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Anticoagulation practices associated with bleeding and thrombosis in pediatric extracorporeal membrane oxygenation; a
David K Bailly1, Ron W Reeder2, Jennifer A Muszynski3,4,5
1Department of Pediatrics, Division of Pediatric Critical Care, 14434University of Utah, Salt Lake, UT, USA.
Insights
Anticoagulation practices impact bleeding and thrombosis in pediatric extracorporeal membrane oxygenation (ECMO). Lower activated clotting time (ACT) and higher fibrinogen may reduce bleeding, while higher heparin doses may reduce thrombosis.
Area of Science:
- Pediatric Critical Care Medicine
- Cardiovascular Surgery
- Hematology
Background:
- Extracorporeal membrane oxygenation (ECMO) requires careful anticoagulation management.
- Bleeding and thrombosis are significant complications in pediatric ECMO patients.
- Optimizing anticoagulation is crucial for improving outcomes.
Purpose of the Study:
- To investigate the association between anticoagulation strategies and the occurrence of bleeding and thrombotic events in children undergoing ECMO.
- To identify specific anticoagulation parameters linked to adverse events.
Main Methods:
- Secondary analysis of prospectively collected data from 481 pediatric ECMO patients (January 2012 - September 2014).
- Primary outcome: bleeding or thrombotic events.
- Bleeding defined by transfusion, hemorrhage, or intracranial bleeding; thrombosis by emboli, clot, ischemia, or circuit changes.
Main Results:
- Bleeding occurred in 42% of patients; thrombosis in 5%, with 89% of thrombotic cases also experiencing bleeding.
- Increased odds of daily bleeding were associated with prior day's activated clotting time (ACT) (OR 1.03) and fibrinogen levels (OR 0.90).
- Increased odds of thrombosis were associated with higher prior day heparin dose (OR 0.88).
Conclusions:
- Lower ACT and higher fibrinogen levels may decrease bleeding risk during pediatric ECMO.
- Increased heparin dose may reduce thrombosis risk.
- Current single-measure monitoring may be insufficient for optimal anticoagulation guidance in ECMO.
Abstract:
To determine associations between anticoagulation practices and bleeding and thrombosis during pediatric extracorporeal membrane oxygenation (ECMO), we performed a secondary analysis of prospectively collected data which included 481 children (<19 years), between January 2012 and September 2014. The primary outcome was bleeding or thrombotic events. Bleeding events included a blood product transfusion >80 ml/kg on any day, pulmonary hemorrhage, or intracranial bleeding, Thrombotic events included pulmonary emboli, intracranial clot, limb ischemia, cardiac clot, and arterial cannula or entire circuit change. Bleeding occurred in 42% of patients. Five percent of subjects thrombosed, of which 89% also bled. Daily bleeding odds were independently associated with day prior activated clotting time (ACT) (OR 1.03, 95% CI= 1.00, 1.05, p=0.047) and fibrinogen levels (OR 0.90, 95% CI 0.84, 0.96, p <0.001). Thrombosis odds decreased with increased day prior heparin dose (OR 0.88, 95% CI 0.81, 0.97, p=0.006). Lower ACT values and increased fibrinogen levels may be considered to decrease the odds of bleeding. Use of this single measure, however, may not be sufficient alone to guide optimal anticoagulation practice during ECMO.
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