Schloemer Nathan J, Abu-Sultaneh Samer, Hanson Sheila J, Yan Ke, Hoffmann Raymond G, Punzalan Rowena C, Havens Peter L
1Department of Pediatrics, Division of Critical Care, Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, WI. 2Department of Pediatrics, Section of Pediatric Critical Care Medicine, Riley Hospital for Children at Indiana University Health and Indiana University School of Medicine, Indianapolis, IN. 3Department of Pediatrics, Division of Quantitative Health Sciences, Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, WI. 4Department of Pediatrics, Division of Hematology, Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, WI. 5Blood Center of Wisconsin, Milwaukee, WI. 6Department of Pediatrics, Division of Infectious Disease, Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, WI.
Pediatr Crit Care Med. 2014 Sep;15(7):e294-9. doi: 10.1097/PCC.0000000000000169.
To demonstrate that low-molecular-weight heparin (enoxaparin) can be used in critically ill pediatric patients to achieve target anti-factor Xa concentrations and determine appropriate dosing corrected for age and illness severity.
Retrospective cohort study.
Single tertiary level PICU.
One hundred ninety-two children age 1 day through 18 years admitted to PICU undergoing every 12-hour enoxaparin therapy with at least one anti-factor Xa concentration obtained. Patients receiving renal replacement therapy or infants with corrected gestational age less than 37 weeks were excluded.
None.
We collected patient characteristics including age, weight, height/length, gender, corrected gestational age, illness severity markers, diagnosis, creatinine, enoxaparin dose and times of administration, anti-factor Xa concentrations, and collection times. Only 42% of critically ill children (80 of 192) and only 29% of children (9 of 31) on inotropes achieved recommended target range of anti-factor Xa concentrations on initial recommended enoxaparin dosing (1.5 mg/kg/dose < 2 mo; 1 mg/kg/dose > 2 mo), but 81% were ultimately within target range with dose titration. Increased enoxaparin dose was required to reach target concentrations in younger patients and those with worse illness severity as evidenced by concurrent use of inotropes, previous ICU admission, mechanical ventilation, cardiac surgery, and increased risk of mortality defined by severity-of-illness scores.
Enoxaparin can be used to reach recommended target range of anti-factor Xa concentrations in the PICU patient. However, younger patients and patients with higher illness severity are less likely to achieve target concentrations using currently recommended dosing and may require higher doses of enoxaparin to reach target anti-factor Xa concentrations. Starting enoxaparin dose at least 1.3 mg/kg dosed every 12 hours for treatment of thromboembolic disease in critically ill patients aged 61 days to 1 year or those requiring inotropic support should be confirmed in prospective study.
证明低分子量肝素（依诺肝素）可用于危重症儿科患者，以达到目标抗Xa因子浓度，并确定根据年龄和疾病严重程度校正后的合适剂量。
回顾性队列研究。
单一三级水平的儿科重症监护病房。
192名年龄从1天至18岁的儿童，入住儿科重症监护病房，接受每12小时一次的依诺肝素治疗，且至少获得一次抗Xa因子浓度检测结果。接受肾脏替代治疗的患者或矫正胎龄小于37周的婴儿被排除。
无。
我们收集了患者的特征，包括年龄、体重、身高/身长、性别、矫正胎龄、疾病严重程度指标、诊断、肌酐、依诺肝素剂量及给药时间、抗Xa因子浓度以及采集时间。在初始推荐的依诺肝素剂量（2个月以下婴儿为1.5mg/kg/剂量；2个月以上婴儿为1mg/kg/剂量）下，只有42%的危重症儿童（192名中的80名）以及只有29%使用血管活性药物的儿童（31名中的9名）达到了推荐的抗Xa因子浓度目标范围，但通过剂量滴定，最终81%的患者达到了目标范围。在较年轻的患者以及疾病严重程度较高的患者中，需要增加依诺肝素剂量才能达到目标浓度，这可通过同时使用血管活性药物、既往入住重症监护病房、机械通气、心脏手术以及疾病严重程度评分所定义的死亡风险增加来证明。
依诺肝素可用于使儿科重症监护病房患者达到推荐的抗Xa因子浓度目标范围。然而，较年轻的患者以及疾病严重程度较高的患者使用当前推荐剂量时不太可能达到目标浓度，可能需要更高剂量的依诺肝素才能达到目标抗Xa因子浓度。对于年龄在61天至1岁的危重症患者或需要血管活性药物支持的患者，开始依诺肝素剂量为至少1.3mg/kg，每12小时给药一次，用于治疗血栓栓塞性疾病，这一方案应在前瞻性研究中得到证实。
