1
|
Li T, Bo F, Meng X, Wang D, Ma J, Dai Z. The effect of perioperative antithrombin supplementation on blood conservation and postoperative complications after cardiopulmonary bypass surgery: A systematic review, meta-analysis and trial sequential analysis. Heliyon 2023; 9:e22266. [PMID: 38053853 PMCID: PMC10694320 DOI: 10.1016/j.heliyon.2023.e22266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 11/07/2023] [Accepted: 11/08/2023] [Indexed: 12/07/2023] Open
Abstract
Study objective Antithrombin (AT) activity is reduced during cardiopulmonary bypass (CPB) surgery. Guidelines has demonstrated that perioperative AT supplementation contributed to blood conservation and prevent perioperative thrombotic complications and target organ injury owing to its role in reducing thrombin generation. But these recommends is lack of support of meta-analysis in the guidelines. This meta-analysis aims to include all the relevant randomized controlled trails (RCT) on patients who experienced cardiac surgeries with CPB and investigate the effect of perioperative AT on blood conservation and complications after cardiac surgery. Methods Standard published RCTs were searched from bibliographic databases to identify all evidence reporting perioperative AT supplementation for patients undergoing cardiovascular surgeries. The primary outcome was postoperative blood loss, the secondary outcomes were blood component transfusion (red blood cell (RBC), fresh frozen plasma (FFP), platelet and autologous blood), postoperative morbidity and in hospital mortality. The relative risk (RR) for dichotomous outcomes and the standardized mean difference (SMD) for continuous outcomes were estimated using a random-effects model. Trial sequential analysis (TSA) was performed using TSA software 0.9.5.10. Results 13 RCTs with 996 participants undergoing different cardiovascular surgeries were included. Meta-analysis showed AT did not decrease postoperative blood loss (SMD -0.01, 95%CI -0.2 to 0.19). Subgroup analysis showed the effect of AT on postoperative blood loss was not associated with age, RCT type, surgery type, injection time of AT and AT deficiency. TSA further suggested that no additional studies were required for the stable result. Perioperative AT also did not reduce RBC ((SMD 0.10, 95%CI -0.66 to 0.85), (RR 0.99, 95%CI 0.83 to 1.19)), FFP ((SMD 0.11, 95%CI -0.19 to 0.41), (RR 1.30, 95%CI 0.90 to 1.87)), platelet (RR 1.10, 95%CI 0.83 to 1.46) and autologous blood (SMD 0.46, 95%CI -0.12 to 1.8504) transfusions. Perioperative AT significantly increased in hospital mortality (RR 2.53, 95%CI 1.02 to 6.28) and acute kidney injury (AKI) (RR 3.72, 95%CI 1.73 to 8.04) incidence. There was no significant difference in postoperative reexploration, thromboembolism, ECMO/IABP support, and stroke incidence between AT and non-AT group. Conclusions With the improvement of AT level and heparin sensitivity, perioperative AT has no significant effect on blood conservation. And it is noteworthy that the treatment increased in hospital mortality and the incidence of AKI after cardiac surgery.
Collapse
Affiliation(s)
- Tao Li
- Department of Anesthesiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, 264000, Shandong, China
| | - FengShan Bo
- Department of Anesthesiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, 264000, Shandong, China
| | - XiangRui Meng
- Department of Anesthesiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, 264000, Shandong, China
| | - Di Wang
- Department of Internal Medicine, Yantai Haigang Hospital, Yantai, 264000, Shandong, China
| | - Jiahai Ma
- Department of Anesthesiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, 264000, Shandong, China
| | - Zhao Dai
- Department of Anesthesiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, 264000, Shandong, China
| |
Collapse
|
2
|
Cardenas JC, Wang YW, Karri JV, Vincent S, Cap AP, Cotton BA, Wade CE. Supplementation with antithrombin III ex vivo optimizes enoxaparin responses in critically injured patients. Thromb Res 2020; 187:131-138. [PMID: 31986476 DOI: 10.1016/j.thromres.2020.01.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 12/17/2019] [Accepted: 01/13/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND The high incidence of venous thromboembolism (VTE) following trauma persists in spite of aggressive thromboprophylaxis strategies. Approximately half of VTE patients do not achieve the recommended anti-FXa response to enoxaparin anticoagulation (0.1-0.4 IU/mL), however, research to explain or correct this phenomenon is lacking. We hypothesized that antithrombin III (AT) deficiency is associated with poor enoxaparin responsiveness in trauma patients that develop VTE which can be reversed through supplementation with AT. METHODS AND FINDINGS A retrospective cohort study was performed on plasma collected from trauma patients who did and did not develop pulmonary embolism (PE) as well as healthy volunteers. AT levels, thrombin generation, and anti-FXa levels were measured in the collected plasma at baseline and in response to supplementation with AT concentrate at 120-200% or plasma (30% volume). A total of 54 PE patients and 46 non-PE patients were enrolled in this study for analysis. Compared to healthy volunteers, trauma patients had lower levels of AT, elevated thrombin generation, and lower anti-FXa levels in response to enoxaparin. Moreover, thrombin generation was higher and responses to enoxaparin were lower in patients who developed PE compared to those who did not develop PE. We found that supplementation with AT, but not plasma, increased AT levels and improved enoxaparin-mediated inhibition of thrombin generation. CONCLUSIONS Supplementation with AT may provide a novel adjunct therapy to increase the effectiveness of enoxaparin thromboprophylaxis and reduce the incidence of VTE in the trauma population.
Collapse
Affiliation(s)
- Jessica C Cardenas
- The Center for Translational Injury Research, Department of Surgery, UTHealth McGovern Medical School, Houston, TX, United States of America; Red Duke Trauma Institute, Memorial Hermann Hospital, Houston, TX, United States of America.
| | - Yao-Wei Wang
- Red Duke Trauma Institute, Memorial Hermann Hospital, Houston, TX, United States of America
| | - Jay V Karri
- Red Duke Trauma Institute, Memorial Hermann Hospital, Houston, TX, United States of America
| | - Seenya Vincent
- Red Duke Trauma Institute, Memorial Hermann Hospital, Houston, TX, United States of America
| | - Andrew P Cap
- The Center for Translational Injury Research, Department of Surgery, UTHealth McGovern Medical School, Houston, TX, United States of America; U.S. Army Institute of Surgical Research, Fort Sam Houston, San Antonio, TX, United States of America
| | - Bryan A Cotton
- The Center for Translational Injury Research, Department of Surgery, UTHealth McGovern Medical School, Houston, TX, United States of America; Red Duke Trauma Institute, Memorial Hermann Hospital, Houston, TX, United States of America
| | - Charles E Wade
- The Center for Translational Injury Research, Department of Surgery, UTHealth McGovern Medical School, Houston, TX, United States of America; Red Duke Trauma Institute, Memorial Hermann Hospital, Houston, TX, United States of America
| |
Collapse
|
3
|
Preoperative Low-Molecular-Weight Heparin Prophylaxis Associated with Increased Heparin Resistance Frequency in On-Pump Coronary Artery Bypass Graft Surgery. Cardiol Res Pract 2019; 2019:4310407. [PMID: 31143477 PMCID: PMC6501132 DOI: 10.1155/2019/4310407] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 12/09/2018] [Accepted: 03/18/2019] [Indexed: 11/21/2022] Open
Abstract
Background Unfractionated heparin (UFH) and low-molecular-weight heparin (LMWH) are being used for preoperative management of critical coronary artery disease. However, preoperative UFH therapy may cause a reduction in antithrombin concentrations, leading to various degrees of heparin resistance (HR). The main purpose of this study is to investigate the effects of preoperative LMWH on HR during cardiopulmonary bypass (CPB). Methods Data were retrospectively reviewed from adult patients that underwent on-pump coronary artery bypass graft (CABG) surgery. Four hundred fifty-seven patients underwent CABG, and 139 of them, who had isolated on-pump CABG, were included in the study. The heparin sensitivity index was calculated if activated clotting time levels were discovered below 400 seconds. Values less than 1.3 were accepted as HR. Results Of 139 patients who underwent on-pump CABG, preoperative LMWH was administered in 59 patients (56.8%). Intraoperative HR occurred in 29 patients (20.9%). Patients who received preoperative LMWH had an increased risk of developing HR compared with patients who did not receive LMWH (odds ratio 4.8 and 95% confidence interval 1.7–13.5). CPB duration and aortic clamp duration were significantly longer in patients who developed intraoperative HR when compared to those in patients who did not develop HR. Conclusion Preoperative treatment with LMWH may cause intraoperative HR. Corrective and preventive arrangements with close follow-up should be performed in this group of patients.
Collapse
|
4
|
Abstract
BACKGROUND Critical illness is associated with uncontrolled inflammation and vascular damage which can result in multiple organ failure and death. Antithrombin III (AT III) is an anticoagulant with anti-inflammatory properties but the efficacy and any harmful effects of AT III supplementation in critically ill patients are unknown. This review was published in 2008 and updated in 2015. OBJECTIVES To examine:1. The effect of AT III on mortality in critically ill participants.2. The benefits and harms of AT III.We investigated complications specific and not specific to the trial intervention, bleeding events, the effect on sepsis and disseminated intravascular coagulation (DIC) and the length of stay in the intensive care unit (ICU) and in hospital in general. SEARCH METHODS We searched the following databases from inception to 27 August 2015: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid SP), EMBASE (Ovid SP,), CAB, BIOSIS and CINAHL. We contacted the main authors of trials to ask for any missed, unreported or ongoing trials. SELECTION CRITERIA We included randomized controlled trials (RCTs) irrespective of publication status, date of publication, blinding status, outcomes published, or language. We contacted the investigators and the trial authors in order to retrieve missing data. In this updated review we include trials only published as abstracts. DATA COLLECTION AND ANALYSIS Our primary outcome measure was mortality. Two authors each independently abstracted data and resolved any disagreements by discussion. We presented pooled estimates of the intervention effects on dichotomous outcomes as risk ratios (RR) with 95% confidence intervals (CI). We performed subgroup analyses to assess risk of bias, the effect of AT III in different populations (sepsis, trauma, obstetrics, and paediatrics), and the effect of AT III in patients with or without the use of concomitant heparin. We assessed the adequacy of the available number of participants and performed trial sequential analysis (TSA) to establish the implications for further research. MAIN RESULTS We included 30 RCTs with a total of 3933 participants (3882 in the primary outcome analyses).Combining all trials, regardless of bias, showed no statistically significant effect of AT III on mortality with a RR of 0.95 (95% CI 0.88 to 1.03), I² statistic = 0%, fixed-effect model, 29 trials, 3882 participants, moderate quality of evidence). For trials with low risk of bias the RR was 0.96 (95% Cl 0.88 to 1.04, I² statistic = 0%, fixed-effect model, 9 trials, 2915 participants) and for high risk of bias RR 0.94 (95% Cl 0.77 to 1.14, I² statistic = 0%, fixed-effect model, 20 trials, 967 participants).For participants with severe sepsis and DIC the RR for mortality was non-significant, 0.95 (95% Cl 0.88 to 1.03, I² statistic = 0%, fixed-effect model, 12 trials, 2858 participants, moderate quality of evidence).We conducted 14 subgroup and sensitivity analyses with respect to the different domains of risk of bias, but detected no statistically significant benefit in any subgroup analyses.Our secondary objective was to assess the benefits and harms of AT III. For complications specific to the trial intervention the RR was 1.26 (95% Cl 0.83 to 1.92, I² statistic = 0%, random-effect model, 3 trials, 2454 participants, very low quality of evidence). For complications not specific to the trial intervention, the RR was 0.71 (95% Cl 0.08 to 6.11, I² statistic = 28%, random-effects model, 2 trials, 65 participants, very low quality of evidence). For complications other than bleeding, the RR was 0.72 ( 95% Cl 0.42 to 1.25, I² statistic = 0%, fixed-effect model, 3 trials, 187 participants, very low quality of evidence). Eleven trials investigated bleeding events and we found a statistically significant increase, RR 1.58 (95% CI 1.35 to 1.84, I² statistic = 0%, fixed-effect model, 11 trials, 3019 participants, moderate quality of evidence) in the AT III group. The amount of red blood cells administered had a mean difference (MD) of 138.49 (95% Cl -391.35 to 668.34, I² statistic = 84%, random-effect model, 4 trials, 137 participants, very low quality of evidence). The effect of AT III in patients with multiple organ failure (MOF) was a MD of -1.24 (95% Cl -2.18 to -0.29, I² statistic = 48%, random-effects model, 3 trials, 156 participants, very low quality of evidence) and for patients with an Acute Physiology and Chronic Health Evaluation score (APACHE) at II and III the MD was -2.18 (95% Cl -4.36 to -0.00, I² statistic = 0%, fixed-effect model, 3 trials, 102 participants, very low quality of evidence). The incidence of respiratory failure had a RR of 0.93 (95% Cl 0.76 to 1.14, I² statistic = 32%, random-effects model, 6 trials, 2591 participants, moderate quality of evidence). AT III had no statistically significant impact on the duration of mechanical ventilation (MD 2.20 days, 95% Cl -1.21 to 5.60, I² statistic = 0%, fixed-effect model, 3 trials, 190 participants, very low quality of evidence); on the length of stay in the ICU (MD 0.24, 95% Cl -1.34 to 1.83, I² statistic = 0%, fixed-effect model, 7 trials, 376 participants, very low quality of evidence) or on the length of stay in hospital in general (MD 1.10, 95% Cl -7.16 to 9.36), I² statistic = 74%, 4 trials, 202 participants, very low quality of evidence). AUTHORS' CONCLUSIONS There is insufficient evidence to support AT III substitution in any category of critically ill participants including the subset of patients with sepsis and DIC. We did not find a statistically significant effect of AT III on mortality, but AT III increased the risk of bleeding events. Subgroup analyses performed according to duration of intervention, length of follow-up, different patient groups, and use of adjuvant heparin did not show differences in the estimates of intervention effects. The majority of included trials were at high risk of bias (GRADE; very low quality of evidence for most of the analyses). Hence a large RCT of AT III is needed, without adjuvant heparin among critically ill patients such as those with severe sepsis and DIC, with prespecified inclusion criteria and good bias protection.
Collapse
Affiliation(s)
- Mikkel Allingstrup
- Rigshospitalet, Copenhagen University HospitalJuliane Marie Centre ‐ Anaesthesia and Surgical Clinic Department 4013CopenhagenDenmark
- Rigshospitalet, Copenhagen University HospitalDepartment of Paediatric and Obstetric AnaesthesiaCopenhagenDenmark
| | - Jørn Wetterslev
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Frederikke B Ravn
- RigshospitaletDepartment of Paediatric and Obstetric AnaesthesiaBlegdamsvej 9, Afsnit 3342, rum 52CopenhagenDenmark
| | - Ann Merete Møller
- Herlev and Gentofte Hospital, University of CopenhagenCochrane Anaesthesia, Critical and Emergency Care GroupHerlev RingvejHerlevDenmark2730
| | - Arash Afshari
- Rigshospitalet, Copenhagen University HospitalJuliane Marie Centre ‐ Anaesthesia and Surgical Clinic Department 4013CopenhagenDenmark
| | | |
Collapse
|
5
|
Niebler RA, Woods KJ, Murkowski K, Ghanayem NS, Hoffman G, Mitchell ME, Punzalan RC, Scott JP, Simpson P, Tweddell JS. A Pilot Study of Antithrombin Replacement Prior to Cardiopulmonary Bypass in Neonates. Artif Organs 2015; 40:80-5. [PMID: 26620919 DOI: 10.1111/aor.12642] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Neonates have low levels of antithrombin. Inadequate anticoagulation during cardiopulmonary bypass (CPB) due to low antithrombin activity may result in a poor preservation of the coagulation system during bypass. We hypothesize that antithrombin replacement to neonates prior to CPB will preserve the hemostatic system and result in less postoperative bleeding. A randomized, double-blinded, placebo-controlled pilot study of antithrombin replacement to neonates prior to CPB was conducted. Preoperative antithrombin levels determined the dose of recombinant antithrombin or placebo to be given. Antithrombin levels were measured following the dosing of the antithrombin/placebo, after initiation of bypass, near the completion of bypass, and upon intensive care unit admission. Eight subjects were enrolled. No subject had safety concerns. Mediastinal exploration occurred in two antithrombin subjects and one placebo subject. Antithrombin activity levels were significantly higher in the treated group following drug administration; levels continued to be higher than preoperatively but not different from the placebo group at all other time points. Total heparin administration was less in the antithrombin group; measurements of blood loss were similar in both groups. A single dose of recombinant antithrombin did not maintain 100% activity levels throughout the entire operation. Although no safety concerns were identified in this pilot study, a larger trial is necessary to determine clinical efficacy.
Collapse
Affiliation(s)
- Robert A Niebler
- Section of Critical Care, Medical College of Wisconsin, Milwaukee, WI, USA.,Herma Heart Center at Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Katherine J Woods
- Section of Critical Care, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Kathleen Murkowski
- Section of Critical Care, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Nancy S Ghanayem
- Section of Critical Care, Medical College of Wisconsin, Milwaukee, WI, USA.,Herma Heart Center at Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - George Hoffman
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA.,Herma Heart Center at Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Michael E Mitchell
- Department of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.,Herma Heart Center at Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Rowena C Punzalan
- Section of Hematology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - J Paul Scott
- Section of Hematology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Pippa Simpson
- Section of Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - James S Tweddell
- Department of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.,Herma Heart Center at Children's Hospital of Wisconsin, Milwaukee, WI, USA
| |
Collapse
|
6
|
Desborough M, Sandu R, Brunskill SJ, Doree C, Trivella M, Montedori A, Abraha I, Stanworth S. Fresh frozen plasma for cardiovascular surgery. Cochrane Database Syst Rev 2015; 2015:CD007614. [PMID: 26171897 PMCID: PMC8406941 DOI: 10.1002/14651858.cd007614.pub2] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Fresh frozen plasma (FFP) is a blood component containing procoagulant factors, which is sometimes used in cardiovascular surgery with the aim of reducing the risk of bleeding. The purpose of this review is to assess the risk of mortality for patients undergoing cardiovascular surgery who receive FFP. OBJECTIVES To evaluate the risk to benefit ratio of FFP transfusion in cardiovascular surgery for the treatment of bleeding patients or for prophylaxis against bleeding. SEARCH METHODS We searched 11 bibliographic databases and four ongoing trials databases including the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 3, 2015), MEDLINE (OvidSP, 1946 to 21 April 2015), EMBASE (OvidSP, 1974 to 21 April 2015), PubMed (e-publications only: searched 21 April 2015), ClinicalTrials.gov, World Health Organization (WHO) ICTRP and the ISRCTN Register (searched 21 April 2015). We also searched the references of all identified trials and relevant review articles. We did not limit the searches by language or publication status. SELECTION CRITERIA We included randomised controlled trials in patients undergoing major cardiac or vascular surgery who were allocated to a FFP group or a comparator (no plasma or an active comparator, either clinical plasma (any type) or a plasma-derived blood product). We included participants of any age (neonates, children and adults). We excluded studies of plasmapheresis and plasma exchange. DATA COLLECTION AND ANALYSIS Two authors screened all electronically derived citations and abstracts of papers identified by the review search strategy. Two authors assessed risk of bias in the included studies and extracted data independently. We took care to note whether FFP was used therapeutically or prophylactically within each trial. MAIN RESULTS We included 15 trials, with a total of 755 participants for analysis in the review. Fourteen trials compared prophylactic use of FFP against no FFP. One study compared therapeutic use of two types of plasma. The timing of intervention varied, including FFP transfusion at the time of heparin neutralisation and stopping cardiopulmonary bypass (CPB) (seven trials), with CPB priming (four trials), after anaesthesia induction (one trial) and postoperatively (two trials). Twelve trials excluded patients having emergency surgery and nine excluded patients with coagulopathies.Overall the trials were small, with only four reporting an a priori sample size calculation. No trial was powered to determine changes in mortality as a primary outcome. There was either high risk of bias, or unclear risk, in the majority of trials included in this review.There was no difference in the number of deaths between the intervention arms in the six trials (with 287 patients) reporting mortality (very low quality evidence). There was also no difference in blood loss in the first 24 hours for neonatal/paediatric patients (four trials with 138 patients; low quality evidence): mean difference (MD) -1.46 ml/kg (95% confidence interval (CI) -4.7 to 1.78 ml/kg); or adult patients (one trial with 120 patients): MD -12.00 ml (95% CI -101.16 to 77.16 ml).Transfusion with FFP was inferior to control for preventing patients receiving any red cell transfusion: Peto odds ratio (OR) 2.57 (95% CI 1.30 to 5.08; moderate quality evidence). There was a difference in prothrombin time within two hours of FFP transfusion in eight trials (with 210 patients; moderate quality evidence) favouring the FFP arm: MD -0.71 seconds (95% CI -1.28 to -0.13 seconds). There was no difference in the risk of returning to theatre for reoperation (eight trials with 398 patients; moderate quality evidence): Peto OR 0.81 (95% CI 0.26 to 2.57). Only one included study reported adverse events as an outcome and reported no significant adverse events following FFP transfusion. AUTHORS' CONCLUSIONS This review has found no evidence to support the prophylactic administration of FFP to patients without coagulopathy undergoing elective cardiac surgery. There was insufficient evidence about treatment of patients with coagulopathies or those who are undergoing emergency surgery. There were no reported adverse events attributable to FFP transfusion, although there was a significant increase in the number of patients requiring red cell transfusion who were randomised to FFP. Variability in outcome reporting between trials precluded meta-analysis for many outcomes across all trials, and there was evidence of a high risk of bias in most of the studies. Further adequately powered studies of FFP, or comparable pro-haemostatic agents, are required to assess whether larger reductions in prothrombin time translate into clinical benefits. Overall the evidence from randomised controlled trials for the safety and efficacy of prophylactic transfusion of FFP for cardiac surgery is insufficient.
Collapse
|
7
|
Antithrombin concentrates use in children on extracorporeal membrane oxygenation: a retrospective cohort study. Pediatr Crit Care Med 2015; 16:264-9. [PMID: 25581634 DOI: 10.1097/pcc.0000000000000322] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate whether receipt of any antithrombin concentrate improves laboratory and clinical outcomes in children undergoing extracorporeal membrane oxygenation for respiratory failure during their hospitalization compared with those who did not receive antithrombin. DESIGN Retrospective cohort study. SETTING Single, tertiary-care pediatric hospital. PATIENTS Sixty-four neonatal and pediatric patients who underwent extracorporeal membrane oxygenation for respiratory failure between January 2007 and September 2011. INTERVENTION Exposure to any antithrombin concentrate during their extracorporeal membrane oxygenation course compared with similar children who never received antithrombin concentrate. MEASUREMENTS AND MAIN RESULTS Thirty patients received at least one dose of antithrombin during their extracorporeal membrane oxygenation course and 34 patients did not receive any. The median age at admission was less than 1-month old. Age, duration of extracorporeal membrane oxygenation, or first antithrombin level did not differ significantly between the two cohorts. The mean plasma antithrombin level in those who never received antithrombin was 42.2% compared with 66% in those who received it. However, few levels reached the targeted antithrombin level of 120% and those who did fell back to deficient levels within an average of 6.8 hours. For those who received antithrombin concentrate, heparin infusion rates decreased by an average of 10.2 U/kg/hr for at least 12 hours following administration. No statistical differences were noted in the number of extracorporeal membrane oxygenation circuit changes, in vivo clots or hemorrhages, transfusion requirements, hospital or ICU length of stay, or in-hospital mortality. CONCLUSIONS Intermittent, on-demand dosing of antithrombin concentrate in pediatric patients on extracorporeal membrane oxygenation for respiratory failure increased antithrombin levels, but not typically to the targeted level. Patients who received antithrombin concentrate also had decreased heparin requirements for at least 12 hours after dosing. However, no differences were noted in the measured clinical endpoints. A prospective, randomized study of this intervention may require different dosing strategies; such a study is warranted given the unproven efficacy of this costly product.
Collapse
|
8
|
Wong TE, Huang YS, Weiser J, Brogan TV, Shah SS, Witmer CM. Antithrombin concentrate use in children: a multicenter cohort study. J Pediatr 2013; 163:1329-34.e1. [PMID: 23932317 PMCID: PMC3812320 DOI: 10.1016/j.jpeds.2013.06.036] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Revised: 05/24/2013] [Accepted: 06/18/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To describe the off-label use of antithrombin concentrate in tertiary care pediatric hospitals across the US. STUDY DESIGN This is a retrospective, multicenter, cohort study of 4210 admissions of children younger than 18 years of age who received antithrombin concentrate between 2002 and 2011 within the Pediatric Health Information System administrative database. An on-label admission was defined as an admission with an International Classification of Diseases diagnostic code for a primary hypercoagulable state; admissions without this code were classified as off-label. RESULTS During the 10-year study period, off-label use of antithrombin concentrate increased 5-fold. Overall, 97% of study subjects received antithrombin off-label. Neonates younger than 30 days of age comprised the largest age group (45.7%) of use; 87% of patients had at least one complex chronic condition, with congenital heart/lung defects being the most prevalent primary diagnosis (36.3%). Extracorporeal membrane oxygenation was the most common procedure associated with antithrombin use (43.7%). CONCLUSIONS The off-label use of antithrombin concentrate is increasing rapidly, particularly in critically ill children receiving extracorporeal membrane oxygenation, with few parallel studies to substantiate its safety or efficacy. Further preclinical and controlled clinical studies are critical to expanding our knowledge of this drug. In the meantime, antithrombin concentrate should be used judiciously by clinicians and following guidelines instated by hospitals.
Collapse
Affiliation(s)
- Trisha E. Wong
- Puget Sound Blood Center, Seattle, WA,Division of Hematology/Oncology, Department of Pediatrics, Seattle Children’s Hospital, University of Washington, Seattle, WA
| | - Yuan-Shung Huang
- Division of General Pediatrics, Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Jason Weiser
- Division of Hospital Medicine, Cincinnati Children’s Hospital and Medical Center, Cincinnati, OH
| | - Thomas V. Brogan
- Division of Critical Care, Department of Pediatrics, Seattle Children’s Hospital, University of Washington, Seattle, WA
| | - Samir S. Shah
- Division of Hospital Medicine, Cincinnati Children’s Hospital and Medical Center, Cincinnati, OH,Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Char M. Witmer
- Division of Hematology, The Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA
| |
Collapse
|
9
|
Current world literature. Curr Opin Cardiol 2012; 27:682-95. [PMID: 23075824 DOI: 10.1097/hco.0b013e32835a0ad8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|