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Nair S, Oommen J, Chandrabose VT, Muhammed H, Kalathingal K, Sivadasan A, Joseph S, Pydi R, Shet S, Samantaray S. An unusual combination of complications in a pediatric burn patient with successful outcome. INDIAN JOURNAL OF BURNS 2019. [DOI: 10.4103/ijb.ijb_25_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Latham GJ, Jefferis Kirk C, Falconer A, Dickey R, Albers EL, McMullan DM. Challenging Argatroban Management of a Child on Extracorporeal Support and Subsequent Heart Transplant. Semin Cardiothorac Vasc Anesth 2015; 20:168-74. [DOI: 10.1177/1089253215624766] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
A 6-year-old child developed heparin-induced thrombocytopenia while on extracorporeal life support. Hours after a difficult transition from heparin to argatroban for anticoagulation therapy, the child underwent heart transplantation. Intraoperative management was plagued with circuit thrombus formation while on cardiopulmonary bypass and subsequent massive hemorrhage after bypass. We review the child’s anticoagulation management, clinical challenges encountered, and review current literature related to the use of argatroban in pediatric cardiac surgery.
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Affiliation(s)
- Gregory J. Latham
- Seattle Children’s Hospital, Seattle, WA, USA
- University of Washington School of Medicine, Seattle, WA, USA
| | | | | | | | - Erin L. Albers
- Seattle Children’s Hospital, Seattle, WA, USA
- University of Washington School of Medicine, Seattle, WA, USA
| | - David Michael McMullan
- Seattle Children’s Hospital, Seattle, WA, USA
- University of Washington School of Medicine, Seattle, WA, USA
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Obeng EA, Harney KM, Moniz T, Arnold A, Neufeld EJ, Trenor CC. Pediatric heparin-induced thrombocytopenia: prevalence, thrombotic risk, and application of the 4Ts scoring system. J Pediatr 2015; 166:144-50. [PMID: 25444534 PMCID: PMC4274245 DOI: 10.1016/j.jpeds.2014.09.017] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Revised: 08/05/2014] [Accepted: 09/09/2014] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To characterize heparin-induced thrombocytopenia (HIT) at a single pediatric center including the prevalence and the accuracy of the 4Ts scoring system as a predictor of HIT. STUDY DESIGN In this retrospective cohort study, we identified 155 consecutive patients <21 years old with sufficient data for 4Ts scoring. The 4Ts scoring system is a validated pretest tool in adults that predicts the likelihood of HIT using clinical features. Hospital-wide exposure to unfractionated and low molecular weight heparin was determined by querying the hospital pharmacy database. RESULTS The majority of patients with suspected HIT (61.2%) were on surgical services. Prediction of HIT risk using initial 4Ts scoring found 3 (2%) had high risk 4Ts scores, 114 (73%) had intermediate risk 4Ts scores, and the remaining 38 (25%) had low risk 4Ts scores. HIT was confirmed in 0/38 patients with low risk 4Ts scores, 2/114 patients with intermediate-risk 4Ts scores, and all 3 patients with high-risk 4Ts scores presented with HIT with thrombosis. Of 12 positive HIT screening tests, results were falsely positive in 66.6% of patients with intermediate risk 4Ts scores and 100% of patients with low risk 4Ts scores. The prevalence of HIT was 0.058% and HIT with thrombosis was 0.046% in pediatric patients on unfractionated heparin. CONCLUSIONS The prevalence of HIT appears significantly lower in pediatric patients compared with adults. Application of the 4Ts system as a pretest tool may reduce laboratory evaluation for HIT in heparin-exposed children with low risk 4Ts scores, decreasing unnecessary further testing, intervention, and cost.
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Affiliation(s)
- Esther A. Obeng
- Division of Hematology/Oncology, Hospital, Boston, Massachusetts,Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts
| | - Kathy M. Harney
- Division of Hematology/Oncology, Hospital, Boston, Massachusetts
| | - Thomas Moniz
- Department of Pharmacy, Boston Children’s Hospital, Boston, Massachusetts
| | - Alana Arnold
- Department of Pharmacy, Boston Children’s Hospital, Boston, Massachusetts
| | - Ellis J. Neufeld
- Division of Hematology/Oncology, Hospital, Boston, Massachusetts,Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts
| | - Cameron C. Trenor
- Division of Hematology/Oncology, Hospital, Boston, Massachusetts,Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts
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Avila ML, Shah V, Brandão LR. Systematic review on heparin-induced thrombocytopenia in children: a call to action. J Thromb Haemost 2013; 11:660-9. [PMID: 23350790 DOI: 10.1111/jth.12153] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2012] [Accepted: 01/20/2013] [Indexed: 01/19/2023]
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) has increasingly been reported in children as an indication for use of new alternative anticoagulant drugs (NAADs). OBJECTIVES To systematically review the literature regarding: (i) the incidence and prevalence of seroconversion and HIT and (ii) the clinical/laboratory findings and management of HIT in children. DESIGN/METHODS MEDLINE and EMBASE databases were searched for studies that reported pediatric cases of HIT. Methodological reliability assessment of studies was performed with the Loney scale. RESULTS The incidence of seroconversion in neonates ranged between 0% and 1.7%. There were no cases of neonatal HIT in the included cohorts. The incidence range of seroconversion in the non-neonatal population was 1.3-52%. The incidence of HIT in non-neonates after cardiopulmonary bypass was 0.33% (95%CI, < 0.01-2.04). Whereas more than half of pediatric cases labeled as HIT (30/52) did not include pivotal features of this syndrome, 80% of them received NAADs. CONCLUSION The incidence of HIT is likely to have been overestimated in children, leading to potential misuse of NAADs in many cases. Clinical findings and laboratory assessment of pediatric cases are poorly described in the literature at present. Thorough laboratory investigation, proper reporting of cases and adequate design of studies are mandatory to elucidate the clinical/laboratory picture of pediatric HIT.
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Affiliation(s)
- M L Avila
- Division of Hematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
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Monagle P, Chan AKC, Goldenberg NA, Ichord RN, Journeycake JM, Nowak-Göttl U, Vesely SK. Antithrombotic therapy in neonates and children: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e737S-e801S. [PMID: 22315277 DOI: 10.1378/chest.11-2308] [Citation(s) in RCA: 970] [Impact Index Per Article: 80.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Neonates and children differ from adults in physiology, pharmacologic responses to drugs, epidemiology, and long-term consequences of thrombosis. This guideline addresses optimal strategies for the management of thrombosis in neonates and children. METHODS The methods of this guideline follow those described in the Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. RESULTS We suggest that where possible, pediatric hematologists with experience in thromboembolism manage pediatric patients with thromboembolism (Grade 2C). When this is not possible, we suggest a combination of a neonatologist/pediatrician and adult hematologist supported by consultation with an experienced pediatric hematologist (Grade 2C). We suggest that therapeutic unfractionated heparin in children is titrated to achieve a target anti-Xa range of 0.35 to 0.7 units/mL or an activated partial thromboplastin time range that correlates to this anti-Xa range or to a protamine titration range of 0.2 to 0.4 units/mL (Grade 2C). For neonates and children receiving either daily or bid therapeutic low-molecular-weight heparin, we suggest that the drug be monitored to a target range of 0.5 to 1.0 units/mL in a sample taken 4 to 6 h after subcutaneous injection or, alternatively, 0.5 to 0.8 units/mL in a sample taken 2 to 6 h after subcutaneous injection (Grade 2C). CONCLUSIONS The evidence supporting most recommendations for antithrombotic therapy in neonates and children remains weak. Studies addressing appropriate drug target ranges and monitoring requirements are urgently required in addition to site- and clinical situation-specific thrombosis management strategies.
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Affiliation(s)
- Paul Monagle
- Haematology Department, The Royal Children's Hospital, Department of Paediatrics, The University of Melbourne, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Anthony K C Chan
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Neil A Goldenberg
- Department of Pediatrics, Section of Hematology/Oncology/Bone Marrow Transplantation and Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado, Aurora, CO
| | - Rebecca N Ichord
- Department of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Janna M Journeycake
- Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas, Dallas, TX
| | - Ulrike Nowak-Göttl
- Thrombosis and Hemostasis Unit, Institute of Clinical Chemistry, University Hospital Kiel, Kiel, Germany
| | - Sara K Vesely
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK.
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Vakil NH, Kanaan AO, Donovan JL. Heparin-induced thrombocytopenia in the pediatric population: a review of current literature. J Pediatr Pharmacol Ther 2012; 17:12-30. [PMID: 23118656 PMCID: PMC3428184 DOI: 10.5863/1551-6776-17.1.12] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Heparin-induced thrombocytopenia is a rare and serious reaction to unfractionated heparin and low-molecular-weight heparins in children. Quick recognition, discontinuation of heparin, and subsequent treatment with an alternative anticoagulant are essential steps to prevent serious complications such as thrombus and limb amputation. The purpose of this review is to describe the clinical features of heparin-induced thrombocytopenia in children and to summarize the data available for its management. This paper summarizes data and relates the use of direct thrombin inhibitors with clinical outcomes. A literature search was conducted with Ovid, using the key terms argatroban, bivalirudin, hirulog, danaparoid, lepirudin, direct thrombin inhibitor, heparin-induced thrombocytopenia, thrombosis, warfarin, and fondaparinux. Articles were excluded if they were classified as editorials, review articles, or conference abstracts or if they involved patients 18 years of age or older or described disease states not related to thrombosis. Nineteen articles containing 33 case reports were identified and evaluated for this review. Of the 33 cases, 14, 10, 4, and 2 cases described the use of lepirudin, danaparoid, argatroban, and bivalirudin, respectively. Two cases did not report the type of anticoagulant used, and 1 case used aspirin. The most commonly reported complication was bleeding.
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Affiliation(s)
- Niyati H. Vakil
- Massachusetts College of Pharmacy and Health Sciences, Worcester, Massachusetts
| | - Abir O. Kanaan
- Massachusetts College of Pharmacy and Health Sciences, Worcester, Massachusetts
| | - Jennifer L. Donovan
- Massachusetts College of Pharmacy and Health Sciences, Worcester, Massachusetts
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Abstract
Abstract
The diagnosis and management of heparin-induced thrombocytopenia (HIT) in pediatric patients poses significant challenges. The cardinal findings in HIT, thrombocytopenia and thrombosis with heparin exposure, are seen commonly in critically ill children, but are most often secondary to etiologies other than HIT. However, without prompt diagnosis, discontinuation of heparin, and treatment with an alternative anticoagulant such as a direct thrombin inhibitor (DTI), HIT can result in life- and limb-threatening thrombotic complications. Conversely, DTIs are associated with higher bleeding risks than heparin in adults and their anticoagulant effects are not rapidly reversible; furthermore, the experience with their use in pediatrics is limited. Whereas immunoassays are widely available to aid in diagnosis, they carry a significant false positive rate. Age-dependent differences in the coagulation and immune system may potentially affect manifestations of HIT in children, but have not been extensively examined. In this chapter, diagnostic approaches and management strategies based on a synthesis of the available pediatric studies and adult literature on HIT are discussed.
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Eaton MP, Iannoli EM. Coagulation considerations for infants and children undergoing cardiopulmonary bypass. Paediatr Anaesth 2011; 21:31-42. [PMID: 21155925 DOI: 10.1111/j.1460-9592.2010.03467.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Cardiac surgery involving cardiopulmonary bypass imposes a significant pathophysiologic burden on patients. Pediatric patients are especially predisposed to the adverse effects of surgery and bypass on the coagulation system, with resultant bleeding, transfusion, and poor outcomes. These risks accrue to pediatric patients in inverse proportion to their weight and are attributable to hematologic immaturity, coagulation defects associated with congenital heart disease, bypass equipment, and the nature of congenital heart surgery. Standard anticoagulation does not completely inhibit thrombin generation, and continuous consumption of coagulation factor continues throughout bypass. Conventional measurements of anticoagulation during bypass poorly reflect this incomplete anticoagulation, and alternate methods may improve anticoagulant therapy. Emerging therapies for blocking the effects of bypass on the coagulation system hold promise for decreasing bleeding and related complications, and improving outcomes in congenital heart surgery.
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Affiliation(s)
- Michael P Eaton
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, NY 14642, USA.
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Ranucci M, Carlucci C, Isgrò G, Brozzi S, Boncilli A, Costa E, Frigiola A. Hypothermic cardiopulmonary bypass as a determinant of late thrombocytopenia following cardiac operations in pediatric patients. Acta Anaesthesiol Scand 2009; 53:1060-7. [PMID: 19496765 DOI: 10.1111/j.1399-6576.2009.02010.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Thrombocytopenia after cardiac operations is a common event in both adult and pediatric patients. Late thrombocytopenia (LTCP) is a less common event that is still without a well-recognized cause. This study explores the role of heparin-induced thrombocytopenia (HIT) and other factors (complexity of the operation, temperature management, and drug use) in determining LTCP. METHODS We conducted an observational study of 63 consecutive patients aged <36 months operated with or without cardiopulmonary bypass (CPB). LTCP was defined as a platelet count <100,000 cells/microl or <50% of the pre-operative count at any point in time between post-operative days 5 and 10. A diagnostic test for heparin-platelet factor 4 (PF4) antibodies was performed in patients with LTCP. Other pre- and post-operative factors were investigated for their association with LTCP. RESULTS LTCP occurred in 15 (24%) patients. No patient had positive heparin-PF4 antibodies. The lowest temperature on CPB was an independent predictor of LTCP, with a cut-off value at 29 degrees C (sensitivity 80%, specificity 70%). Other factors associated with LTCP were prolonged post-operative use of unfractionated heparin and milrinone. LTCP was associated with increased post-operative morbidity. CONCLUSION LTCP was related to a combination of factors (operation severity, degree of hypothermia during CPB, prolonged use of unfractionated heparin, and milrinone). The individual contribution of each factor seems difficult to establish. However, the degree of hypothermia during CPB and drug-associated effects were identified. HIT could be excluded in all cases.
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Affiliation(s)
- M Ranucci
- Department of Cardiothoracic-vascular Anesthesia and Intensive Care, IRCCS Policlinico S.Donato, Milan, Italy.
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Kilbridge PM, Noirot LA, Reichley RM, Berchelmann KM, Schneider C, Heard KM, Nelson M, Bailey TC. Computerized surveillance for adverse drug events in a pediatric hospital. J Am Med Inform Assoc 2009; 16:607-12. [PMID: 19567791 DOI: 10.1197/jamia.m3167] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
There are limited data on adverse drug event rates in pediatrics. The authors describe the implementation and evaluation of an automated surveillance system modified to detect adverse drug events (ADEs) in pediatric patients. The authors constructed an automated surveillance system to screen admissions to a large pediatric hospital. Potential ADEs identified by the system were reviewed by medication safety pharmacists and a physician and scored for causality and severity. Over the 6 month study period, 6,889 study children were admitted to the hospital for a total of 40,250 patient-days. The ADE surveillance system generated 1226 alerts, which yielded 160 true ADEs. This represents a rate of 2.3 ADEs per 100 admissions or 4 per 1,000 patient-days. Medications most frequently implicated were diuretics, antibiotics, immunosuppressants, narcotics, and anticonvulsants. The composite positive predictive value of the ADE surveillance system was 13%. Automated surveillance can be an effective method for detecting ADEs in hospitalized children.
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Affiliation(s)
- Peter M Kilbridge
- St. Louis Children's Hospital, One Children's Place, St Louis, MO 63110, USA.
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Abstract
Lepirudin, a recombinant hirudin, is a direct irreversible thrombin inhibitor by binding to both free and clot-bound thrombin. It is approved for treatment of heparin-induced thrombocytopenia (HIT), which is a serious antibody-mediated drug reaction mostly associated with the use of unfractionated heparin. Clinical experience during the last 10 years has proved the efficacy of lepirudin in the management of HIT. The major route of elimination of lepirudin is the kidney, accounting for approximately 90% of its systemic clearance. The most important adverse reactions are bleeding and the induction of immunologic reactions. The risk of bleeding can be reduced by implementing an optimal monitoring and dose adjustment strategy, particularly in patients undergoing cardiopulmonary bypass surgery and in those with impaired renal function. Development of antihirudin antibodies may enhance the anticoagulant effect of lepirudin. Anaphylactic reactions associated with lepirudin therapy are rare. The lack of an antidote against lepirudin is still a concern, particularly during cardiopulmonary bypass surgery with a heart-lung machine and during artificial renal support. Currently, hemofiltration using high-flux filter systems is the only available and valid means to manage hirudin overdose. Nevertheless, the drug can be safely used if meticulous monitoring strategy is installed.
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Affiliation(s)
- Sirak Petros
- Department of Internal Medicine, University of Leipzig, Leipzig, Germany
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Hanson SJ, Punzalan RC, Ghanayem N, Havens P. Prevalence of heparin-dependent platelet antibodies in children after cardiopulmonary bypass. Pediatr Crit Care Med 2007; 8:358-61. [PMID: 17545932 DOI: 10.1097/01.pcc.0000269398.10804.7f] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To determine the prevalence of heparin-dependent platelet antibodies (HDPA) in children requiring heparin for >5 days after cardiopulmonary bypass surgery. DESIGN Prospective, observational study. SETTING Tertiary care pediatric intensive care unit. PATIENTS Thirty children were enrolled: 15 patients <30 days old and 15 patients between 30 days and 12 yrs of age. INTERVENTIONS Detection of HDPA by heparin-platelet factor 4 enzyme-linked immunosorbent assay after 5-10 days of postoperative heparin exposure. Positive or equivocal results were confirmed with serotonin release assay. MEASUREMENTS AND MAIN RESULTS There were no confirmed cases of HDPA in this study (95% confidence interval 0-11.6%). Despite the lack of HDPA, the study population was at high risk of thrombosis with symptomatic clot developing in six patients (20%). Clinical models developed in adults to determine the pretest risk of heparin-induced thrombocytopenia were not valid in this study population. CONCLUSIONS The prevalence of HDPA in children after cardiopulmonary bypass surgery is low. After bypass surgery, critically ill children are at risk of developing thrombosis from multiple etiologies, and suspicion of heparin-induced thrombocytopenia needs to be confirmed with laboratory testing including a functional assay.
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Affiliation(s)
- Sheila J Hanson
- Department of Pediatrics, Critical Care Medicine, Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, WI 53226, USA.
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Lee DH, Warkentin TE. Frequency of Heparin-Induced Thrombocytopenia. HEPARIN-INDUCED THROMBOCYTOPENIA 2007. [DOI: 10.3109/9781420045093.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Newall F, Ignjatovic V, Monagle P. Temporal Aspects of Anti-Heparin-PF4 Antibodies in Heparin-Induced Thrombocytopenia. Ann Thorac Surg 2006; 81:1944; author reply 1944-5. [PMID: 16631722 DOI: 10.1016/j.athoracsur.2005.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2005] [Revised: 07/27/2005] [Accepted: 09/01/2005] [Indexed: 10/24/2022]
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Knoderer CA, Knoderer HM, Turrentine MW, Kumar M. Lepirudin Anticoagulation for Heparin-Induced Thrombocytopenia After Cardiac Surgery in a Pediatric Patient. Pharmacotherapy 2006; 26:709-12. [PMID: 16718945 DOI: 10.1592/phco.26.5.709] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
A 21-month-old boy received anticoagulation with lepirudin for heparin-induced thrombocytopenia (HIT) after undergoing cardiac surgery and receiving extracorporeal membrane oxygenation (ECMO). This report illustrates the significance of HIT in pediatric patients after cardiac surgery and the successful administration of lepirudin in this setting. To our knowledge, this is the first published report of lepirudin administered to treat HIT in a child after cardiac surgery and ECMO. Although guidelines exist that suggest the potential administration of lepirudin as treatment for children with HIT, further studies are needed to determine the safest yet most effective dosage for this population.
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Affiliation(s)
- Chad A Knoderer
- Department of Pharmacy, Clarian Health Partners, Riley Hospital for Children, Indianapolis, IN 46202, USA.
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2006. [DOI: 10.1002/pds.1175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Chow JL, Brock-Utne JG. Minimizing the incidence of heparin-induced thrombocytopenia: to heparinize or not to heparinize vascular access? Paediatr Anaesth 2005; 15:1037-40. [PMID: 16324020 DOI: 10.1111/j.1460-9592.2005.01755.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Eghtesady P, Nelson D, Schwartz SM, Wheeler D, Pearl JM, Cripe LH, Manning PB. Heparin-Induced Thrombocytopenia Complicating Support by the Berlin Heart. ASAIO J 2005; 51:820-5. [PMID: 16340375 DOI: 10.1097/01.mat.0000185630.83985.49] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Since 1992, miniaturized pulsatile air-driven ventricular assist devices (VADs), "Berlin Heart," have been used at many institutions (36 cases in North America in 19 different institutions) for pediatric use. Heparin-induced thrombocytopenia (HIT II) is a significant complication rarely reported in the setting of adult VAD support; no similar report exists concerning pediatric VAD support. We report on a 13-month-old, 8.1 kg girl who required LVAD support for cardiogenic shock of unclear etiology. The patient had a history of multiple surgical repairs for correction of complex congenital heart disease consisting of a series of left heart obstructive lesions (Shone's complex). Despite aggressive ventilatory and inotropic support, the patient continued to deteriorate and subsequently required extracorporeal life support. After 7 days of conventional venoarterial extracorporeal membrane oxygenation, a 10 ml Berlin Heart VAD was implanted. After implantation, the patient developed persistent low-grade fever of unclear etiology, gradual thrombocytopenia, and deterioration of renal function. On postimplant day 10, the pump required replacement because of concerns about an inlet valve thrombus; the explanted device demonstrated a nearly occlusive clot not appreciable from external inspection. Simultaneously, HIT II was diagnosed as a result of hematology workup for persistent thrombocytopenia. We discuss the unique challenges posed by HIT II complicating pediatric VAD support and in relation to the heparin coating of the device.
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Affiliation(s)
- Pirooz Eghtesady
- Division of Pediatric Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.
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