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Thrombomodulin in pediatric cardiac surgery
J Boldt1, C Knothe, E Schindler
1Department of Anesthesiology and Intensive Care Medicine, Justus-Liebig-University Giessen, Germany.
Insights
Pediatric cardiac surgery impacts coagulation in children. Younger children (<10kg) show altered thrombomodulin and protein S levels, indicating potential thrombotic risks post-cardiopulmonary bypass.
Area of Science:
- Biochemistry
- Pediatric Cardiology
- Hematology
Background:
- Congenital heart disease (CHD) necessitates complex surgical interventions.
- Pediatric cardiac operations often involve cardiopulmonary bypass (CPB), a procedure known to affect hemostasis.
- Understanding coagulation factor dynamics in children undergoing CPB is crucial for managing perioperative risks.
Purpose of the Study:
- To investigate the impact of pediatric cardiac surgery and cardiopulmonary bypass on key coagulation factors in children.
- To compare the levels of thrombomodulin, protein C, free protein S, and thrombin-antithrombin complex between children of different weight groups undergoing CPB.
- To assess the postoperative recovery of these coagulation markers in relation to patient weight.
Main Methods:
- Prospective study of 30 children with CHD undergoing cardiac operations.
- Measurement of thrombomodulin, protein C, free protein S, and thrombin-antithrombin complex using enzyme-linked immunosorbent assay.
- Serial blood sampling at baseline, during, and after CPB until the first postoperative day.
- Patients divided into two groups based on weight: <10 kg (Group 1) and >10 kg (Group 2).
Main Results:
- Baseline thrombomodulin levels were significantly higher in smaller children (<10 kg) compared to larger children (>10 kg).
- Cardiopulmonary bypass reduced thrombomodulin levels in both groups; however, levels remained elevated postoperatively only in the <10 kg group.
- Protein C levels were below normal at baseline in all patients. Protein S levels were higher in smaller children but decreased significantly after CPB, with incomplete recovery in the <10 kg group.
- Thrombin-antithrombin complex increased markedly at the end of CPB in both groups, returning to near-normal levels postoperatively.
Conclusions:
- Children weighing less than 10 kg exhibit distinct alterations in thrombomodulin and protein S levels during and after cardiopulmonary bypass.
- These findings suggest a potential prothrombotic state in smaller children following CPB, warranting further investigation and clinical consideration.
- Coagulation factor monitoring is essential in pediatric cardiac surgery, particularly in younger, smaller patients, to guide management and mitigate risks.
Abstract:
In 30 consecutive children with congenital heart disease scheduled for pediatric cardiac operations, thrombomodulin, protein C, free protein S, and thrombin-antithrombin complex were measured by enzyme-linked immunosorbent assay after the induction of anesthesia (baseline value), and then before, during, and after cardiopulmonary bypass until the first postoperative day. The patients were divided prospectively into two groups: children weighing less than 10 kg (group 1; n = 15) and those weighing more than 10 kg (group 2; n = 15). At baseline, the plasma concentration of thrombomodulin was significantly higher in the children in group 1 than in those in group 2 (83.1 +/- 11.0 ng/mL versus 29.2 +/- 12.1 ng/mL). During cardiopulmonary bypass, the thrombomodulin level was reduced in both groups without showing any significant group differences. Five hours after cardiopulmonary bypass and on the first postoperative day, the thrombomodulin level exceeded normal values only in the children weighing less than 10 kg. In both groups, the protein C levels were already below normal at the beginning of the study. The baseline protein S concentration was higher in the smaller children (80% +/- 18%) than in the larger children (66% +/- 11%). It was reduced by cardiopulmonary bypass in both groups; however, postoperatively it did not return to normal in group 1 (45.1% +/- 10%). Plasma levels of the thrombin-antithrombin complex were similar in both groups, with a marked increase at the end of cardiopulmonary bypass, and returned to near-normal levels by 5 hours after bypass.(ABSTRACT TRUNCATED AT 250 WORDS)