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De Rose DU, Maddaloni C, Ronci S, Bersani I, Martini L, Caoci S, Savarese I, Di Pede A, Campi F, Di Felice G, Berti P, Porzio O, Luciani M, Dotta A. Coagulation profiles and percentiles in neonates with hypoxic-ischemic encephalopathy undergoing therapeutic hypothermia: A step toward more accurate transfusion thresholds. Pediatr Blood Cancer 2024:e31193. [PMID: 39022989 DOI: 10.1002/pbc.31193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 06/24/2024] [Accepted: 06/26/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND In the literature, there are no studies about the transfusion threshold for neonates with hypoxic-ischemic encephalopathy (HIE) undergoing therapeutic hypothermia (TH). In order to facilitate accurate interpretation of coagulation results in these neonates, we aimed to generate specific reference intervals in this specific population. METHODS This retrospective study included all HIE neonates admitted from 2014 to 2022 to undergo TH. All infants during TH underwent blood exams, including the coagulation profile. Our primary outcome was to assess the estimates of the 3rd, 10th, 25th, 50th, 75th, 90th, and 97th percentiles for each parameter on admission (before transfusion). By the receiver operating characteristic (ROC) analysis, the area under the ROC curve (AUC) and the best cut-off point were used to evaluate the ability of the prothrombin time expressed as international normalized ratio (PT-INR) to predict the risk of any bleeding. RESULTS A total of 143 infants were included in this study. On admission, the median fibrinogen value was 205 mg/dL, prothrombin time 18.6 seconds, PT-INR 1.50, activated partial thromboplastin time 38.3 seconds, thrombin time 18.6 seconds, antithrombin 57.0%. The optimal cut-off of PT-INR in predicting the risk of any bleeding was greater than 1.84 (AUC .623, p = .024). CONCLUSION For the first time, we proposed the percentiles of coagulation parameters in our cohort of neonates with HIE. Furthermore, we found that a PT-INR greater than 1.84 can significantly predict the risk of any bleeding. Further studies are needed to determine if a restrictive versus a liberal transfusion approach can be equally safer for these high-risk infants.
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Affiliation(s)
| | - Chiara Maddaloni
- Neonatal Intensive Care Unit, "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Sara Ronci
- Neonatal Intensive Care Unit, "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Iliana Bersani
- Neonatal Intensive Care Unit, "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Ludovica Martini
- Neonatal Intensive Care Unit, "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Stefano Caoci
- Neonatal Intensive Care Unit, "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Immacolata Savarese
- Neonatal Intensive Care Unit, "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Alessandra Di Pede
- Neonatal Intensive Care Unit, "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Francesca Campi
- Neonatal Intensive Care Unit, "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Giovina Di Felice
- Clinical Biochemistry Laboratory, "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Pierpaolo Berti
- Transfusion Medicine Unit, "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Ottavia Porzio
- Clinical Biochemistry Laboratory, "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
- Transfusion Medicine Unit, "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
- Department of Experimental Medicine, "Tor Vergata" University, Rome, Italy
| | - Matteo Luciani
- Hematology and Oncology Unit, "Bambino Gesù" Children Hospital IRCSS, Rome, Italy
| | - Andrea Dotta
- Neonatal Intensive Care Unit, "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
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Elsebey M, Nandlal V, Litra F. Hemorrhagic Disease of the Newborn as a Consequence of Vitamin K Refusal Due to Language Barrier. Cureus 2024; 16:e57065. [PMID: 38681352 PMCID: PMC11052555 DOI: 10.7759/cureus.57065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2024] [Indexed: 05/01/2024] Open
Abstract
Newborns are prone to hemorrhagic disease due to vitamin K deficiency for multiple reasons, including vitamin K absence in breast milk and formula preparation, sterile gut with limited absorption, and lack of placental transfer. Despite the importance of vitamin K administration at birth in preventing hemorrhagic disease in infants, some parents still refuse administration to their newborns. One of the unexpected but preventable reasons is the language barrier related to special dialects, resulting in misunderstanding the benefits of vitamin K administration and complications related to vitamin K deficiency. We present a case of hemorrhagic disease of the newborn due to vitamin K deficiency following the parental refusal of postnatal prophylactic vitamin K due to a language barrier that resulted in miscommunication. Although appropriate education was provided to the family via Spanish interpreter as requested, it was later revealed that the family was speaking a special dialect, and they did not fully understand the importance of vitamin K prophylaxis. The patient experienced intracranial hemorrhage with full recovery after treatment and surgical intervention. Upon reviewing the case, the parents were speaking a rare dialect of Spanish, that was not known to the Spanish medical interpreters. A combination of a Spanish medical translator and a family friend was necessary for effective communication with the family.
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Affiliation(s)
- Moustafa Elsebey
- Department of Pediatrics, University of Florida, Pensacola, USA
- Department of Pediatrics, Ascension Sacred Heart Pensacola, Pensacola, USA
| | - Vidya Nandlal
- Department of Pediatrics, University of Florida, Pensacola, USA
- Department of Pediatrics, Ascension Sacred Heart Pensacola, Pensacola, USA
| | - Florentina Litra
- Department of Pediatrics, University of Florida, Pensacola, USA
- Department of Pediatrics, Ascension Sacred Heart Pensacola, Pensacola, USA
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3
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Sellers A, Lew A, Tudyk M, Nakagawa TA, Sochet AA. Hemorrhagic Disease of the Newborn: A Case Series Illustrating Preventable Harm. J Pediatr Health Care 2023; 37:67-73. [PMID: 36117074 DOI: 10.1016/j.pedhc.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 08/10/2022] [Accepted: 08/20/2022] [Indexed: 01/31/2023]
Abstract
Newborns are susceptible to postnatal Vitamin K deficiencies from limited placental transfer, gastrointestinal absorption, and bioavailability in breast milk and formula preparations. For over 50 years, the American Academy of Pediatrics has recommended prophylactic vitamin K to prevent hemorrhagic disease in newborns. Yet, public skepticism contributes to increasing refusal rates. We present three cases of vitamin K-dependent bleeding following parental refusal of postnatal prophylaxis. Two patients experienced intracranial hemorrhage with resultant neurological devastation and mortality, respectively. The third child presented with symptomatic hematuria. Perinatal providers must partner with families and advocate vitamin K prophylaxis to limit unnecessary morbidity and mortality.
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Affiliation(s)
- Austin Sellers
- Austin Sellers, MS, Institue of Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Alicia Lew
- Alicia Lew, MD, Department of Pediatrics, University of South Florida College of Medicine, Tampa, FL
| | - Miriam Tudyk
- Miriam Tudyk, MD, Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Thomas A Nakagawa
- Thomas A. Nakagawa, MD, Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Florida College of Medicine, Jacksonville, FL
| | - Anthony A Sochet
- Anthony A. Sochet, MD, MSc, Division of Pediatric Critical Care Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, FL; Anthony A. Sochet, MD, MSc, Department of Anesthesia and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
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4
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Abstract
The neonatal hemostatic system is strikingly different from that of adults. Among other differences, neonates exhibit hyporeactive platelets and decreased levels of coagulation factors, the latter translating into prolonged clotting times (PT and PTT). Since pre-term neonates have a high incidence of bleeding, particularly intraventricular hemorrhages, neonatologists frequently administer blood products (i.e., platelets and FFP) to non-bleeding neonates with low platelet counts or prolonged clotting times in an attempt to overcome these "deficiencies" and reduce bleeding risk. However, it has become increasingly clear that both the platelet hyporeactivity as well as the decreased coagulation factor levels are effectively counteracted by other factors in neonatal blood that promote hemostasis (i.e., high levels of vWF, high hematocrit and MCV, reduced levels of natural anticoagulants), resulting in a well-balanced neonatal hemostatic system, perhaps slightly tilted toward a prothrombotic phenotype. While life-saving in the presence of active major bleeding, the administration of platelets and/or FFP to non-bleeding neonates based on laboratory tests has not only failed to decrease bleeding, but has been associated with increased neonatal morbidity and mortality in the case of platelets. In this review, we will present a clinical overview of bleeding in neonates (incidence, sites, risk factors), followed by a description of the key developmental differences between neonates and adults in primary and secondary hemostasis. Next, we will review the clinical tests available for the evaluation of bleeding neonates and their limitations in the context of the developmentally unique neonatal hemostatic system, and will discuss current and emerging approaches to more accurately predict, evaluate and treat bleeding in neonates.
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Affiliation(s)
- Patricia Davenport
- Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, United States
| | - Martha Sola-Visner
- Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, United States
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5
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Sribnick EA, Wenger N, Nicol K, Tobias JD. Use of viscoelastic monitoring and prothrombin complex concentrate in a paediatric patient with polytrauma and severe traumatic brain injury. BMJ Case Rep 2020; 13:13/12/e236608. [PMID: 33318272 PMCID: PMC7737072 DOI: 10.1136/bcr-2020-236608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Viscoelastic monitoring (VEM) tools, such as rotational thrombelastometry, have been used extensively to measure coagulopathy in adults but have received less attention in paediatric care. The presented case involves a 5-year-old boy who was brought to the emergency department after a motor vehicle collision with a Glasgow Coma Scale score of 6T and extensive injuries, including a subdural hematoma. VEM was used to monitor the patient's coagulopathy and to inform treatment measures by allowing real-time visualisation of the patient's coagulation status. VEM was additionally used to direct blood product replacement in preparation for neurosurgical intervention, and 4-factor prothrombin complex concentrate (PCC) was used to help reverse the coagulopathy. The patient underwent successful hemicraniectomy after improvement of his coagulopathy. In paediatrics, VEM and PCC are increasingly being used for post-trauma coagulopathy, and this case highlights their potential promise and the need for further research.
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Affiliation(s)
- Eric A Sribnick
- Department of Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio, USA,Deparmtent of Neurosurgery, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Nicole Wenger
- The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Kathleen Nicol
- Deaprtment of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA,Department of Pathology, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA,Depatment of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
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6
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Loyal J, Shapiro ED. Refusal of Intramuscular Vitamin K by Parents of Newborns: A Review. Hosp Pediatr 2020; 10:286-294. [PMID: 32019806 DOI: 10.1542/hpeds.2019-0228] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
In 2019, the American Academy of Pediatrics made public education about intramuscular vitamin K administration at birth a public health priority, partly in response to reports of refusal of intramuscular vitamin K by parents of newborns that led to vitamin K deficiency bleeding (VKDB). We reviewed the literature on the frequency of, reported reasons for, and factors associated with refusal of intramuscular vitamin K, incidence of VKDB in newborns who did not receive intramuscular vitamin K, and use of oral vitamin K to prevent VKDB. Without prophylaxis, estimates of the incidence per 100 000 births of VKDB range from 250 to 1700 for early VKDB and from 10.5 to 80 for late VKDB. The frequency of refusal of intramuscular vitamin K by parents ranged from 0% to 3.2% in US hospitals, up to 14.5% in home births, and up to 31.0% in birthing centers. Reported reasons for refusal were concern of harm from the injection, a desire to be natural, and a belief in alternative methods of prophylaxis. Parents who refused intramuscular vitamin K were more likely to refuse immunizations. Many different regimens were used for orally administered vitamin K; it is not clear which is best, but all are less effective than intramuscular vitamin K. VKDB is rare but can result in either neurologic sequelae or death. In addition to continued surveillance of the frequency of both refusal of intramuscular vitamin K and VKDB, a renewed focus on education of and collaboration with parents is needed to address this major public health threat.
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Affiliation(s)
- Jaspreet Loyal
- Department of Pediatrics, Yale University, New Haven, Connecticut
| | - Eugene D Shapiro
- Department of Pediatrics, Yale University, New Haven, Connecticut
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7
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Karube T, Andersen C, Tobias JD. Single-Center Use of Prothrombin Complex Concentrate in Pediatric Patients. J Pediatr Intensive Care 2020; 9:106-112. [PMID: 32351764 DOI: 10.1055/s-0039-1700953] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 12/06/2019] [Indexed: 01/21/2023] Open
Abstract
Coagulation disturbances frequently occur in critically ill children. Four-factor prothrombin complex concentrate (4F-PCC) may have a potential role in managing these patients while avoiding concerns associated with fresh frozen plasma. However, data on this product in critically ill children is scarce. We retrospectively identified 24 critically ill pediatric patients who received 4F-PCC. The primary indication was to correct coagulopathy and control bleeding in the trauma or surgical setting. 4F-PCC effectively decreased the international normalized ratio level, a surrogate marker of hemostasis. Further study is warranted to identify efficacy, indications, optimal dosing, and adverse effects in the critically ill pediatric patients.
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Affiliation(s)
- Takaharu Karube
- Division of Pediatric Critical Care Medicine, Nationwide Children's Hospital, Columbus, Ohio, United States
| | - Courtney Andersen
- Ohio University Heritage College of Osteopathic Medicine, Dublin, Ohio, United States
| | - Joseph D Tobias
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, United States.,Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, United States.,Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, United States
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8
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Effectiveness and Safety of 4-factor Prothrombin Complex Concentrate (4PCC) in Neonates With Intractable Bleeding or Severe Coagulation Disturbances: A Retrospective Study of 37 Cases. J Pediatr Hematol Oncol 2019; 41:e135-e140. [PMID: 30601403 DOI: 10.1097/mph.0000000000001397] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND To date, clinical experience with prothrombin complex concentrate (PCC) in the neonatal population has been limited. AIM The objective of this study was to describe our experience regarding the effectiveness and safety of PCC administration in newborns with severe bleeding or coagulopathy resistant to conventional therapy. METHODOLOGY We retrospectively analyzed data from 37 neonates with intractable bleeding or severe coagulation disturbances. All patients received intravenous bolus administration of 20 or 30 u/kg of PCC per dose, as a rescue procedure. RESULTS Hemostasis was achieved in the majority of neonates and we observed statistically significant improvement in prothrombin time, international normalized ratio, and activated partial thromboplastin time (P<0.001, P=0.044, P<0.001, respectively). Thirteen neonates survived, whereas 24 did not survive. In those who survived, PCC had been administered earlier (<24 h) in the disease process compared with those who died (P=0.043). Neither acute adverse events nor thromboembolic complications were observed in all neonates. CONCLUSIONS In our study, PCC seemed to be a safe and effective intervention for hemostasis and early intervention was more effective as a rescue therapy, without any adverse event. Further prospective controlled trials are required to determine optimal dose and timing of PCC administration in neonates.
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9
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Tursunov D, Yoshida Y, Yrysov K, Sabirov D, Alimova K, Yamamoto E, Reyer JA, Hamajima N. Estimated costs for treatment and prophylaxis of newborn vitamin K deficiency bleeding in Tashkent, Uzbekistan. NAGOYA JOURNAL OF MEDICAL SCIENCE 2018; 80:11-20. [PMID: 29581610 PMCID: PMC5857497 DOI: 10.18999/nagjms.80.1.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Vitamin K deficiency bleeding (VKDB) is a preventable cause of infant mortality and long-term morbidity through the world. This study aimed to demonstrate the costs of VKDB treatment estimated from the hospital records in Tashkent, Uzbekistan, as well as the prophylaxis costs for mass vitamin K medication. Subjects were 50 patients with no operation and 50 patients who had received a brain operation, consecutively enrolled from 180 cases diagnosed at Republican Research Center of Emergency Medicine in 2014. In that year, an additional 22 VKDB patients were found in Tashkent; the incidence of VKDB was 478/100,000 among 42,225 newborns. The prophylaxis costs for all newborns in Tashkent were estimated under a plausible condition. The average age at admission was 43.2 days among 100 patients (67 boys and 33 girls) with birth weight from 2,600 g to 3,800 g (3,105 g on average). The great majority of patients (92.0%) were breastfed; 89.5% in boys and 97.0% in girls. Average treatment cost per VKDB patient was 365 USD for the operated and 285 USD for the non-operated. Total expenses of the 202 patients were estimated to be 64,603 USD. A single prophylaxis was estimated to cost 1.24 USD, totaling 52,359 USD for the prophylaxis of 42,225 newborns. Since the reduction of VKDB incidence through prophylaxis is considered to be higher than 78.5% (52,359/64,603), provision of prophylaxis services would reduce the total costs of VKDB treatment in Uzbekistan, where prophylaxis is not provided.
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Affiliation(s)
- Doniyorjon Tursunov
- Department of Healthcare Administration, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Republican Research Centre of Emergency Medicine, Department of Pediatrics, Tashkent, Uzbekistan
| | - Yoshitoku Yoshida
- Department of Healthcare Administration, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Keneshbek Yrysov
- Department of Healthcare Administration, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Dilmurad Sabirov
- Republican Research Centre of Emergency Medicine, Department of Pediatrics, Tashkent, Uzbekistan
| | - Khilola Alimova
- Republican Research Centre of Emergency Medicine, Department of Pediatrics, Tashkent, Uzbekistan
| | - Eiko Yamamoto
- Department of Healthcare Administration, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Joshua A Reyer
- Department of Healthcare Administration, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Nobuyuki Hamajima
- Department of Healthcare Administration, Nagoya University Graduate School of Medicine, Nagoya, Japan
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10
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Smith MM, Ashikhmina E, Brinkman NJ, Barbara DW. Perioperative Use of Coagulation Factor Concentrates in Patients Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth 2017; 31:1810-1819. [DOI: 10.1053/j.jvca.2017.05.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Indexed: 11/11/2022]
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11
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Ashikhmina E, Said S, Smith MM, Rodriguez V, Oliver WC, Nuttall GA, Dearani JA, Schaff HV. Prothrombin Complex Concentrates in Pediatric Cardiac Surgery: The Current State and the Future. Ann Thorac Surg 2017. [PMID: 28648539 DOI: 10.1016/j.athoracsur.2017.04.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND After decades of practice of pediatric cardiac surgery, postoperative bleeding due to the immaturity of hemostasis, hemodilution, and hypothermia remains a concern. Recently, a new approach for adult coagulopathy after bypass has emerged. Prothrombin complex concentrates (PCCs), designed to treat bleeding in hemophilia patients, are safely and efficiently used off label for hemorrhage after bypass. However, optimal dosing, indications and contraindications, and laboratory tests to assess the efficacy of PCC use in children have not yet been established. This literature review outlines the challenges of bypass-related coagulopathy, the pharmacology, and the experience in use of PCCs, with a focus on their potential in pediatric cardiac surgery. METHODS After a thorough literature search of MEDLINE, Scopus, and Ovid databases using the term "prothrombin complex concentrate AND pediatric," 23 relevant articles were selected. RESULTS The data supporting successful use of PCCs in acquired coagulopathy after cardiac surgery in adults have been increasing. Although small volume, low immunogenicity, efficiency, and speed in correcting coagulopathy are attractive qualities of PCCs for pediatric practice, current evidence is only anecdotal. The main concerns are unknown dosing regimens, the inability to closely monitor the effects of PCCs in real time, and a possibility of thrombotic complications, which can be particularly devastating in young congenital cardiac patients whose lives frequently depend upon the patency of artificial shunts. CONCLUSIONS Extensive, high-quality research is warranted to fill in the gaps of knowledge regarding using PCCs in pediatric cardiac practice.
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Affiliation(s)
- Elena Ashikhmina
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota.
| | - Sameh Said
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Mark M Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Vilmarie Rodriguez
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - William C Oliver
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Gregory A Nuttall
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
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12
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Ackermann S, Schimpf J, Richter M. [Intracranial hemorrhage secondary to vitamin K deficiency in an infant despite oral vitamin K prophylaxis : Also a challenge for the anesthesiologist]. Anaesthesist 2017; 66:598-603. [PMID: 28577108 DOI: 10.1007/s00101-017-0307-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 02/10/2017] [Accepted: 03/22/2017] [Indexed: 10/19/2022]
Abstract
This article presents the case of a 6-week-old infant who, despite oral vitamin K prophylaxis and otherwise normal developmental progress, suffered a severe intracerebral and subdural hemorrhage, which required surgical evacuation. The interdisciplinary approach is described with emphasis on the management of hemostasis. Furthermore, the clinical picture of intracranial bleeding due to vitamin K deficiency, which is nowadays rare in the Western World, is described in the anesthesiology literature for the first time. The usual recommendations regarding prophylaxis as well as certain risk factors are presented.
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Affiliation(s)
- S Ackermann
- Klinik für Anästhesiologie und Operative Intensivmedizin, Klinikum Augsburg, Stenglinstraße 2, 86156, Augsburg, Deutschland.
| | - J Schimpf
- Klinik für Anästhesiologie und Operative Intensivmedizin, Klinikum Augsburg, Stenglinstraße 2, 86156, Augsburg, Deutschland
| | - M Richter
- I. Klinik für Kinder und Jugendliche, Klinikum Augsburg, Augsburg, Deutschland
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13
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Zeng L, Choonara I, Zhang L, Li Y, Shi J. Effectiveness of prothrombin complex concentrate (PCC) in neonates and infants with bleeding or risk of bleeding: a systematic review and meta-analysis. Eur J Pediatr 2017; 176:581-589. [PMID: 28281092 DOI: 10.1007/s00431-017-2877-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 02/07/2017] [Accepted: 02/09/2017] [Indexed: 02/05/2023]
Abstract
UNLABELLED To systematically evaluate the effectiveness of prothrombin complex concentrate (PCC) in neonates and infants, we performed a systematic review and meta-analysis based on current evidence. Quality of studies was assessed by Cochrane Collaboration's risk of bias tool and Newcastle-Ottawa quality assessment scale. For dichotomous data, we obtained the number of events and total number and calculated the relative risk (RR) with 95% confidence intervals (CI). For continuous variables, we obtained mean and standard deviation (SD) values and calculated mean difference (MD) with 95% CI. We identified six trials and two cohort studies. For trials, selection bias and performance bias were high, while detection bias, attrition bias, and reporting bias were relatively low. For cohort studies, selection bias was low. Both individual studies and meta-analysis failed to find any benefit of PCC on mortality. Meta-analysis also failed to show any benefit in reducing intracranial hemorrhage. The effectiveness of PCC on the correction of hemostatic defects was inconsistent among studies. In addition, PCC was not more effective than fresh frozen plasma (FFP) in correcting hemostatic defects. CONCLUSION There is insufficient evidence to allow a recommendation for use of PCC in neonates and infants. What is Known: • Prothrombin Complex Concentrate is becoming increasingly used off-label for treatment of neonates and infants with severe bleeding or risk of severe bleeding. • Some case reports showed PCC seemed to be effective for infants and children with coagulation factor deficiency, but evidence about the effectiveness of PCC to reverse serious Vitamin K Deficiency Bleeding is limited. What is New: • As far as we know, this is the first systematic review that evaluates the effectiveness of PPC in neonates with bleeding or risk of bleeding. • There is insufficient evidence to allow a recommendation for use of PCCs in neonates and infants.
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Affiliation(s)
- Linan Zeng
- Department of Pharmacy/Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Imti Choonara
- Academic Division of Child Health, University of Nottingham, Derbyshire Children's Hospital, Derby, UK
| | - Lingli Zhang
- Department of Pharmacy/Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China.
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China.
| | - Youping Li
- Chinese Evidence-Based Medicine Centre/Chinese Cochrane Center, West China Hospital, Sichuan University, Chengdu, China.
| | - Jing Shi
- Department of Neonatology, West China Second University Hospital, Sichuan University, Chengdu, China
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14
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Punzalan RC, Gottschall JL. Use and Future Investigations of Recombinant and Plasma-Derived Coagulation and Anticoagulant Products in the Neonate. Transfus Med Rev 2016; 30:189-96. [PMID: 27576087 DOI: 10.1016/j.tmrv.2016.07.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 07/18/2016] [Indexed: 12/27/2022]
Abstract
Although congenital bleeding disorders can manifest in the newborn period, the most common causes of bleeding and thrombosis in neonates are acquired conditions. Factor concentrates are used for specific diagnoses (hemophilia with inhibitors, specific factor deficiency, von Willebrand disease) and approved indications, and increasingly for off-label indications (bleeding in surgery cardiopulmonary bypass, extracorporeal membrane oxygenation). We will review the approved indications for factor products in the neonate and discuss the evidence and rationale for off-label use of factor products in management of bleeding and thrombosis in the neonate.
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Affiliation(s)
- Rowena C Punzalan
- BloodCenter of Wisconsin, Milwaukee, WI; Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI.
| | - Jerome L Gottschall
- BloodCenter of Wisconsin, Milwaukee, WI; Department of Pathology, Medical College of Wisconsin, Milwaukee, WI
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