1Department of Anesthesia, University of California, San Francisco, CA. 2Division of Pediatric Critical Care, Department of Pediatrics, University of Michigan, Ann Arbor, MI. 3Pediatric Cardiac Intensive Care Unit, Stollery Children's Hospital, Edmonton, AB, Canada. 4Department of Pediatrics, Stollery Children's Hospital, Edmonton, AB, Canada. 5 Pediatric Intensive Care Unit, Stollery Children's Hospital, Edmonton, AB, Canada. 6 Critical Care Medicine, Hospital for Sick Children, Toronto, ON, Canada.
Pediatr Crit Care Med. 2017 Nov;18(11):1055-1062. doi: 10.1097/PCC.0000000000001306.
A continuous infusion of unfractionated heparin is the most common anticoagulant used for pediatric patients on extracorporeal life support. The objective of this study was to compare extracorporeal life support complications and outcomes between two large-volume pediatric extracorporeal life support centers that use different anticoagulation strategies.
Prospective, observational cohort study.
The University of Michigan used simple anticoagulation monitoring, whereas the University of Alberta used an intensive anticoagulation monitoring strategy.
Pediatric patients on extracorporeal life support.
None.
The primary outcome measure was major bleeding per extracorporeal life support run defined as bleeding that was retroperitoneal, pulmonary, or involved the CNS; bleeding greater than 20 mL/kg over 24 hours; or bleeding that required surgical intervention. Secondary outcomes measured were patient thrombosis per run, circuit thrombosis per run, and survival to hospital discharge per patient. Eighty-eight patients (95 runs) less than 18 years old were enrolled at the two centers over 2 years. The two centers enrolled different extracorporeal life support populations; University of Alberta enrolled more postcardiac surgical patients (74% vs 47%; p = 0.005). The indication for extracorporeal life support support also varied by center (p = 0.04). The two centers used similar proportions of VA extracorporeal life support (p = 0.3). Median (interquartile range) unfractionated heparin doses were similar between University of Michigan and University of Alberta, 30 (21-34) U/kg/hr and 26 (22-31) U/kg/hr, p value equals to 0.3, respectively. Median (interquartile range) antifactor Xa was lower in the University of Michigan cohort (0.23 [0.19-0.28] vs 0.41 [0.36-0.46] U/mL; p < 0.001). There was no significant difference in major bleeding (15% University of Michigan vs 21% University of Alberta; p = 0.6) or in patient thromboses (18% University of Michigan vs 13% University of Alberta; p = 0.5). There was no significant difference in survival to hospital discharge (University of Michigan 63% vs University of Alberta 73%; p = 0.1).
Although this prospective cohort study compared different pediatric extracorporeal life support populations, the results did not identify a significant difference in outcomes between simple and intensive anticoagulation monitoring strategies.
未分馏肝素持续输注是体外生命支持中儿科患者最常用的抗凝剂。本研究的目的是比较两所大型儿科体外生命支持中心使用不同抗凝策略的体外生命支持并发症和结果。
前瞻性观察队列研究。
密歇根大学采用简单的抗凝监测，而阿尔伯塔大学采用强化抗凝监测策略。
接受体外生命支持的儿科患者。
无。
主要结局测量是每个体外生命支持运行的主要出血，定义为腹膜后、肺或涉及中枢神经系统的出血；24 小时内出血超过 20 毫升/公斤；或需要手术干预的出血。次要结局测量为每个运行的患者血栓形成、每个运行的回路血栓形成以及每个患者的医院出院存活率。在两年内，两个中心共纳入了 88 名（95 个运行）年龄小于 18 岁的患者。两个中心纳入了不同的体外生命支持人群；阿尔伯塔大学纳入了更多心脏手术后患者（74%对 47%；p = 0.005）。体外生命支持支持的适应证也因中心而异（p = 0.04）。两个中心使用相似比例的 VA 体外生命支持（p = 0.3）。密歇根大学和阿尔伯塔大学的未分馏肝素剂量中位数（四分位距）相似，分别为 30（21-34）U/kg/hr 和 26（22-31）U/kg/hr，p 值等于 0.3。密歇根大学队列的抗因子 Xa 中位数（四分位距）较低（0.23 [0.19-0.28] 对 0.41 [0.36-0.46] U/mL；p < 0.001）。密歇根大学大出血（15%对 21%；p = 0.6）或患者血栓形成（18%对 13%；p = 0.5）无显著差异。出院存活率无显著差异（密歇根大学 63%对阿尔伯塔大学 73%；p = 0.1）。
尽管这项前瞻性队列研究比较了不同的儿科体外生命支持人群，但结果并未确定简单和强化抗凝监测策略之间的结果有显著差异。
