Fausat BelloPerfusion TechnologyRush University

PEDIATRIC ECMO: A SURVEY OF ANTICOAGULATION MONITORING PRACTICES

Disclosures I have no disclosures

Why am I here? The objective of this talk is to review:

The history of pediatric ECMO and ACT usage.Review the literature on monitoring modalities of

pediatric anticoagulation. Reveal the preliminary results of my survey.

Extracorporeal Membrane Oxygenation

ECMO Complications Patient Related

AnticoagulationNeurologicalInfectiousEnd Organ Damage

Device Related

Blood Surface Interfacing

Annich, G., & Adachi, I. (2013). Anticoagulation for pediatric mechanical circulatory support. Pediatric Critical Care Medicine : A Journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies, 14(5 Suppl 1), S37-42.

Coagulation Cascade

David Lillicrap; Nigel Key; Michael Makris; Denise O'Shaughnessy (2009). Practical Hemostasis and Thrombosis. Wiley-Blackwell. pp. 1–5.

Pediatric HemostasisProcoagulants

ClotInhibitors

Fibrinolytic

Degradation

Inhibitors

2macroglobulinProtein C,S***antithrombin

thrombin

PAI

II, VII,IX,X,XI,XII

***plasminogen tPA

Platelets

ECMO Complications

Neonatal Pediatric Adult 0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Circuit ClotsDIC

Baird, C. W., Zurakowski, D., Robinson, B., Gandhi, S., Burdis-Koch, L., Tamblyn, J., et al. (2007). Anticoagulation and pediatric extracorporeal membrane oxygenation: Impact of activated clotting time and heparin dose on survival. The Annals of Thoracic Surgery, 83(3), 912-9; discussion 919-20.

Anticoagulants Heparin is the primary anticoagulant of choice for

pediatric patients undergoing extracorporeal membrane oxygenation.

Mechanism of action: Indirect thrombin inhibitor that couple and potentiates the action of antithrombin III

Limitations• Narrow therapeutic window of adequate

anticoagulation without bleeding• Highly variable dose-response

Solution?

Monitoring patterns for Anticoagulation

93%

34%

28%76%78%

54% 45%

ACTD-DimerAnti- XAFibrinogenATIICBCaPTT

Baird, C. W., Zurakowski, D., Robinson, B., Gandhi, S., Burdis-Koch, L., Tamblyn, J., et al. (2007). Anticoagulation and pediatric extracorporeal membrane oxygenation: Impact of activated clotting time and heparin dose on survival. The Annals of Thoracic Surgery, 83(3), 912-9; discussion 919-20.

Phase 1Monitoring Practices1966-2006

Activated Clotting Time Described by Hattersly

1966 Proven correlation with

weight normalized heparin dosing….in adults

Factors affecting ACT results Patient Related Factors

Platelet countFibrinogenAntithrombin III levelsHemodilution

Technically Related Factors Agitator and timersLack of a single sample

precisionVenous vs. Arterial bloodSmaller sample volumesTemperature and timing of

ACT levels Uncertainty of results for

ACT levels less than 250

ACT tests alone cannot provide proper titration of heparin and thus be the test used to monitor anticoagulation alone.

Phase 2Monitoring Practices2007-

TEG

Anti-Factor Xa

10 20 30 40 500

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

Anti-Xa vs Heparin Dose

Heparin

An

ti--

Xa

10 20 30 40 5020

40

60

80

100

120

140

PTT vs Heparin Dose

Heparin

PT

T

10 20 30 40 50100

200

300

400

ACT vs Heparin Dose

Heparin

Act

ivat

ed C

lott

ing

Tim

e

Phase 3? Multi-modality testing...

Anti-Xa

ACT

PTT

TEG

AT-III

Objective The objective of my study is to examine:

Current status of anticoagulation monitoring practices Relationship between monitoring modalities, heparin

dosing and the perfusionist role in the solution.

Yes95%

No5%

Do you employ extracorporeal membrane oxygenation (ECMO) for patients between the ages of 0-18? (n=65)

Yes86%

No14%

Does your institution have a written anticoagulation management (frequency of testing and/or guidelines for heparin dosing) protocols for ECMO? (n=65)

If Yes, is your institution’s protocol specific to the population under the age of 18? (n=65)

Yes49%No

51%

Check all monitoring modalities used to asses proper anticoagulation at your institution. (n=65)

ACT33%

aPTT28%

Ant-Xa24%

TEG16%

Select the single test one should use in the absence of all other tests to monitor and measure anticoagulation for pediatric ECMO patients. (n=65)

ACT37%

aPTT12%

Anti-Xa39%

TEG5%

Other7%

How satisfied are you with your institutions monitoring protocol in decreasing hemorrhagic/thrombotic complications. (n=65)

Very Satisfied8%

Gener-ally Sat-is-

fied10%

Indifferent40%

Generally dissatisfied43%

Conclusion

Questions?Fausat_bello@rush.edu