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Vandewalle RJ, Greiten LE. Diaphragmatic Defects in Infants: Acute Management and Repair. Thorac Surg Clin 2024; 34:133-145. [PMID: 38705661 DOI: 10.1016/j.thorsurg.2024.01.003] [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] [Indexed: 05/07/2024]
Abstract
Congenital diaphragmatic hernia (CDH) is a complex and highly variable disease process that should be treated at institutions with multidisciplinary teams designed for their care. Treatment in the neonatal period focuses on pulmonary hypoplasia, pulmonary hypertension, and cardiac dysfunction. Extracorporeal membrane oxygenation (ECMO) can be considered in patients refractory to medical management. Repair of CDH early during the ECMO course seems to improve mortality compared with other times for surgical intervention. The choice of surgical approach to CDH repair should consider the patient's physiologic status and the surgeon's familiarity with the operative approaches available, recognizing the pros/cons of each technique.
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Affiliation(s)
- Robert J Vandewalle
- Department of Surgery, University of Arkansas for Medical Sciences/Arkansas Children's Hospital, 1 Children's Way, Slot 844, Little Rock, AR 72202, USA.
| | - Lawrence E Greiten
- Department of Surgery, University of Arkansas for Medical Sciences/Arkansas Children's Hospital, 1 Children's Way, Slot 677, Little Rock, AR 72202, USA
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2
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Salem AM, Smith T, Wilkes J, Bailly DK, Heyrend C, Profsky M, Yellepeddi VK, Gopalakrishnan M. Pharmacokinetic Modeling Using Real-World Data to Optimize Unfractionated Heparin Dosing in Pediatric Patients on Extracorporeal Membrane Oxygenation and Evaluate Target Achievement-Clinical Outcomes Relationship. J Clin Pharmacol 2024; 64:30-44. [PMID: 37565528 DOI: 10.1002/jcph.2333] [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: 04/19/2023] [Accepted: 08/07/2023] [Indexed: 08/12/2023]
Abstract
Unfractionated heparin (UFH) is a commonly used anticoagulant for pediatric patients undergoing extracorporeal membrane oxygenation (ECMO), but evidence is lacking on the ideal dosing. We aimed to (1) develop a population pharmacokinetic (PK) model for UFH, measured through anti-factor Xa assay; (2) optimize UFH starting infusions and dose titrations through simulations; and (3) explore UFH exposure-clinical outcomes relationship. Data from 218 patients admitted to Utah's Primary Children's Hospital were retrospectively collected. A 1-compartment PK model with time-varying clearance (CL) adequately described UFH PK. Weight on CL and volume of distribution and ECMO circuit change on CL were significant covariates. The typical estimates for initial CL and first-order rate constant to reach steady-state CL were 0.57 L/(h·10 kg) and 0.02/h. Comparable to non-ECMO patients, the typical steady-state CL was 0.81 L/(h·10 kg). Simulations showed that a 75 IU/kg UFH bolus dose followed by starting infusions of 25 and 20 IU/h/kg for patients aged younger than 6 years and 6 years or older, respectively, achieved the therapeutic target in 56.6% of all patients, whereas only 3.1% exceeded the target. The proposed UFH titration schemes achieved the target in more than 90% of patients while less than 0.63% were above the target after 24 and 48 hours of treatment. The median intensive care unit survival time in patients within and below the target at 24 hours was 136 and 66 hours, respectively. In conclusion, PK model of UFH was developed for pediatric patients on ECMO. The proposed UFH dosing scheme attained the anti-factor Xa target rapidly and safely.
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Affiliation(s)
- Ahmed M Salem
- Center for Translational Medicine, Department of Pharmacy Practice, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Trey Smith
- Department of Pharmacy, Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Jacob Wilkes
- Pediatric Analytics, Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, UT, USA
| | - David K Bailly
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Caroline Heyrend
- Department of Pharmacy, Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Michael Profsky
- Mechanical Circulatory Support, Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Venkata K Yellepeddi
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
- Department of Molecular Pharmaceutics, College of Pharmacy, University of Utah, Salt Lake City, UT, USA
| | - Mathangi Gopalakrishnan
- Center for Translational Medicine, Department of Pharmacy Practice, University of Maryland School of Pharmacy, Baltimore, MD, USA
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3
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Hosseinnejad A, Ludwig N, Mersmann S, Winnerbach P, Bleilevens C, Rossaint R, Rossaint J, Singh S. Bioactive Nanogels Mimicking the Antithrombogenic Nitric Oxide-Release Function of the Endothelium. SMALL (WEINHEIM AN DER BERGSTRASSE, GERMANY) 2023; 19:e2205185. [PMID: 36635040 DOI: 10.1002/smll.202205185] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 11/07/2022] [Indexed: 06/17/2023]
Abstract
Nitric oxide (NO) plays a significant role in controlling the physiology and pathophysiology of the body, including the endothelial antiplatelet function and therefore, antithrombogenic property of the blood vessels. This property of NO can be exploited to prevent thrombus formation on artificial surfaces like extracorporeal membrane oxygenators, which when come into contact with blood lead to protein adsorption and thereby platelet activation causing thrombus formation. However, NO is extremely reactive and has a very short biological half-life in blood, so only endogenous generation of NO from the blood contacting material can result into a stable and kinetically controllable local delivery of NO. In this regards, highly hydrophilic bioactive nanogels are presented which can endogenously generate NO in blood plasma from endogenous NO-donors thereby maintaining a physiological NO flux. It is shown that NO releasing nanogels could initiate cGMP-dependent protein kinase signaling followed by phosphorylation of vasodilator-stimulated phosphoprotein in platelets. This prevents platelet activation and aggregation even in presence of highly potent platelet activators like thrombin, adenosine 5'-diphosphate, and U46619 (thromboxane A2 mimetic).
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Affiliation(s)
- Aisa Hosseinnejad
- DWI-Leibniz-Institute for Interactive Materials e.V. Forckenbeckstr. 50, 52056, Aachen, Germany
| | - Nadine Ludwig
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Albert-Schweitzer-Campus 1, Bldg. A1, 48149, Münster, Germany
| | - Sina Mersmann
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Albert-Schweitzer-Campus 1, Bldg. A1, 48149, Münster, Germany
| | - Patrick Winnerbach
- Department of Anesthesiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Christian Bleilevens
- Department of Anesthesiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Rolf Rossaint
- Department of Anesthesiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Jan Rossaint
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Albert-Schweitzer-Campus 1, Bldg. A1, 48149, Münster, Germany
| | - Smriti Singh
- DWI-Leibniz-Institute for Interactive Materials e.V. Forckenbeckstr. 50, 52056, Aachen, Germany
- Max-Planck-Institut für medizinische Forschung, Jahnstraße 29, 69120, Heidelberg, Germany
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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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Luo J, Yu H, Lu B, Wang D, Deng X. Superhydrophobic Biological Fluid-Repellent Surfaces: Mechanisms and Applications. SMALL METHODS 2022; 6:e2201106. [PMID: 36287096 DOI: 10.1002/smtd.202201106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 09/26/2022] [Indexed: 06/16/2023]
Abstract
Superhydrophobic biological fluid-repellent surfaces (SBFRSs) have attracted great attention in the treatment of blood and urine-related diseases because of their unique wettability and compatibility, which creates a new path for the development of medical apparatus and instruments, and are expected to create advances in various fields. Here, this review provides an up-to-date summary of research progress on the repellent mechanism and application of SBFRSs. The underlying physical and chemical principles for designing superhydrophobic surfaces are first introduced. Then, the dialectical influences of solid-liquid interactions between superhydrophobic surfaces and biological fluids on the wettability and compatibility are emphatically expounded. Subsequently, attention is drawn to the recent applications of SBFRSs in biomedical fields, such as surgical medical apparatus, implant materials, extracorporeal circulation devices, and biological fluid detection. Finally, the outlook and challenges in terms of employing SBFRSs are also discussed. This review is expected to provide a comprehensive guidance for the preparation of SBFRSs with compatibility and long-term superhydrophobic stability that is closely related to clinical applications.
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Affiliation(s)
- Jing Luo
- Institute of Fundamental and Frontier Sciences, University of Electronic Science and Technology of China, Chengdu, 610054, P. R. China
| | - Huali Yu
- Institute of Fundamental and Frontier Sciences, University of Electronic Science and Technology of China, Chengdu, 610054, P. R. China
| | - Binyang Lu
- Institute of Fundamental and Frontier Sciences, University of Electronic Science and Technology of China, Chengdu, 610054, P. R. China
| | - Dehui Wang
- Institute of Fundamental and Frontier Sciences, University of Electronic Science and Technology of China, Chengdu, 610054, P. R. China
| | - Xu Deng
- Institute of Fundamental and Frontier Sciences, University of Electronic Science and Technology of China, Chengdu, 610054, P. R. China
- Shenzhen Institute for Advanced Study, University of Electronic Science and Technology of China, Shenzhen, 518110, P. R. China
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6
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Incidence and predictors of brain infarction in neonatal patients on extracorporeal membrane oxygenation: an observational cohort study. Sci Rep 2022; 12:17932. [PMID: 36289242 PMCID: PMC9605965 DOI: 10.1038/s41598-022-21749-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 09/30/2022] [Indexed: 01/20/2023] Open
Abstract
To determine the incidence and identify predictors of brain infarctions (BI) in neonatal patients treated with extracorporeal membrane oxygenation (ECMO). We performed a retrospective cohort study at ECMO Centre Karolinska, Stockholm, Sweden. Logistic regression models were used to identify BI predictors. Neonates (age 0-28 days) treated with veno-arterial (VA) or veno-venous (VV) ECMO between 2010 and 2018. The primary outcome was a computed tomography (CT) verified BI diagnosed during ECMO treatment. In total, 223 patients were included, 102 patients (46%) underwent at least one brain CT and 27 patients (12%) were diagnosed with a BI. BI diagnosis was associated with increased 30-day mortality (48% vs. 18%). High pre-ECMO Pediatric Index of Mortality score, sepsis as the indication for ECMO treatment, VA ECMO, conversion between ECMO modes, use of continuous renal replacement therapy, and extracranial thrombosis were identified as independent predictors of BI development. The incidence of BI in neonatal ECMO patients may be higher than previously understood. Risk factor identification may help initiate steps to lower the risk or facilitate earlier diagnosis of BI in neonates undergoing ECMO treatment.
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7
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Membranes for extracorporeal membrane oxygenator (ECMO): history, preparation, modification and mass transfer. Chin J Chem Eng 2022. [DOI: 10.1016/j.cjche.2022.05.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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8
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Lee JH, Park JH, Jang JH, Kim SH, Hong SY, Heo W, Lee DH, Choi HS, Kim KH, Jang HJ. The role of nafamostat mesilate as a regional anticoagulant during extracorporeal membrane oxygenation. Acute Crit Care 2022; 37:177-184. [PMID: 35545240 PMCID: PMC9184977 DOI: 10.4266/acc.2021.01312] [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: 09/13/2021] [Accepted: 11/29/2021] [Indexed: 11/30/2022] Open
Abstract
Background Anticoagulation during extracorporeal membrane oxygenation (ECMO) usually is required to prevent thrombosis. The aim of this study was to investigate the usefulness of nafamostat mesilate (NM) as a regional anticoagulant during veno-arterial ECMO (VA-ECMO) treatment. Methods We retrospectively reviewed the medical records of 16 patients receiving VA-ECMO and NM from January 2017 to June 2020 at Haeundae Paik Hospital. We compared clinical and laboratory data, including activated partial thromboplastin time (aPTT), which was measured simultaneously in patients and the ECMO site, to estimate the efficacy of regional anticoagulation. Results The median patient age was 68.5 years, and 56.3% of patients were men. Cardiovascular disease was the most common primary disease (75.0%) requiring ECMO treatment, followed by respiratory disease (12.5%). The median duration of ECMO treatment was 7.5 days. Among 16 patients, seven were switched to NM after first using heparin as an anticoagulation agent, and nine received only NM. When comparing aPTT values in the NM group between patients and the ECMO site, that in patients was significantly lower than that at the ECMO site (73.57 vs. 79.25 seconds; P=0.010); in contrast, no difference was observed in the heparin group. Conclusions NM showed efficacy as a regional anticoagulation method by sustaining a lower aPTT value compared to that measured at the ECMO site. NM should be considered as a safer regional anticoagulation method in VA-ECMO for patients at high risk of bleeding.
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Jenks CL, Landry LM, Garrison CF, Campbell JG, Weeks MF, Tramel SW, Knudson JD. Pediatric Extracorporeal Membrane Oxygenation Anticoagulation Protocol Associated with a Decrease in Complications. ASAIO J 2022; 68:275-280. [PMID: 33883505 DOI: 10.1097/mat.0000000000001438] [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
Extracorporeal membrane oxygenation (ECMO) in pediatrics has rapidly progressed in recent years; however, there continues to be considerable variation in anticoagulation practices. In 2016, we implemented a standardized anticoagulation protocol in effort to reduce clotting and bleeding complications. A single-center retrospective analysis of pediatric patients requiring ECMO between 2014 and 2018 was performed. One hundred one ECMO cases in 94 pediatric patients met eligibility criteria (preprotocol = 64 cases; postprotocol = 37 cases). Demographics, ECMO parameters, complications, laboratories, and blood product requirements were analyzed for differences between the two groups. There was a significant decrease in the incidence of hematologic (p < 0.022), neurologic (p < 0.001), and renal complications (p < 0.001) in the postprotocol era. Incidence of bleeding, cardiac/pulmonary complications, and circuit changes were similar between the groups. The postprotocol group required fewer transfusions of red blood cells and cryoprecipitate. Additionally, platelet counts and fibrinogen levels were maintained higher in the postprotocol era. In conclusion, implementation of a standardized anticoagulation protocol was associated with improved anticoagulation parameters and a decrease in hematologic and neurologic complications, coagulopathy, renal injury, and blood product administration. We attribute these findings to transitioning to anti-Xa as a measure of heparinization and maintaining higher platelet counts.
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Affiliation(s)
- Christopher L Jenks
- From the Department of Pediatrics, Division of Pediatric Critical Care, University of Mississippi Medical Center, Jackson, Mississippi
| | - Lily M Landry
- Department of Pediatrics, Division of Pediatric Cardiology, University of Mississippi Medical Center, Jackson, Mississippi
| | - Carrie F Garrison
- Department of Pediatrics, Division of Pediatric Critical Care, Studer Family Children's Hospital at Sacred Heart, Pensacola, Florida
| | - Joshua G Campbell
- School of Medicine, University of Mississippi Medical Center, Jackson, Mississippi
| | - Mary F Weeks
- School of Medicine, University of Mississippi Medical Center, Jackson, Mississippi
| | - Sarah W Tramel
- School of Medicine, University of Mississippi Medical Center, Jackson, Mississippi
| | - Jarrod D Knudson
- From the Department of Pediatrics, Division of Pediatric Critical Care, University of Mississippi Medical Center, Jackson, Mississippi
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Major Bleeding in Adults Undergoing Peripheral Extracorporeal Membrane Oxygenation (ECMO): Prognosis and Predictors. Crit Care Res Pract 2022; 2022:5348835. [PMID: 35075397 PMCID: PMC8783736 DOI: 10.1155/2022/5348835] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 12/14/2021] [Accepted: 01/03/2022] [Indexed: 12/13/2022] Open
Abstract
Background. Major bleeding has been a common and serious complication with poor outcomes in ECMO patients. With a novel, less-invasive cannulation approach and closer coagulation monitoring regime, the incidence of major bleeding is currently not determined yet. Our study aims to examine the incidence of major bleeding, its determinants, and association with mortality in peripheral-ECMO patients. Method. We conducted a single-center retrospective study on adult patients undergoing peripheral-ECMO between January 2019 and January 2020 at a tertiary referral hospital. Determinants of major bleeding were defined by logistic regression analysis. Risk factors of in-hospital mortality were determined by Cox proportional hazard regression analysis. Results. Major bleeding was reported in 33/105 patients (31.4%) and was associated with higher in-hospital mortality [adjusted hazard ratio (aHR) 3.56, 95% confidence interval (CI) 1.63–7.80,
). There were no significant difference in age, sex, ECMO indications, ECMO modality, pre-ECMO APACHE-II and SOFA scores between two groups with and without major bleeding. Only APTT >72 seconds [adjusted odds ratio (aOR) 7.10, 95% CI 2.60–19.50,
], fibrinogen <2 g/L [aOR = 7.10, 95% CI 2.60–19.50,
], and ACT >220 seconds [aOR = 3.9, 95% CI 1.20–11.80,
] on days with major bleeding were independent predictors. Conclusions. In summary, major bleeding still had a fairly high incidence and poor outcome in peripheral-ECMO patients. APTT > 72 seconds, fibrinogen < 2 g/L were the strongest predicting factors for major bleeding events.
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Burton CL, Furlong-Dillard JM, Jawad K, Feygin Y, Berkenbosch JW, Tzanetos DT. Analysis of Viscoelastic Testing in Pediatric Patients Using the Pediatric Extracorporeal Membrane Oxygenation Outcomes Registry. ASAIO J 2021; 67:1251-1256. [PMID: 33852495 DOI: 10.1097/mat.0000000000001388] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Use of viscoelastic tests (VETs), including thromboelastography (TEG) and rotational thromboelastometry (ROTEM), is increasing in the management of anticoagulation in extracorporeal membrane oxygenation (ECMO) patients. A retrospective review of data on 265 pediatric (<20 years old) ECMO patients who underwent VET and were submitted to the Pediatric ECMO Outcomes Registry (PEDECOR) was conducted to describe common coagulopathies in patients who underwent VET; associations between the VET parameters and traditional tests of coagulation; and comparisons in blood product usage in patients who underwent VET with those who did not. We calculated patient-level summary statistics and assessed differences between the groups using χ2 tests (categorical variables) and Kruskal-Wallis and Wilcoxon rank-sum tests (continuous variables). Viscoelastic test was utilized in 77% of patients in the analysis. Platelet dysfunction was the most common abnormality identified by TEG (30.8%) and ROTEM (9.7%). Bleeding patients who had VET performed received more cryoprecipitate transfusions than those who did not have VET (VET median = 9.7 ml/kg; interquartile range (IQR) = 4.3-22.0 ml/kg vs. no VET median = 5.1 ml/kg; IQR = 0-10.4 ml/kg; p = 0.0013). Given the growing use of VET in pediatric ECMO patients, further studies evaluating VET in managing complications as well as aiding in titration of anticoagulation therapy are needed.
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Affiliation(s)
- Cassondra L Burton
- From the Division of Pediatric Critical Care, Norton Children's Hospital, University of Louisville, Louisville, Kentucky
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12
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Drop JG, Erdem Ö, Wildschut ED, van Rosmalen J, de Maat MPM, Kuiper J, Houmes RJM, van Ommen CH. Use of rotational thromboelastometry to predict hemostatic complications in pediatric patients undergoing extracorporeal membrane oxygenation: A retrospective cohort study. Res Pract Thromb Haemost 2021; 5:e12553. [PMID: 34278189 PMCID: PMC8279126 DOI: 10.1002/rth2.12553] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 04/23/2021] [Accepted: 05/07/2021] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND The incidence of hemostatic complications in pediatric patients undergoing extracorporeal membrane oxygenation (ECMO) is high. The optimal anticoagulation strategy in children undergoing ECMO is unknown. OBJECTIVES To study the association between hemostatic complications, coagulation tests, and clinical parameters in pediatric patients undergoing ECMO and their effect on survival. METHODS We performed a retrospective cohort study of pediatric patients undergoing centrifugal pump ECMO. Collected data included patient characteristics, risk factors, and coagulation test results. Statistical analysis was done using logistic regression analysis for repeated measurements. Dependent variables were thrombosis and bleeding, independent variables were rotational thromboelastometry (ROTEM), activated partial thromboplastin time (aPTT) and antifactor-Xa assay (aXa) results, ECMO duration, age <29 days, sepsis and surgery. RESULTS Seventy-three patients with 623 ECMO days were included. Cumulative incidences of thrombosis and bleeding were 43.5% (95% confidence interval [CI], 26.0%-59.8%) and 25.4% (95% CI, 13.4%-39.3%), respectively. A lower maximum clot firmness of intrinsic ROTEM (INTEM; odds ratio [OR], 0.946; 95% CI, 0.920-0.969), extrinsic ROTEM (OR, 0.945; 95% CI, 0.912-0.973), and INTEM with heparinase (OR, 0.936; 95% CI, 0.896-0.968); higher activated partial thromboplastin time aPTT; OR, 1.020; 95% CI, 1.006-1.024) and age <29 days (OR, 2.900; 95% CI, 1.282-6.694); surgery (OR, 4.426; 95% CI, 1.543-12.694); and longer ECMO duration (OR, 1.149; 95% CI, 1.022-1.292) significantly increased thrombotic risk. Surgery (OR, 2.698; 95% CI, 1.543-12.694) and age <29 days (OR 2.242, 95% CI 1.282-6.694) were significantly associated with major bleeding. Patients with hemostatic complications had significantly decreased survival to hospital discharge (P = .009). CONCLUSION The results of this study help elucidate the role of ROTEM, aPTT, anti-factor Xa, and clinical risk factors in predicting hemostatic complications in pediatric patients undergoing ECMO.
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Affiliation(s)
- Joppe G. Drop
- Department of Pediatric HematologyErasmus Medical Center ‐ Sophia Children's HospitalRotterdamThe Netherlands
- Department of Intensive Care and Pediatric SurgeryErasmus University Medical Center – Sophia Children’s HospitalRotterdamThe Netherlands
| | - Özge Erdem
- Department of Intensive Care and Pediatric SurgeryErasmus University Medical Center – Sophia Children’s HospitalRotterdamThe Netherlands
| | - Enno D. Wildschut
- Department of Intensive Care and Pediatric SurgeryErasmus University Medical Center – Sophia Children’s HospitalRotterdamThe Netherlands
| | - Joost van Rosmalen
- Department of BiostatisticsErasmus Medical CenterRotterdamThe Netherlands
- Department of EpidemiologyErasmus Medical CenterRotterdamThe Netherlands
| | | | - Jan‐Willem Kuiper
- Department of Intensive Care and Pediatric SurgeryErasmus University Medical Center – Sophia Children’s HospitalRotterdamThe Netherlands
| | - Robert Jan M. Houmes
- Department of Intensive Care and Pediatric SurgeryErasmus University Medical Center – Sophia Children’s HospitalRotterdamThe Netherlands
| | - C. Heleen van Ommen
- Department of Pediatric HematologyErasmus Medical Center ‐ Sophia Children's HospitalRotterdamThe Netherlands
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Troy L, Su F, Kilbaugh T, Rasmussen L, Kuo T, Jett E, Cornell T, Berg M, Haileselassie B. Characteristics of Pediatric Extracorporeal Membrane Oxygenation Programs in the United States and Canada. ASAIO J 2021; 67:792-797. [PMID: 33181543 DOI: 10.1097/mat.0000000000001311] [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
The aim of this study was to evaluate the current infrastructure and practice characteristics of pediatric extracorporeal membrane oxygenation (ECMO) programs. A 40-question survey of center-specific demographics, practice structure, program experience, and support network utilized to cannulate and maintain a pediatric patient on ECMO was designed via a web-based survey tool. The survey was distributed to pediatric ECMO programs in the United States and Canada. Of the 101 centers that were identified to participate, 41 completed the survey. The majority of responding centers are university affiliated (73%) and have an intensive care unit (ICU) with 15-25 beds (58%). Extracorporeal membrane oxygenation has been offered for >10 years in 85% of the centers. The median number of total cannulations per center in 2017 was 15 (interquartile range [IQR] = 5-30), with the majority occurring in the cardiovascular intensive care unit (median = 13, IQR = 5-25). Fifty-seven percent of responding centers offer ECPR, with a median number of four cases per year (IQR = 2-7). Most centers cannulate in an operating room or ICU; 11 centers can cannulate in the pediatric ED. Sixty-three percent of centers have standardized protocols for postcannulation management. The majority of protocols guide anticoagulation, sedation, or ventilator management; left ventricle decompression and reperfusion catheter placement are the least standardized procedures. The majority of pediatric ECMO centers have adopted the infrastructure recommendations from the Extracorporeal Life Support Organization. However, there remains broad variability of practice characteristics and organizational infrastructure for pediatric ECMO centers across the United States and Canada.
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Affiliation(s)
- Lindsey Troy
- From the Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Felice Su
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Todd Kilbaugh
- Department of Anesthesia and Critical Care, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Lindsey Rasmussen
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Tony Kuo
- Stanford Children's Health, Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Eric Jett
- Stanford Children's Health, Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Timothy Cornell
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Marc Berg
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Bereketeab Haileselassie
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Stanford University School of Medicine, Palo Alto, California
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14
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Heinsar S, Raman S, Suen JY, Cho HJ, Fraser JF. The use of extracorporeal membrane oxygenation in children with acute fulminant myocarditis. Clin Exp Pediatr 2021; 64:188-195. [PMID: 32777915 PMCID: PMC8103038 DOI: 10.3345/cep.2020.00836] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 07/02/2020] [Indexed: 12/28/2022] Open
Abstract
Acute fulminant myocarditis (AFM) occurs as an inflammatory response to an initial myocardial insult. Its rapid and deadly progression calls for prompt diagnosis with aggressive treatment measures. The demonstration of its excellent recovery potential has led to increasing use of mechanical circulatory support, especially extracorporeal membrane oxygenation (ECMO). Arrhythmias, organ failure, elevated cardiac biomarkers, and decreased ventricular function at presentation predict requirement for ECMO. In these patients, ECMO should be considered earlier as the clinical course of AFM can be unpredictable and can lead to rapid haemodynamic collapse. Key uncertainties that clinicians face when managing children with AFM such as timing of initiation of ECMO and left ventricular decompression need further investigation.
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Affiliation(s)
- Silver Heinsar
- Critical Care Research Group, Faculty of Medicine, University of Queensland and The Prince Charles Hospital, Brisbane, Australia
| | - Sainath Raman
- Critical Care Research Group, Faculty of Medicine, University of Queensland and The Prince Charles Hospital, Brisbane, Australia.,Paediatric Critical Care Research Group, Child Health Research Centre, The University of Queensland, Queensland, Australia.,Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Australia
| | - Jacky Y Suen
- Critical Care Research Group, Faculty of Medicine, University of Queensland and The Prince Charles Hospital, Brisbane, Australia
| | - Hwa Jin Cho
- Critical Care Research Group, Faculty of Medicine, University of Queensland and The Prince Charles Hospital, Brisbane, Australia.,Department of Pediatrics, Chonnam National University Children's Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - John F Fraser
- Critical Care Research Group, Faculty of Medicine, University of Queensland and The Prince Charles Hospital, Brisbane, Australia
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15
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Kulig CE, Schomer KJ, Black HB, Dager WE. Activated Partial Thromboplastin Time Versus Anti-Factor Xa Monitoring of Heparin Anticoagulation in Adult Venoarterial Extracorporeal Membrane Oxygenation Patients. ASAIO J 2021; 67:411-415. [PMID: 33769995 DOI: 10.1097/mat.0000000000001246] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The preferred assay for measuring and adjusting unfractionated heparin (UFH) infusion to achieve optimal outcomes during extracorporeal membrane oxygenation (ECMO) is not well established. This retrospective cohort study explored safety and efficacy outcome differences between anti-factor Xa (anti-Xa) and activated partial thromboplastin time (aPTT) for UFH in adult venoarterial ECMO. Forty-one patients were included and analyzed. The UFH rate at first goal and time to goal were both higher in the aPTT versus anti-Xa cohort but did not achieve statistical significance (12.14 vs. 9.58 unit/kg/hour (p = 0.29), 20.22 vs. 12.05 hours (p = 0.11)). The aPTT cohort was in target goals 35.0% of the time versus 47.7% in the anti-Xa cohort (p = 0.13), above goal 41.0% vs. 17.3% (p = 0.02), and below-goal 24.0% versus 35.0% of the time (p = 0.34). Minimum heparin rates in the aPTT cohort were 6.28 vs. 3.33 unit/kg/hour in the anti-Xa cohort (p = 0.07), and the maximum UFH rate was 18.77 unit/kg/hour vs. 15.48 unit/kg/hour (p = 0.10). Our findings suggest that aPTT monitoring may result in a delay to target attainment, higher UFH rates, and overall exposure.
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Affiliation(s)
- Caitlin E Kulig
- University of California, Davis Medical Center, Sacramento, California
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16
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Perez Ortiz A, Dempfle CE, Jung T, Doniga T, Weiß C, Hetjens S, Schaible T, Rafat N. Assessing Anticoagulation in Neonates With Congenital Diaphragmatic Hernia During Extracorporeal Membrane Oxygenation: Does Anti-Factor Xa or Thromboelastometry Provide Additional Benefit? Front Pediatr 2021; 9:685906. [PMID: 34604133 PMCID: PMC8485026 DOI: 10.3389/fped.2021.685906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 08/16/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: The optimal management of anticoagulation in neonatal/pediatric patients during extracorporeal membrane oxygenation (ECMO) has not been established yet and varies greatly among ECMO centers worldwide. Therefore, we aimed to assess whether the use of anti-factor Xa assay and/or thromboelastometry correlate better than activated clotting time with heparin dose in newborns with congenital diaphragmatic hernia during ECMO. We also examined whether these coagulation assays correlate with thrombotic and/or hemorrhagic complications, when the management of anticoagulation is based only on activated clotting time values. Methods: A prospective observational study in a neonatal ECMO center was conducted. We included all neonates with congenital diaphragmatic hernia born in our institution between March 2018 and January 2019 and requiring support with venoarterial ECMO. A total of 26 ECMO runs were analyzed. During the study, the heparin dose was still adjusted according to activated clotting time values. Measurements of anti-factor Xa assay, activated partial thromboplastin time, and a thromboelastometry from the same blood specimen were performed twice a day. Results: Anti-factor Xa levels showed a moderate correlation with heparin dose, whereas the other tests showed a weak correlation. Four patients (17.4%) had thrombotic complications, 2 patients (8.7%) experienced life-threatening bleeding, and in 11 patients (47.8%) disseminated intravascular coagulation (DIC) occurred. Anti-factor Xa levels were lower in the group with thrombotic complications (0.23 vs. 0.27 IU/ml; p = 0.002), while activated partial thromboplastin time was higher in the group with hemorrhagic complications (69.4 s vs. 59.8 s; p = 0.01). In patients experiencing DIC, heparin dose and anti-factor Xa levels were lower, while no difference in activated clotting time and clotting time in INTEM and INTEM-HEPTEM were shown. Conclusions: Anti-factor Xa levels correlate better to heparin dose than activated clotting time. The use of anti-factor Xa assay instead of activated clotting time for dosing of unfractionated heparin could reduce thrombotic complications in neonates with congenital diaphragmatic hernia on ECMO support. The thromboelastometry showed no additional benefit for this purpose.
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Affiliation(s)
- Alba Perez Ortiz
- Department of Neonatology, University Children's Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | | | - Toni Jung
- Department of Neonatology, University Children's Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Thalia Doniga
- Department of Neonatology, University Children's Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Christel Weiß
- Department for Medical Statistics and Biomathematics, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Svetlana Hetjens
- Department for Medical Statistics and Biomathematics, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Thomas Schaible
- Department of Neonatology, University Children's Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Neysan Rafat
- Department of Neonatology, University Children's Hospital Mannheim, University of Heidelberg, Mannheim, Germany
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17
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Klug TD, Craig J, Shires CB. Awake ECMO without anticoagulation for nearly completely obstructive squamous cell carcinoma of the trachea. Clin Case Rep 2021; 9:164-168. [PMID: 33489153 PMCID: PMC7813012 DOI: 10.1002/ccr3.3490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 09/05/2020] [Accepted: 09/20/2020] [Indexed: 11/08/2022] Open
Abstract
Awake veno-venous ECMO without anticoagulation is a safe and successful way to remove a significantly obstructive malignancy in the trachea.
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18
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Park A, Song Y, Yi E, Duy Nguyen BT, Han D, Sohn E, Park Y, Jung J, Lee YM, Cho YH, Kim JF. Blood Oxygenation Using Fluoropolymer-Based Artificial Lung Membranes. ACS Biomater Sci Eng 2020; 6:6424-6434. [PMID: 33449658 DOI: 10.1021/acsbiomaterials.0c01251] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Artificial lung (AL) membranes are used for blood oxygenation for patients undergoing open-heart surgery or acute lung failures. Current AL technology employs polypropylene and polymethylpentene membranes. Although effective, these membranes suffer from low biocompatibility, leading to undesired blood coagulation and hemolysis over a long term. In this work, we propose a new generation of AL membranes based on amphiphobic fluoropolymers. We employed poly(vinylidene-co-hexafluoropropylene), or PVDF-co-HFP, to fabricate macrovoid-free membranes with an optimal pore size range of 30-50 nm. The phase inversion behavior of PVDF-co-HFP was investigated in detail for structural optimization. To improve the wetting stability of the membranes, the fabricated membranes were coated using Hyflon AD60X, a type of fluoropolymer with an extremely low surface energy. Hyflon-coated materials displayed very low protein adsorption and a high contact angle for both water and blood. In the hydrophobic spectrum, the data showed an inverse relationship between the surface free energy and protein adsorption, suggesting an appropriate direction with respect to biocompatibility for AL research. The blood oxygenation performance was assessed using animal sheep blood, and the fabricated fluoropolymer membranes showed competitive performance to that of commercial polyolefin membranes without any detectable hemolysis. The data also confirmed that the bottleneck in the blood oxygenation performance was not the membrane permeance but rather the rate of mass transfer in the blood phase, highlighting the importance of efficient module design.
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Affiliation(s)
- Ahrumi Park
- Membrane Research Center, Korea Research Institute of Chemical Technology (KRICT), Daejeon 305-600, Republic of Korea
| | - Yejin Song
- Membrane Research Center, Korea Research Institute of Chemical Technology (KRICT), Daejeon 305-600, Republic of Korea
| | - Eunsung Yi
- Membrane Research Center, Korea Research Institute of Chemical Technology (KRICT), Daejeon 305-600, Republic of Korea.,University of Science and Technology (UST), Daejeon 305-350, Republic of Korea
| | - Bao Tran Duy Nguyen
- Department of Energy and Chemical Engineering, Incheon National University, Incheon 22012, Republic of Korea
| | - Dongje Han
- Interface Material and Chemical Engineering Research Center, Korea Research Institute of Chemical Technology (KRICT), Daejeon 305-600, Republic of Korea.,School of Chemical and Biological Engineering, Seoul National University, Seoul 151-742, Republic of Korea
| | - EunHo Sohn
- Interface Material and Chemical Engineering Research Center, Korea Research Institute of Chemical Technology (KRICT), Daejeon 305-600, Republic of Korea.,University of Science and Technology (UST), Daejeon 305-350, Republic of Korea
| | - YouIn Park
- Membrane Research Center, Korea Research Institute of Chemical Technology (KRICT), Daejeon 305-600, Republic of Korea
| | - JunTae Jung
- Department of Energy Engineering, Hanyang University, Seoul 133-791, Republic of Korea
| | - Young Moo Lee
- Department of Energy Engineering, Hanyang University, Seoul 133-791, Republic of Korea
| | - Young Hoon Cho
- Membrane Research Center, Korea Research Institute of Chemical Technology (KRICT), Daejeon 305-600, Republic of Korea
| | - Jeong F Kim
- Innovation Center for Chemical Engineering, Incheon National University, Incheon 22012, Republic of Korea.,Department of Energy and Chemical Engineering, Incheon National University, Incheon 22012, Republic of Korea
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19
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Cerebral Hemodynamic Profile in Ischemic and Hemorrhagic Brain Injury Acquired During Pediatric Extracorporeal Membrane Oxygenation. Pediatr Crit Care Med 2020; 21:879-885. [PMID: 32569240 DOI: 10.1097/pcc.0000000000002438] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe the cerebral hemodynamic profiles associated with ischemic and hemorrhagic brain injury during neonatal and pediatric extracorporeal membrane oxygenation. DESIGN A retrospective cohort study. SETTING Tertiary PICU. PATIENTS Forty-seven neonatal and pediatric patients (0-15 yr of age) placed on extracorporeal membrane oxygenation from January 2014 to December 2018. MEASUREMENTS AND MAIN RESULTS Continuous monitoring of mean arterial pressure and cerebral tissue oxygen saturation was conducted through entire extracorporeal membrane oxygenation run. Wavelet analysis was performed to assess changes in cerebral autoregulation and to derive pressure-dependent autoregulation curves based on the mean arterial pressure and cerebral tissue oxygen saturation data. Patients were classified into three brain injury groups: no-injury, ischemic injury, and hemorrhagic injury based on neuroimaging results. No-injury patients (n = 23) had minimal variability in the autoregulation curve over a broad range of blood pressure. Ischemic injury (n = 16) was more common than hemorrhagic injury (n = 8), and the former was associated with increased mortality and morbidity. Ischemic group showed significant abnormalities in cerebral autoregulation in the lower blood pressure range, suggesting pressure-dependent cerebral perfusion. Hemorrhagic group had highest average blood pressure as well as the lowest cerebral tissue oxygenation saturation, suggesting elevated cerebral vascular resistance. Mean heparin dose during extracorporeal membrane oxygenation was lower in both ischemic and hemorrhagic groups compared with the no-injury group. CONCLUSIONS This study outlines distinct differences in underlying cerebral hemodynamics associated with ischemic and hemorrhagic brain injury acquired during extracorporeal membrane oxygenation. Real-time monitoring of cerebral hemodynamics in patients acquiring brain injury during extracorporeal membrane oxygenation can help optimize their management.
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20
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Aiello SR, Flores S, Coughlin M, Villarreal EG, Loomba RS. Antithrombin use during pediatric cardiac extracorporeal membrane oxygenation admission: insights from a national database. Perfusion 2020; 36:138-145. [PMID: 32650697 DOI: 10.1177/0267659120939758] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION The frequency of extracorporeal membrane oxygenation in pediatric patients continues to increase, especially in patients with complex congenital heart disease. Providing adequate anticoagulation is necessary for patients on extracorporeal membrane oxygenation and is achieved with adequate heparin administration. Antithrombin is administered to potentiate heparin's effects. However, the efficacy of antithrombin supplementation is unclear and a clear clinical benefit has not been established. We present a large retrospective study examining the effects of antithrombin on pediatric patients receiving extracorporeal membrane oxygenation. METHODS Data for this study were obtained from the Pediatric Health Information System and Pediatric Health Information System+ databases from 2004 to 2015. Pediatric patients receiving extracorporeal membrane oxygenation with a congenital heart disease diagnosis were included and divided into groups that did or did not utilize antithrombin. For all admissions, the following were captured: age of admission, gender, year of admission, length of stay, billed charges, inpatient mortality, the presence of specific congenital malformations of the heart, specific cardiac surgeries, and comorbidities. RESULTS A total of 9,193 admissions were included and 865 (9.4%) utilized antithrombin. Between groups, there were significantly different frequencies of co-morbidities, cardiac lesion types and antithrombin usage over the study period. There were significantly lower odds in the antithrombin group of venous thrombosis. Antithrombin was not significantly associated with hemorrhage; however, antithrombin was associated with increased inpatient mortality and a decrease in length of stay and billed charges. CONCLUSION Antithrombin administration is associated with increased mortality, a shorter length of stay, and decreased billing cost. Recently, antithrombin usage has been decreasing-potentially due to the reported lack of clinical benefit. Together, these results reinforce that antithrombin may not be indicated for all pediatric extracorporeal membrane oxygenation patients.
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Affiliation(s)
- Salvatore R Aiello
- Division of Cardiology, Advocate Children's Hospital, Chicago Medical School, Chicago, IL, USA
| | - Saul Flores
- Cardiac Intensive Care Unit, Section of Critical Care and Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Megan Coughlin
- Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Enrique G Villarreal
- Cardiac Intensive Care Unit, Section of Critical Care and Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.,Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Mexico
| | - Rohit S Loomba
- Division of Cardiology, Advocate Children's Hospital, Chicago Medical School, Chicago, IL, USA
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21
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Campbell CT, Diaz L, Kelly B. Description of Bivalirudin Use for Anticoagulation in Pediatric Patients on Mechanical Circulatory Support. Ann Pharmacother 2020; 55:59-64. [PMID: 32590908 DOI: 10.1177/1060028020937819] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Although heparin has previously been the anticoagulant of choice during mechanical circulatory support (MCS), there is a lack of consistency in dose-response in pediatric patients. Bivalirudin offers more consistent dose-response in adults; however, there are limited data for pediatrics use. OBJECTIVE The purpose was to characterize the usage, dosage, and safety profile of bivalirudin when used for pediatric MCS in a tertiary care pediatric hospital. METHODS A retrospective review of pediatric patients receiving bivalirudin for extracorporeal membrane oxygenation/ventricular assist device (ECMO/VAD) anticoagulation was conducted. The primary outcome was the average dose of bivalirudin. Additional outcomes included initial and maximum bivalirudin dose, time to first therapeutic activated partial thromboplastin time (aPTT), time within goal aPTT range, bleeding and clotting complications, and cost. Data were compared between ECMO and VAD patients. RESULTS Thirty-four patients were included. The median dose of bivalirudin was 0.37 mg/kg/h (interquartile range [IQR] = 0.21-0.56), with a maximum dose of 0.62 mg/kg/h (IQR = 0.33-0.91). VAD patients had a higher median and maximum dose as compared with ECMO patients. Patients achieved their therapeutic goal in a median of 6.1 hours and averaged 61.9% time within therapeutic aPTT. One patient had significant hemorrhage, whereas 3 patients had clotting requiring a circuit change. Bivalirudin acquisition cost was higher than heparin. CONCLUSION AND RELEVANCE Bivalirudin dosing in ECMO and VAD patients is consistent with dosing seen in previous reports but may be higher in VAD patients. Comparative studies between heparin and bivalirudin are necessary to compare cost-effective outcomes for pediatric patients.
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Affiliation(s)
- Christopher T Campbell
- University of Florida Health Shands Children's Hospital, Gainesville, FL, USA.,University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Lucas Diaz
- University of Florida Health Shands Children's Hospital, Gainesville, FL, USA
| | - Brian Kelly
- University of Florida Health Shands Children's Hospital, Gainesville, FL, USA
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22
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Mazzeffi M. Patient Blood Management in Adult Extracorporeal Membrane Oxygenation Patients. CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00384-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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23
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Guihaire J, Haddad F, Hoppenfeld M, Amsallem M, Christle JW, Owyang C, Shaikh K, Hsu JL. Physiology of the Assisted Circulation in Cardiogenic Shock: A State-of-the-Art Perspective. Can J Cardiol 2020; 36:170-183. [PMID: 32036862 PMCID: PMC7121859 DOI: 10.1016/j.cjca.2019.11.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 11/03/2019] [Accepted: 11/04/2019] [Indexed: 01/18/2023] Open
Abstract
Mechanical circulatory support (MCS) has made rapid progress over the last 3 decades. This was driven by the need to develop acute and chronic circulatory support as well as by the limited organ availability for heart transplantation. The growth of MCS was also driven by the use of extracorporeal membrane oxygenation (ECMO) after the worldwide H1N1 influenza outbreak of 2009. The majority of mechanical pumps (ECMO and left ventricular assist devices) are currently based on continuous flow pump design. It is interesting to note that in the current era, we have reverted from the mammalian pulsatile heart back to the continuous flow pumps seen in our simple multicellular ancestors. This review will highlight key physiological concepts of the assisted circulation from its effects on cardiac dynamic to principles of cardiopulmonary fitness. We will also examine the physiological principles of the ECMO-assisted circulation, anticoagulation, and the haemocompatibility challenges that arise when the blood is exposed to a foreign mechanical circuit. Finally, we conclude with a perspective on smart design for future development of devices used for MCS.
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Affiliation(s)
- Julien Guihaire
- Department of Cardiac Surgery, Research and Innovation Unit, RHU BioArt Lung 2020, Marie Lannelongue Hospital, Paris-Sud University, Le Plessis-Robinson, France.
| | - Francois Haddad
- Department of Medicine, Division of Cardiology, Stanford University School of Medicine, Stanford, California, USA
| | - Mita Hoppenfeld
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Myriam Amsallem
- Department of Medicine, Division of Cardiology, Stanford University School of Medicine, Stanford, California, USA
| | - Jeffrey W Christle
- Department of Medicine, Division of Critical Care Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Clark Owyang
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Khizer Shaikh
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Joe L Hsu
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Stanford University School of Medicine, Stanford, California, USA
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24
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Berlioz B, Kaseer HS, Sanghavi DK, Guru PK. Bivalirudin resistance in a patient on veno-venous extracorporeal membrane oxygenation with a therapeutic response to argatroban. BMJ Case Rep 2020; 13:13/1/e232262. [PMID: 31915185 DOI: 10.1136/bcr-2019-232262] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 48-year-old male patient requiring extracorporeal membrane oxygenation (ECMO) support for hypoxaemic respiratory failure failed to achieve therapeutic anticoagulation with bivalirudin after continuous dose escalations, and continued to have recurrent fibrin stranding in the circuit over a 6-day course of treatment. Suspecting bivalirudin resistance, the patient was transitioned to argatroban and achieved a therapeutic response in less than 24 hours. The case describes the challenges of anticoagulation in ECMO supported patients. The interplay between bivalirudin metabolism, renal replacement therapy, and immunological effects leading to a heparin-like-effect, inflammatory mediators, and thrombotic burdens may all impact the clinical effect during bivalirudin therapy. The structural biochemistry of thrombin and bivalirudin likely plays a role in the presented patient's successful response to argatroban. Bivalirudin may fail at achieving therapeutic anticoagulation in patients with genetic thrombin mutations or structural defects that alter the binding pockets at the thrombin exosites.
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Affiliation(s)
- Beric Berlioz
- Anesthesiology, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Haya S Kaseer
- Critical Care, Mayo Clinic Florida, Jacksonville, Florida, USA
| | | | - Pramod K Guru
- Critical Care, Mayo Clinic Florida, Jacksonville, Florida, USA
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25
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Treatment of a Rat Model of LPS-Induced ARDS via Peritoneal Perfusion of Oxygen Microbubbles. J Surg Res 2019; 246:450-456. [PMID: 31629496 DOI: 10.1016/j.jss.2019.09.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 09/07/2019] [Accepted: 09/13/2019] [Indexed: 12/12/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is a serious respiratory condition that occurs in approximately 10% of patients entering intensive care units around the world, affecting nearly 190,000 patients annually in the United States. Owing to the severity of the condition, conventional methods of oxygenation are often insufficient. However, current alternate methods of oxygenation are associated with contraindications and a mortality rate near 50%. Therefore, a need exists for a safer and more effective method of oxygenation for patients with ARDS. In this work, the feasibility of using intraperitoneal perfusions of oxygen microbubbles-peritoneal microbubble oxygenation (PMO)-to treat lipopolysaccharide-induced ARDS was explored with the objective of showing restoration of normoxic conditions after a single bolus infusion of oxygen microbubbles. Male Wistar rats induced with ARDS via lipopolysaccharide inhalation were treated with PMO at 12-h intervals over a period of 48 h. Their physiological responses were monitored throughout the study, after which necropsy was performed. Response data were then compared with saline control and untreated groups. We conclude that rats experiencing moderate to severe ARDS that were treated with PMO experienced a survival rate 37% higher than animals not given treatment and exhibited increased peripheral blood oxygen saturation when compared with untreated and saline-treated groups. Moreover, those treated with PMO experienced a lower lung wet/dry ratio and less severe lung pathology, indicating a surprising improvement in lung health. Overall, this study demonstrates the ability of PMO to deliver life-sustaining supplemental oxygen to rats suffering from ARDS and warrants further work toward clinical translation.
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26
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Pollak U. Heparin-induced thrombocytopenia complicating extracorporeal membrane oxygenation support: Review of the literature and alternative anticoagulants. J Thromb Haemost 2019; 17:1608-1622. [PMID: 31313454 DOI: 10.1111/jth.14575] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 06/25/2019] [Accepted: 07/11/2019] [Indexed: 01/19/2023]
Abstract
Heparin-induced thrombocytopenia (HIT) is a life-threatening prothrombotic, immune-mediated complication of unfractionated heparin and low molecular weight heparin therapy. HIT is characterized by moderate thrombocytopenia 5-10 days after initial heparin exposure, detection of platelet-activating anti-platelet factor 4/heparin antibodies and an increased risk of venous and arterial thrombosis. Extracorporeal membrane oxygenation (ECMO) is a form of mechanical circulatory support used in critically ill patients with respiratory or cardiac failure. Systemic anticoagulation is used to alleviate the thrombotic complications that may occur when blood is exposed to artificial surfaces within the ECMO circuit. Therefore, when HIT complicates patients on ECMO support, it is associated with a high thrombotic morbidity and mortality. The risk for HIT correlates with the accumulative dosage of heparin exposure. In ECMO patients receiving continuous infusion of heparin for circuit patency, the risk for HIT is not neglected and must be thought of in the differential diagnosis of the appropriate clinical and laboratory circumstances. The following article reviews the current knowledge in HIT complicating ECMO patients and the alternative anticoagulation options in the presence of HIT.
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Affiliation(s)
- Uri Pollak
- Pediatric Cardiac Critical Care Unit, Hadassah University Medical Center, Jerusalem, Israel
- Pediatric Cardiology, Hadassah University Medical Center, Jerusalem, Israel
- Pediatric Extracorporeal Support Program, Hadassah University Medical Center, Jerusalem, Israel
- The Hebrew University Hadassah Medical School, Jerusalem, Israel
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27
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Cairo SB, Arbuthnot M, Boomer LA, Dingeldein MW, Feliz A, Gadepalli S, Newton CR, Ricca R, Vogel AM, Rothstein DH. Controversies in extracorporeal membrane oxygenation (ECMO) utilization and congenital diaphragmatic hernia (CDH) repair using a Delphi approach: from the American Pediatric Surgical Association Critical Care Committee (APSA-CCC). Pediatr Surg Int 2018; 34:1163-1169. [PMID: 30132059 DOI: 10.1007/s00383-018-4337-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/10/2018] [Indexed: 11/28/2022]
Abstract
PURPOSE Review current practices and expert opinions on contraindications to extracorporeal membrane oxygenation (ECMO) in congenital diaphragmatic hernia (CDH) and contraindications to repair of CDH following initiation of ECMO. METHODS Modified Delphi method was employed to achieve consensus among members of the American Pediatric Surgical Association Critical Care Committee (APSA-CCC). RESULTS Overall response rate was 81% including current and former members of the APSA-CCC. An average of 5-15 CDH repairs were reported annually per institution; 26-50% of patients required ECMO. 100% of respondents would not offer ECMO to a patient with a complex or unrepairable cardiac defects or lethal chromosomal abnormality; 94.1% would not in the setting of severe intracranial hemorrhage (ICH). 76.5% and 72.2% of respondents would not offer CDH repair to patients on ECMO with grade III-IV ICH or new diagnosis of lethal genetic or metabolic abnormalities, respectively. There was significant variability in whether or not to repair CDH if unable to wean from ECMO at 4-5 weeks. CONCLUSIONS Significant variability in practice pattern and opinions exist regarding contraindications to ECMO and when to offer repair of CDH for patients on ECMO. Ongoing work to evaluate outcomes is needed to standardize management and minimize potentially futile interventions. LEVEL OF EVIDENCE V (expert opinion).
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Affiliation(s)
- Sarah B Cairo
- Department of Pediatric Surgery, John R. Oishei Children's Hospital, 1001 Main Street, Buffalo, NY, 14203, USA.
| | - Mary Arbuthnot
- Department of Pediatric and General Surgery, Naval Medical Center Portsmouth, Portsmouth, USA
| | - Laura A Boomer
- Department of Surgery, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, USA
| | - Michael W Dingeldein
- Department of Pediatric Surgery, Rainbow Babies and Children Hospital, Cleveland, USA
| | - Alexander Feliz
- Department of Pediatric Surgery, University of Tennessee Health Sciences, Memphis, USA
| | - Samir Gadepalli
- C.S. Mott Children's Hospital, Michigan Medicine, Ann Arbor, USA
| | - Chris R Newton
- Department of Pediatric Surgery, University of California at San Francisco Benioff Children's Hospital Oakland, San Francisco, USA
| | - Robert Ricca
- Department of Pediatric and General Surgery, Naval Medical Center Portsmouth, Portsmouth, USA
| | - Adam M Vogel
- Department of Pediatric General Surgery, Texas Children's Hospital, Houston, USA
| | - David H Rothstein
- Department of Pediatric Surgery, John R. Oishei Children's Hospital, 1001 Main Street, Buffalo, NY, 14203, USA.,Department of Surgery, Jacobs School of Medicine, State University of New York, University at Buffalo, Buffalo, USA
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28
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Cairo SB, Lautz TB, Schaefer BA, Yu G, Naseem HUR, Rothstein DH. Risk factors for venous thromboembolic events in pediatric surgical patients: Defining indications for prophylaxis. J Pediatr Surg 2018; 53:1996-2002. [PMID: 29370891 DOI: 10.1016/j.jpedsurg.2017.12.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Revised: 11/24/2017] [Accepted: 12/14/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) in pediatric surgical patients is a rare event. The risk factors for VTE in pediatric general surgery patients undergoing abdominopelvic procedures are unknown. STUDY DESIGN The American College of Surgeon's National Surgical Quality Improvement Program-Pediatric (NSQIP-P) database (2012-2015) was queried for patients with VTE after abdominopelvic general surgery procedures. Patient and operative variables were assessed to identify risk factors associated with VTE and develop a pediatric risk score. RESULTS From 2012-2015, 68 of 34,813 (0.20%) patients who underwent abdominopelvic general surgery procedures were diagnosed with VTE. On multivariate analysis, there was no increased risk of VTE based on concomitant malignancy, chemotherapy, inflammatory bowel disease, or laparoscopic surgical approach, while a higher rate of VTE was identified among female patients. The odds of experiencing VTE were increased on stepwise regression for patients older than 15 years and those with preexisting renal failure or a diagnosis of septic shock, patients with American Society of Anesthesia (ASA) classification ≥ 2, and for anesthesia time longer than 2 h. The combination of age > 15 years, ASA classification ≥ 2, anesthesia time > 2 h, renal failure, and septic shock was included in a model for predicting risk of VTE (AUC = 0.907, sensitivity 84.4%, specificity 88.2%). CONCLUSION VTE is rare in pediatric patients, but prediction modeling may help identify those patients at heightened risk. Additional studies are needed to validate the factors identified in this study in a risk assessment model as well as to assess the efficacy and cost-effectiveness of prophylaxis methods. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Sarah B Cairo
- Department of Pediatric Surgery, John R Oshei Children's Hospital, 1001 Main Street, Buffalo, NY 14202.
| | - Timothy B Lautz
- Department of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611
| | - Beverly A Schaefer
- Department of Pediatric Hematology and Oncology, John R Oshei Children's Hospital, 1001 Main Street, Buffalo, NY 14202; Department of Pediatrics, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263; Department of Pediatrics, State University of New York, University at Buffalo, 3435 Main Street, Buffalo, NY 14214
| | - Guan Yu
- Department of Biostatistics, State University of New York, University at Buffalo, 3435 Main Street, Buffalo, NY 14214
| | - Hibbut-Ur-Rauf Naseem
- Department of Pediatric Surgery, John R Oshei Children's Hospital, 1001 Main Street, Buffalo, NY 14202
| | - David H Rothstein
- Department of Pediatric Surgery, John R Oshei Children's Hospital, 1001 Main Street, Buffalo, NY 14202; Department of Surgery, State University of New York, University at Buffalo, 3435 Main Street, Buffalo, NY 14214
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29
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Comparing Percutaneous to Open Access for Extracorporeal Membrane Oxygenation in Pediatric Respiratory Failure. Pediatr Crit Care Med 2018; 19:981-991. [PMID: 30080776 PMCID: PMC6173194 DOI: 10.1097/pcc.0000000000001691] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Evaluate trends in method of access (percutaneous cannulation vs open cannulation) for pediatric extracorporeal membrane oxygenation and determine the effects of cannulation method on morbidity and mortality. DESIGN Retrospective cohort study. SETTING AND SUBJECTS The Extracorporeal Life Support Organization's registry was queried for pediatric patients on extracorporeal membrane oxygenation for respiratory failure from 2007 to 2015. INVERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 3,501 patients identified, 77.2% underwent open cannulation, with the frequency of open cannulation decreasing over the study period from approximately 80% to 70% (p < 0.001). Percutaneous cannulation patients were more commonly male (24.2% vs 21.5%; p = 0.01), older (average 7.6 vs 4.5 yr; p < 0.001), and heavier (average 33.0 vs 20.2 kg; p < 0.001). Subset analysis of patients on venovenous extracorporeal membrane oxygenation revealed higher rates of mechanical complications due to blood clots (28.9% vs 22.6%; p = 0.003) or cannula problems (18.9% vs 12.7%; p < 0.001), cannula site bleeding (25.3% vs 20.2%; p = 0.01) and increased rates of cannula site repair in the open cannulation cohort. Limb related complications were not significantly different on subset analysis for venovenous extracorporeal membrane oxygenation patients stratified by access site. Logistic regression analysis revealed that method of access was not associated with a difference in mortality. CONCLUSIONS The proportion of pediatric patients undergoing percutaneous extracorporeal membrane oxygenation cannulation is increasing. Mechanical and physiologic complications occur with both methods of cannulation, but percutaneous cannulation appears safe in this cohort. Further analysis is needed to evaluate long-term outcomes with this technique.
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30
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Lee KH, Cho JG, Park HW, Yoon NS, Jeong HK, Lee N. Role of Red Cell Distribution Width in the Relationship between Clinical Outcomes and Anticoagulation Response in Patients with Atrial Fibrillation. Chonnam Med J 2018; 54:113-120. [PMID: 29854676 PMCID: PMC5972124 DOI: 10.4068/cmj.2018.54.2.113] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 03/30/2018] [Accepted: 04/03/2018] [Indexed: 02/03/2023] Open
Abstract
Little is known as to why elevated red cell distribution width (RDW) is associated with adverse clinical outcomes in patients with atrial fibrillation (AF). We hypothesized that RDW value might predict the intensity of anticoagulation, resulting in higher adverse events in patients with AF taking warfarin. We analyzed 657 patients with non-valuvular AF who took warfarin. The intensity of anticoagulation was assessed as mean time in the therapeutic range (TTR) and defined TTR ≥60% as an optimal intensity. The primary end-point was the composite of stroke/systemic embolism and major bleeding. The secondary end-point was the composite of stroke/systemic embolism, major bleeding and death. The relationship between the baseline RDW with TTR and clinical outcomes was assessed using categorical variables as quartiles or dichotomous variables. The mean value of TTR decreased as an increment of the RDW (45.2% vs. 44.7% vs. 40.8% vs. 35.2%, p<0.001). Primary and secondary end-points were significantly increased when TTR was less than 60% and RDW was more than 13.6%. Ratio of patients achieving optimal anticoagulation were significantly decreased as an increment of RDW. A RDW of ≥13.6% was a significant predictor for poor anticoagulation control (adjusted Odds ratio [OR] 0.43, 95% confidence interval [CI] 0.23–0.82), stroke (adjusted hazard ratio [HR] 3.86, 95% CI 1.11–13.40), primary (adjusted HR 1.88, 95% CI 1.12–3.16) and secondary end-point (adjusted HR 2.46, 95% CI 1.26–4.81). RDW was negatively associated with TTR in patients with AF. Therefore, RDW might be a useful marker for the prediction of anticoagulation response and clinical outcomes in patients with AF.
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Affiliation(s)
- Ki Hong Lee
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Jeong Gwan Cho
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Hyung Wook Park
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Nam Sik Yoon
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Hyung Ki Jeong
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Nuri Lee
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea
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31
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Barton R, Ignjatovic V, Monagle P. Anticoagulation during ECMO in neonatal and paediatric patients. Thromb Res 2018; 173:172-177. [PMID: 29779622 DOI: 10.1016/j.thromres.2018.05.009] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 04/05/2018] [Accepted: 05/07/2018] [Indexed: 12/17/2022]
Abstract
Extracorporeal Membrane Oxygenation (ECMO) is a form of Extracorporeal Life Support (ECLS) which is used frequently in the paediatric and neonatal setting to support either the pulmonary, or both the pulmonary and cardiac systems. Management of ECMO requires the use of systemic anticoagulation to prevent patient and circuit based thrombosis, which in turn increases the risk of haemorrhage. A number of coagulation tests, laboratory and point of care based, are used to monitor anticoagulation, however the evidence for correlation of the test results with level of anticoagulant and clinical outcomes in children remains poor.
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Affiliation(s)
- Rebecca Barton
- Clinical Haematology, Royal Children's Hospital, Australia; Murdoch Children's Research Institute, Australia; Department of Paediatrics, The University of Melbourne, Australia
| | - Vera Ignjatovic
- Murdoch Children's Research Institute, Australia; Department of Paediatrics, The University of Melbourne, Australia
| | - Paul Monagle
- Clinical Haematology, Royal Children's Hospital, Australia; Murdoch Children's Research Institute, Australia; Department of Paediatrics, The University of Melbourne, Australia.
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32
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Kim DW, Cho HJ, Kim GS, Song SY, Na KJ, Oh SG, Oh BS, Jeong IS. Predictive Value of Procalcitonin for Infection and Survival in Adult Cardiogenic Shock Patients Treated with Extracorporeal Membrane Oxygenation. Chonnam Med J 2018; 54:48-54. [PMID: 29399566 PMCID: PMC5794479 DOI: 10.4068/cmj.2018.54.1.48] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 12/22/2017] [Accepted: 12/26/2017] [Indexed: 01/11/2023] Open
Abstract
Procalcitonin (PCT) is a predictive marker for the occurrence of bacterial infection and the decision to terminate antibiotic treatment in critically ill patients. An unusual increase in PCT, regardless of infection, has been observed during extracorporeal membrane oxygenation (ECMO) support. We evaluated trends and the predictive value of PCT levels in adult cardiogenic shock during treatment with ECMO. We reviewed the clinical records of 38 adult cardiogenic shock patients undergoing veno-arterial ECMO support between January 2014 and December 2016. The exclusion criteria were age <18 years, pre-ECMO infection, and less than 48 hours of support. The mean patient age was 56.7±14.7 years and 12 (31.6%) patients were female. The mean duration of ECMO support was 9.0±7.6 days. The rates of successful ECMO weaning and survival to discharge were 55.3% (n=21) and 52.6% (n=20), respectively. There were 17 nosocomial infections in 16 (42.1%) patients. Peak PCT levels (mean 25.6±9.4 ng/mL) were reached within 48 hours after initiation of ECMO support and decreased to ≤5 ng/mL within one week. The change in PCT levels was not useful in predicting the occurrence of new nosocomial infections during the ECMO run. However, a PCT level >10 ng/mL during the first week of ECMO support was significantly associated with mortality (p<0.01). The change in PCT level was not useful in predicting new infection during ECMO support. However, higher PCT levels within the first week of the ECMO run are associated with significantly higher mortality.
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Affiliation(s)
- Do Wan Kim
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Gwangju, Korea
| | - Hwa Jin Cho
- Department of Pediatrics, Chonnam National University Hospital, Gwangju, Korea
| | - Gwan Sic Kim
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Gwangju, Korea
| | - Sang Yun Song
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Gwangju, Korea
| | - Kook Joo Na
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Gwangju, Korea
| | - Sang Gi Oh
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Gwangju, Korea
| | - Bong Suk Oh
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Gwangju, Korea.,Research Institute of Medical Sciences, Chonnam National University, Gwangju, Korea
| | - In Seok Jeong
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Gwangju, Korea.,Research Institute of Medical Sciences, Chonnam National University, Gwangju, Korea
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33
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Gutierrez ME, Alten JA, Law MA. Successful Angiojet ® aortic thrombectomy of extracorporeal membrane oxygenation-related thrombus in a newborn. Ann Pediatr Cardiol 2018; 11:300-303. [PMID: 30271021 PMCID: PMC6146852 DOI: 10.4103/apc.apc_26_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Thrombosis and systemic embolization are important complications of extracorporeal membrane oxygenation (ECMO). We present a 2.5 kg neonate born at 37.4 weeks with hypoplastic left heart supported on ECMO that developed an acute, occlusive distal aortic thrombus that was emergently managed by transcatheter Angiojet® (Boston Scientific, Boston, MA) thrombectomy. The procedure successfully restored perfusion to the lower extremities with sustained result upon 1-week follow-up. This case highlights the Angiojet® thrombectomy as a treatment option for limb- or organ-threatening acute thrombus in even the most complex ECMO patients.
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Affiliation(s)
- Maria Elena Gutierrez
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jeffrey A Alten
- Division of Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, Division of Critical Care, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Mark A Law
- Department of Pediatrics, Division of Pediatric Cardiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
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