Bleeding and Thrombosis in Pediatric Cardiac Intensive Care

Bivalirudin versus Heparin in Pediatric and Adult Patients on Extracorporeal Membrane Oxygenation: A Meta-analysis

AIMS

Unfractionated heparin (UFH) has been the primary anticoagulant of choice on extracorporeal membrane oxygenation (ECMO). However, it is debatable whether bivalirudin (BIV), a direct thrombin inhibitor, may be considered a better alternative anticoagulant option.

METHODS

We searched Embase, Pubmed, Cochrane library, Clinicaltrials.gov, CNKI, and Wanfang databases up to June 15, 2021. Randomized controlled trials (RCTs) and observational studies were considered eligible for inclusion. Random-effects meta-analyses, including subgroup analyses, were conducted.

RESULTS

A total of 9 studies containing 994 patients were enrolled. All articles were retrospective cohort studies. Compared with UFH, BIV was associated with lower risks of major bleeding (risk ratio [RR]: 0.32, 95% confidence interval [CI] 0.22-0.49), ECMO in-circuit thrombosis (RR: 0.57, 95% CI 0.43-0.74), stroke (RR: 0.52, 95% CI 0.29-0.95), in-hospital mortality (RR: 0.82, 95% CI 0.69-0.99) and higher rates of survival to ECMO decannulation (RR: 1.18, 95% CI 1.03-1.34). Pooled risk estimates did not show a significant association with clinical thrombotic events (RR: 0.69, 95% CI 0.45-1.07). Moreover, BIV was associated with a lower risk of ECMO in-circuit thrombosis and in-hospital mortality in the adult subgroup but not in the pediatric subgroup. However, leave-one-out sensitivity analyses indicated that the results of stroke, survival to ECMO decannulation and in-hospital mortality should be interpreted with caution.

CONCLUSIONS

BIV appears to be a potential alternative to UFH in pediatric and adult patients requiring ECMO.

Bivalirudin May Reduce the Need for Red Blood Cell Transfusion in Pediatric Cardiac Patients on Extracorporeal Membrane Oxygenation

We retrospectively compared anticoagulation with heparin and bivalirudin for 32 consecutive children under 18 years old during extracorporeal membrane oxygenation (ECMO) in our pediatric cardiac intensive care unit (PCICU). Between September 2015 and January 2018, 14 patients received heparin, 13 venoarterial (VA), and 1 venovenous (VV). From February 2018 to September 2019, 18 received bivalirudin (all VA). The mean (standard deviation [SD]) percentage of time with therapeutic activated partial thromboplastin time and activated clotting time was bivalirudin 54 (14%) and heparin 57 (11%), p = 0.4647, and percentage of time supratherapeutic was bivalirudin 18 (10%) and heparin 27 (12%), p = 0.0238. Phlebotomy-associated blood loss per hour of ECMO was double in the heparin compared with bivalirudin group 1.08 ml/h (0.20 ml/h), compared with 0.51 ml/h (0.07 ml/h), p = 0.0003, as well as interventions to control bleeding. Packed red blood cell (PRBC) transfusions significantly correlated with higher blood loss in the heparin group (Pearson correlation coefficient = 0.49, p = 0.0047). Overall amount of blood product utilization was not different between the groups. Survival to ECMO decannulation was 89% for bivalirudin and 57% for heparin, p = 0.0396, although 6 month survival was not significantly different (67% versus 57%, p = 0.5809). Heparin may increase the need for PRBC transfusions and strategies to attenuate bleeding when compared with bivalirudin for children receiving ECMO in PCICU.

Bleeding in Critically Ill Children-Review of Literature, Knowledge Gaps, and Suggestions for Future Investigation

Clinically significant bleeding complicates up to 20% of admissions to the intensive care unit in adults and is associated with severe physiologic derangements, requirement for significant interventions and worse outcome. There is a paucity of published data on bleeding in critically ill children. In this manuscript, we will provide an overview of the epidemiology and characteristics of bleeding in critically ill children, address the association between bleeding and clinical outcomes, describe the current definitions of bleeding and their respective limitations, and finally provide an overview of current knowledge gaps and suggested areas for future research.

Useful References in Pediatric Cardiac Intensive Care: The 2017 Update

OBJECTIVES

Pediatric cardiac intensive care continues to evolve, with rapid advances in knowledge and improvement in clinical outcomes. In the past, the Board of Directors of the Pediatric Cardiac Intensive Care Society created and subsequently updated a list of sentinel references focused on the care of critically ill children with congenital and acquired heart disease. The objective of this article is to provide clinicians with a compilation and brief summary of updated and useful references that have been published since 2012.

DATA SELECTION

Pediatric Cardiac Intensive Care Society members were solicited via a survey sent out between March 20, 2017, and April 28, 2017, to provide important references that have impacted clinical care. The survey was sent to approximately 523 members. Responses were received from 45 members, of which some included multiple references.

DATA EXTRACTION

Following review of the list of references, and removing editorials, references were compiled by the first and last author. The final list was submitted to members of the society's Research Briefs Committee, who ranked each publication.

DATA SYNTHESIS

Rankings were compiled and the references with the highest scores included. Research Briefs Committee members ranked the articles from 1 to 3, with one being highly relevant and should be included and 3 being less important and should be excluded. Averages were computed, and the top articles included in this article. The first (K.C.U.) and last author (K.M.G.) reviewed and developed summaries of each article.

CONCLUSIONS

This article contains a compilation of useful references for the critical care of children with congenital and acquired heart disease published in the last 5 years. In conjunction with the prior version of this update in 2012, this article may be used as an educational reference in pediatric cardiac intensive care.