Galura Genevra, Said Sana J, Shah Pooja A, Hissong Alexandria M, Chokshi Nikunj K, Fauman Karen R, Rose Rebecca, Bondi Deborah S
Department of Pharmacy (GG, SJS, PAS, AMH, DSB), University of Chicago Medicine, Chicago, IL.
Section of Pediatric Surgery (NKC), Department of Surgery, University of Chicago, Chicago, IL.
J Pediatr Pharmacol Ther. 2022;27(6):517-523. doi: 10.5863/1551-6776-27.6.517. Epub 2022 Aug 19.
To evaluate an institutional practice change from an extracorporeal life support (ECLS) anticoagulation monitoring strategy of activated clotting time (ACT) alone to a multimodal strategy including ACT, activated partial thrombin time, heparin anti-factor-Xa, and thromboelastography.
This was a retrospective review of patients younger than 18 years on ECLS and heparin between January 2014 and June 2020 at a single institution.
Twenty-seven patients used an ACT-directed strategy and 25 used a multimodal strategy. The ACT-directed group was on ECLS for a shorter median duration than the multimodal group (136 versus 164 hours; p = 0.046). There was a non-significant increase in major hemorrhage (85.1% versus 60%; p = 0.061) and a significantly higher incidence of central nervous system (CNS) hemorrhage in the ACT-directed group (29.6% versus 0%; p = 0.004). Rates of thrombosis were similar, with a median of 3 circuit changes per group (p = 0.921). The ACT-directed group had larger median heparin doses (55 versus 34 units/kg/hr; p < 0.001), required more dose adjustments per day (3.8 versus 1.7; p < 0.001), and had higher rates of heparin doses >50 units/kg/hr (62.9% versus 16%; p = 0.001). More anticoagulation parameters were supratherapeutic (p = 0.015) and fewer were therapeutic (p < 0.001) in the ACT-directed group.
Patients with a multimodal strategy for monitoring anticoagulation during ECLS had lower rates of CNS hemorrhage and decreased need for large heparin doses of >50 units/kg/hr without an increase in clotting complications, compared with ACT-directed anticoagulation. Multimodal anticoagulation monitoring appears superior to ACT-only strategies and may reduce heparin exposure and risk of hemorrhagic complications for pediatric patients on ECLS.
评估一项机构实践变革，即从仅采用活化凝血时间（ACT）的体外膜肺氧合（ECLS）抗凝监测策略转变为包括ACT、活化部分凝血活酶时间、肝素抗Xa因子和血栓弹力图的多模式策略。
这是一项对2014年1月至2020年6月期间在单一机构接受ECLS和肝素治疗的18岁以下患者的回顾性研究。
27例患者采用ACT导向策略，25例采用多模式策略。ACT导向组接受ECLS的中位持续时间短于多模式组（136小时对164小时；p = 0.046）。ACT导向组的大出血发生率有非显著性增加（85.1%对60%；p = 0.061），且中枢神经系统（CNS）出血发生率显著更高（29.6%对0%；p = 0.004）。血栓形成率相似，每组的回路更换中位数均为3次（p = 0.921）。ACT导向组的肝素中位剂量更大（55单位/千克/小时对34单位/千克/小时；p < 0.001），每天需要更多的剂量调整（3.8次对1.7次；p < 0.001），且肝素剂量>50单位/千克/小时的发生率更高（62.9%对16%；p = 0.001）。ACT导向组有更多的抗凝参数高于治疗范围（p = 0.015），而处于治疗范围内的参数更少（p < 0.001）。
与ACT导向的抗凝治疗相比，采用多模式策略监测ECLS期间抗凝的患者CNS出血率更低，且减少了对大于50单位/千克/小时的大剂量肝素的需求，同时凝血并发症未增加。多模式抗凝监测似乎优于仅采用ACT的策略，可能会减少接受ECLS的儿科患者的肝素暴露和出血并发症风险。
