospital Kiel, Kiel, Germany
| | - Sara K Vesely
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK.
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Schechter T, Finkelstein Y, Ali M, Kahr WH, Williams S, Chan AK, Deveber G, Brandão LR. Unfractionated heparin dosing in young infants: clinical outcomes in a cohort monitored with anti-factor Xa levels. J Thromb Haemost 2012; 10:368-74. [PMID: 22244010 DOI: 10.1111/j.1538-7836.2012.04624.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Unfractionated heparin (UFH) is a widely used anticoagulant. Current American College of Chest Physicians guidelines for infants extrapolated from adults recommend 28 U kg(-1) h(1) of UFH to achieve an anti-factor Xa level of 0.35-0.7 IU mL(-1). OBJECTIVE To assess the profile of anti-FXa-based UFH dosing guidelines in infants. PATIENTS/METHODS We included all infants aged < 6 months treated with per-protocol intravenous UFH at the Hospital for Sick Children, Toronto, over a 3.5-year period. RESULTS Of 100 infants, 11% achieved sustained therapeutic anti-FXa levels with current dose recommendations. Only 15% achieved target anti-FXa levels within 24 h with per-protocol dose escalations. Seventeen per cent of patients never achieved therapeutic anti-FXa levels, despite up to 60 days of therapy and triple the recommended dose. The median dose needed to achieve therapeutic anti-FXa levels in the remaining 83 infants was 33 U kg(-1) h(-1) (interquartile range, 30-36). Two in three infants had decreased thrombus size at completion of therapy and no thrombus progression/recurrence, and 11/100 infants suffered major bleeding. Without exclusion of extracorporeal membrane oxygenation patients, an activated partial thromboplastin time (APTT) of > 180 s was detected as a risk factor for major bleeding. CONCLUSIONS UFH monitoring is challenging in infants. Despite their delay in reaching therapeutic anti-FXa levels, infants monitored with the adult-based anti-FXa range have a high thrombus resolution rate, no thrombus progression, but a relatively high bleeding rate. Extreme APTT elevation may contribute to this bleeding risk, particularly in critically ill patients. Current UFH guidelines for young infants may still be inadequate, and laboratory methods with age-appropriate ranges may be required to further improve clinical outcomes within this population.
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Affiliation(s)
- T Schechter
- Division of Hematology/Oncology, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.
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Newall F, Chan AK, Ignjatovic V, Monagle P. Recommendations for developing uniform laboratory monitoring of heparinoid anticoagulants in children. J Thromb Haemost 2012; 10:145-7. [PMID: 22470925 DOI: 10.1111/j.1538-7836.2011.04561.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Fiona Newall
- Clinical Haematology Department, Royal Children's Hospital, Melbourne, Australia.
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26
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Abstract
Thromboembolic complications are becoming more frequent in children and the use of anticoagulation has increased considerably. The most widely used agents in children, heparin, low molecular weight heparin, and warfarin all have limitations which are exaggerated in children. This has led to the study of newer agents with improved pharmacologic properties such as bivalirudin, argatroban, and fondaparinux. Clinical trials are under way to assess several new oral anticoagulants that are in late phase studies or already licensed in adults. Based on the completed studies in children, several recommendations for the use of currently available agents (bivalirudin, argatroban, and fondaparinux) are suggested for clinical use today. Additional studies need to be conducted for the these agents, so that their use may be expanded in selected indications. New regulatory requirements are leading to a number of studies in the newer anticoagulants that are yet to be licensed in adults for treatment of venous thromboembolism. Pediatric thrombosis is entering a fruitful era of research in anticoagulation management, which is sure to lead to significant changes in how children are treated in the next 10 years.
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Affiliation(s)
- Guy Young
- Hemostasis and Thrombosis Center, Children's Hospital Los Angeles, Los Angeles, CA, USA.
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27
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Moffett BS, Teruya J, Petit C. Heparin Dosing in Obese Pediatric Patients in the Cardiac Catheterization Laboratory. Ann Pharmacother 2011; 45:876-80. [DOI: 10.1345/aph.1q090] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background: Unfractionated heparin (UFH) dosing may need to be adjusted when used in obese patients. The prevalence of pediatric obesity is increasing and, to our knowledge, no data exist to determine the effect of obesity on UFH therapy in children. Objective: To determine whether obese pediatric patients who receive a weight-based dose of UFH in the cardiac catheterization laboratory exhibit an enhanced response compared with those of normal body habitus. Methods: The records of pediatric patients who underwent a cardiac catheterization procedure from September 2006 to September 2010 at Texas Children's Hospital were reviewed. Patients were included if they had received a bolus dose of UFH during their procedure, and had pre- and post-UFH bolus activated clotting time (ACT) values determined. Patients were identified as obese if their body mass index (BMI) was at the 95th percentile or more for age and sex and were matched by age, sex, and catheterization procedure to a control group of patients with a BMI lower than the 95th percentile. Differences in demographic, UFH, and ACT variables were compared between obese and nonobese paired groups. Results: Seventy-eight patients (39 obese) met study criteria; 46 (58.9%) patients were male. The primary catheterization procedure was radiofrequency ablation (n = 32). There was no statistically significant difference in the mean (SD) dose per kilogram of UFH administered (72.3 [24.9] vs 63.6 [23.6] units/kg; p = 0.12) and no statistically significant difference in the time after the UFH bolus that the ACT was measured (52 [26] vs 56 [26] minutes; p = 0.59) between the 2 groups. No statistically significant difference was noted in the percent change in ACT after UFH bolus in obese compared to nonobese pediatric patients (196% [106] vs 165% [97]; p = 0.17). Conclusions: No significant difference in response to UFH was identified in obese pediatric patients compared to nonobese pediatric patients as measured by ACT in the cardiac catheterization laboratory.
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Affiliation(s)
- Brady S Moffett
- Department of Pharmacy, Texas Children's Hospital, Houston, TX
| | - Jun Teruya
- Departments of Pathology, Immunology, Pediatrics, and Medicine, Baylor College of Medicine, Houston
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28
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Lebas A, Chabrier S, Tardieu M, Kossorotoff M. Traitement anticoagulant des thromboses veineuses cérébrales de l’enfant et du nouveau-né. Les recommandations de la Société française de neurologie pédiatrique (SFNP). Arch Pediatr 2011; 18:446-58. [DOI: 10.1016/j.arcped.2011.01.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2010] [Accepted: 01/20/2011] [Indexed: 10/18/2022]
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