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Viscoelastic Testing in Pediatric Mechanical Circulatory Support
Katherine Regling1, Arun Saini2, Katherine Cashen3
1Division of Hematology Oncology, Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University School of Medicine, Detroit, MI, United States.
Insights
Viscoelastic testing (VET) aids anticoagulation management in pediatric mechanical circulatory support. This review explores TEG®/ROTEM® utility for extracorporeal membrane oxygenation (ECMO) and ventricular assist devices (VAD).
Area of Science:
- Pediatric critical care medicine
- Hematology
- Biomedical engineering
Background:
- Mechanical circulatory support (MCS) is vital for critically ill children.
- Anticoagulation management in pediatric MCS is complex due to unique physiological factors.
- Viscoelastic testing (VET) offers a global assessment of hemostasis.
Purpose of the Study:
- To review the application of TEG®/ROTEM® in pediatric patients on ECMO and VAD.
- To discuss laboratory and patient-specific considerations for VET interpretation.
- To evaluate VET's association with clinical outcomes.
Main Methods:
- Systematic review of adult and pediatric literature on VET in MCS.
- Analysis of TEG®/ROTEM® values and platelet mapping data.
- Comparison of VET with standard laboratory monitoring.
Main Results:
- VET provides a comprehensive hemostatic profile, including clot initiation, strength, and lysis.
- Platelet mapping via VET can guide targeted therapy.
- VET may offer advantages over standard tests in guiding blood product use and predicting outcomes.
Conclusions:
- VET, particularly TEG®/ROTEM®, is a valuable tool for managing anticoagulation in pediatric MCS.
- Further research is needed to standardize VET protocols and confirm its impact on patient outcomes.
- Integration of VET into clinical practice can optimize patient care and resource utilization.
Abstract:
Pediatric mechanical circulatory support can be lifesaving. However, managing anticoagulation is one of the most challenging aspects of care in patients requiring mechanical circulatory support. Effective anticoagulation is even more difficult in pediatric patients due to the smaller size of their blood vessels, increased turbulent flow, and developmental hemostasis. Recently, viscoelastic testing (VET) has been used as a qualitative measure of anticoagulation efficacy in patients receiving extracorporeal membrane oxygenation (ECMO) and ventricular assist devices (VAD). Thromboelastography (TEG®) and thromboelastometry (ROTEM®) provide a global qualitative assessment of hemostatic function from initiation of clot formation with the platelet-fibrin interaction, platelet aggregation, clot strength, and clot lysis. This review focuses on the TEG®/ROTEM® and important laboratory and patient considerations for interpretation in the ECMO and VAD population. We summarize the adult and pediatric ECMO/VAD literature regarding VET values, VET-platelet mapping, utility over standard laboratory monitoring, and association with outcome measures such as blood product utilization, bleeding, and thrombosis.
