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Cashen K, Saini A, Brandão LR, Le J, Monagle P, Moynihan KM, Ryerson LM, Gehred A, Lyman E, Muszynski JA, Alexander PMA, Dalton HJ. Anticoagulant Medications: The Pediatric Extracorporeal Membrane Oxygenation Anticoagulation CollaborativE Consensus Conference. Pediatr Crit Care Med 2024; 25:e7-e13. [PMID: 38959355 PMCID: PMC11216397 DOI: 10.1097/pcc.0000000000003495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
OBJECTIVES To derive systematic-review informed, modified Delphi consensus regarding the medications used for anticoagulation for pediatric extracorporeal membrane oxygenation (ECMO) for the Pediatric ECMO Anticoagulation CollaborativE (PEACE). DATA SOURCES A structured literature search was performed using PubMed, EMBASE, and Cochrane Library (CENTRAL) databases from January 1988 to May 2021. STUDY SELECTION Included studies assessed anticoagulation used in pediatric ECMO. DATA EXTRACTION Two authors reviewed all citations independently, with a third reviewer adjudicating any conflicts. Eighteen references were used for data extraction as well as for creation of recommendations. Evidence tables were constructed using a standardized data extraction form. DATA SYNTHESIS Risk of bias was assessed using the Quality in Prognosis Studies tool. The evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation system. Forty-eight experts met over 2 years to develop evidence-informed recommendations and, when evidence was lacking, expert-based consensus statements, or good practice statements for anticoagulation during pediatric ECMO. A web-based modified Delphi process was used to build consensus via the Research and Development/University of California Appropriateness Method. Consensus was based on a modified Delphi process with agreement defined as greater than 80%. Two recommendations, two consensus statements, and one good practice statement were developed, and, in all, agreement greater than 80% was reached. CONCLUSIONS There is insufficient evidence to formulate optimal anticoagulation therapy during pediatric ECMO. Additional high-quality research is needed to inform evidence-based practice for anticoagulation during pediatric ECMO.
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Affiliation(s)
- Katherine Cashen
- Division of Critical Care Medicine, Department of Pediatrics, Duke University and Duke University Health System, Durham, NC
| | - Arun Saini
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Leonardo R Brandão
- Department of Pediatrics, The Hospital for Sick Children, Dalla Lana School of Public Health, University of Toronto, Toronto, ON
| | - Jennifer Le
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA
| | - Paul Monagle
- University of Melbourne, Melbourne, VIC, Australia
- Kids Cancer Centre Sydney Children's Hospital, Melbourne, VIC, Australia
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
- Royal Children's Hospital, Melbourne, VIC, Australia
| | - Katie M Moynihan
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Westmead Children's Hospital, Sydney, NSW, Australia
| | - Lindsay M Ryerson
- Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada
| | - Alison Gehred
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital Columbus, OH
| | - Elizabeth Lyman
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - Jennifer A Muszynski
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - Peta M A Alexander
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Heidi J Dalton
- Department of Pediatrics, INOVA Fairfax Medical Center, Falls Church, VA
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Jesudas R, Takemoto CM. Where have all the platelets gone? HIT, DIC, or something else? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:43-50. [PMID: 38066886 PMCID: PMC10727081 DOI: 10.1182/hematology.2023000465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Thrombocytopenia in ill children is common; accurately diagnosing the underlying etiology is challenging and essential for appropriate management. Triggers for accelerated consumption of platelets are numerous; common downstream mechanisms of clearance include platelet trapping in microvascular thrombi, phagocytosis, and platelet activation. Thrombocytopenia with microangiopathic hemolytic anemia (MAHA) is frequently due to disseminated intravascular coagulation. Thrombotic microangiopathy (TMA) is a subgroup of MAHA. Specific TMA syndromes include thrombotic thrombocytopenic purpura, complement-mediated TMA (CM-TMA), and Shiga toxin-mediated hemolytic uremic syndrome. Isolated thrombocytopenia is characteristic of immune thrombocytopenia; however, concomitant cytopenias are frequent in critically ill patients, making the diagnosis difficult. Immune thrombocytopenia with large vessel thrombosis is a feature of heparin-induced thrombocytopenia and antiphospholipid antibody syndrome. In addition, thrombocytopenia is common with macrophage activation, which is characteristic of hemophagocytic lymphohistiocytosis. While thrombocytopenia in ill patients can be driven by hypoproliferative processes such as myelosuppression and/or bone marrow failure, this review will focus on consumptive thrombocytopenia due to immune and nonimmune causes.
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Cohen O, Lange K, Budnik I, Tamarin I, Brutman-Barazani T, Barg AA, Rosenberg N, Lubetsky A, Kenet G, Levy-Mendelovich S. Application of a clinical decision rule and laboratory assays in pediatrics: Adult heparin-induced thrombocytopenia. Pediatr Blood Cancer 2022; 69:e29929. [PMID: 35997577 DOI: 10.1002/pbc.29929] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 07/18/2022] [Accepted: 07/24/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) is rare among pediatric patients. The diagnosis of HIT depends upon clinical decision tools to assess its pretest probability, supported by laboratory evidence of anti-platelet factor 4 (anti-PF4)/heparin antibodies. AIMS To compare the use of the 4Ts score clinical decision tool, clinical characteristics, and laboratory findings between pediatric and adult patients with suspected HIT. METHODS We compiled all pediatric patients in our center for whom HIT testing was performed during the years 2015-2021. These were compared with a cohort of consecutive adult patients. Laboratory diagnosis of HIT was performed with particle gel immunoassay (PaGIA) as screening test and confirmed by an automated latex-enhanced immunoturbidimetric assay (LIA) and/or by functional flow cytometry assay (FCA). RESULTS The cohort included 34 children (under 18 years) and 105 adults. Adults mostly received heparins for thromboembolism prophylaxis and treatment (72.4%, n = 76), and were more frequently treated with low-molecular-weight heparin (LMWH). Children were mostly exposed during cardiopulmonary bypass and extracorporeal membrane oxygenation (ECMO, 61.8%, n = 21), and were more frequently treated with unfractionated heparin (UFH). Compared with adults, children had significantly higher 4Ts scores. Nevertheless, adults had a slightly higher rate of a positive diagnosis of HIT. Six out of 16 adults with confirmed HIT presented with thrombosis (37.5%), whereas all three pediatric patients with HIT presented with thrombosis (p = .087). CONCLUSIONS 4Ts scores are higher in children compared with adult patients for whom laboratory tests for HIT were obtained. A potentially higher incidence of thrombosis in children with HIT may be attributable to the severity of underlying illness.
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Affiliation(s)
- Omri Cohen
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel HaShomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Kfir Lange
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel HaShomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ivan Budnik
- Department of Pathophysiology, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Ilia Tamarin
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel HaShomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,The Dworman Automated-Mega Laboratory, Sheba Medical Center, Tel HaShomer, Israel
| | - Tami Brutman-Barazani
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel HaShomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Assaf Arie Barg
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel HaShomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nurit Rosenberg
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel HaShomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Aharon Lubetsky
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel HaShomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gili Kenet
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel HaShomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sarina Levy-Mendelovich
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel HaShomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Talpiot Medical Leadership Program, Sheba Medical Center, Tel HaShomer, Israel
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Chok R, Turley E, Bruce A. Screening and diagnosis of heparin-induced thrombocytopenia in the pediatric population: A tertiary centre experience. Thromb Res 2021; 207:1-6. [PMID: 34482163 DOI: 10.1016/j.thromres.2021.08.020] [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: 06/03/2021] [Revised: 07/31/2021] [Accepted: 08/19/2021] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Heparin-induced thrombocytopenia (HIT) is a life-threatening side effect of heparin necessitating immediate heparin discontinuation. A missed diagnosis of HIT carries significant morbidity and mortality, while overdiagnosis may result in unnecessary and potentially harmful use of alternative anticoagulants in the pediatric population. We aimed to determine the proportion of HIT screening tests at our pediatric tertiary care centre ultimately leading to a diagnosis of HIT by functional assay (either lumi-aggregometry or serotonin-release assay). We hypothesized that the frequency of HIT at our centre would be lower than that reported in the literature. MATERIALS AND METHODS We conducted a retrospective review including children aged 0 to 18 years who had HIT testing performed at our centre between 2010 and 2018 (N = 189; 51% female). A screening enzyme immunoassay, if positive, is followed by a functional assay which must be positive to establish the diagnosis of HIT. Data were analyzed to establish trends in demographic and clinical features of patients with a positive HIT screening test. Our primary outcome was the rate of HIT confirmed by functional testing amongst children screened for HIT from 2010 to 2018. RESULTS AND CONCLUSIONS There were 233 screening tests performed on 189 distinct patients. Only one patient (0.4%) received a diagnosis of HIT based on functional assay. This patient was a 16-year-old female later found to have a JAK2 mutation. The false positive rate of the enzyme immunoassay was 9.4% (N = 22). There were no positive enzyme immunoassay tests in the neonatal age group (N = 49). These results reinforce that HIT is rare in children.
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Affiliation(s)
- Rozalyn Chok
- Department of Pediatrics, University of Alberta, 11405-87th Avenue, Edmonton, Alberta T6G 1C9, Canada.
| | - Elona Turley
- Department of Laboratory Medicine and Pathology, Division of Hematological Pathology, University of Alberta Hospital and University of Alberta, 4B1. 19 Walter Mackenzie Centre, 8440-112 Street, Edmonton, Alberta T6G 2B7, Canada.
| | - Aisha Bruce
- Department of Pediatrics, Division of Hematology/Oncology, Stollery Children's Hospital and University of Alberta, 11405-87th Avenue, Edmonton, Alberta T6G 1C9, Canada.
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