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Prospective Side by Side Comparison of Outcomes and Complications With a Simple Versus Intensive Anticoagulation
Jane S Yu1, Ryan P Barbaro, Donald A Granoski
11Department of Anesthesia, University of California, San Francisco, CA. 2Division of Pediatric Critical Care, Department of Pediatrics, University of Michigan, Ann Arbor, MI. 3Pediatric Cardiac Intensive Care Unit, Stollery Children's Hospital, Edmonton, AB, Canada. 4Department of Pediatrics, Stollery Children's Hospital, Edmonton, AB, Canada. 5 Pediatric Intensive Care Unit, Stollery Children's Hospital, Edmonton, AB, Canada. 6 Critical Care Medicine, Hospital for Sick Children, Toronto, ON, Canada.
Insights
This study found no significant difference in major bleeding, thrombosis, or survival for pediatric patients on extracorporeal life support (ECLS) using simple versus intensive anticoagulation monitoring. Both strategies showed similar outcomes in ECLS complications.
Area of Science:
- Pediatric critical care medicine
- Cardiovascular research
- Biomedical engineering
Background:
- Continuous infusion of unfractionated heparin is standard for pediatric anticoagulation during extracorporeal life support (ECLS).
- Varying anticoagulation monitoring strategies exist, necessitating comparative outcome analysis.
Purpose of the Study:
- To compare extracorporeal life support complications and patient outcomes between two centers with differing anticoagulation monitoring strategies.
- Evaluate the efficacy of simple versus intensive anticoagulation monitoring in pediatric ECLS.
Main Methods:
- Prospective, observational cohort study involving pediatric patients on ECLS.
- Compared outcomes between the University of Michigan (simple monitoring) and University of Alberta (intensive monitoring).
- Primary outcome: major bleeding; Secondary outcomes: thrombosis and survival to discharge.
Main Results:
- No significant differences in major bleeding (15% vs 21%), patient thrombosis (18% vs 13%), or survival to discharge (63% vs 73%) were observed.
- Antifactor Xa levels were lower with simple monitoring (University of Michigan).
- Centers differed in patient populations and ECLS indications, but unfractionated heparin doses were similar.
Conclusions:
- Simple and intensive anticoagulation monitoring strategies yielded comparable outcomes for pediatric patients on extracorporeal life support.
- Despite population differences, neither strategy demonstrated superiority in reducing ECLS complications or improving survival.
Objectives:
A continuous infusion of unfractionated heparin is the most common anticoagulant used for pediatric patients on extracorporeal life support. The objective of this study was to compare extracorporeal life support complications and outcomes between two large-volume pediatric extracorporeal life support centers that use different anticoagulation strategies.
Design:
Prospective, observational cohort study.
Setting:
The University of Michigan used simple anticoagulation monitoring, whereas the University of Alberta used an intensive anticoagulation monitoring strategy.
Patients:
Pediatric patients on extracorporeal life support.
Interventions:
None.
Measurements And Main Results:
The primary outcome measure was major bleeding per extracorporeal life support run defined as bleeding that was retroperitoneal, pulmonary, or involved the CNS; bleeding greater than 20 mL/kg over 24 hours; or bleeding that required surgical intervention. Secondary outcomes measured were patient thrombosis per run, circuit thrombosis per run, and survival to hospital discharge per patient. Eighty-eight patients (95 runs) less than 18 years old were enrolled at the two centers over 2 years. The two centers enrolled different extracorporeal life support populations; University of Alberta enrolled more postcardiac surgical patients (74% vs 47%; p = 0.005). The indication for extracorporeal life support support also varied by center (p = 0.04). The two centers used similar proportions of VA extracorporeal life support (p = 0.3). Median (interquartile range) unfractionated heparin doses were similar between University of Michigan and University of Alberta, 30 (21-34) U/kg/hr and 26 (22-31) U/kg/hr, p value equals to 0.3, respectively. Median (interquartile range) antifactor Xa was lower in the University of Michigan cohort (0.23 [0.19-0.28] vs 0.41 [0.36-0.46] U/mL; p < 0.001). There was no significant difference in major bleeding (15% University of Michigan vs 21% University of Alberta; p = 0.6) or in patient thromboses (18% University of Michigan vs 13% University of Alberta; p = 0.5). There was no significant difference in survival to hospital discharge (University of Michigan 63% vs University of Alberta 73%; p = 0.1).
Conclusions:
Although this prospective cohort study compared different pediatric extracorporeal life support populations, the results did not identify a significant difference in outcomes between simple and intensive anticoagulation monitoring strategies.
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