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Rintoul NE, McMichael ABV, Bembea MM, DiGeronimo R, Patregnani J, Alexander PMA, Muszynski JA, Steffen K, Gehred A, Lyman E, Cheifetz IM. Management of Bleeding and Thrombotic Complications During Pediatric Extracorporeal Membrane Oxygenation: The Pediatric Extracorporeal Membrane Oxygenation Anticoagulation CollaborativE Consensus Conference. Pediatr Crit Care Med 2024; 25:e66-e77. [PMID: 38959361 PMCID: PMC11216396 DOI: 10.1097/pcc.0000000000003489] [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 management of bleeding and thrombotic complications during pediatric extracorporeal membrane oxygenation (ECMO) for the Pediatric ECMO Anticoagulation CollaborativE Consensus Conference. DATA SOURCES A structured literature search was performed using PubMed, EMBASE, and Cochrane Library (CENTRAL) databases from January 1988 to May 2021. STUDY SELECTION The management of bleeding and thrombotic complications of ECMO. DATA EXTRACTION Two authors reviewed all citations independently, with a third independent reviewer resolving conflicts. Twelve references were used for data extraction and informed 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-based recommendations and, when evidence was lacking, expert-based consensus statements for the management of bleeding and thrombotic complications in pediatric ECMO patients. A web-based modified Delphi process was used to build consensus via the Research And Development/University of California Appropriateness Method. Consensus was defined as greater than 80% agreement. Two good practice statements, 5 weak recommendations, and 18 consensus statements are presented. CONCLUSIONS Although bleeding and thrombotic complications during pediatric ECMO remain common, limited definitive data exist to support an evidence-based approach to treating these complications. Research is needed to improve hemostatic management of children supported with ECMO.
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Affiliation(s)
- Natalie E Rintoul
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Ali B V McMichael
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
- Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Robert DiGeronimo
- Division of Neonatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
| | - Jason Patregnani
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Barbara Bush Children's Hospital, Portland, ME
| | - Peta M A Alexander
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Jennifer A Muszynski
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University of Medicine, Columbus, OH
| | - Katherine Steffen
- Department of Pediatrics (Pediatric Critical Care Medicine), Stanford University, Palo Alto, CA
| | - Alison Gehred
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital Columbus, Columbus, OH
| | - Elizabeth Lyman
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital Columbus, Columbus, OH
| | - Ira M Cheifetz
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, OH
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Bai YB, Zhao F, Wu ZH, Shi GN, Jiang N. Left ventricular thrombosis caused cerebral embolism during venoarterial extracorporeal membrane oxygenation support: A case report. World J Clin Cases 2024; 12:973-979. [PMID: 38414596 PMCID: PMC10895634 DOI: 10.12998/wjcc.v12.i5.973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 12/13/2023] [Accepted: 01/18/2024] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND Venoarterial (VA) extracorporeal membrane oxygenation (ECMO), an effective short-term circulatory support method for refractory cardiogenic shock, is widely applied. However, retrospective analyses have shown that VA-ECMO-assisted cases were associated with a relatively high mortality rate of approximately 60%. Embolization in important organs caused by complications of left ventricular thrombosis (LVT) during VA-ECMO is also an important reason. Although the incidence of LVT during VA-ECMO is not high, the consequences of embolization are disastrous. CASE SUMMARY A 37-year-old female patient was admitted to hospital because of fever for 4 d and palpitations for 3 d. After excluding the diagnosis of coronary heart disease, we established a diagnosis of "clinically explosive myocarditis". The patient still had unstable hemodynamics after drug treatment supported by VA-ECMO, with heparin for anticoagulation. On day 4 of ECMO support, a left ventricular thrombus attached to the papillary muscle root of the mitral valve was found by transthoracic echocardiography. Left ventricular decompression was performed and ECMO was successfully removed, but the patient eventually died of multiple cerebral embolism. CONCLUSION LVT with high mobility during VA-ECMO may cause embolism in important organs. Therefore, a "wait and see" strategy should be avoided.
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Affiliation(s)
- Yao-Bang Bai
- Intensive Care Unit, Department of Cardiac Surgery, Tianjin Chest Hospital, Tianjin 300222, China
| | - Feng Zhao
- Department of Cardiac Surgery, Tianjin Chest Hospital, Tianjin 300222, China
| | - Zhen-Hua Wu
- Intensive Care Unit, Department of Cardiac Surgery, Tianjin Chest Hospital, Tianjin 300222, China
| | - Guo-Ning Shi
- Intensive Care Unit, Department of Cardiac Surgery, Tianjin Chest Hospital, Tianjin 300222, China
| | - Nan Jiang
- Department of Cardiac Surgery, Tianjin Chest Hospital, Tianjin 300222, China
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Mejia EJ, O'Connor MJ, Samelson-Jones BJ, Mavroudis CD, Giglia TM, Keashen R, Rossano J, Naim MY, Maeda K. Successful Treatment of Intracardiac Thrombosis in the Presence of Fulminant Myocarditis Requiring ECMO associated with COVID-19. J Heart Lung Transplant 2022; 41:849-851. [PMID: 35370032 PMCID: PMC8908727 DOI: 10.1016/j.healun.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 02/22/2022] [Accepted: 03/01/2022] [Indexed: 11/14/2022] Open
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Woods GM, Kim DW, Paden ML, Viamonte HK. Thrombolysis in Children: A Case Report and Review of the Literature. Front Pediatr 2021; 9:814033. [PMID: 35141182 PMCID: PMC8818955 DOI: 10.3389/fped.2021.814033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 12/23/2021] [Indexed: 12/24/2022] Open
Abstract
Thromboembolism (TE), including venous thromboembolism (VTE), arterial TE, arterial ischemic stroke (AIS), and myocardial infarction (MI), is considered a relatively rare complication in the pediatric population. Yet, the incidence is rising, especially in hospitalized children. The vast majority of pediatric TE occurs in the setting of at least one identifiable risk factor. Most recently, acute COVID-19 and multisystem inflammatory syndrome in children (MIS-C) have demonstrated an increased risk for TE development. The mainstay for the management pediatric TE has been anticoagulation. Thrombolytic therapy is employed more frequently in adult patients with ample data supporting its use. The data for thrombolysis in pediatric patients is more limited, but the utilization of this therapy is becoming more commonplace in tertiary care pediatric hospitals. Understanding the data on thrombolysis use in pediatric TE and the involved risks is critical before initiating one of these therapies. In this paper, we present the case of an adolescent male with acute fulminant myocarditis and cardiogenic shock likely secondary to MIS-C requiring extracorporeal life support (ECLS) who developed an extensive thrombus burden that was successfully resolved utilizing four simultaneous catheter-directed thrombolysis (CDT) infusions in addition to a review of the literature on the use of thrombolytic therapy in children.
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Affiliation(s)
- Gary M Woods
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, United States
| | - Dennis W Kim
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, United States
| | - Matthew L Paden
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, United States
| | - Heather K Viamonte
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, United States
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5
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ARDS and Massive Pulmonary Embolism: The Combined Use of Extracorporeal Membrane Oxygenation (ECMO) with Thrombolytics. Case Rep Crit Care 2020; 2020:1032629. [PMID: 32411485 PMCID: PMC7204351 DOI: 10.1155/2020/1032629] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 01/30/2020] [Accepted: 02/14/2020] [Indexed: 12/12/2022] Open
Abstract
Pancreatitis causes a systemic inflammatory response that can lead to acute respiratory distress syndrome (ARDS). We present a case of severe ARDS complicated by a pulmonary embolism (PE) in a 39-year-old female that developed rapidly progressive pancreatitis secondary to hypertriglyceridemia.
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The use of alteplase in a newborn with an aortic arch thrombus during extracorporeal membrane oxygenation. Cardiol Young 2019; 29:1307-1309. [PMID: 31475664 DOI: 10.1017/s1047951119002026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
We report a neonatal case of the use of alteplase for the lysis of a large aortic arch thrombus formed during extracorporeal membrane oxygenation support. Alteplase (0.1-0.15 mg/kg/hour) was infused for thrombolysis, and meanwhile, unfractionated heparin was administrated at 5-10 U/kg/hour for the anticoagulation purpose. Alteplase was successfully administered to this neonate after the repair of congenital diaphragmatic hernia on extracorporeal membrane oxygenation, and the patient survived without apparent catastrophic long-term complications. It is reasonable to consider alteplase therapy during extracorporeal membrane oxygenation support in this setting.
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Van Ommen CH, Neunert CE, Chitlur MB. Neonatal ECMO. Front Med (Lausanne) 2018; 5:289. [PMID: 30410882 PMCID: PMC6209668 DOI: 10.3389/fmed.2018.00289] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Accepted: 09/21/2018] [Indexed: 11/13/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is becoming increasingly utilized to manage neonates with cardiac and respiratory failure. The procedure involves extensive anticoagulation in a sick neonate with underlying disease pathology. In addition, the immature hemostatic system in the neonate adds to the complexity of titrating the necessary anticoagulation. This places the infant at greater risk for life threatening hemorrhage and thrombosis. Managing anticoagulation in these infants is extremely challenging and needs the expertise of a physician with a thorough knowledge of the intricacies of developmental hemostasis and limitations of the current laboratory techniques available to manage anticoagulation. This article provides a brief overview of the developing hemostatic system of the neonate and the challenges associated with managing anticoagulation in this vulnerable population of patients.
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Affiliation(s)
| | - Cindy E Neunert
- Department of Pediatrics, Columbia University Medical Center, New York, NY, United States
| | - Meera B Chitlur
- Division of Hematology, Oncology, Carmen and Ann Adams Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit, MI, United States
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Martin AK, Allen WL, Fritz AV, Diaz-Gomez JL. Successful Rescue Utilization of Intraoperative Tissue Plasminogen Activator in the Setting of Massive Thrombosis of Avalon Catheter and Patient in Extremis with Refractory Hypoxemia. J Cardiothorac Vasc Anesth 2018; 32:2278-2281. [DOI: 10.1053/j.jvca.2017.12.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Indexed: 11/11/2022]
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Onwubiko C, Koppelmann T, Waters AM, Radulescu A, Chen MK, Martin CA, Anderson SA, Russell RT, Mortellaro VE, Rogers DA, Beierle EA. Systemic Thrombolysis of an Occlusive Aortic Thrombus in a Neonate on Extracorporeal Membrane Oxygenation. Am Surg 2018. [DOI: 10.1177/000313481808400911] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Chinwendu Onwubiko
- Division of Pediatric Surgery University of Alabama at Birmingham Birmingham, Alabama
| | - Tal Koppelmann
- Division of Pediatric Surgery University of Alabama at Birmingham Birmingham, Alabama
| | - Alicia M. Waters
- Division of Pediatric Surgery University of Alabama at Birmingham Birmingham, Alabama
| | - Andrei Radulescu
- Division of Pediatric Surgery University of Alabama at Birmingham Birmingham, Alabama
| | - Mike K. Chen
- Division of Pediatric Surgery University of Alabama at Birmingham Birmingham, Alabama
| | - Colin A. Martin
- Division of Pediatric Surgery University of Alabama at Birmingham Birmingham, Alabama
| | - Scott A. Anderson
- Division of Pediatric Surgery University of Alabama at Birmingham Birmingham, Alabama
| | - Robert T. Russell
- Division of Pediatric Surgery University of Alabama at Birmingham Birmingham, Alabama
| | - Vincent E. Mortellaro
- Division of Pediatric Surgery University of Alabama at Birmingham Birmingham, Alabama
| | - David A. Rogers
- Division of Pediatric Surgery University of Alabama at Birmingham Birmingham, Alabama
| | - Elizabeth A. Beierle
- Division of Pediatric Surgery University of Alabama at Birmingham Birmingham, Alabama
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Gutierrez ME, Alten JA, Law MA. Successful Angiojet ® aortic thrombectomy of extracorporeal membrane oxygenation-related thrombus in a newborn. Ann Pediatr Cardiol 2018; 11:300-303. [PMID: 30271021 PMCID: PMC6146852 DOI: 10.4103/apc.apc_26_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Thrombosis and systemic embolization are important complications of extracorporeal membrane oxygenation (ECMO). We present a 2.5 kg neonate born at 37.4 weeks with hypoplastic left heart supported on ECMO that developed an acute, occlusive distal aortic thrombus that was emergently managed by transcatheter Angiojet® (Boston Scientific, Boston, MA) thrombectomy. The procedure successfully restored perfusion to the lower extremities with sustained result upon 1-week follow-up. This case highlights the Angiojet® thrombectomy as a treatment option for limb- or organ-threatening acute thrombus in even the most complex ECMO patients.
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Affiliation(s)
- Maria Elena Gutierrez
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jeffrey A Alten
- Division of Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, Division of Critical Care, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Mark A Law
- Department of Pediatrics, Division of Pediatric Cardiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
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11
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Kim BJ, Song SH, Shin YR, Park HK, Park YH, Shin HJ. Intracardiac Thrombosis Involving All Four Cardiac Chambers after Extracardiac Membranous Oxygenation Associated with MTHFR Mutations. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2016; 49:207-9. [PMID: 27298801 PMCID: PMC4900866 DOI: 10.5090/kjtcs.2016.49.3.207] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Revised: 02/23/2016] [Accepted: 03/02/2016] [Indexed: 11/30/2022]
Abstract
A 4-month-old boy diagnosed with acute myocarditis was treated with extracorporeal membrane oxygenation (ECMO). Follow-up echocardiography eight hours after ECMO revealed intracardiac thrombosis involving all four heart chambers. Because of the high risk of systemic embolization due to a pedunculated thrombus of the aortic valve, we performed an emergency thrombectomy. After the operation, the patient had a minor neurologic sequela of left upper arm hypertonia, which had almost disappeared at the last outpatient clinic two months later. He was diagnosed with a major mutation in MTHFR (methylenetetrahydrofolate reductase), which is related to thrombosis.
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Affiliation(s)
- Bong Jun Kim
- Division of Cardiovascular Surgery, Department of Thoracic and Cardiovascular Surgery, Congenital Heart Disease Center, Severance Cardiovascular Hospital, Yonsei University College of Medicine
| | - Seung Hwan Song
- Division of Cardiovascular Surgery, Department of Thoracic and Cardiovascular Surgery, Congenital Heart Disease Center, Severance Cardiovascular Hospital, Yonsei University College of Medicine
| | - Yu Rim Shin
- Division of Cardiovascular Surgery, Department of Thoracic and Cardiovascular Surgery, Congenital Heart Disease Center, Severance Cardiovascular Hospital, Yonsei University College of Medicine
| | - Han Ki Park
- Division of Cardiovascular Surgery, Department of Thoracic and Cardiovascular Surgery, Congenital Heart Disease Center, Severance Cardiovascular Hospital, Yonsei University College of Medicine
| | - Young Hwan Park
- Division of Cardiovascular Surgery, Department of Thoracic and Cardiovascular Surgery, Congenital Heart Disease Center, Severance Cardiovascular Hospital, Yonsei University College of Medicine
| | - Hong Ju Shin
- Division of Cardiovascular Surgery, Department of Thoracic and Cardiovascular Surgery, Congenital Heart Disease Center, Severance Cardiovascular Hospital, Yonsei University College of Medicine; Department of Thoracic and Cardiovascular Surgery, Chungbuk National University Hospital, College of Medicine, Chungbuk National University
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12
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Crystal MA. Thrombolytic Use in Children: Breaking Down Barriers. J Pediatr 2016; 171:12-3. [PMID: 26778259 DOI: 10.1016/j.jpeds.2015.12.068] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 12/23/2015] [Indexed: 12/13/2022]
Affiliation(s)
- Matthew A Crystal
- Columbia University Medical Center, Morgan Stanley Children's Hospital of New York-New York Presbyterian Hospital, New York, New York.
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13
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Tissue Plasminogen Activator Use in Children: Bleeding Complications and Thrombus Resolution. J Pediatr 2016; 171:67-72.e1-2. [PMID: 26707578 DOI: 10.1016/j.jpeds.2015.11.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 10/02/2015] [Accepted: 11/06/2015] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To review our institutional experience with tissue plasminogen activator (tPA) to determine outcomes related to bleeding complications and thrombus resolution. STUDY DESIGN We performed a retrospective review of all patients who received systemic tPA for thrombolysis. Data points included location of thrombus, initial and maximum tPA dose, and duration of tPA. The primary endpoint was bleeding complication. RESULTS Between 2005 and 2014, 46 patients received systemic tPA for thrombolysis: 17 (37%) were patients with a primary cardiac diagnosis, there were 17 (37%) hematology/oncology patients, and 12 (26%) patients with noncardiac, nonhematology/oncology diagnoses. The indication for tPA was central venous thrombus (n = 23), pulmonary artery thrombus (n = 9), and cardiac or aortic thrombus (n = 14). Bleeding complications occurred in 15 patients (33%). Median initial tPA dose in the bleeding complication group was 0.10 mg/kg/h vs 0.03 mg/kg/h in the group without bleeding complication group (P = .01). Cardiac patients experienced more bleeding complications (P = .01). Multivariate analysis indicated that dose of tPA (P = .01) and diagnostic category (P < .01) were associated with bleeding complication. Complete thrombus resolution occurred in 21 patients, partial in 10 patients, and no resolution in 15 patients. Complete resolution of thrombus was not associated with diagnosis, thrombus location, tPA dose, or duration. CONCLUSIONS Cardiac patients appear to be at highest risk of bleeding complication; bleeding complications were associated with higher doses of tPA, and cardiac patients were the cohort who received the highest doses of tPA. Higher tPA doses are associated with increased risk of bleeding complication but are not associated with successful thrombus resolution.
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Pediatric Cardiac Intensive Care Society 2014 Consensus Statement: Pharmacotherapies in Cardiac Critical Care Anticoagulation and Thrombolysis. Pediatr Crit Care Med 2016; 17:S77-88. [PMID: 26945332 DOI: 10.1097/pcc.0000000000000623] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Thrombotic complications are increasingly being recognized as a significant cause of morbidity and mortality in pediatric and congenital heart disease. The objective of this article is to review the medications currently available to prevent and treat such complications. DATA SOURCES Online searches were conducted using PubMed. STUDY SELECTION Studies were selected for inclusion based on their scientific merit and applicability to the pediatric cardiac population. DATA EXTRACTION Pertinent information from each selected study or scientific review was extracted for inclusion. DATA SYNTHESIS Four classes of medications were identified as potentially beneficial in this patient group: anticoagulants, antiplatelet agents, thrombolytic agents, and novel oral anticoagulants. Data on each class of medication were synthesized into the follow sections: mechanism of action, pharmacokinetics, dosing, monitoring, reversal, considerations for use, and evidence to support. CONCLUSIONS Anticoagulants, antiplatelet agents, and thrombolytic agents are routinely used successfully in the pediatric patient with heart disease for the prevention and treatment of a wide range of thrombotic complications. Although the novel oral anticoagulants have been approved for a limited number of indications in adults, studies on the safety and efficacy of these agents in children are pending.
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Sangalli F, Greco G, Galbiati L, Formica F, Calcinati S, Avalli L. Regional Thrombolysis with Tenecteplase During Extracorporeal Membrane Oxygenation: A New Approach for Left Ventricular Thrombosis. J Card Surg 2015; 30:541-3. [DOI: 10.1111/jocs.12556] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Fabio Sangalli
- Department of Anesthesia and Intensive Care; San Gerardo Hospital; University of Milano-Bicocca; Monza Italy
| | - Gianluca Greco
- Department of Anesthesia and Intensive Care; San Gerardo Hospital; University of Milano-Bicocca; Monza Italy
| | - Lucia Galbiati
- Department of Anesthesia and Intensive Care; San Gerardo Hospital; University of Milano-Bicocca; Monza Italy
| | - Francesco Formica
- Department of Cardiac Surgery; San Gerardo Hospital; University of Milano-Bicocca; Monza Italy
| | - Serena Calcinati
- Department of Anesthesia and Intensive Care; San Gerardo Hospital; University of Milano-Bicocca; Monza Italy
| | - Leonello Avalli
- Department of Anesthesia and Intensive Care; San Gerardo Hospital; University of Milano-Bicocca; Monza Italy
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Increased risk of cardiovascular perforation during ECMO with a bicaval, wire-reinforced cannula. J Pediatr Surg 2014; 49:46-49; discussion 49-50. [PMID: 24439579 DOI: 10.1016/j.jpedsurg.2013.09.029] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2013] [Accepted: 09/30/2013] [Indexed: 11/23/2022]
Abstract
PURPOSE Cardiac or major vascular perforation is a rare but serious risk of ECMO. We sought to determine if perforation rates are related to cannula design. METHODS We utilized three methods to evaluate perforation on ECMO. 1. The ELSO registry was queried to establish the historical rate of hemorrhagic pericardial tamponade. 2. ELSO centers were surveyed regarding cannula related perforation events and brands of cannulas used over a four year time period (January 2008-March 2012). 3. The FDA's MAUDE database was reviewed looking for adverse events related to ECMO cannulas. RESULTS The historical rate of hemorrhagic pericardial tamponade in the ELSO registry was 0.53% (~1985-2010, ELSO registry). In the survey there were eleven reports of cannula-related perforation, 0.74% (11/1482 p-value=0.29) at 7 different ELSO centers with 23 ELSO centers responding (17% response rate). The incidence of perforation was much higher for the wire-reinforced bicaval design 3.6% (10/279) as compared to catheters designed for the atrial position, 0.1% (1/1203, p-value<0.0001). Review of the FDA's MAUDE database revealed 19 adverse events related to the bicaval cannula design, 16 of which were hemorrhagic pericardial effusions or tamponade. CONCLUSION These findings suggest a relatively high rate of cardiac perforation associated with the dual lumen bicaval cannula. This may be related to inherent differences in cannula design or the IVC positioning required by the design.
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Bělohlávek J, Springer D, Mlček M, Huptych M, Bouček T, Hodková G, Fichtl J, Mrázek V, Zima T, Linhart A, Kittnar O. Early vancomycin, amikacin and gentamicin concentrations in pulmonary artery and pulmonary tissue are not affected by VA ECMO (venoarterial extracorporeal membrane oxygenation) in a pig model of prolonged cardiac arrest. Pulm Pharmacol Ther 2013; 26:655-60. [DOI: 10.1016/j.pupt.2013.03.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Revised: 03/07/2013] [Accepted: 03/12/2013] [Indexed: 10/27/2022]
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Veress LA, Hendry-Hofer TB, Loader JE, Rioux JS, Garlick RB, White CW. Tissue plasminogen activator prevents mortality from sulfur mustard analog-induced airway obstruction. Am J Respir Cell Mol Biol 2013; 48:439-47. [PMID: 23258228 DOI: 10.1165/rcmb.2012-0177oc] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Sulfur mustard (SM) inhalation causes the rare but life-threatening disorder of plastic bronchitis, characterized by bronchial cast formation, resulting in severe airway obstruction that can lead to respiratory failure and death. Mortality in those requiring intubation is greater than 80%. To date, no antidote exists for SM toxicity. In addition, therapies for plastic bronchitis are solely anecdotal, due to lack of systematic research available to assess drug efficacy in improving mortality and/or morbidity. Adult rats exposed to SM analog were treated with intratracheal tissue plasminogen activator (tPA) (0.15-0.7 mg/kg, 5.5 and 6.5 h), compared with controls (no treatment, isoflurane, and placebo). Respiratory distress and pulse oximetry were assessed (for 12 or 48 h), and arterial blood gases were obtained at study termination (12 h). Microdissection of fixed lungs was done to assess airway obstruction by casts. Optimal intratracheal tPA treatment (0.7 mg/kg) completely eliminated mortality (0% at 48 h), and greatly improved morbidity in this nearly uniformly fatal disease model (90-100% mortality at 48 h). tPA normalized plastic bronchitis-associated hypoxemia, hypercarbia, and lactic acidosis, and improved respiratory distress (i.e., clinical scores) while decreasing airway fibrin casts. Intratracheal tPA diminished airway-obstructive fibrin-containing casts while improving clinical respiratory distress, pulmonary gas exchange, tissue oxygenation, and oxygen utilization in our model of severe chemically induced plastic bronchitis. Most importantly, mortality, which was associated with hypoxemia and clinical respiratory distress, was eliminated.
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Affiliation(s)
- Livia A Veress
- Department of Pediatrics, University of Colorado Health Sciences Center, Denver, CO, USA.
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