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Chegondi M, Vijayakumar N, Totapally BR. Management of Anticoagulation during Extracorporeal Membrane Oxygenation in Children. Pediatr Rep 2022; 14:320-332. [PMID: 35894028 PMCID: PMC9326610 DOI: 10.3390/pediatric14030039] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 06/20/2022] [Accepted: 07/01/2022] [Indexed: 02/04/2023] Open
Abstract
Extracorporeal Membrane Oxygenation (ECMO) is often used in critically ill children with severe cardiopulmonary failure. Worldwide, about 3600 children are supported by ECMO each year, with an increase of 10% in cases per year. Although anticoagulation is necessary to prevent circuit thrombosis during ECMO support, bleeding and thrombosis are associated with significantly increased mortality risk. In addition, maintaining balanced hemostasis is a challenging task during ECMO support. While heparin is a standard anticoagulation therapy in ECMO, recently, newer anticoagulant agents are also in use. Currently, there is a wide variation in anticoagulation management and diagnostic monitoring in children receiving ECMO. This review intends to describe the pathophysiology of coagulation during ECMO support, review of literature on current and newer anticoagulant agents, and outline various diagnostic tests used for anticoagulation monitoring. We will also discuss knowledge gaps and future areas of research.
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Affiliation(s)
- Madhuradhar Chegondi
- Division of Pediatric Critical Care Medicine, Stead Family Children’s Hospital, University of Iowa, Iowa City, IA 52242, USA
- Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA
- Correspondence: ; Tel.: +1-319-356-1615
| | - Niranjan Vijayakumar
- Division of Cardiac Critical Care, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA;
| | - Balagangadhar R. Totapally
- Division of Critical Care Medicine, Nicklaus Children’s Hospital, Miami, FL 33155, USA;
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA
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Abstract
Extracorporeal membrane oxygenation (ECMO) for neonates is applied routinely at major children's hospitals around the world. While the practice seems routine, the peculiar physiology of the small human imposes particular constraints on selection of equipment, performance of the circuit, and risks to the child. The physiology of small patients and physics of circuit elements leave many areas opaque and far from optimal, but still allow assembly of a set of useful heuristics for good practice. Here, we examine individual mechanical components of the ECMO circuit with attention to selection, pitfalls, and peculiarities of each when applied to the neonate.
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Affiliation(s)
- James Connelly
- ECMO Program, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Thane Blinman
- ECMO Program, Children's Hospital of Philadelphia, Philadelphia, PA; Division of General, Thoracic, and Fetal Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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Della Torre V, Badenes R, Corradi F, Racca F, Lavinio A, Matta B, Bilotta F, Robba C. Acute respiratory distress syndrome in traumatic brain injury: how do we manage it? J Thorac Dis 2017; 9:5368-5381. [PMID: 29312748 PMCID: PMC5756968 DOI: 10.21037/jtd.2017.11.03] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 10/31/2017] [Indexed: 12/24/2022]
Abstract
Traumatic brain injury (TBI) is an important cause of morbidity and mortality worldwide. TBI patients frequently suffer from lung complications and acute respiratory distress syndrome (ARDS), which is associated with poor clinical outcomes. Moreover, the association between TBI and ARDS in trauma patients is well recognized. Mechanical ventilation of patients with a concomitance of acute brain injury and lung injury can present significant challenges. Frequently, guidelines recommending management strategies for patients with traumatic brain injuries come into conflict with what is now considered best ventilator practice. In this review, we will explore the strategies of the best practice in the ventilatory management of patients with ARDS and TBI, concentrating on those areas in which a conflict exists. We will discuss the use of ventilator strategies such as protective ventilation, high positive end expiratory pressure (PEEP), prone position, recruitment maneuvers (RMs), as well as techniques which at present are used for 'rescue' in ARDS (including extracorporeal membrane oxygenation) in patients with TBI. Furthermore, general principles of fluid, haemodynamic and hemoglobin management will be discussed. Currently, there are inadequate data addressing the safety or efficacy of ventilator strategies used in ARDS in adult patients with TBI. At present, choice of ventilator rescue strategies is best decided on a case-by-case basis in conjunction with local expertise.
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Affiliation(s)
- Valentina Della Torre
- Neurocritical Care Unit, Addenbrooke’s Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Rafael Badenes
- Department of Anesthesiology and Surgical Trauma Intensive Care, Hospital Clinic Universitari Valencia, University of Valencia, Valencia, Spain
| | | | - Fabrizio Racca
- Department of Anesthesiology and Intensive Care Unit, SS Antonio Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Andrea Lavinio
- Neurocritical Care Unit, Addenbrooke’s Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Basil Matta
- Neurocritical Care Unit, Addenbrooke’s Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Federico Bilotta
- Department of Anaesthesia and Intensive Care, La Sapienza University, Rome, Italy
| | - Chiara Robba
- Neurocritical Care Unit, Addenbrooke’s Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
- Department of Neuroscience, University of Genova, Italy
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Pardinas M, Mendirichaga R, Budhrani G, Garg R, Rosario L, Rico R, Panos A, Baier H, Krick S. Use of Aminocaproic Acid in Combination With Extracorporeal Membrane Oxygenation in a Case of Leptospirosis Pulmonary Hemorrhage Syndrome. CLINICAL MEDICINE INSIGHTS-CIRCULATORY RESPIRATORY AND PULMONARY MEDICINE 2017; 11:1179548416686068. [PMID: 28469503 PMCID: PMC5392109 DOI: 10.1177/1179548416686068] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 09/27/2016] [Indexed: 01/13/2023]
Abstract
A 32-year-old man presented with a 10-day history of fever, chills, nausea, vomiting, myalgia, nonproductive cough, and worsening dyspnea after freshwater swimming in the Caribbean 1 week prior to presentation. Shortly after arrival at the hospital, the patient developed severe respiratory distress with massive hemoptysis. Based on serologic workup, he was diagnosed with leptospirosis pulmonary hemorrhage syndrome leading to diffuse alveolar hemorrhage, severe hypoxemic respiratory failure, and multiorgan failure. He received appropriate antibiotic coverage along with hemodynamic support with norepinephrine and vasopressin, mechanical ventilation, and renal replacement therapy in an intensive care unit. Introduction of extracorporeal membrane oxygenation was initiated to provide lung-protective ventilation supporting the recovery of his pulmonary function. Aminocaproic acid was used to stop and prevent further alveolar hemorrhage. He fully recovered thereafter; however, it is uncertain whether it was the use of aminocaproic acid that led to the resolution of his disease.
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Affiliation(s)
- Miguel Pardinas
- Division of Internal Medicine, Jackson Memorial Hospital and University of Miami Miller School of Medicine, Miami, FL, USA
| | - Rodrigo Mendirichaga
- Division of Internal Medicine, Jackson Memorial Hospital and University of Miami Miller School of Medicine, Miami, FL, USA
| | - Gaurav Budhrani
- Division of Anesthesiology, Emory University, Atlanta, GA, USA
| | - Rajan Garg
- Division of Pulmonary, Critical Care and Sleep Medicine, Jackson Memorial Hospital and University of Miami Miller School of Medicine, Miami, FL, USA
| | - Luis Rosario
- Division of Pulmonary, Critical Care and Sleep Medicine, Jackson Memorial Hospital and University of Miami Miller School of Medicine, Miami, FL, USA
| | - Rene Rico
- Division of Pulmonary, Critical Care and Sleep Medicine, Jackson Memorial Hospital and University of Miami Miller School of Medicine, Miami, FL, USA
| | - Anthony Panos
- Division of Thoracic Transplantation and Cardiothoracic Surgery, Jackson Memorial Hospital and University of Miami Miller School of Medicine, Miami, FL, USA
| | - Horst Baier
- Division of Pulmonary, Critical Care and Sleep Medicine, Jackson Memorial Hospital and University of Miami Miller School of Medicine, Miami, FL, USA
| | - Stefanie Krick
- Division of Pulmonary, Critical Care and Sleep Medicine, Jackson Memorial Hospital and University of Miami Miller School of Medicine, Miami, FL, USA
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Extracorporeal membrane oxygenation for adult respiratory distress syndrome in trauma patients. J Trauma Acute Care Surg 2017; 82:165-173. [DOI: 10.1097/ta.0000000000001276] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Giglia TM, Massicotte MP, Tweddell JS, Barst RJ, Bauman M, Erickson CC, Feltes TF, Foster E, Hinoki K, Ichord RN, Kreutzer J, McCrindle BW, Newburger JW, Tabbutt S, Todd JL, Webb CL. Prevention and Treatment of Thrombosis in Pediatric and Congenital Heart Disease. Circulation 2013; 128:2622-703. [DOI: 10.1161/01.cir.0000436140.77832.7a] [Citation(s) in RCA: 202] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Activated recombinant factor VII and extracorporeal membrane oxygenation: everything is all right, nothing is wrong? Pediatr Crit Care Med 2010; 11:155-6. [PMID: 20051799 DOI: 10.1097/pcc.0b013e3181b80dc1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Dickerson HA, Chang AC. Perioperative management of ventricular assist devices in children and adolescents. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2006:128-39. [PMID: 16638558 DOI: 10.1053/j.pcsu.2006.02.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Ventricular assist devices are an integral part of therapy for patients with end-stage heart failure. Devices can either bridge to recovery or to transplantation. Options for ventricular assist devices include those that are centrifugal, pulsatile, and new rotary/axial devices. Care of the patient on a ventricular assist device is multifaceted, involving pharmacologic or mechanical support of the right ventricle, management of systemic vascular resistance, and manipulation of the hematologic system to avoid bleeding or thrombosis. In addition, care of these patients involves support of all end organs and avoidance of infectious complications. Care of these patients is complex, requiring a highly integrated team for optimal outcome.
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Lequier L, Chan A. Anticoagulation during extracorporeal life support. PROGRESS IN PEDIATRIC CARDIOLOGY 2005. [DOI: 10.1016/j.ppedcard.2005.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Chang AC, McKenzie ED. Mechanical cardiopulmonary support in children and young adults: extracorporeal membrane oxygenation, ventricular assist devices, and long-term support devices. Pediatr Cardiol 2005; 26:2-28. [PMID: 15156301 DOI: 10.1007/s00246-004-0715-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- A C Chang
- Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, 6621 Fannin, MC 19345-C, Houston, TX 77030, USA.
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Fortenberry JD, Meier AH, Pettignano R, Heard M, Chambliss CR, Wulkan M. Extracorporeal life support for posttraumatic acute respiratory distress syndrome at a children's medical center. J Pediatr Surg 2003; 38:1221-6. [PMID: 12891497 DOI: 10.1016/s0022-3468(03)00272-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Primary traumatic injury was considered previously a contraindication for institution of extracorporeal life support because of high risk for persistent or new bleeding. Published experience in adults suggests that extracorporeal membrane oxygenation (ECMO) can successfully support trauma victims with pulmonary failure. The authors reviewed their experience with the use of ECMO in pediatric and adult trauma patients with acute respiratory distress syndrome (ARDS) at a children's medical center. METHODS ECMO Center records from 1991 through 2001 (76 children, 8 adults) were reviewed to identify all patients with a primary or secondary ICD-9 diagnostic code of posttraumatic ARDS in addition to documented trauma. RESULTS Five children and 3 adults with traumatic injury and ARDS received ECMO support. Seven patients were injured in motor vehicle collisions; one patient suffered a gunshot wound to the chest. Patient ages ranged from 21 months to 29 years (pediatric median, 4 years; range, 21 months to 18 years). Four patients had pre-ECMO laparotomies, including 3 who required splenectomy. Four patients had liver lacerations, 3 had pulmonary contusions, and 1 had a renal contusion. Median ventilation before ECMO was 6 days (range, 2 to 10). Seven of 8 patients were placed on venovenous (VV) ECMO. Seven patients had significant bleeding on ECMO. Patients were treated with blood product replacement, epsilon-aminocaproic acid (EACA), and aprotinin infusions. Surgical intervention was not required for bleeding. Six patients received hemofiltration. Median time on ECMO was 653 hours (range, 190 to 921 hours). Six of 8 patients overall survived (75%). Four of 5 pediatric patients survived. CONCLUSIONS Children and adults with severe posttraumatic ARDS can be treated successfully on VV extracorporeal support. Hemorrhage occurs frequently but is manageable.
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Affiliation(s)
- James D Fortenberry
- Center for ECMO and Advanced Technologies and Critical Care Division, Children's Healthcare of Atlanta at Egleston, Atlanta, GA 30322, USA
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Gomez D, Olshove V, Weinstein S, Davis JT. Blood Conservation During Pediatric Cardiac Surgery. ACTA ACUST UNITED AC 2002. [DOI: 10.1111/j.1778-428x.2002.tb00057.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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