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Antithrombin concentrates use in children on extracorporeal membrane oxygenation: a retrospective cohort study
Trisha E Wong1, Meghan Delaney, Terry Gernsheimer
11Division of Pediatric Hematology/Oncology and Department of Pathology, Oregon Health and Science University, Portland, OR. 2Puget Sound Blood Center, Seattle, WA. 3Department of Laboratory Medicine, University of Washington, Seattle, WA. 4Seattle Children's Hospital, Seattle, WA. 5Division of Hematology, Department of Medicine, University of Washington, Seattle, WA. 6Division of Pediatric Hematology/Oncology, University of Washington, Seattle, WA. 7Division of Pediatric Critical Care, University of Washington, Seattle, WA. 8Department of Surgery, University of Washington, Seattle, WA. 9Department of Epidemiology, University of Washington, Seattle, WA.
Insights
Antithrombin concentrate increased antithrombin levels in pediatric patients on extracorporeal membrane oxygenation (ECMO), but not to target levels. This intervention reduced heparin needs but did not improve clinical outcomes or reduce mortality.
Area of Science:
- Pediatric Critical Care Medicine
- Hematology
- Cardiopulmonary Support
Background:
- Extracorporeal membrane oxygenation (ECMO) is a life-support measure for pediatric respiratory failure.
- Antithrombin is crucial for anticoagulation during ECMO, and its levels may decrease.
- The efficacy of antithrombin concentrate supplementation in pediatric ECMO is not well-established.
Purpose of the Study:
- To determine if antithrombin concentrate improves laboratory and clinical outcomes in pediatric patients undergoing ECMO for respiratory failure.
- To compare outcomes between children who received antithrombin concentrate and those who did not.
Main Methods:
- Retrospective cohort study of 64 pediatric patients on ECMO for respiratory failure.
- Compared outcomes in patients who received antithrombin concentrate during ECMO versus those who did not.
- Analyzed laboratory markers (antithrombin levels) and clinical endpoints (mortality, bleeding, clotting, length of stay).
Main Results:
- Patients receiving antithrombin concentrate had higher antithrombin levels (66% vs. 42.2%), but rarely reached the target of 120%.
- Antithrombin concentrate administration decreased heparin infusion rates by 10.2 U/kg/hr for at least 12 hours.
- No significant differences were observed in ECMO circuit changes, thrombosis, hemorrhage, transfusion needs, length of stay, or mortality between groups.
Conclusions:
- Intermittent antithrombin concentrate dosing increases antithrombin levels in pediatric ECMO patients but typically not to target levels.
- While it reduces heparin requirements, antithrombin concentrate did not improve clinical outcomes or reduce mortality in this cohort.
- Further research with different dosing strategies via prospective, randomized trials is warranted to evaluate the efficacy of this intervention.
Objective:
To investigate whether receipt of any antithrombin concentrate improves laboratory and clinical outcomes in children undergoing extracorporeal membrane oxygenation for respiratory failure during their hospitalization compared with those who did not receive antithrombin.
Design:
Retrospective cohort study.
Setting:
Single, tertiary-care pediatric hospital.
Patients:
Sixty-four neonatal and pediatric patients who underwent extracorporeal membrane oxygenation for respiratory failure between January 2007 and September 2011.
Intervention:
Exposure to any antithrombin concentrate during their extracorporeal membrane oxygenation course compared with similar children who never received antithrombin concentrate.
Measurements And Main Results:
Thirty patients received at least one dose of antithrombin during their extracorporeal membrane oxygenation course and 34 patients did not receive any. The median age at admission was less than 1-month old. Age, duration of extracorporeal membrane oxygenation, or first antithrombin level did not differ significantly between the two cohorts. The mean plasma antithrombin level in those who never received antithrombin was 42.2% compared with 66% in those who received it. However, few levels reached the targeted antithrombin level of 120% and those who did fell back to deficient levels within an average of 6.8 hours. For those who received antithrombin concentrate, heparin infusion rates decreased by an average of 10.2 U/kg/hr for at least 12 hours following administration. No statistical differences were noted in the number of extracorporeal membrane oxygenation circuit changes, in vivo clots or hemorrhages, transfusion requirements, hospital or ICU length of stay, or in-hospital mortality.
Conclusions:
Intermittent, on-demand dosing of antithrombin concentrate in pediatric patients on extracorporeal membrane oxygenation for respiratory failure increased antithrombin levels, but not typically to the targeted level. Patients who received antithrombin concentrate also had decreased heparin requirements for at least 12 hours after dosing. However, no differences were noted in the measured clinical endpoints. A prospective, randomized study of this intervention may require different dosing strategies; such a study is warranted given the unproven efficacy of this costly product.
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