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Moore GW. Thrombophilia Screening: Not So Straightforward. Semin Thromb Hemost 2024. [PMID: 38733983 DOI: 10.1055/s-0044-1786807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2024]
Abstract
Although inherited thrombophilias are lifelong risk factors for a first thrombotic episode, progression to thrombosis is multifactorial and not all individuals with inherited thrombophilia develop thrombosis in their lifetimes. Consequently, indiscriminate screening in patients with idiopathic thrombosis is not recommended, since presence of a thrombophilia does not necessarily predict recurrence or influence management, and testing should be selective. It follows that a decision to undertake laboratory detection of thrombophilia should be aligned with a concerted effort to identify any significant abnormalities, because it will inform patient management. Deficiencies of antithrombin and protein C are rare and usually determined using phenotypic assays assessing biological activities, whereas protein S deficiency (also rare) is commonly detected with antigenic assays for the free form of protein S since available activity assays are considered to lack specificity. In each case, no single phenotypic assay is capable of detecting every deficiency, because the various mutations express different molecular characteristics, rendering thrombophilia screening repertoires employing one assay per potential deficiency, of limited effectiveness. Activated protein C resistance (APCR) is more common than discrete deficiencies of antithrombin, protein C, and protein S and also often detected initially with phenotypic assays; however, some centres perform only genetic analysis for factor V Leiden, as this is responsible for most cases of hereditary APCR, accepting that acquired APCR and rare F5 mutations conferring APCR will go undetected if only factor V Leiden is evaluated. All phenotypic assays have interferences and limitations, which must be factored into decisions about if, and when, to test, and be given consideration in the laboratory during assay performance and interpretation. This review looks in detail at performance and limitations of routine phenotypic thrombophilia assays.
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Affiliation(s)
- Gary W Moore
- Specialist Haemostasis Laboratory, Cambridge Haemophilia and Thrombophilia Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- Department of Natural Sciences, Middlesex University, London, United Kingdom
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2
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Neto BV, Tavares V, da Silva JB, Liz-Pimenta J, Marques IS, Salgado L, Carvalho L, Pereira D, Medeiros R. Haemostatic gene variations in cervical cancer-associated venous thrombosis: considerations for clinical strategies. J Thromb Thrombolysis 2024:10.1007/s11239-024-02983-2. [PMID: 38643313 DOI: 10.1007/s11239-024-02983-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/09/2024] [Indexed: 04/22/2024]
Abstract
Venous thromboembolism (VTE) is a life-threatening haemostatic disease frequently diagnosed among the cancer population. The Khorana Score is currently the primal risk assessment model to stratify oncological patients according to their susceptibility to VTE, however, it displays a limited performance. Meanwhile, intensive research on VTE pathophysiology in the general population has uncovered a range of single-nucleotide polymorphisms (SNPs) associated with the condition. Nonetheless, their predictive ability concerning cancer-associated thrombosis (CAT) is controversial. Cervical cancer (CC) patients undergoing chemoradiotherapy often experience VTE, which negatively affects their survival. Thus, aiming for an improvement in thromboprophylaxis, new thrombotic biomarkers, including SNPs, are currently under investigation. In this study, the predictive capability of haemostatic gene SNPs on CC-related VTE and their prognostic value regardless of VTE were explored. Six SNPs in haemostatic genes were evaluated. A total of 401 CC patients undergoing chemoradiotherapy were enrolled in a retrospective cohort study. The implications for the time to VTE occurrence and overall survival (OS) were assessed. CAT considerably impacted the CC patients' OS (log-rank test, P < 0.001). SERPINE1 rs2070682 (T > C) showed a significant association with the risk of CC-related VTE (CC/CT vs. TT, log-rank test, P = 0.002; C allele, Cox model, hazard ratio (HR) = 6.99 and P = 0.009), while F2 rs1799963 (G > A) demonstrated an important prognostic value regardless of VTE (AA/AG vs. GG, log-rank test, P = 0.020; A allele, Cox model, HR = 2.76 and P = 0.026). For the remaining SNPs, no significant associations were detected. The polymorphisms SERPINE1 rs2070682 and F2 rs1799963 could be valuable tools in clinical decision-making, aiding in thromboprophylaxis and CC management, respectively.
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Affiliation(s)
- Beatriz Vieira Neto
- Molecular Oncology and Viral Pathology Group, Research Center of IPO Porto (CI-IPOP)/Pathology and Laboratory Medicine Dep, Clinical Pathology SV/ RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto) / Porto Comprehensive Cancer Centre (Porto.CCC), Porto, 4200-072, Portugal
- Research Department, Portuguese League Against Cancer (NRNorte), Porto, 4200-172, Portugal
| | - Valéria Tavares
- Molecular Oncology and Viral Pathology Group, Research Center of IPO Porto (CI-IPOP)/Pathology and Laboratory Medicine Dep, Clinical Pathology SV/ RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto) / Porto Comprehensive Cancer Centre (Porto.CCC), Porto, 4200-072, Portugal
- Faculty of Medicine, University of Porto (FMUP), Porto, 4200-072, Portugal
- Instituto de Ciências Biomédicas Abel Salazar, ICBAS, Universidade do Porto, Porto, Portugal
| | - José Brito da Silva
- Oncology Department, Portuguese Institute of Oncology of Porto (IPOP), Porto, 4200-072, Portugal
| | - Joana Liz-Pimenta
- Faculty of Medicine, University of Porto (FMUP), Porto, 4200-072, Portugal
- Department of Medical Oncology, Centro Hospitalar de Trás-os-Montes e Alto Douro (CHTMAD), Vila Real, 5000-508, Portugal
| | - Inês Soares Marques
- Molecular Oncology and Viral Pathology Group, Research Center of IPO Porto (CI-IPOP)/Pathology and Laboratory Medicine Dep, Clinical Pathology SV/ RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto) / Porto Comprehensive Cancer Centre (Porto.CCC), Porto, 4200-072, Portugal
| | - Lurdes Salgado
- External Radiotherapy Department, Portuguese Institute of Oncology of Porto (IPOP), Porto, 4200-072, Portugal
| | - Luísa Carvalho
- External Radiotherapy Department, Portuguese Institute of Oncology of Porto (IPOP), Porto, 4200-072, Portugal
| | - Deolinda Pereira
- Oncology Department, Portuguese Institute of Oncology of Porto (IPOP), Porto, 4200-072, Portugal
| | - Rui Medeiros
- Molecular Oncology and Viral Pathology Group, Research Center of IPO Porto (CI-IPOP)/Pathology and Laboratory Medicine Dep, Clinical Pathology SV/ RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto) / Porto Comprehensive Cancer Centre (Porto.CCC), Porto, 4200-072, Portugal.
- Research Department, Portuguese League Against Cancer (NRNorte), Porto, 4200-172, Portugal.
- Faculty of Medicine, University of Porto (FMUP), Porto, 4200-072, Portugal.
- Instituto de Ciências Biomédicas Abel Salazar, ICBAS, Universidade do Porto, Porto, Portugal.
- External Radiotherapy Department, Portuguese Institute of Oncology of Porto (IPOP), Porto, 4200-072, Portugal.
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Sokou R, Parastatidou S, Konstantinidi A, Tsantes AG, Iacovidou N, Piovani D, Bonovas S, Tsantes AE. Contemporary tools for evaluation of hemostasis in neonates. Where are we and where are we headed? Blood Rev 2024; 64:101157. [PMID: 38016836 DOI: 10.1016/j.blre.2023.101157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 11/20/2023] [Accepted: 11/21/2023] [Indexed: 11/30/2023]
Abstract
The assessment of hemostatic disorders in neonates is crucial, but remains challenging for clinicians. Although the concept of developmental hemostasis is widely accepted among hemostasis specialists globally, it is probably under-recognized by clinicians and laboratory practitioners. In parallel with age-dependent hemostatic status maturation, comprehension of the differences between normal values is crucial for the accurate diagnosis of potential hemorrhagic and thrombotic disorders of the vulnerable neonatal population. This review outlines the basics of developmental hemostasis and the features of the available coagulation testing methods, with a focus on novel tools for evaluating the neonatal hemostatic profile. Common errors, issues, and pitfalls during the assessment of neonatal hemostasis are discussed, along with their impact on patient management. Current knowledge gaps and research areas are addressed. Further studying to improve our understanding of developmental hemostasis and its reflection on everyday clinical practice is warranted.
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Affiliation(s)
- Rozeta Sokou
- Neonatal Intensive Care Unit, "Agios Panteleimon" General Hospital of Nikea, Piraeus, Greece.
| | | | | | - Andreas G Tsantes
- Laboratory of Haematology and Blood Bank Unit, "Attiko" Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece
| | - Nicoletta Iacovidou
- Neonatal Department, National and Kapodistrian University of Athens, Aretaieio Hospital, Athens, Greece
| | - Daniele Piovani
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; IRCCS Humanitas Research Hospital, Milan, Italy
| | - Stefanos Bonovas
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; IRCCS Humanitas Research Hospital, Milan, Italy
| | - Argirios E Tsantes
- Laboratory of Haematology and Blood Bank Unit, "Attiko" Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece
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4
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Tuttle MG, Yan K, Zhang J, Niebler RA. Argatroban Use in Pediatric Patients Supported by Paracorporeal Ventricular Assist Devices. ASAIO J 2024; 70:224-229. [PMID: 37934717 DOI: 10.1097/mat.0000000000002086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023] Open
Abstract
Direct thrombin inhibitor (DTI) use has been associated with decreased stroke and death rates in children on ventricular assist devices (VADs). Most information about DTI use for children on VADs has focused on bivalirudin with limited data on argatroban. We hypothesized that, compared to unfractionated heparin (UFH), argatroban would be associated with decreased bleeding, stroke, and death rates in children on VADs. We retrospectively collected data from patients <18 years old on paracorporeal VADs at Children's Wisconsin between January 1, 2010 and July 1, 2021. We divided patients into cohorts based on anticoagulation strategy with heparin or argatroban. Definitions of bleeding and neurologic events were the same as in other published reports on this population. We compared categorical variables with the χ 2 or Fisher's exact test, and continuous variables with the Mann-Whitney U test. Nineteen children were anticoagulated with argatroban, and 16 with heparin. Demographics between groups were not significantly different. Stroke, bleeding, and death rates did not differ between patients treated with UFH versus argatroban. The study population was complex with a high rate of extracorporeal membrane oxygenation (ECMO) use before VAD support, which likely impacted our findings. Our study does not support argatroban as a superior alternative anticoagulant compared to UFH in children requiring VADs.
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Affiliation(s)
- Merritt G Tuttle
- From the Department of Pediatric Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ke Yan
- Department of Quantitative Health Sciences, Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jian Zhang
- Department of Quantitative Health Sciences, Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Robert A Niebler
- From the Department of Pediatric Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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5
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Nakagawa T, Ogiwara K, Tonegawa H, Takahashi Y, Nishikubo T, Nogami K. Anticoagulant effects of protein C, protein S, and antithrombin levels on the protein C pathway in young children. Int J Hematol 2024; 119:196-204. [PMID: 38228939 DOI: 10.1007/s12185-023-03699-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/22/2023] [Accepted: 12/27/2023] [Indexed: 01/18/2024]
Abstract
The protein C (PC) pathway involves physiological anticoagulant factors (PC, protein S [PS], and factor V) and performs major anticoagulant functions in adults. Variations in overall PC pathway function due to dynamic changes in PC and PS in early childhood are poorly understood. We aimed to evaluate the contributions of PC pathway function during early childhood by measuring changes in plasma thrombin generation (TG) after administration of the PC activator protac. We evaluated correlations between anticoagulant factors and percentage of protac-induced coagulation inhibition (PiCi%). Before protac addition, TG in newborns (n = 35), infants (n = 42), young children (n = 35), and adults (n = 20) were 525 ± 74, 720 ± 96, 785 ± 53, and 802 ± 64 mOD/min, and PiCi% were 42.1 ± 9.9, 69.8 ± 11.0, 82.9 ± 4.4, and 86.9 ± 3.4%, respectively. The distribution of PiCi% on the two axes of TG (with or without protac) changed continuously with age and differed from that of warfarin-treated plasma and adult PC- or PS-deficient plasma. PiCi% increased dynamically during infancy and correlated with PS levels in newborns and PC levels in young children. Addition of PC or fresh frozen plasma equivalent to approximately 25% PC to PC-deficient plasma improved PiCi%. This automatic measurement requires only a small sample volume and is useful for analysis of developmental hemostasis.
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Affiliation(s)
- Takashi Nakagawa
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
- Division of Neonatal Intensive Care Unit, Maternal, Fetal and Neonatal Medical Center, Nara Medical University Hospital, Kashihara, Nara, Japan
| | - Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan.
| | - Hitoshi Tonegawa
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
- Division of Neonatal Intensive Care Unit, Maternal, Fetal and Neonatal Medical Center, Nara Medical University Hospital, Kashihara, Nara, Japan
| | - Yukihiro Takahashi
- Division of Neonatal Intensive Care Unit, Maternal, Fetal and Neonatal Medical Center, Nara Medical University Hospital, Kashihara, Nara, Japan
| | - Toshiya Nishikubo
- Division of Neonatal Intensive Care Unit, Maternal, Fetal and Neonatal Medical Center, Nara Medical University Hospital, Kashihara, Nara, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
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Morgan KM, Abou-Khalil E, Strotmeyer S, Richardson WM, Gaines BA, Leeper CM. Age-related changes in thromboelastography profiles in injured children. J Trauma Acute Care Surg 2023; 95:905-911. [PMID: 37317003 DOI: 10.1097/ta.0000000000004036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND The role of age in mediating coagulation characteristics in injured children is not well defined. We hypothesize thromboelastography (TEG) profiles are unique across pediatric age groups. METHODS Consecutive trauma patients younger than 18 years from a Level I pediatric trauma center database from 2016 to 2020 with TEG obtained on arrival to the trauma bay were identified. Children were categorized by age according to the National Institute of Child Health and Human Development categories (infant, ≤1 year; toddler, 1-2 years; early childhood, 3-5 years; older childhood, 6-11 years; adolescent, 12-17 years). Thromboelastography values were compared across age groups using Kruskal-Wallis and Dunn's tests. Analysis of covariance was performed controlling for sex, Injury Severity Score (ISS), arrival Glasgow Coma Scale (GCS) score, shock, and mechanism of injury. RESULTS In total, 726 subjects were identified; 69% male, median (interquartile range [IQR]) ISS = 12 (5-25), and 83% had a blunt mechanism. On univariate analysis, there were significant differences in TEG α-angle ( p < 0.001), MA ( p = 0.004), and fibrinolysis 30 minutes after MA (LY30) ( p = 0.01) between groups. In post hoc tests, the infant group had significantly greater α-angle (median, 77; IQR, 71-79) and MA (median, 64; IQR, 59-70) compared with other groups, while the adolescent group had significantly lower α-angle (median, 71; IQR, 67-74), MA (median, 60; IQR, 56-64), and LY30 (median, 0.8; IQR, 0.2-1.9) compared with other groups. There were no significant differences between toddler, early childhood, and middle childhood groups. On multivariate analysis, the relationship between age group and TEG values (α-angle, MA, and LY30) persisted after controlling for sex, ISS, GCS, shock, and mechanism of injury. CONCLUSION Age-associated differences in TEG profiles across pediatric age groups exist. Further pediatric-specific research is required to assess whether the unique profiles at extremes of childhood translate to differential clinical outcomes or responses to therapies in injured children. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
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Affiliation(s)
- Katrina M Morgan
- From the Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
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7
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Drop J, Letunica N, Van Den Helm S, Heleen van Ommen C, Wildschut E, de Hoog M, van Rosmalen J, Barton R, Yaw HP, Newall F, Horton SB, Chiletti R, Johansen A, Best D, McKittrick J, Butt W, d’Udekem Y, MacLaren G, Linden MD, Ignjatovic V, Attard C, Monagle P. Factors XI and XII in extracorporeal membrane oxygenation: longitudinal profile in children. Res Pract Thromb Haemost 2023; 7:102252. [PMID: 38193071 PMCID: PMC10772870 DOI: 10.1016/j.rpth.2023.102252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 08/30/2023] [Accepted: 09/21/2023] [Indexed: 01/10/2024] Open
Abstract
Background Extracorporeal membrane oxygenation (ECMO) is used in children with cardiopulmonary failure. While the majority of ECMO centers use unfractionated heparin, other anticoagulants, including factor XI and factor XII inhibitors are emerging, which may prove suitable for ECMO patients. However, before these anticoagulants can be applied in these patients, baseline data of FXI and FXII changes need to be acquired. Objectives This study aimed to describe the longitudinal profile of FXI and FXII antigenic levels and function before, during, and after ECMO in children. Methods This is a prospective observational study in neonatal and pediatric patients with ECMO (<18 years). All patients with venoarterial ECMO and with sufficient plasma volume collected before ECMO, on day 1 and day 3, and 24 hours postdecannulation were included. Antigenic levels and functional activity of FXI and FXII were determined in these samples. Longitudinal profiles of these values were created using a linear mixed model. Results Sixteen patients were included in this study. Mean FXI and FXII antigenic levels (U/mL) changed from 7.9 and 53.2 before ECMO to 6.0 and 34.5 on day 3 and they recovered to 8.8 and 39.4, respectively, after stopping ECMO. Function (%) of FXI and FXII decreased from 59.1 and 59.0 to 49.0 and 50.7 on day 3 and recovered to 66.0 and 54.4, respectively. Conclusion This study provides the first insights into changes of the contact pathway in children undergoing ECMO. FXI and FXII antigen and function change during ECMO. Results from this study can be used as starting point for future contact pathway anticoagulant studies in pediatric patients with ECMO.
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Affiliation(s)
- Joppe Drop
- Department of Paediatrics, Division of Paediatric Hematology, Erasmus Medical Centre—Sophia Children’s Hospital, Rotterdam, South Holland, The Netherlands
- Department of Paediatrics, Division of Paediatric Intensive Care and Paediatric Surgery, Erasmus Medical Centre – Sophia Children’s Hospital, Rotterdam, South Holland, The Netherlands
- Haematology Research, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
| | - Natasha Letunica
- Haematology Research, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
| | - Suelyn Van Den Helm
- Haematology Research, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - C. Heleen van Ommen
- Department of Paediatrics, Division of Paediatric Hematology, Erasmus Medical Centre—Sophia Children’s Hospital, Rotterdam, South Holland, The Netherlands
| | - Enno Wildschut
- Department of Paediatrics, Division of Paediatric Intensive Care and Paediatric Surgery, Erasmus Medical Centre – Sophia Children’s Hospital, Rotterdam, South Holland, The Netherlands
| | - Matthijs de Hoog
- Department of Paediatrics, Division of Paediatric Intensive Care and Paediatric Surgery, Erasmus Medical Centre – Sophia Children’s Hospital, Rotterdam, South Holland, The Netherlands
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus University Medical Center, Rotterdam, South Holland, The Netherlands
- Department of Epidemiology, Erasmus University Medical Center, University Medical Center Rotterdam, Rotterdam, South Holland, The Netherlands
| | - Rebecca Barton
- Haematology Research, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Clinical Haematology, The Royal Children’s Hospital, Melbourne, Victoria, Australia
| | - Hui Ping Yaw
- Haematology Research, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
| | - Fiona Newall
- Haematology Research, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Clinical Haematology, The Royal Children’s Hospital, Melbourne, Victoria, Australia
| | - Stephen B. Horton
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Cardiac Surgery, The Royal Children’s Hospital, Melbourne, Victoria, Australia
| | - Roberto Chiletti
- Department of Intensive Care, The Royal Children’s Hospital, Melbourne, Victoria, Australia
- Paediatric Intensive Care Research Group, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Amy Johansen
- Department of Intensive Care, The Royal Children’s Hospital, Melbourne, Victoria, Australia
- Paediatric Intensive Care Research Group, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
| | - Derek Best
- Department of Intensive Care, The Royal Children’s Hospital, Melbourne, Victoria, Australia
- Paediatric Intensive Care Research Group, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
| | - Joanne McKittrick
- Department of Intensive Care, The Royal Children’s Hospital, Melbourne, Victoria, Australia
| | - Warwick Butt
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Intensive Care, The Royal Children’s Hospital, Melbourne, Victoria, Australia
- Paediatric Intensive Care Research Group, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Yves d’Udekem
- Department of Cardiac Surgery, Children’s National Heart Institute, Washington DC, USA
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, National University Health System, Singapore
| | - Matthew D. Linden
- School of Biomedical Sciences, The University of Western Australia, Perth, Western Australia, Australia
| | - Vera Ignjatovic
- Haematology Research, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
- Johns Hopkins All Children’s Institute for Clinical and Translational Research, St Petersburg, Florida, USA
- Department of Paediatrics, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Chantal Attard
- Haematology Research, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Paul Monagle
- Haematology Research, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Clinical Haematology, The Royal Children’s Hospital, Melbourne, Victoria, Australia
- Kids Cancer Centre, Sydney Children’s Hospital, Randwick, New South Wales, Australia
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8
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Van Den Helm S, McCafferty C, Letunica N, Chau KY, Monagle P, Ignjatovic V. Platelet function in neonates and children. Thromb Res 2023; 231:236-246. [PMID: 36997443 DOI: 10.1016/j.thromres.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 11/22/2022] [Accepted: 03/17/2023] [Indexed: 03/29/2023]
Abstract
Platelets are major regulators of haemostasis and coagulation. The primary role of platelets in coagulation is to form a stable clot and stop bleeding. Studies of platelet phenotype and function in neonates and children have been restricted by the large volumes required for many common platelet function tests such as platelet aggregometry. Developmental changes in platelets have not been as well described as developmental changes in plasma coagulation proteins, and overall, platelet phenotype and function in neonates and children has been understudied when compared to adults. Recent developments in more sensitive platelet function testing methods requiring smaller blood volumes such as flow cytometry has enabled recent studies to further investigate platelet phenotype and function in neonates and children. In this review we will provide an overview of recent advances from the past five years in platelets in the context of developmental haemostasis, as well as the role of platelets in neonatal paediatric disease.
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Affiliation(s)
- Suelyn Van Den Helm
- Haematology Research, Murdoch Children's Research Institute, Melbourne, Australia; Department of Paediatrics, The University of Melbourne, Melbourne, Australia
| | - Conor McCafferty
- Haematology Research, Murdoch Children's Research Institute, Melbourne, Australia; Department of Paediatrics, The University of Melbourne, Melbourne, Australia
| | - Natasha Letunica
- Haematology Research, Murdoch Children's Research Institute, Melbourne, Australia
| | - Ka Ying Chau
- Haematology Research, Murdoch Children's Research Institute, Melbourne, Australia
| | - Paul Monagle
- Haematology Research, Murdoch Children's Research Institute, Melbourne, Australia; Department of Paediatrics, The University of Melbourne, Melbourne, Australia; Department of Clinical Haematology, The Royal Children's Hospital, Melbourne, Australia; Kids Cancer Centre, Sydney Children's Hospital, Randwick, Australia
| | - Vera Ignjatovic
- Haematology Research, Murdoch Children's Research Institute, Melbourne, Australia; Department of Paediatrics, The University of Melbourne, Melbourne, Australia; Johns Hopkins All Children's Hospital, St Petersburg, USA.
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9
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Al-Jazairi AS, Shorog EM, Owaidah TM, Al Dalaty H, Alheriash YA, Almehizia RA, Alahmadi MD. Performance Assessment of Anti-Xa Assay-Based Heparin Dosing Protocol in Pediatric Patients on Extracorporeal Membrane Oxygenation. World J Pediatr Congenit Heart Surg 2023; 14:723-728. [PMID: 37654250 DOI: 10.1177/21501351231178761] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
BACKGROUND The use of extracorporeal membrane oxygenation (ECMO) in the postoperative cardiac critical care setting is evolving. Anticoagulation monitoring is among the most challenging aspects of pediatrics. However, there is no consensus on the optimal dosing and monitoring of unfractionated heparin in this setting. To address this, we developed an anti-Xa assay-based protocol derived from the best available clinical and anecdotal evidence of ECMO use and assessed its effectiveness in achieving the anti-Xa assay therapeutic target. METHODS This prospective single-arm study was conducted in the pediatric carcardiac-surgery intensive care unit of a large tertiary hospital. We used two different anti-Xa assay intensity levels based on the patients' bleeding status. RESULTS The median patient age was 7 (interquartile range [IQR]: 5-11.25) months, and the median weight was 5.7 (IQR: 3.8-13.82) kg. The median ECMO duration was 6 (IQR: 4.5-7.5) days. The bleeding protocol was used for most patients. Seventy percent achieved the anti-Xa assay therapeutic target during the study period (median: 75.5 h, IQR: 60.5-117.5 h). Hemorrhagic complications were reported in 40% of the patients, and thrombotic complications were reported in 25%. The median length of stay was 37 (IQR: 22-43) days, with a survival-to-discharge rate of 75%. CONCLUSIONS Despite a failure to achieve the anti-Xa assay target within the first ECMO days, most patients achieved the target by the median ECMO duration. Moreover, using two different anti-Xa assay levels reduced thrombotic complications.
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Affiliation(s)
- Abdulrazaq S Al-Jazairi
- Clinical Trials Transformation Initiative, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Eman M Shorog
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Clinical Pharmacy Department, King Khalid University, College of Pharmacy, Abha, Saudi Arabia
| | - Tarek M Owaidah
- Department of Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Hani Al Dalaty
- Cardiovascular Nursing, Department of Nursing Affairs, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Yasser A Alheriash
- Pediatric Cardiac Intensive Care Unit, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Rayd A Almehizia
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Mamdouh D Alahmadi
- Heart Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
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10
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Berna-Erro A, Granados MP, Rosado JA, Redondo PC. Thrombotic Alterations under Perinatal Hypoxic Conditions: HIF and Other Hypoxic Markers. Int J Mol Sci 2023; 24:14541. [PMID: 37833987 PMCID: PMC10572648 DOI: 10.3390/ijms241914541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/07/2023] [Accepted: 09/08/2023] [Indexed: 10/15/2023] Open
Abstract
Hypoxia is considered to be a stressful physiological condition, which may occur during labor and the later stages of pregnancy as a result of, among other reasons, an aged placenta. Therefore, when gestation or labor is prolonged, low oxygen supply to the tissues may last for minutes, and newborns may present breathing problems and may require resuscitation maneuvers. As a result, poor oxygen supply to tissues and to circulating cells may last for longer periods of time, leading to life-threatening conditions. In contrast to the well-known platelet activation that occurs after reperfusion of the tissues due to an ischemia/reperfusion episode, platelet alterations in response to reduced oxygen exposition following labor have been less frequently investigated. Newborns overcome temporal hypoxic conditions by changing their organ functions or by adaptation of the intracellular molecular pathways. In the present review, we aim to analyze the main platelet modifications that appear at the protein level during hypoxia in order to highlight new platelet markers linked to complications arising from temporal hypoxic conditions during labor. Thus, we demonstrate that hypoxia modifies the expression and activity of hypoxic-response proteins (HRPs), including hypoxia-induced factor (HIF-1), endoplasmic reticulum oxidase 1 (Ero1), and carbonic anhydrase (CIX). Finally, we provide updates on research related to the regulation of platelet function due to HRP activation, as well as the role of HRPs in intracellular Ca2+ homeostasis.
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Affiliation(s)
- Alejandro Berna-Erro
- Department of Physiology (Phycell), University of Extremadura, Avd de la Universidad s/n, 10003 Caceres, Spain; (A.B.-E.); (P.C.R.)
| | | | - Juan Antonio Rosado
- Department of Physiology (Phycell), University of Extremadura, Avd de la Universidad s/n, 10003 Caceres, Spain; (A.B.-E.); (P.C.R.)
| | - Pedro Cosme Redondo
- Department of Physiology (Phycell), University of Extremadura, Avd de la Universidad s/n, 10003 Caceres, Spain; (A.B.-E.); (P.C.R.)
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11
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Hamzah M, Seelhammer TG, Beshish AG, Byrnes J, Yabrodi M, Szadkowski A, Lutfi R, Andrijasevic N, Hock K, Worley S, Macrae DJ. Bivalirudin or heparin for systemic anticoagulation during pediatric extracorporeal membrane oxygenation: Multicenter retrospective study. Thromb Res 2023; 229:178-186. [PMID: 37517208 DOI: 10.1016/j.thromres.2023.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 03/23/2023] [Accepted: 07/19/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND The objective of this study is to evaluate the outcomes of unfractionated heparin (UFH) compared to bivalirudin anticoagulation in pediatric ExtraCorporeal Membrane Oxygenation (ECMO). METHODS A multicenter retrospective study, that included pediatric patients <18 years of age, who were supported on ECMO between June 2017 and May 2020. Patients treated with UFH were matched 2:1 by age and type of ECMO support to the bivalirudin group. RESULTS The bivalirudin group (75 patients) were matched to 150 patients treated with UFH. Baseline characteristics and comorbidities of the two groups were similar. Veno-Arterial ECMO was the most common mode (141/225 [63 %]) followed by extracorporeal cardiopulmonary resuscitation (48/225 [21 %]). Bivalirudin treatment was associated with lower odds of bleeding events (aOR 0.23, 95%CI 0.12-0.45, p < 0.001) and lower odds of thrombotic events (aOR 0.48, 95%CI 0.23-0.98, p = 0.045). Patients who received bivalirudin had lesser odds for transfusion with fresh frozen plasma, and platelets (aOR 0.26, CI 0.12-0.57, p ≤0.001 and aOR 0.28, CI 0.15-0.53, p < 0.001, respectively). After adjusting for the type of ECMO support and adjusting for age, bivalirudin was associated with a decrease in hospital mortality by 50 % compared to the UFH group (aOR 0.50, 95%CI 0.27-0.93, p = 0.028). Similarly, for neurological disability at time of discharge, bivalirudin was associated with higher odds of intact neurological outcomes compared to UFH (OR 1.99 [95%CI 1.13-3.51], p = 0.017). CONCLUSIONS This study demonstrated that effective anticoagulation can be achieved with bivalirudin, which was associated with lesser odds of bleeding events and utilization of blood products. Bivalirudin, in comparison with UFH, was associated with greater odds of hospital survival and intact neurological function at the time of discharge. A prospective randomized trial is required to validate the results of this study.
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Affiliation(s)
- Mohammed Hamzah
- Department of Pediatric Critical Care, Cleveland Clinic Children's, Cleveland, OH, USA.
| | - Troy G Seelhammer
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Asaad G Beshish
- Children's Healthcare of Atlanta, Department of Pediatrics, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Jonathan Byrnes
- Department of Pediatric Cardiology, Children's of Alabama, Birmingham, AL, USA
| | - Mouhammad Yabrodi
- Department of Pediatrics Critical Care, Indiana University, Riley Hospital for Children, Indiana University Health Physicians, Indianapolis, IN, USA
| | - Adam Szadkowski
- Departments of Pediatrics, Section of Critical Care, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Riad Lutfi
- Department of Pediatrics Critical Care, Indiana University, Riley Hospital for Children, Indiana University Health Physicians, Indianapolis, IN, USA
| | - Nicole Andrijasevic
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kristal Hock
- Department of Pediatric Cardiology, Children's of Alabama, Birmingham, AL, USA
| | - Sarah Worley
- Department of Quantitative Health Sciences, Cleveland Clinic Children's, Cleveland, OH, USA
| | - Duncan J Macrae
- Department of Pediatric Intensive Care, Royal Brompton and Harefield NHS Foundation Trust, London, UK
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12
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Garrido-Barbero M, Arnaez J, Martín-Ancel A, González H, García-Alix A. Thrombin, protein C, and protein S values in mother-infant dyads in the postpartum period. An Pediatr (Barc) 2023; 98:338-343. [PMID: 37076369 DOI: 10.1016/j.anpede.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 12/17/2022] [Indexed: 04/21/2023] Open
Abstract
INTRODUCTION The objective of the study was to establish the normal range for the levels of antithrombin (AT), protein C (PC), and protein S (PS) in the first week post birth in mother-infant pairings, adjusting for obstetric and perinatal factors, based on 2 different laboratory methods. METHODS Determinations were carried out in 83 healthy term neonates and their mothers, establishing 3 postpartum age groups: 1-2 days, 3 days, and 4-7 days. RESULTS There were no differences in the levels of any of the proteins between the different age groups in neonates or mothers in the first week post birth. The adjusted analysis found no association with obstetric or perinatal factors. The AT and PC levels were higher in mothers compared to infants (P < .001), while the PS levels were similar in both. Overall, the correlation of maternal and infant protein values was poor, except for the levels of free PS in the first 2 days after delivery. Although we found no differences based on which of the 2 laboratory methods was applied, the absolute values did differ.
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Affiliation(s)
| | - Juan Arnaez
- Unidad de Neonatología, Complejo Asistencial Universitario de Burgos, Burgos, Spain; Fundación NeNe, Madrid, Spain; Profesor Sociedad Iberoamericana de Neonatología, Nueva Yersey, EE.UU.
| | - Ana Martín-Ancel
- Unidad de Neonatología, Centro de Medicina Maternofetal y Neonatal de Barcelona (BCNatal), Hospital Sant Joan de Déu y Hospital Clínic de Barcelona, Barcelona, Spain
| | | | - Alfredo García-Alix
- Fundación NeNe, Madrid, Spain; Profesor Sociedad Iberoamericana de Neonatología, Nueva Yersey, EE.UU
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13
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Levy-Mendelovich S, Cohen O, Klang E, Kenet G. 50 Years of Pediatric Hemostasis: Knowledge, Diagnosis, and Treatment. Semin Thromb Hemost 2023; 49:217-224. [PMID: 36174607 DOI: 10.1055/s-0042-1756704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Studies from the past 50 years have contributed to the expanding knowledge regarding developmental hemostasis. This is a dynamic process that begins in the fetal phase and is characterized by physiological variations in platelet counts and function, and concentrations of most coagulation factors and the native coagulation inhibitors in early life, as compared with adulthood. The developmental hemostasis studies since the 1980 to 1990s established the laboratory reference values for coagulation factors. It was only a decade or two later, that thromboelastography (TEG) or (rotational thromboelastometry [ROTEM]) as well as thrombin generation studies, provided special pediatric reference values along with the ability to evaluate clot formation and lysis. In addition, global whole blood-based clotting assays provided point of care guidance for proper transfusion support to children hospitalized in intensive care units or undergoing surgery. Although uncommon, thrombosis in children and neonates is gaining increasing recognition, typically as a secondary complication in sick children. Bleeding in children, and particularly intracerebral hemorrhage in newborns, still represent a therapeutic challenge. Notably, our review will outline the advancements in understanding developmental hemostasis and its manifestations, with respect to the pathophysiology of thrombosis and bleeding complications in young children. The changes of transfusion policy and approach to thrombophilia testing during the last decade will be mentioned. Subsequently, a brief summary of the data on anticoagulant treatments in pediatric patients will be presented. Finally, we will point out the 10 most cited articles in the field of pediatric and neonatal hemostasis.
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Affiliation(s)
- Sarina Levy-Mendelovich
- National Hemophilia Center, Coagulation Unit and Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Omri Cohen
- National Hemophilia Center, Coagulation Unit and Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eyal Klang
- Department of Diagnostic Imaging, Sheba Medical Center, Tel Hashomer, Israel
| | - Gili Kenet
- National Hemophilia Center, Coagulation Unit and Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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14
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Valores de antitrombina, proteína C y proteína S en parejas madre-recién nacido durante el posparto. An Pediatr (Barc) 2023. [DOI: 10.1016/j.anpedi.2022.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
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15
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Sokou R, Georgiadou P, Tsantes AG, Parastatidou S, Konstantinidi A, Ioakeimidis G, Makrogianni A, Theodoraki M, Kokoris S, Iacovidou N, Kriebardis AG, Piovani D, Bonovas S, Tsantes AE. The Utility of NATEM Assay in Predicting Bleeding Risk in Critically Ill Neonates. Semin Thromb Hemost 2023; 49:182-191. [PMID: 36055275 DOI: 10.1055/s-0042-1753513] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
We aimed to investigate the hemostatic status of diseased neonates using nonactivated rotational thromboelastometry (ROTEM) assay (NATEM) assay and, in addition, to evaluate the discriminative power of NATEM parameters in predicting the risk of bleeding in critically ill neonates and compare it to that of EXTEM (extrinsically activated ROTEM) parameters. This cohort study included 158 consecutive, critically ill neonates with presumed sepsis, perinatal hypoxia, or respiratory distress syndrome. The EXTEM and NATEM assays were performed on the first day of disease onset. The neonatal bleeding assessment tool was used to record and assess clinical bleeding events on the day of ROTEM analysis. Several EXTEM and NATEM ROTEM parameters differed between neonates with and without clinical bleeding events, indicating a hypo-coagulable state in neonates with clinical bleeding. NATEM parameters had comparable predictive performance for clinical bleeding events with EXTEM parameters for clotting time, clot formation time (CFT), A10 (clot amplitude at 10minutes), maximum clot firmness, lysis index at 60minutes, and maximum clot elasticity (p>0.05). However, NATEM A20, A30, and α angle demonstrated better predictive ability than EXTEM A20, A30, and α angle, respectively (p<0.05). A NATEM CFT value ≥147seconds presented 95.2% sensitivity (95% confidence interval [CI]: 76.1-99.8%) and 65.6% specificity (95% CI: 57.1-73.5%) to detect neonates with clinical bleeding, while a NATEM A10 value ≤42mm had 80.8% sensitivity (95% CI: 71.8-85.9%) and 76.0% specificity (95% CI: 52.8-91.7%) to detect neonates with clinical bleeding events. The NATEM assay has shown remarkable sensitivity in predicting bleeding in critically ill neonates, exceeding EXTEM performance in some selected parameters. The incorporation of NATEM test parameters in predictive models for neonatal hemorrhage seems promising.
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Affiliation(s)
- Rozeta Sokou
- Neonatal Intensive Care Unit, "Agios Panteleimon" General Hospital of Nikea, Piraeus, Greece
| | - Petroula Georgiadou
- Neonatal Intensive Care Unit, "Agios Panteleimon" General Hospital of Nikea, Piraeus, Greece
| | - Andreas G Tsantes
- Laboratory of Haematology and Blood Bank Unit, "Attiko" Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Stavroula Parastatidou
- Neonatal Intensive Care Unit, "Agios Panteleimon" General Hospital of Nikea, Piraeus, Greece
| | | | - Georgios Ioakeimidis
- Neonatal Intensive Care Unit, "Agios Panteleimon" General Hospital of Nikea, Piraeus, Greece
| | - Athanasia Makrogianni
- Neonatal Intensive Care Unit, "Agios Panteleimon" General Hospital of Nikea, Piraeus, Greece
| | - Martha Theodoraki
- Neonatal Intensive Care Unit, "Agios Panteleimon" General Hospital of Nikea, Piraeus, Greece
| | - Styliani Kokoris
- Laboratory of Haematology and Blood Bank Unit, "Attiko" Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Nicoletta Iacovidou
- Neonatal Department, Aretaieio Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Anastasios G Kriebardis
- Laboratory of Reliability and Quality Control in Laboratory Hematology, Department of Biomedical Science, School of Health and Caring Science, University of West Attica, Egaleo, Athens, Greece
| | - Daniele Piovani
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,IRCCS Humanitas Research Hospital, Milan, Italy
| | - Stefanos Bonovas
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,IRCCS Humanitas Research Hospital, Milan, Italy
| | - Argirios E Tsantes
- Laboratory of Haematology and Blood Bank Unit, "Attiko" Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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16
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Procaccini DE, Roem J, Ng DK, Rappold TE, Jung D, Gobburu JVS, Bembea MM. Evaluation of acquired antithrombin deficiency in paediatric patients supported on extracorporeal membrane oxygenation. Br J Clin Pharmacol 2023. [PMID: 36850024 DOI: 10.1111/bcp.15703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 02/10/2023] [Accepted: 02/12/2023] [Indexed: 03/01/2023] Open
Abstract
AIMS There remains a paucity of literature regarding best practice for antithrombin (AT) monitoring, dosing and dose-response in paediatric extracorporeal membrane oxygenation (ECMO) patients. METHODS We conducted a retrospective cohort study at a quaternary care paediatric intensive care unit in all patients <18 years of age supported on ECMO from 1 June 2011 to 30 April 2020. Adverse events and outcomes were characterized for all ECMO runs. AT activity and replacement were characterized and compared between two clinical protocols. AT activities measured post- vs. pre-AT replacement were compared in order to characterize a dose-response relationship. RESULTS The final cohort included 191 patients with 201 ECMO runs and 2028 AT activity measurements. The median AT activity was 65% (interquartile range [IQR], 51-82) and 879 (43.3%) measurements met the criteria of deficient. The overall median AT dose and increase in AT activity were 50.6 units/kg/dose (IQR, 39.5-67.2) and 23.5% (IQR, 9.8-36.0), respectively. In the protocol that restricted AT activity measurements to clinical scenarios concerning for heparin resistance, there was significantly higher dosing in conjunction with significantly fewer overall administrations. Approximately one third of AT activity remained deficient after repletion. There was no difference in mechanical complications, reasons for discontinuation of ECMO support, time on ECMO or survival between protocols. CONCLUSIONS There was a high prevalence of AT deficiency in paediatric ECMO patients. An AT replacement protocol based on evaluating heparin resistance is associated with fewer AT administrations, with similar circuit and patient outcomes. Further data are needed to identify optimal dosing strategies.
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Affiliation(s)
- David E Procaccini
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Jennifer Roem
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Derek K Ng
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Thomas E Rappold
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Dawoon Jung
- Center for Translational Medicine, School of Pharmacy, University of Maryland, Baltimore, Maryland, USA
| | - Jogarao V S Gobburu
- Center for Translational Medicine, School of Pharmacy, University of Maryland, Baltimore, Maryland, USA
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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17
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Zdenek CN, Rodrigues CFB, Bourke LA, Tanaka-Azevedo AM, Monagle P, Fry BG. Children and Snakebite: Snake Venom Effects on Adult and Paediatric Plasma. Toxins (Basel) 2023; 15:158. [PMID: 36828472 PMCID: PMC9961128 DOI: 10.3390/toxins15020158] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/26/2023] [Accepted: 02/07/2023] [Indexed: 02/17/2023] Open
Abstract
Snakebite is a globally neglected tropical disease, with coagulation disturbances being the primary pathology of many deadly snake venoms. Age-related differences in human plasma have been abundantly reported, yet the effect that these differences pose regarding snakebite is largely unknown. We tested for differences in coagulotoxic effects (via clotting time) of multiple snake venoms upon healthy human adult (18+) and paediatric (median 3.3 years old) plasma in vivo and compared these effects to the time it takes the plasmas to clot without the addition of venom (the spontaneous clotting time). We tested venoms from 15 medically significant snake species (from 13 genera) from around the world with various mechanisms of coagulotoxic actions, across the three broad categories of procoagulant, pseudo-procoagulant, and anticoagulant, to identify any differences between the two plasmas in their relative pathophysiological vulnerability to snakebite. One procoagulant venom (Daboia russelii, Russell's Viper) produced significantly greater potency on paediatric plasma compared with adult plasma. In contrast, the two anticoagulant venoms (Pseudechis australis, Mulga Snake; and Bitis cornuta, Many-horned Adder) were significantly more potent on adult plasma. All other procoagulant venoms and all pseudo-procoagulant venoms displayed similar potency across both plasmas. Our preliminary results may inform future studies on the effect of snake venoms upon plasmas from different age demographics and hope to reduce the burden of snakebite upon society.
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Affiliation(s)
- Christina N. Zdenek
- Venom Evolution Lab, School of Biological Sciences, The University of Queensland, St. Lucia, QLD 4072, Australia
| | | | - Lachlan A. Bourke
- Venom Evolution Lab, School of Biological Sciences, The University of Queensland, St. Lucia, QLD 4072, Australia
| | - Anita Mitico Tanaka-Azevedo
- Laboratório de Herpetologia, Instituto Butantan, São Paulo 05508-040, SP, Brazil
- Programa de Pós-Graduação Interunidades Em Biotecnologia, USP, IPT e Instituto Butantan, São Paulo 05508-040, SP, Brazil
| | - Paul Monagle
- Department of Paediatrics, University of Melbourne, Parkville, VIC 3010, Australia
- Haematology Research, Murdoch children’s Research Institute, Flemington Rd., Parkville, VIC 3052, Australia
- Department of Clinical Haematology, Royal Children’s Hospital, Flemington Rd., Parkville, VIC 3052, Australia
- Kids Cancer Centre, Sydney Children’s Hospital, High St., Randwick, NSW 2031, Australia
| | - Bryan G. Fry
- Venom Evolution Lab, School of Biological Sciences, The University of Queensland, St. Lucia, QLD 4072, Australia
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18
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Letunica N, Karlaftis V, Monagle P, Ignjatovic V. Newborn and Pediatric Reference Intervals for Coagulation Assays Using Novel Reagents. Thromb Haemost 2022; 122:2042-2044. [PMID: 36343639 DOI: 10.1055/s-0042-1756437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Natasha Letunica
- Haematology, Murdoch Children's Research Institute, Melbourne, Australia
| | - Vasiliki Karlaftis
- Haematology, Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Australia
| | - Paul Monagle
- Haematology, Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Australia.,Department of Clinical Haematology, Royal Children's Hospital, Melbourne, Australia.,Kids Cancer Centre, Sydney Children's Hospital, Randwick, Australia
| | - Vera Ignjatovic
- Haematology, Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Australia
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An Up-to-Date Literature Review on Ventricular Assist Devices Experience in Pediatric Hearts. LIFE (BASEL, SWITZERLAND) 2022; 12:life12122001. [PMID: 36556366 PMCID: PMC9788166 DOI: 10.3390/life12122001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 11/22/2022] [Accepted: 11/29/2022] [Indexed: 12/02/2022]
Abstract
Ventricular assist devices (VAD) have gained popularity in the pediatric population during recent years, as more and more children require a heart transplant due to improved palliation methods, allowing congenital heart defect patients and children with cardiomyopathies to live longer. Eventually, these children may require heart transplantation, and ventricular assist devices provide a bridge to transplantation in these cases. The FDA has so far approved two types of device: pulsatile and continuous flow (non-pulsatile), which can be axial and centrifugal. Potential eligible studies were searched in three databases: Medline, Embase, and ScienceDirect. Our endeavor retrieved 16 eligible studies focusing on five ventricular assist devices in children. We critically reviewed ventricular assist devices approved for pediatric use in terms of implant indication, main adverse effects, and outcomes. The main adverse effects associated with these devices have been noted to be thromboembolism, infection, bleeding, and hemolysis. However, utilizing left VAD early on, before end-organ dysfunction and deterioration of heart function, may give the patient enough time to recuperate before considering a more long-term solution for ventricular support.
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20
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Extracorporeal Anticoagulation With Bivalirudin; Is the Best Still to Come? ASAIO J 2022; 68:e223. [PMID: 36326707 DOI: 10.1097/mat.0000000000001705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
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21
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Di Felice G, Vidali M, Parisi G, Pezzi S, Di Pede A, Deidda G, D’Agostini M, Carletti M, Ceccarelli S, Porzio O. Reference Intervals for Coagulation Parameters in Developmental Hemostasis from Infancy to Adolescence. Diagnostics (Basel) 2022; 12:diagnostics12102552. [PMID: 36292241 PMCID: PMC9601585 DOI: 10.3390/diagnostics12102552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 10/17/2022] [Accepted: 10/19/2022] [Indexed: 11/21/2022] Open
Abstract
Background: The objective of this study was to establish the age and sex-dependent reference intervals for coagulation assays evaluated in healthy children, ranging from 0 days to 16 years old. Methods: PT, aPTT, Fibrinogen (functional), Antithrombin activity, Protein C anticoagulant activity, Protein S free antigen, Thrombin time, D-Dimer, Von Willebrand Factor antigen, Lupus anticoagulant (screening), extrinsic and intrinsic pathway factors, and activated Protein C resistance were evaluated using STA-R Max2. Results: A total of 1280 subjects (671 males and 609 females) were divided into five groups, according to their age: 0–15 days (n = 280, 174 M and 106 F), 15–30 days (n = 208, 101 M and 107 F), 1–6 months (n = 369, 178 M and 191 F), 6–12 months (n = 214, 110 M and 104 F), and 1–16 years (n = 209, 108 M and 101 F). The 95% reference intervals and the 90% CI were established using the Harrell–Davis bootstrap method and the bootstrap percentile method, respectively. Conclusions: The present study supports the concept that adult and pediatric subjects should be evaluated using different reference intervals, at least for some coagulation tests, to avoid misdiagnosis, which can potentially lead to serious consequences for patients and their families, and ultimately the healthcare system.
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Affiliation(s)
- Giovina Di Felice
- Clinical Laboratory Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
- Correspondence: ; Tel.: +39-066-859-2334; Fax: +39-066-859-2014
| | - Matteo Vidali
- Clinical Chemistry Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Gelsomina Parisi
- Clinical Laboratory Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Simona Pezzi
- Clinical Laboratory Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Alessandra Di Pede
- Neonatal Intensive Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Giulia Deidda
- Clinical Laboratory Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Matteo D’Agostini
- Clinical Laboratory Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Michaela Carletti
- Clinical Laboratory Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Stefano Ceccarelli
- Clinical Laboratory Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Ottavia Porzio
- Clinical Laboratory Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
- Department of Experimental Medicine, University of Rome Tor Vergata, 00133 Rome, Italy
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Gammon RR, Al-Mozain N, Auron M, Bocquet C, Clem S, Gupta GK, Hensch L, Klein N, Lea NC, Mandal S, Pelletier P, Resheidat A, Yossi Schwartz J. Transfusion therapy of neonatal and paediatric patients: They are not just little adults. Transfus Med 2022; 32:448-459. [PMID: 36207985 DOI: 10.1111/tme.12921] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 08/01/2022] [Accepted: 09/11/2022] [Indexed: 11/28/2022]
Abstract
Patient blood management (PBM) strategies are needed in the neonate and paediatric population, given that haemoglobin thresholds used are often higher than recommended by evidence, with exposure of children to potential complications without meaningful benefit. A literature review was performed on the following topics: evidence-based transfusions of blood components and pharmaceutical agents. Other topics reviewed included perioperative coagulation assessment and perioperative PBM. The Transfusion and Anaemia Expertise Initiative (TAXI) consortium published a consensus statement addressing haemoglobin (Hb) transfusion threshold in multiple subsets of patients. A multicentre trial (PlaNeT-2) reported a higher risk of bleeding and death or serious new bleeding among infants who received platelet transfusion at a higher (50 000/μl) compared to a lower (25 000/μl) threshold. Recent data support the use of a restrictive transfusion threshold of 25 000/μl for prophylactic platelet transfusions in preterm neonates. The TAXI-CAB consortium mentioned that in critically ill paediatric patients undergoing invasive procedures outside of the operating room, platelet transfusion might be considered when the platelet count is less than or equal to 20 000/μl and there is no benefit of platelet transfusion when the platelet count is more than 50 000/μl. There are limited controlled studies in paediatric and neonatal population regarding plasma transfusion. Blood conservation strategies to minimise allogenic blood exposure are essential to positive patient outcomes neonatal and paediatric transfusion practices have changed significantly in recent years since randomised controlled trials were published to guide practice. Additional studies are needed in order to provide practice change recommendations.
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Affiliation(s)
| | - Nour Al-Mozain
- King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia.,Whittington Health NHS Trust, London, UK
| | | | - Christopher Bocquet
- Association for the Advancement of Blood and Biotherapies, Bethesda, Maryland, USA
| | - Sam Clem
- American Red Cross, Fort Wayne, Indiana, USA
| | - Gaurav K Gupta
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Lisa Hensch
- Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Norma Klein
- University of California, Davis, California, USA
| | | | | | | | - Ashraf Resheidat
- Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
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Characterization of Biomarkers of Hemostasis and Bleeding-Related Outcomes in Children With Cirrhosis. J Pediatr Gastroenterol Nutr 2022; 75:506-513. [PMID: 35797560 DOI: 10.1097/mpg.0000000000003555] [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: 12/10/2022]
Abstract
OBJECTIVES We aimed to evaluate differences in laboratory tests, bleeding, transfusions, and thrombosis between (1) children without and with cirrhosis and (2) children and adults with cirrhosis, and to correlate thromboelastography (TEG) parameters with biomarkers of hemostasis, bleeding, and transfusions in children and adults with cirrhosis. METHODS This single-center, retrospective study included 20 children without cirrhosis, 40 children with cirrhosis, and 40 adults with cirrhosis who underwent a liver transplant (LT). We collected demographic data, preoperative laboratory values, and intraoperative TEG parameters. Biomarkers of hemostasis just prior to the start of LT surgery were analyzed including international normalized ratio (INR), platelet, fibrinogen level, R time, K time, alpha angle (α), and maximum amplitude (MA). We also collected outcome data including blood loss, transfusion requirements, and thrombosis. RESULTS A significantly higher proportion of children with cirrhosis had abnormal PT ( P = 0.001), platelet ( P = 0.001), K time ( P = 0.02), and MA ( P = 0.05) compared to children without cirrhosis. The incidences of thrombosis, bleeding events, blood loss or PRBC transfusion were not significantly different between these 2 groups. A significantly higher proportion of adults with cirrhosis had abnormal R time ( P = 0.01) and alpha angle ( P = 0.01) than children with cirrhosis. CONCLUSIONS Children with cirrhosis had defects in fibrinogen and platelets compared to children without cirrhosis at time of LT; however, these abnormalities did not translate into higher rates of bleeding in the former. Adults with cirrhosis had more defects in clotting factors compared to children with cirrhosis.
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Biss T, Sibson K, Baker P, Macartney C, Grayson C, Grainger J, Chalmers E, Dixon S. Haematological evaluation of bruising and bleeding in children undergoing child protection investigation for possible physical maltreatment: A British Society for Haematology Good Practice Paper. Br J Haematol 2022; 199:45-53. [PMID: 35881677 DOI: 10.1111/bjh.18361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/01/2022] [Accepted: 07/05/2022] [Indexed: 01/12/2023]
Affiliation(s)
- Tina Biss
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | - Peter Baker
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Caroline Grayson
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - John Grainger
- Royal Manchester Children's Hospital, Manchester, UK
| | | | - Sarah Dixon
- Manchester Health and Care Commissioning, Manchester, UK
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25
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İbrahimkhalilov Z, Ünsal A, Altuntaş N. THE D-DİMER REFERENCE INTERVALS İN HEALTY TERM NEWBORNS. Transfus Apher Sci 2022; 61:103493. [DOI: 10.1016/j.transci.2022.103493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 06/12/2022] [Accepted: 06/20/2022] [Indexed: 11/30/2022]
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26
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Villa C, Zafar F, Lorts A, Kung E. Hemodynamic Response to Device Titration in the Shunted Single Ventricle Circulation: A Patient Cohort Modeling Study. ASAIO J 2022; 68:268-274. [PMID: 33788799 DOI: 10.1097/mat.0000000000001433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Clinical outcomes of ventricular assist device (VAD) support for shunted single ventricle patients trail the larger population due in part to the challenges in optimizing VAD support and balancing systemic and pulmonary circulations. We sought to understand the response to VAD titration in the shunted circulation using a lumped-parameter network modeling six patient-specific clinical cases. Hemodynamic data from six patients (mean body surface area = 0.30 m2) with a systemic-to-pulmonary shunt was used to construct simulated cases of heart failure and hemodynamic response to increasing VAD flow from 5 to 10 L/min/m2. With increasing VAD flow, the pulmonary arterial pressure stayed relatively constant in five patient cases and increased in one patient case. The mean VAD flow needed to attain an arterial-venous O2 saturation difference of 30% was 6.5 ± 1.2 L/min/m2, which is higher than that in the equivalent nonshunted scenario due to the partial diversion of flow to the pulmonary circulation. The hemodynamic responses to VAD support can vary significantly between specific patient cases; therefore hemodynamic modeling may help guide an individualized approach to perioperative VAD management in the shunted single-ventricle circulation and to understand the patients who may benefit the most from VAD support.
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Affiliation(s)
- Chet Villa
- From the Department of Pediatrics, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Farhan Zafar
- Department of Surgery, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Angela Lorts
- From the Department of Pediatrics, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Ethan Kung
- Department of Mechanical Engineering, Clemson University, Clemson, South Carolina
- Department of Bioengineering, Clemson University, Clemson, South Carolina
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27
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Boucher AA, Francisco BJ, Pfeiffer A, Martin M, Martin J, Shova A, Nathan JD, Tiao GM, Luchtman-Jones L. Urinary 11-dehydrothromboxane B2 aspirin efficacy testing is sensitive to perioperative inflammation in pediatric solid-organ transplant patients. Pediatr Blood Cancer 2022; 69:e29413. [PMID: 34676969 DOI: 10.1002/pbc.29413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 09/22/2021] [Accepted: 10/02/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Evidence for aspirin efficacy testing in pediatrics is limited, especially outside of cardiology, yet thrombotic events have high morbidity in other areas such as pediatric transplant surgery. Debates about whether thromboembolic events while on aspirin represent "aspirin resistance" or "high on-treatment platelet reactivity" persist, given the poor intertest agreement between testing platforms. PROCEDURE This prospective observational study involved measuring aspirin efficacy using ex vivo testing of platelet aggregation (VerifyNow-Aspirin, VN) and urine 11-dehydrothromboxane B2 (AsprinWorks, UTxB2) contemporaneously at up to three time points after major noncardiac organ transplant surgery. The collection days (CD) were the second and seventh days after stable aspirin dosing and then a convalescent time point 2-9 months later. RESULTS Fifty-five participants (age range, 0-21 years) were enrolled, having undergone total pancreatectomy with islet autotransplantation (N = 36), orthotopic liver transplantation (N = 18), and combined liver-kidney transplantation (N = 1). Platelet reactivity measured by VN remained unchanged, whereas UTxB2, which was elevated postoperatively, decreased significantly from CD1 to CD2 and CD3. Discordance in therapeutic efficacy was noted per manufacturer cutoffs, with therapeutic VN results in 86% of tests, whereas 12% of UTxB2 were therapeutic. Age-based stratification of UTxB2 results using previously published pediatric median levels increased overall UTxB2 therapeutic rates (80%) and intertest concordance (67% vs 27% if using adult range). No thrombotic events were observed. CONCLUSIONS Our data suggest that urine thromboxane production may be an underappreciated reflection of postoperative inflammation. Validation of pediatric normal ranges for UTxB2 is a critical next step.
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Affiliation(s)
- Alexander A Boucher
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Brenton J Francisco
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Amanda Pfeiffer
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Matthew Martin
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Janine Martin
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Amy Shova
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jaimie D Nathan
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Gregory M Tiao
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Lori Luchtman-Jones
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Guzzardo GM, Regling K. Developmental Hemostasis: The Evolution of our Coagulation System. Neoreviews 2022; 23:e82-e95. [PMID: 35102383 DOI: 10.1542/neo.23-2-e82] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Developmental hemostasis describes the evolution of the coagulation system from the neonatal period through adulthood. Neonates have lower levels of coagulation factors and elevated screening levels at birth. These levels can be influenced by various circumstances including gestational age, labor effects, and clinical status. The most commonly used screening tests for coagulopathy are the prothrombin time, partial thromboplastin time, and fibrinogen level. These values can be difficult to interpret as every laboratory has its own age-specific reference ranges. An understanding of developmental hemostasis is important when evaluating, diagnosing, and treating clinical manifestations, including vitamin K deficiency, surgical needs, infections, inherited thrombophilias, and inherited bleeding disorders. The mainstay of treatment for bleeding or hemorrhage is platelet and fresh frozen plasma transfusions. For the treatment of thrombosis, unfractionated heparin and low-molecular-weight heparin are the 2 most commonly used anticoagulants in the neonatal setting.
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Affiliation(s)
- Gianna M Guzzardo
- Department of Pediatric Hematology Oncology, Children's Hospital of Michigan, Detroit, MI
| | - Katherine Regling
- Department of Pediatric Hematology Oncology, Children's Hospital of Michigan, Detroit, MI
- Central Michigan University School of Medicine, Detroit, MI
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29
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Van Den Helm S, Yaw HP, Letunica N, Barton R, Weaver A, Newall F, Horton SB, Chiletti R, Johansen A, Best D, McKittrick J, Butt W, d'Udekem Y, MacLaren G, Linden MD, Ignjatovic V, Monagle P. Platelet Phenotype and Function Changes With Increasing Duration of Extracorporeal Membrane Oxygenation. Crit Care Med 2022; 50:1236-1245. [PMID: 35020670 DOI: 10.1097/ccm.0000000000005435] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To investigate platelet pathophysiology associated with pediatric extracorporeal membrane oxygenation (ECMO). DESIGN Prospective observational study of neonatal and pediatric ECMO patients from September 1, 2016, to December 31, 2019. SETTING The PICU in a large tertiary referral pediatric ECMO center. PATIENTS Eighty-seven neonates and children (< 18 yr) supported by ECMO. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Arterial blood samples were collected on days 1, 2, and 5 of ECMO and were analyzed by whole blood flow cytometry. Corresponding clinical data for each patient was also recorded. A total of 87 patients were recruited (median age, 65 d; interquartile range [IQR], 7 d to 4 yr). The median duration of ECMO was 5 days (IQR, 3-8 d) with a median length of stay in PICU and hospital of 18 days (IQR, 10-29 d) and 35 days (IQR, 19-75 d), respectively. Forty-two patients (48%) had at least one major bleed according to a priori determined definitions, and 12 patients (14%) had at least one thrombotic event during ECMO. Platelet fibrinogen receptor expression decreased (median fluorescence intensity [MFI], 29,256 vs 26,544; p = 0.0005), while von Willebrand Factor expression increased (MFI: 7,620 vs 8,829; p = 0.0459) from day 2 to day 5 of ECMO. Platelet response to agonist, Thrombin Receptor Activator Peptide 6, also decreased from day 2 to day 5 of ECMO, as measured by binding with anti-P-selectin, PAC-1 (binds activated GPIIb/IIIa), and anti-CD63 monoclonal antibodies (P-selectin area under the curve [AUC]: 63.46 vs 42.82, respectively, p = 0.0022; PAC-1 AUC: 93.75 vs 74.46, p = 0.0191; CD63 AUC: 55.69 vs 41.76, p = 0.0020). CONCLUSIONS The loss of platelet response over time may contribute to bleeding during ECMO. These novel insights may be useful in understanding mechanisms of bleeding in pediatric ECMO and monitoring platelet markers clinically could allow for prediction or early detection of bleeding and thrombosis.
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Affiliation(s)
- Suelyn Van Den Helm
- Haematology, 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. Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, VIC, Australia. Department of Intensive Care, The Royal Children's Hospital, Melbourne, VIC, Australia. Paediatric Intensive Care Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia. Department of Cardiac Surgery, Children's National Heart Institute, Washington, DC. Cardiothoracic Intensive Care Unit, National University Health System, Singapore. School of Biomedical Sciences, The University of Western Australia, Perth, WA, Australia. Kids Cancer Centre, Sydney Children's Hospital, Randwick, NSW, Australia
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30
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Male C, Monagle P, Albisetti M, Brandão LR, Young G. Direct Oral Anticoagulants: Overcoming the Challenges of Managing Venous Thromboembolism in Children. J Pediatr 2022; 240:14-23. [PMID: 34687696 DOI: 10.1016/j.jpeds.2021.09.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 09/15/2021] [Accepted: 09/16/2021] [Indexed: 12/16/2022]
Affiliation(s)
- Christoph Male
- Department of Pediatrics, Medical University of Vienna, Vienna, Austria.
| | - Paul Monagle
- Royal Children's Hospital, Murdoch Children's Research Institute, University of Melbourne, Melbourne, Australia; Australia and Kids Cancer Centre, Sydney Children's Hospital, Sydney, Australia
| | - Manuela Albisetti
- Division of Hematology, University Children's Hospital of Zurich, Zurich, Switzerland
| | - Leonardo R Brandão
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Guy Young
- Children's Hospital Los Angeles, University of Southern California, Keck School of Medicine, Los Angeles, CA
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31
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Nielsen ST, Strandkjær N, Juul Rasmussen I, Hansen MK, Lytsen RM, Kamstrup PR, Rode L, Goetze JP, Iversen K, Bundgaard H, Frikke-Schmidt R. Coagulation parameters in the newborn and infant - the Copenhagen Baby Heart and COMPARE studies. Clin Chem Lab Med 2021; 60:261-270. [PMID: 34752018 DOI: 10.1515/cclm-2021-0967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 10/25/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The coagulation system is not fully developed at birth and matures during the first months of infancy, complicating clinical decision making within hemostasis. This study evaluates coagulation parameters at birth and two months after birth, and tests whether cord blood can be used as a proxy for neonatal venous blood measurements. METHODS The Copenhagen Baby Heart Study (CBHS) and the COMPARE study comprise 13,237 cord blood samples and 444 parallel neonatal venous blood samples, with a two month follow-up in 362 children. RESULTS Because coagulation parameters differed according to gestational age (GA), all analyses were stratified by GA. For neonatal venous blood, reference intervals for activated partial thromboplastin time (APTT) and prothrombin time (PT) were 28-43 s and 33-61% for GA 37-39 and 24-38 s and 30-65% for GA 40-42. Reference intervals for international normalized ratio (INR) and thrombocyte count were 1.1-1.7 and 194-409 × 109/L for GA 37-39 and 1.2-1.8 and 188-433 × 109/L for GA 40-42. Correlation coefficients between umbilical cord and neonatal venous blood for APTT, PT, INR, and thrombocyte count were 0.68, 0.72, 0.69, and 0.77 respectively, and the distributions of the parameters did not differ between the two types of blood (all p-values>0.05). CONCLUSIONS This study describes new GA dependent reference intervals for common coagulation parameters in newborns and suggests that cord blood may serve as a proxy for neonatal venous blood for these traits. Such data will likely improve clinical decision making within hemostasis among newborn and infant children.
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Affiliation(s)
- Sofie Taageby Nielsen
- Department of Clinical Biochemistry, Rigshospitalet, Copenhagen, Denmark.,Department of Cardiology, Rigshospitalet, Copenhagen, Denmark.,Department of Cardiology, Herlev-Gentofte Hospital, Herlev, Denmark
| | - Nina Strandkjær
- Department of Clinical Biochemistry, Rigshospitalet, Copenhagen, Denmark.,Department of Cardiology, Rigshospitalet, Copenhagen, Denmark.,Department of Cardiology, Herlev-Gentofte Hospital, Herlev, Denmark
| | - Ida Juul Rasmussen
- Department of Clinical Biochemistry, Rigshospitalet, Copenhagen, Denmark
| | - Malene Kongsgaard Hansen
- Department of Clinical Biochemistry, Rigshospitalet, Copenhagen, Denmark.,Department of Cardiology, Rigshospitalet, Copenhagen, Denmark.,Department of Cardiology, Herlev-Gentofte Hospital, Herlev, Denmark
| | - Rikke Mohr Lytsen
- Department of Clinical Biochemistry, Rigshospitalet, Copenhagen, Denmark.,Department of Cardiology, Rigshospitalet, Copenhagen, Denmark.,Department of Cardiology, Herlev-Gentofte Hospital, Herlev, Denmark
| | - Pia R Kamstrup
- Department of Clinical Biochemistry, Herlev-Gentofte Hospital, Herlev, Denmark
| | - Line Rode
- Department of Clinical Biochemistry, Rigshospitalet, Copenhagen, Denmark
| | - Jens P Goetze
- Department of Clinical Biochemistry, Rigshospitalet, Copenhagen, Denmark.,Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Kasper Iversen
- Department of Cardiology, Herlev-Gentofte Hospital, Herlev, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Henning Bundgaard
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Ruth Frikke-Schmidt
- Department of Clinical Biochemistry, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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32
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Anand T, Obaid O, Nelson A, Chehab M, Ditillo M, Hammad A, Douglas M, Bible L, Joseph B. Whole blood hemostatic resuscitation in pediatric trauma: A nationwide propensity-matched analysis. J Trauma Acute Care Surg 2021; 91:573-578. [PMID: 34086658 DOI: 10.1097/ta.0000000000003306] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Whole blood (WB) has shown promise in pediatric trauma resuscitation following its prominent role in the resuscitation of adult trauma patients. Although WB in children has been shown to be feasible, its effectiveness has yet to be explored. The aim of this study was to examine the outcomes of WB transfusion as an adjunct to component therapy (CT) compared with CT only as early resuscitation for pediatric trauma patients. METHODS Children aged 1 to 17 years, who were transfused within 4 hours of presentation, were identified in the Trauma Quality Improvement Program 2017 database. Patients were stratified into those receiving WB-CT versus CT alone. Propensity score matching in a 1:2 ratio was performed based on patient demographics, injury characteristics, hemorrhage control interventions, and trauma center level. The primary outcome measure was patient transfusion requirement. Secondary outcome measures were mortality, hospital length of stay, ventilation days, and major complications. RESULTS A total of 135 children receiving WB-CT were matched to 270 patients receiving CT only. Mean (SD) age was 12 (5) years, 66% were male, and the median Injury Severity Score was 32 (range, 20-43). A total of 51% of patients were in shock, 34% had penetrating injuries, and 41% required surgical intervention for hemorrhage control. Total blood products transfused were significantly decreased in children receiving WB, both at 4 hours (35 [22-73] vs. 48 [33-95] mL/kg; p = 0.013) and 24 hours (39 [24-97] vs. 53 [36-119] mL/kg; p < 0.001). Mortality rate at 24 hours (19.3% vs. 21.9%; p = 0.546) and in-hospital mortality (31.1% vs. 34.4%; p = 0.502) were not different. Similarly, no difference in hospital length of stay and rates of major complications was found. Patients in the WB group required significantly less ventilation days (2 [2-6] vs. 3 [2-8] days; p = 0.021). CONCLUSION Using WB as an adjunct to CT was associated with decreased transfusion requirements and ventilation days in pediatric trauma patients. LEVEL OF EVIDENCE Therapeutic, level III.
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Affiliation(s)
- Tanya Anand
- From the Division of Trauma, Critical Care, Burn, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
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33
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Cannata G, Mariotti Zani E, Argentiero A, Caminiti C, Perrone S, Esposito S. TEG ® and ROTEM ® Traces: Clinical Applications of Viscoelastic Coagulation Monitoring in Neonatal Intensive Care Unit. Diagnostics (Basel) 2021; 11:diagnostics11091642. [PMID: 34573982 PMCID: PMC8465234 DOI: 10.3390/diagnostics11091642] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 08/28/2021] [Accepted: 09/04/2021] [Indexed: 12/14/2022] Open
Abstract
The concentration of the majority of hemostatic proteins differs considerably in early life, especially in neonates compared to adulthood. Knowledge of the concept of developmental hemostasis is an essential prerequisite for the proper interpretation of conventional coagulation tests (CCT) and is critical to ensure the optimal diagnosis and treatment of hemorrhagic and thrombotic diseases in neonatal age. Viscoelastic tests (VETs) provide a point-of-care, real-time, global, and dynamic assessment of the mechanical properties of the coagulation system with the examination of both cellular and plasma protein contributions to the initiation, formation, and lysis of clots. In this work, we provide a narrative review of the basic principles of VETs and summarize current evidence regarding the two most studied point-of-care VETs, thromboelastography (TEG®) and rotational thromboelastometry (ROTEM®), in the field of neonatal care. A literature analysis shows that viscoelastic hemostatic monitoring appears to be a useful additive technique to CCT, allowing targeted therapy to be delivered quickly. These tools may allow researchers to determine the neonatal coagulation profile and detect neonatal patients at risk for postoperative bleeding, coagulation abnormalities in neonatal sepsis, and other bleeding events in a timely manner, guiding transfusion therapies using the goal-oriented transfusion algorithm. However, diagnosis and treatment algorithms incorporating VETs for neonatal patients in a variety of clinical situations should be developed and applied to improve clinical outcomes. Further studies should be performed to make routinary diagnostic and therapeutic application possible for the neonatal population.
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Affiliation(s)
- Giulia Cannata
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, via Gramsci 14, 43126 Parma, Italy; (G.C.); (E.M.Z.); (A.A.)
| | - Elena Mariotti Zani
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, via Gramsci 14, 43126 Parma, Italy; (G.C.); (E.M.Z.); (A.A.)
| | - Alberto Argentiero
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, via Gramsci 14, 43126 Parma, Italy; (G.C.); (E.M.Z.); (A.A.)
| | - Caterina Caminiti
- Research and Innovation Unit, University Hospital of Parma, via Gramsci 14, 43126 Parma, Italy;
| | - Serafina Perrone
- Neonatology Unit, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, via Gramsci 14, 43126 Parma, Italy;
| | - Susanna Esposito
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, via Gramsci 14, 43126 Parma, Italy; (G.C.); (E.M.Z.); (A.A.)
- Correspondence: ; Tel.: +39-0521-903524
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34
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Iyer N, Al Qaryoute A, Kacham M, Jagadeeswaran P. Identification of zebrafish ortholog for human coagulation factor IX and its age-dependent expression. J Thromb Haemost 2021; 19:2137-2150. [PMID: 33974340 DOI: 10.1111/jth.15365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/25/2021] [Accepted: 04/15/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Coagulation factor IX (FIX) is a serine protease zymogen involved in the intrinsic blood coagulation pathway, and its deficiency causes hemophilia B. Zebrafish has three f9 genes, and the ortholog to human F9 is unknown. OBJECTIVE To identify the zebrafish ortholog to F9 using sequence analysis and piggyback knockdown technology. METHODS Gene and protein sequence analysis for three f9 genes, f9a, f9b, and f9l, present in the zebrafish genome was performed. In vivo and in vitro assays after knockdown of each gene and immunodepletion using specific antibodies were carried out. RESULTS Sequence analysis revealed that f9a and f9b are similar to human F9, whereas f9l is similar to human F10. RNA analysis showed an age-dependent increase in expression of all three genes. Zebrafish f9a gene knockdown and Fixa immunodepletion prolonged kinetic partial thromboplastin time (kPTT), whereas f9l knockdown and Fixl immunodepletion prolonged kPTT, kinetic prothrombin time, and kinetic Russell viper venom activation time. Laser-assisted venous thrombosis increased time to occlusion after f9a and f9l knockdown and antibody inhibition of Fixa and Fixl. Further, analysis of plasma proteins by mass spectrometry and immunohistochemistry detected all three proteins. CONCLUSIONS Our findings suggest that zebrafish f9a has functional activity similar to human F9. Fixl is functionally similar to Fx. The age-dependent increases of these factors are comparable to those observed in mice and humans. Thus, the zebrafish model could be used to study factors involved in increasing f9a expression during aging. It could also be used to test whether normal human Factor IX and Factor IX Leyden promoter work in zebrafish background.
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Affiliation(s)
- Neha Iyer
- Department of Biological Sciences, University of North Texas, Denton, TX, USA
| | - Ayah Al Qaryoute
- Department of Biological Sciences, University of North Texas, Denton, TX, USA
| | - Meghana Kacham
- Department of Biological Sciences, University of North Texas, Denton, TX, USA
| | - Pudur Jagadeeswaran
- Department of Biological Sciences, University of North Texas, Denton, TX, USA
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Morrison S, Lacey C, Attard C, Davies B, Monagle P, Davies P. Recombinant Factor VIIa in Pediatric Cardiac Surgery. J Cardiothorac Vasc Anesth 2021; 36:684-689. [PMID: 34479781 DOI: 10.1053/j.jvca.2021.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/28/2021] [Accepted: 08/01/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Recombinant activated factor VIIa (rVIIa) is used off-label for refractory bleeding after cardiac surgery. This study reviewed the indications, usage rates, and complications of rVIIa. DESIGN A retrospective case-control observational study. SETTING A single quaternary pediatric hospital. PARTICIPANTS All children undergoing cardiac surgery with cardiopulmonary bypass over a three-year period. INTERVENTIONS Administration of rVIIa as rescue therapy for refractory bleeding after weaning from cardiopulmonary bypass. MEASUREMENTS AND MAIN RESULTS Onethousand, five hundred fifteen cardiopulmonary bypass procedures were reviewed. Patients receiving rVIIa were each matched to two control patients by age, procedure type, and bypass time. Data collected included weight, crossclamp time, anticoagulant and antifibrinolytic dose, return to the operating room for bleeding, thrombotic events, and extracorporeal membrane oxygenation (ECMO) circuit interventions. Forty-two patients received rVIIa (2.8%). Major systemic thrombotic complications were observed in 19% (controls 12.5%) of patients; 80% of recombinant factor VIIa patients requiring postoperative ECMO had interventions for circuit thrombosis (controls 31.25%); 4.76% of rVIIa recipients required reexploration for intractable bleeding (controls 1.39%). CONCLUSIONS This study added to understanding regarding the use of recombinant factor VIIa in pediatric cardiac surgery and reported increased thrombotic complications, especially for children who progress to ECMO. Prospective studies to better understand the pathophysiology of coagulopathy and hemorrhage in pediatric cardiac surgery and the role of hemostatic agents, such as rVIIa, are required.
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Affiliation(s)
- Shannon Morrison
- Department of Anesthesia and Pain Management, The Royal Children's Hospital, Parkville, Australia
| | - Cara Lacey
- Department of Clinical Haematology, The Royal Children's Hospital, Parkville, Australia
| | - Chantal Attard
- Haematology Research Laboratory, Murdoch Children's Research Institute, Parkville, Australia; Department of Pediatrics, The University of Melbourne, Reception Level 2, The Royal Children's Hospital, Parkville, Australia
| | - Ben Davies
- Department of Cardiac Surgery, The Royal Children's Hospital, Parkville, Australia
| | - Paul Monagle
- Department of Clinical Haematology, The Royal Children's Hospital, Parkville, Australia; Haematology Research Laboratory, Murdoch Children's Research Institute, Parkville, Australia; Department of Pediatrics, The University of Melbourne, Reception Level 2, The Royal Children's Hospital, Parkville, Australia; Kids Cancer Centre, Sydney Children's Hospital, High Street, Randwick, Australia
| | - Paul Davies
- Department of Anesthesia and Pain Management, The Royal Children's Hospital, Parkville, Australia.
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36
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Gassiot S, Ruiz-Llobet A, Suleman W, Sarrate E, Berrueco R. Thrombin generation in children using ThromboScreen reagent kit with ST Genesia-A pilot study. Int J Lab Hematol 2021; 43:1612-1619. [PMID: 34323010 DOI: 10.1111/ijlh.13668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 06/22/2021] [Accepted: 07/15/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Thrombin generation assays assess overall coagulation system and are widely used in research; however, they still need standardization and clinical validation. The new ST Genesia is a benchtop, automated analyzer that normalizes each thrombin generation parameter using a reference plasma. The ThromboScreen reagent kit has two triggers, one of which contains thrombomodulin to assess the effect of the protein C pathway. This study aimed to make a pilot approach to the ThromboScreen reference range in children and evaluate the impact of sex, age, and pro- and anticoagulant plasma proteins on thrombin generation parameters. METHODS This study included 55 healthy children from the following age groups: 1-6 years (n = 14), 7-11 years (n = 15), and 12-17 years (n = 26). Children younger than 1 year were excluded from the study. We measured thrombin generation using ThromboScreen, coagulation routine and test, pro- and anticoagulant proteins. RESULTS Age did not influence ThromboScreen results. Males showed significantly lower endogenous thrombin potential and peak height values than females. The strongest determinants of endogenous thrombin potential were von Willebrand factor parameters, whereas for endogenous thrombin potential inhibition, the strongest determinants were protein C and protein S. No statistically significant differences were found between groups on temporal parameters. CONCLUSIONS For the ThromboScreen reagent kit, it may not be necessary to subdivide reference ranges according to age for children (>1 year).
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Affiliation(s)
- Susanna Gassiot
- Hematology Laboratory, Hospital Sant Joan de Déu, Barcelona, Spain.,Institut de Recerca Hospital Sant Joan de Déu, Barcelona, Spain
| | - Anna Ruiz-Llobet
- Institut de Recerca Hospital Sant Joan de Déu, Barcelona, Spain.,Service of Pediatric Hematology, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
| | - Warda Suleman
- Hematology Laboratory, Hospital Sant Joan de Déu, Barcelona, Spain.,Institut de Recerca Hospital Sant Joan de Déu, Barcelona, Spain
| | - Edurne Sarrate
- Hematology Laboratory, Hospital Sant Joan de Déu, Barcelona, Spain.,Institut de Recerca Hospital Sant Joan de Déu, Barcelona, Spain
| | - Ruben Berrueco
- Institut de Recerca Hospital Sant Joan de Déu, Barcelona, Spain.,Service of Pediatric Hematology, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
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McCafferty C, Van Den Helm S, Letunica N, Attard C, Karlaftis V, Cai T, Praporski S, Swaney E, Burgner D, Neeland M, Dohle K, Crawford NW, Clucas L, Tosif S, Ignjatovic V, Monagle P. Increased platelet activation in SARS-CoV-2 infected non-hospitalised children and adults, and their household contacts. Br J Haematol 2021; 195:90-94. [PMID: 34101171 PMCID: PMC8239564 DOI: 10.1111/bjh.17629] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 05/18/2021] [Accepted: 05/18/2021] [Indexed: 12/13/2022]
Affiliation(s)
- Conor McCafferty
- Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | | | | | - Chantal Attard
- Murdoch Children's Research Institute, Melbourne, Australia
| | | | - Tengyi Cai
- Murdoch Children's Research Institute, Melbourne, Australia
| | | | - Ella Swaney
- Murdoch Children's Research Institute, Melbourne, Australia
| | - David Burgner
- Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia.,Infectious Diseases Unit, Royal Children's Hospital, Australia.,Department of General Medicine, Royal Children's Hospital, Parkville, Australia
| | - Melanie Neeland
- Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Kate Dohle
- Murdoch Children's Research Institute, Melbourne, Australia
| | - Nigel W Crawford
- Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia.,Department of General Medicine, Royal Children's Hospital, Parkville, Australia
| | - Luisa Clucas
- Department of Haematology, Royal Children's Hospital, Parkville, Australia.,Immunisation Service, Royal Children's Hospital, Parkville, Australia
| | - Shidan Tosif
- Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia.,Department of General Medicine, Royal Children's Hospital, Parkville, Australia
| | - Vera Ignjatovic
- Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Paul Monagle
- Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia.,Department of Haematology, Royal Children's Hospital, Parkville, Australia
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Lorts A, Conway J, Schweiger M, Adachi I, Amdani S, Auerbach SR, Barr C, Bleiweis MS, Blume ED, Burstein DS, Cedars A, Chen S, Cousino-Hood MK, Daly KP, Danziger-Isakov LA, Dubyk N, Eastaugh L, Friedland-Little J, Gajarski R, Hasan A, Hawkins B, Jeewa A, Kindel SJ, Kogaki S, Lantz J, Law SP, Maeda K, Mathew J, May LJ, Miera O, Murray J, Niebler RA, O'Connor MJ, Özbaran M, Peng DM, Philip J, Reardon LC, Rosenthal DN, Rossano J, Salazar L, Schumacher KR, Simpson KE, Stiller B, Sutcliffe DL, Tunuguntla H, VanderPluym C, Villa C, Wearden PD, Zafar F, Zimpfer D, Zinn MD, Morales IRD, Cowger J, Buchholz H, Amodeo A. ISHLT consensus statement for the selection and management of pediatric and congenital heart disease patients on ventricular assist devices Endorsed by the American Heart Association. J Heart Lung Transplant 2021; 40:709-732. [PMID: 34193359 DOI: 10.1016/j.healun.2021.04.015] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 04/22/2021] [Indexed: 01/17/2023] Open
Affiliation(s)
- Angela Lorts
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio.
| | | | - Martin Schweiger
- Universitäts-Kinderspitals Zürich - Herzchirurgie, Zurich, Switzerland
| | - Iki Adachi
- Texas Children's Hospital, Houston, Texas
| | | | - Scott R Auerbach
- Anschutz Medical Campus, Children's Hospital of Colorado, University of Colorado Denver, Aurora, Colorado
| | - Charlotte Barr
- The Royal Children's Hospital, Victoria Melbourne, Australia
| | - Mark S Bleiweis
- Shands Children's Hospital, University of Florida Health, Gainesville, Florida
| | | | | | - Ari Cedars
- Children's Health, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sharon Chen
- Stanford Children's Health and Lucile Packard Children's Hospital, Palo Alto, California
| | | | - Kevin P Daly
- Boston Children's Hospital, Boston, Massachusetts
| | - Lara A Danziger-Isakov
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | - Nicole Dubyk
- Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Lucas Eastaugh
- The Royal Children's Hospital, Victoria Melbourne, Australia
| | | | | | - Asif Hasan
- Freeman Hospital, Newcastle upon Tyne, UK
| | - Beth Hawkins
- Boston Children's Hospital, Boston, Massachusetts
| | - Aamir Jeewa
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Steven J Kindel
- Department of Pediatrics, Medical College of Wisconsin and Herma Heart Institute, Children's Hospital of Wisconsin, Milwaukee, Winscoin
| | | | - Jodie Lantz
- Children's Health, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sabrina P Law
- Morgan Stanley Children's Hospital of New York Presbyterian, New York, New York
| | - Katsuhide Maeda
- Stanford Children's Health and Lucile Packard Children's Hospital, Palo Alto, California
| | - Jacob Mathew
- The Royal Children's Hospital, Victoria Melbourne, Australia
| | | | | | - Jenna Murray
- Stanford Children's Health and Lucile Packard Children's Hospital, Palo Alto, California
| | - Robert A Niebler
- Department of Pediatrics, Medical College of Wisconsin and Herma Heart Institute, Children's Hospital of Wisconsin, Milwaukee, Winscoin
| | | | | | - David M Peng
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Joseph Philip
- Shands Children's Hospital, University of Florida Health, Gainesville, Florida
| | | | - David N Rosenthal
- Stanford Children's Health and Lucile Packard Children's Hospital, Palo Alto, California
| | - Joseph Rossano
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Kurt R Schumacher
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | | | | | - David L Sutcliffe
- Children's Health, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | | - Chet Villa
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | | | - Farhan Zafar
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | | | - Matthew D Zinn
- Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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Crighton GL, Huisman EJ. Pediatric Fibrinogen PART II-Overview of Indications for Fibrinogen Use in Critically Ill Children. Front Pediatr 2021; 9:647680. [PMID: 33968851 PMCID: PMC8097134 DOI: 10.3389/fped.2021.647680] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 03/09/2021] [Indexed: 01/16/2023] Open
Abstract
Bleeding is frequently seen in critically ill children and is associated with increased morbidity and mortality. Fibrinogen is an essential coagulation factor for hemostasis and hypofibrinogenemia is an important risk factor for bleeding in pediatric and adult settings. Cryoprecipitate and fibrinogen concentrate are often given to critically ill children to prevent bleeding and improve fibrinogen levels, especially in the setting of surgery, trauma, leukemia, disseminated intravascular coagulopathy, and liver failure. The theoretical benefit of fibrinogen supplementation to treat hypofibrinogenemia appears obvious, yet the evidence to support fibrinogen supplementation in children is sparce and clinical indications are poorly defined. In addition, it is unknown what the optimal fibrinogen replacement product is in children and neonates or what the targets of treatment should be. As a result, there is considerable variability in practice. In this article we will review the current pediatric and applicable adult literature with regard to the use of fibrinogen replacement in different pediatric critical care contexts. We will discuss the clinical indications for fibrinogen supplementation in critically ill children and the evidence to support their use. We summarize by highlighting current knowledge gaps and areas for future research.
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Affiliation(s)
| | - Elise J. Huisman
- Department of Hematology, Erasmus MC–Sophia Children's Hospital, Rotterdam, Netherlands
- Department of Clinical Chemistry and Blood Transfusion, Erasmus MC, Rotterdam, Netherlands
- Department of Transfusion Medicine, Sanquin Blood Supply, Amsterdam, Netherlands
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40
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Comparison of Bivalirudin Versus Heparin for Maintenance Systemic Anticoagulation During Adult and Pediatric Extracorporeal Membrane Oxygenation. Crit Care Med 2021; 49:1481-1492. [PMID: 33870916 DOI: 10.1097/ccm.0000000000005033] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To provide a comparative analysis of conventional heparin-versus bivalirudin-based systemic anticoagulation in adult and pediatric patients supported on extracorporeal membrane oxygenation. DESIGN Retrospective chart review study of adult and pediatric patients receiving extracorporeal membrane oxygenation from January 1, 2014, to October 1, 2019. SETTING A large, high-volume tertiary referral adult and pediatric extracorporeal membrane oxygenation center. PATIENTS Four hundred twenty-four individuals requiring extracorporeal membrane oxygenation support and systemically anticoagulated with either unfractionated heparin (223 adult and 65 pediatric patients) or bivalirudin (110 adult and 24 pediatric patients) were included. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Digital data abstraction was used to retrospectively collect patient details. The majority of both groups were cannulated centrally (67%), and the extracorporeal membrane oxygenation type was predominantly venoarterial (84%). The adult bivalirudin group had a greater occurrence of heparin-induced thrombocytopenia (12% vs 1%; p < 0.01) and was more likely to require postcardiotomy extracorporeal membrane oxygenation (36% vs 55%; p < 0.01). There were no statistical differences between the groups in regards to age, sex, and extracorporeal membrane oxygenation initiation location. The main finding was a reduced mortality in the adult bivalirudin group (odds ratio, 0.39; p < 0.01), whereas no difference was noted in the pediatric group. A significant reduction in the composite transfusion requirement in the first 24 hours was noted in the pediatric bivaluridin group with an odds ratio of 0.28 (p = 0.02). Groups did not differ in regard to laboratories per day, anticoagulant dose adjustments, or ischemic complications. CONCLUSIONS When compared with heparin-based systemic anticoagulation, bivalirudin demonstrated feasibility and safety as established by the absence of increases in identifiable adverse outcomes while manifesting substantial improvements in hospital mortality in adult patients. Further studies are necessary to corroborate these findings and further elucidate the role of bivalirudin during extracorporeal membrane oxygenation support.
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41
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Waller AP, Troost JP, Parikh SV, Wolfgang KJ, Rovin BH, Nieman MT, Smoyer WE, Kretzler M, Kerlin BA. Nephrotic syndrome disease activity is proportional to its associated hypercoagulopathy. Thromb Res 2021; 201:50-59. [PMID: 33636573 DOI: 10.1016/j.thromres.2021.02.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 01/19/2021] [Accepted: 02/01/2021] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Nephrotic syndrome (NS) is associated with an acquired hypercoagulopathy that drives its strong predilection for life-threatening thrombosis. We previously demonstrated that hypercoagulopathy is proportional to NS disease severity in animal models. Therefore, hypercoagulopathy and disease severity may inform thrombosis risk and better guide therapeutic decision making. The objective of this study was thus to establish the relationship between disease severity and hypercoagulopathy in human NS. MATERIALS AND METHODS Thrombin generation assays (TGA) were performed on biorepository plasma samples from a prospective longitudinal NS cohort study. TGA was also determined on a separate cohort of incident NS patients. Multivariable regression was used to build NS-hypercoagulopathy relationship models. RESULTS Endogenous thrombin potential (ETP) was the TGA parameter most strongly correlated with NS severity and was proportional to conventional measures of NS disease activity including proteinuria, hypercholesterolemia, and hypoalbuminemia. The overall disease activity model was well correlated with ETP (R2 = 0.38). The relationship with disease activity was confirmed in the second cohort. These models further revealed that ETP is related to disease activity in a manner dependent on remission status. CONCLUSION Consistent with our previously reported animal model observations, we found that the combination of proteinuria, hypercholesterolemia, and hypoalbuminemia correlated with ETP-defined hypercoagulopathy. Hypercoagulopathy improved significantly with partial or complete NS remission. These data are expected to inform studies designed to stratify thrombotic risk for patients with NS.
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Affiliation(s)
- Amanda P Waller
- Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's, Columbus, OH, USA
| | - Jonathan P Troost
- Michigan Institute for Clinical and Health Research, University of Michigan, Ann Arbor, MI, USA
| | - Samir V Parikh
- Division of Nephrology, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Katelyn J Wolfgang
- Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's, Columbus, OH, USA
| | - Brad H Rovin
- Division of Nephrology, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Marvin T Nieman
- Department of Pharmacology, Case Western Reserve University, Cleveland, OH, USA
| | - William E Smoyer
- Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's, Columbus, OH, USA; Division of Nephrology, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Matthias Kretzler
- Departments of Internal Medicine and Computational Medicine and Bioinformatics, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Bryce A Kerlin
- Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's, Columbus, OH, USA; Division of Hematology/Oncology/Blood & Marrow Transplantation, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA.
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Ghbeis MB, Vander Pluym CJ, Thiagarajan RR. Hemostatic Challenges in Pediatric Critical Care Medicine-Hemostatic Balance in VAD. Front Pediatr 2021; 9:625632. [PMID: 33732668 PMCID: PMC7959853 DOI: 10.3389/fped.2021.625632] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 01/06/2021] [Indexed: 01/19/2023] Open
Abstract
Ventricular assist devices (VAD) are used more in children. Safe and effective anticoagulation is required for successful management of children supported with ventricular assist devices. Developmental hemostasis, device hemocompatibility, plastic to body ratio, surgical variable techniques, lack of knowledge on pharmacokinetics of anticoagulants, and wide variability in anticoagulation protocols have all contributed to increased incidence of bleeding and thromboembolic complications. New collaborative learning networks, such as the ACTION network, provide opportunities to define best practices, optimize, and reduce anticoagulation related adverse events. ACTION was established Dec 2017. It consists of expert clinicians in heart failure, as well as researchers, parents, and patients, with goals to improve outcomes, share data, improve education and standard practice for children with heart failure (, n.d). Changes in pediatric VAD anticoagulation strategy from using mainly heparin to DTI such as bivalirudin have helped reduce bleeding and clotting complications.
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Affiliation(s)
- Muhammad Bakr Ghbeis
- Division of Cardiac Critical Care, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Christina J Vander Pluym
- Division of Advanced Cardiac Therapies, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Ravi Ram Thiagarajan
- Division of Cardiac Critical Care, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
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Huisman EJ, Crighton GL. Pediatric Fibrinogen PART I-Pitfalls in Fibrinogen Evaluation and Use of Fibrinogen Replacement Products in Children. Front Pediatr 2021; 9:617500. [PMID: 33968842 PMCID: PMC8097151 DOI: 10.3389/fped.2021.617500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 02/26/2021] [Indexed: 11/13/2022] Open
Abstract
Fibrinogen is a key coagulation protein, playing a critical role in hemostasis. It is the first factor to decrease to critical levels during bleeding. Hypofibrinogenemia is an important risk factor for bleeding in clinical settings, including pediatric surgery. Yet, the optimal measurement of fibrinogen levels is subject to debate, as is the critical threshold for intervention. Fibrinogen replacement may be provided by cryoprecipitate and fibrinogen concentrate. Whilst both products contain fibrinogen, they are not equivalent, each has its own advantages and disadvantages, especially for pediatric use. Unfortunately, medical literature to support fibrinogen replacement in children is limited. In this article we review the current diagnostic tools to measure fibrinogen, with respect to their use in the pediatric critical care setting. Secondly, we evaluate the different fibrinogen replacement therapies, focusing on cryoprecipitate and fibrinogen concentrate and examine their individual product characteristics, associated risks and benefits, different dosing strategies and specific pitfalls for use in children. We summarize by highlighting current knowledge gaps and areas for future research.
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Affiliation(s)
- Elise J Huisman
- Department of Hematology, Erasmus Medical Center (MC)-Sophia Children's Hospital, Rotterdam, Netherlands.,Department of Clinical Chemistry and Blood Transfusion, Erasmus Medical Center (MC), Rotterdam, Netherlands.,Department of Transfusion Medicine, Sanquin Blood Supply, Amsterdam, Netherlands
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44
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Danese E, Montagnana M, Gelati M, Lippi G. The Role of Epigenetics in the Regulation of Hemostatic Balance. Semin Thromb Hemost 2020; 47:53-62. [PMID: 33368118 DOI: 10.1055/s-0040-1718400] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Epigenetics, a term conventionally used to explain the intricate interplay between genes and the environment, is now regarded as the fundament of developmental biology. Several lines of evidence garnered over the past decades suggest that epigenetic alterations, mostly encompassing DNA methylation, histone tail modifications, and generation of microRNAs, play an important, though still incompletely explored, role in both primary and secondary hemostasis. Epigenetic variations may interplay with platelet functions and their responsiveness to antiplatelet drugs, and they may also exert a substantial contribution in modulating the production and release into the bloodstream of proteins involved in blood coagulation and fibrinolysis. This emerging evidence may have substantial biological and clinical implications. An enhanced understanding of posttranscriptional mechanisms would help to clarify some remaining enigmatic issues in primary and secondary hemostasis, which cannot be thoughtfully explained by genetics or biochemistry alone. Increased understanding would also pave the way to developing innovative tests for better assessment of individual risk of bleeding or thrombosis. The accurate recognition of key epigenetic mechanisms in hemostasis would then contribute to identify new putative therapeutic targets, and develop innovative agents that could be helpful for preventing or managing a vast array of hemostasis disturbances.
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Affiliation(s)
- Elisa Danese
- Section of Clinical Biochemistry, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Martina Montagnana
- Section of Clinical Biochemistry, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Matteo Gelati
- Section of Clinical Biochemistry, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
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45
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Han H, Hensch L, Hui SKR, Teruya J. Evaluation and Management of Coagulopathies and Thrombophilias in Pediatric Patients. Clin Lab Med 2020; 41:83-100. [PMID: 33494887 DOI: 10.1016/j.cll.2020.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The diagnosis of coagulopathy or thrombophilia in pediatric patients can be challenging. Congenital coagulopathies often present in the pediatric period and require appropriate work-up for diagnosis and ongoing management. Acquired coagulopathies of childhood are frequently encountered in hospitalized children and warrant appropriate coagulation testing for goal-directed therapy. The incidence of thrombosis is increasing in pediatric patients. After identifying the presence of thrombus, acute management includes initiating therapeutic anticoagulation. Choice of anticoagulant depends on patient's clinical status, along with availability of the anticoagulant. Thrombophilia evaluation is performed when children present with spontaneous thrombosis. Thrombophilia tests are inaccurate during acute illness.
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Affiliation(s)
- HyoJeong Han
- Pathology & Immunology, Baylor College of Medicine, 6621 Fannin Street, Houston, TX 77030, USA
| | - Lisa Hensch
- Pathology & Immunology, Baylor College of Medicine, 6621 Fannin Street, Houston, TX 77030, USA
| | - Shiu-Ki Rocky Hui
- Pathology & Immunology, Baylor College of Medicine, 6621 Fannin Street, Houston, TX 77030, USA
| | - Jun Teruya
- Pathology & Immunology, Baylor College of Medicine, 6621 Fannin Street, Houston, TX 77030, USA.
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Hochart A, Pierache A, Jeanpierre E, Laffargue A, Susen S, Goudemand J. Coagulation standards in healthy newborns and infants. Arch Pediatr 2020; 28:156-158. [PMID: 33277135 DOI: 10.1016/j.arcped.2020.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 02/12/2020] [Accepted: 10/02/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND The range of normal values for coagulation factors in the healthy newborn was described 30 years ago but since then the reagents, automated systems, and dosing techniques have changed considerably. For 30 years, several authors have tried to update the standards and references in children using updated reagents but the newborn and infant population in these studies has been quite small, limiting the findings. The aim of this study was to establish the normal coagulation standards in healthy newborns. METHODS We included all consecutive healthy newborns with pyloric stenosis presenting to our reference center over a period of 5 years. We calculated the reference ranges defined as mean±2 SD. Normality of distribution was checked graphically and by using the Shapiro-Wilk test. Correlations between two continuous variables were assessed using Spearman's rank coefficient correlation. Statistical testing was done at the two-tailed α-level of 0.05. Data were analyzed using the SAS software package, release 9.4 (SAS Institute, Cary, NC). RESULTS We included 112 healthy newborns and infants. The median age was 35.5 days (15.0-88.0), median weight was 4062g (2855-6040), and 90.2% were boys. Activated partial thromboplastin time (aPTT) and prothrombin time (PT) were not correlated with age (P=0.92 and P=0.21, respectively) or with weight (P=0.16 and P=0.90, respectively). The reference range was 28.6-46.2 s for aPTT, 0.91-1.49 for aPTT ratio, and 71.3-110.6 s for PT. Regarding fibrinogen (n=24), the median was 2.2g/L (1.2-3.2); the median for factor II was 67.0U/dL (51.0-130.0; n=20), and 101.5U/dL for factor V (68.0-233.0; n=20). Regarding factor VIII, the median was 75.0U/dL (45.0-152.0; n=25), 49.0U/dL for factor IX (32.0-96.0; n=25) and 53.0U/dL (29.0-112.0) for factor XI (n=23). CONCLUSION This study can help to establish standards for coagulation testing in this very specific population. Indeed, our study represents the largest newborn population in a recent investigation of PT and aPTT using updated reagents.
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Affiliation(s)
- A Hochart
- Hematology and transfusion, CHU Lille, 59000 Lille, France.
| | - A Pierache
- EA 2694 - Santé publique: épidémiologie et qualité des soins, CHU Lille, university of Lille, 59000 Lille, France
| | - E Jeanpierre
- Hematology and transfusion, CHU Lille, 59000 Lille, France
| | - A Laffargue
- Pediatric anesthesia department, CHU Lille, 59000 Lille, France
| | - S Susen
- Hematology and transfusion, CHU Lille, 59000 Lille, France
| | - J Goudemand
- Hematology and transfusion, CHU Lille, 59000 Lille, France
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Coagulopathy Characterized by Rotational Thromboelastometry in a Porcine Pediatric ECMO Model. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2020; 52:203-211. [PMID: 32981958 DOI: 10.1182/ject-2000011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 07/16/2020] [Indexed: 11/20/2022]
Abstract
Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is used to support patients with reversible cardiopulmonary insufficiency. Although it is a lifesaving technology, bleeding, inflammation, and thrombosis are well-described complications of ECMO. Adult porcine models of ECMO have been used to recapitulate the physiology and hemostatic consequences of ECMO cannulation in adults. However, these models lack the unique physiology and persistence of fetal forms of coagulation factors and fibrinogen as in human infants. We aimed to describe physiologic and coagulation parameters of piglets cannulated and supported with VA-ECMO. Four healthy piglets (5.7-6.4 kg) were cannulated via jugular vein and carotid artery by cutdown and supported for a maximum of 20 hours. Heparin was used with a goal activated clotting time of 180-220 seconds. Arterial blood gas (ABG) was performed hourly, and blood was transfused from an adult donor to maintain hematocrit (Hct) > 24%. Rotational thromboelastometry (ROTEM) was performed at seven time points. All animals achieved adequate flow with a patent circuit throughout the run (pre- and post-oxygenator pressure gradient <10 mmHg). There was slow but significant hemorrhage at cannulation, arterial line, and bladder catheter sites. All animals required the maximum blood transfusion volume available. All animals became anemic after exhaustion of blood for transfusion. ABG showed progressively declining Hct and adequate oxygenation. ROTEM demonstrated decreasing fibrin-only ROTEM (FIBTEM) clot firmness. Histology was overall unremarkable. Pediatric swine are an important model for the study of pediatric ECMO. We have demonstrated the feasibility of such a model while providing descriptions of physiologic, hematologic, and coagulation parameters throughout. Weak whole-blood clot firmness by ROTEM suggested defects in fibrinogen, and there was a clinical bleeding tendency in all animals studied. This model serves as an important means to study the complex derangements in hemostasis during ECMO.
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Evaluation of Bivalirudin As an Alternative to Heparin for Systemic Anticoagulation in Pediatric Extracorporeal Membrane Oxygenation. Pediatr Crit Care Med 2020; 21:827-834. [PMID: 32404633 DOI: 10.1097/pcc.0000000000002384] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Heparin is the universal anticoagulant for patients receiving extracorporeal membrane oxygenation support. However, heparin has many disadvantages, especially in young children, who develop heparin resistance. Recently our center has used bivalirudin, a direct thrombin inhibitor, for systemic anticoagulation in pediatric extracorporeal life support. Bivalirudin binds directly to thrombin with no need for antithrombin III and it inhibits both circulating and clot-bound thrombin. In this study, we sought to evaluate our experience with bivalirudin in pediatric extracorporeal life support. DESIGN Retrospective chart review study of patients receiving extracorporeal membrane oxygenation support between October 2014 and May 2018. SETTING Tertiary, academic PICU. PATIENTS Sixteen patients receiving heparin and 16 patients receiving bivalirudin on extracorporeal life support were included in the study. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patients in the bivalirudin group had a median age of 31 months versus 59 months in the heparin group (p = 0.41). Recovery and extracorporeal membrane oxygenation decannulation were similar in both groups (56% in the heparin group and 62% in the bivalirudin group; p = 0.62). Time to reach goal therapeutic anticoagulation level was shorter in the bivalirudin group (11 vs 29 hr; p = 0.01). Bleeding events were fewer in the bivalirudin group, and there was no difference in the rate of thrombotic events between the two groups. Comprehensive cost analysis that includes anticoagulant, laboratories, and antithrombin III cost, showed that heparin anticoagulation therapy total cost was significantly higher than bivalirudin (1,184 dollars per day in heparin group vs 494 dollars per day in bivalirudin group; p = 0.03). Bivalirudin dose required to maintain target anticoagulation will increase over time, and this is associated with an increase in creatinine clearance and an increase in fibrinogen serum levels. CONCLUSIONS This study showed that the use of bivalirudin in pediatric extracorporeal membrane oxygenation support is feasible, safe, reliable, and cost-effective in comparison to heparin. Further prospective randomized clinical trials are necessary to confirm our observations.
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VanderPluym CJ, Cantor RS, Machado D, Boyle G, May L, Griffiths E, Niebler RA, Lorts A, Rossano J, Sutcliffe DL, Lytrivi ID, Buchholz H, Fynn-Thompson F, Hawkins B, Conway J. Utilization and Outcomes of Children Treated with Direct Thrombin Inhibitors on Paracorporeal Ventricular Assist Device Support. ASAIO J 2020; 66:939-945. [PMID: 32740356 DOI: 10.1097/mat.0000000000001093] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Thrombotic and bleeding complications have historically been major causes of morbidity and mortality in pediatric ventricular assist device (VAD) support. Standard anticoagulation with unfractionated heparin is fraught with problems related to its heterogeneous biochemical composition and unpredictable pharmacokinetics. We sought to describe the utilization and outcomes in children with paracorporeal VAD support who are treated with direct thrombin inhibitors (DTIs) antithrombosis therapy. Retrospective multicenter review of all pediatric patients (aged <19 years) treated with a DTI (bivalirudin or argatroban) on paracorporeal VAD support, examining bleeding and thrombotic adverse events. From May 2012 to 2018, 43 children (21 females) at 10 centers in North America, median age 9.5 months (0.1-215 months) weighing 8.6 kg (2.8-150 kg), were implanted with paracorporeal VADs and treated with a DTI. Diagnoses included cardiomyopathy 40% (n = 17), congenital heart disease 37% (n = 16; single ventricle n = 5), graft vasculopathy 9% (n = 4), and other 14% (n = 6). First device implanted included Berlin Heart EXCOR 49% (n = 21), paracorporeal continuous flow device 44% (n = 19), and combination of devices in 7% (n = 3). Adverse events on DTI therapy included; major bleeding in 16% (n = 7) (2.6 events per 1,000 patient days of support on DTI), and stroke 12% (n = 5) (1.7 events per 1,000 patient days of support on DTI). Overall survival to transplantation (n = 30) or explantation (n = 8) was 88%. This is the largest multicenter experience of DTI use for anticoagulation therapy in pediatric VAD support. Outcomes are encouraging with lower major bleeding and stroke event rate than that reported in literature using other anticoagulation agents in pediatric VAD support.
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Affiliation(s)
- Christina J VanderPluym
- From the Department of Cardiology, Boston Children's Hospital, Harvard School of Medicine, Boston, Massachusetts
| | - Ryan S Cantor
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| | - Desiree Machado
- Department of Pediatrics and Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Congenital Heart Center, University of Florida, Gainesville, Florida
| | - Gerald Boyle
- Center for Pediatric and Congenital Heart Disease, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Lindsay May
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Eric Griffiths
- Division of Cardiothoracic Surgery, University of Utah Health Care, Salt Lake City, Utah
| | - Robert A Niebler
- Department of Pediatrics, Section of Critical Care, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Angela Lorts
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Joseph Rossano
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - David L Sutcliffe
- Division of Cardiology, Children's Health Dallas, UT Southwestern Medical Center, Dallas, Texas
| | - Irene D Lytrivi
- From the Department of Cardiology, Boston Children's Hospital, Harvard School of Medicine, Boston, Massachusetts
| | - Holger Buchholz
- Department of Cardiovascular Surgery, University of Alberta, Edmonton, Alberta
| | - Francis Fynn-Thompson
- Department of Cardiovascular Surgery, Boston Children's Hospital, Harvard School of Medicine, Boston, Massachusetts
| | - Beth Hawkins
- From the Department of Cardiology, Boston Children's Hospital, Harvard School of Medicine, Boston, Massachusetts
| | - Jennifer Conway
- Division of Cardiology, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta
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Raffaeli G, Tripodi A, Cavallaro G, Cortesi V, Scalambrino E, Pesenti N, Artoni A, Mosca F, Ghirardello S. Thromboelastographic profiles of healthy very low birthweight infants serially during their first month. Arch Dis Child Fetal Neonatal Ed 2020; 105:412-418. [PMID: 31704736 DOI: 10.1136/archdischild-2019-317860] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 09/11/2019] [Accepted: 10/18/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVE We determined thromboelastographic (TEG) profiles of healthy very low birthweight infants (VLBWIs) of the day of birth and at set intervals during their first month. DESIGN Prospective observational study with blinded clinical and laboratory follow-up. SETTING Level III neonatal intensive care unit (June 2015 to June 2018). PATIENTS Consecutive qualifying VLBWIs were enrolled at birth and followed up for 30 days. INTERVENTIONS AND MAIN OUTCOMES MEASURES Laboratory (citrated-native TEG, prothrombin time (PT), activated partial thromboplastin time (APTT), fibrinogen, blood count) and clinical variables were retrieved at birth, 3rd-5th, 10th and 30th day of life. Blood samples temporally related to events with a potential hemostatic impact (sepsis, bleeding, platelets/plasma transfusions, ibuprofen/indomethacin administration) were excluded from analysis. RESULTS We enrolled 201 VLBWIs and 72 full-term neonates. Sixty-seven of the healthy VLBWIs completed the 30-day follow-up. 541 TEG traces were analysed.On day 1, the median (minimum-maximum) TEG values were as follows: reaction time (R), 8.2 min (1-21.8); kinetics (K), 2.8 min (0.8-16); α angle, 51° (14.2-80.6); maximum amplitude (MA), 54.9 mm (23.9-76.8). PT and APTT were 15.9 s (11.7-51.2) and 59 s (37.8-97.5), respectively. The above parameters suggest minor hypocoagulability compared with term infants. On day 30, the median (minimum-maximum) R was 5 (1-16.9), K 1 (0.8-4.1), α 74.7 (41.1-86.7) and MA 70.2 (35.8-79.7). PT and APTT were 12.1 (10.4-16.6) and 38.8 (29.6-51.4), respectively. Those parameters are consistent with a relatively hypercoagulable phenotype, compared with term infants. CONCLUSIONS Healthy VLBWIs have a prolonged PT and APTT, but their TEG profiles suggest a relatively balanced hemostatic system, with slight hypocoagulability initially (compared with term neonates), gradually evolving to a somewhat more procoagulant phenotype over the first month.
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Affiliation(s)
- Genny Raffaeli
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Armando Tripodi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giacomo Cavallaro
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Valeria Cortesi
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Erica Scalambrino
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicola Pesenti
- Department of Statistics and Quantitative Methods, Division of Biostatistics, Epidemiology and Public Health, University of Milano-Bicocca, Milan, Italy
| | - Andrea Artoni
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Fabio Mosca
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Stefano Ghirardello
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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