Seattle Children's Hospital, University of Washington, Seattle, WA.
Department of Pediatrics, University of Washington, Seattle, WA.
Crit Care Med. 2020 Dec;48(12):e1179-e1184. doi: 10.1097/CCM.0000000000004615.
Anticoagulation with unfractionated heparin remains the most common therapy used to prevent circuit thrombosis during extracorporeal membrane oxygenation, but no consensus exists on the optimal method or targets for heparin monitoring. From 2015 to 2018, we switched from monitoring heparin during extracorporeal membrane oxygenation using activated clotting times to anti-Xa heparin activity assays. This study describes the transition from activated clotting time to anti-Xa heparin activity assay monitoring and the associated clinical changes.
Retrospective analysis at single institution.
Referral Children's Hospital.
A total of 145 pediatric patients over 152 extracorporeal membrane oxygenation runs using 206 extracorporeal membrane oxygenation circuits.
Anticoagulation protocol quality improvement.
From 2015 to 2018, heparin monitoring during extracorporeal membrane oxygenation changed from hourly activated clotting time to anti-Xa heparin activity assay every 6 hours with an associated 75% reduction in the circuit changes per extracorporeal membrane oxygenation day. Over the 4 years, patients with an average anti-Xa heparin activity assay of at least 0.25 U/mL showed a 59% reduction in circuit changes per extracorporeal membrane oxygenation day compared with less than 0.15 U/mL. In addition to its association with reduced circuit changes, anti-Xa heparin activity assay monitoring was also associated with reduced heparin dose changes per day from 11 ± 4 to 2 ± 1 (p < 0.001), smaller heparin dose changes (less variation in dose), and reduced diagnostic phlebotomy volumes from 41 ± 6 to 25 ± 11 mL/day (p < 0.001). The number of patients with reported bleeding decreased from 69% using activated clotting time to 51% (p = 0.03). Transfusion rates did not change.
Over 4 years, we replaced the activated clotting time assay with the anti-Xa heparin activity assay for heparin monitoring during extracorporeal membrane oxygenation. Minimum anti-Xa heparin activity assay levels of 0.25 U/mL were associated with reduced circuit changes. Further studies are needed to determine the optimum anti-Xa heparin activity assay therapeutic range during extracorporeal membrane oxygenation.
在体外膜肺氧合期间，使用未分级肝素进行抗凝仍然是最常用的预防回路血栓形成的治疗方法，但在肝素监测的最佳方法或目标方面尚无共识。从 2015 年到 2018 年，我们从使用激活凝血时间监测体外膜肺氧合期间的肝素改为监测抗 Xa 肝素活性测定。本研究描述了从激活凝血时间监测到抗 Xa 肝素活性测定监测的转变以及相关的临床变化。
单机构回顾性分析。
转诊儿童医院。
共有 145 名儿科患者，共进行了 152 次体外膜肺氧合，使用了 206 个体外膜肺氧合回路。
抗凝方案质量改进。
从 2015 年到 2018 年，体外膜肺氧合期间的肝素监测从每小时激活凝血时间改为每 6 小时进行抗 Xa 肝素活性测定，与体外膜肺氧合日每回路变化减少 75%相关。在 4 年期间，平均抗 Xa 肝素活性测定值至少为 0.25 U/mL 的患者，与低于 0.15 U/mL 的患者相比，体外膜肺氧合日的回路变化减少了 59%。除了与减少回路变化相关外，抗 Xa 肝素活性测定监测还与每天肝素剂量变化减少有关，从 11 ± 4 到 2 ± 1（p < 0.001），肝素剂量变化较小（剂量变化较小），诊断性采血体积从 41 ± 6 减少到 25 ± 11 mL/天（p < 0.001）。使用激活凝血时间的患者报告出血减少了 69%，至 51%（p = 0.03）。输血率没有变化。
在 4 年期间，我们用抗 Xa 肝素活性测定代替激活凝血时间测定来监测体外膜肺氧合期间的肝素。最低抗 Xa 肝素活性测定值为 0.25 U/mL 与减少回路变化有关。需要进一步的研究来确定体外膜肺氧合期间最佳的抗 Xa 肝素活性测定治疗范围。
