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Haftmann RJ, Pineda EM, Hall BA, Wilson MD, Mateev SN. Comparison of Time Within Therapeutic Range Using Anti-Factor Xa Versus Activated Partial Thromboplastin Time Monitoring of Unfractionated Heparin in Children. J Pediatr Pharmacol Ther 2023; 28:228-234. [PMID: 37303766 PMCID: PMC10249978 DOI: 10.5863/1551-6776-28.3.228] [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: 04/13/2022] [Accepted: 07/19/2022] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To compare unfractionated heparin (UFH) monitoring using time in therapeutic range of activated partial thromboplastin time (aPTT) versus anti-factor Xa activity (anti-Xa) in children. METHODS This retrospective chart review, with data between October 2015 and October 2019, included pediatric patients younger than 18 years on therapeutic UFH infusion with aPTT or anti-Xa monitoring. Patients receiving extracorporeal membrane oxygenation, dialysis, concomitant anticoagulants, prophylactic UFH, no stated goal, and UFH administered for less than 12 hours were excluded. The primary outcome compared the percentage of time in therapeutic range between aPTT and anti-Xa. Secondary outcomes included time to first therapeutic value, UFH infusion rates, mean rate adjustments, and adverse events. RESULTS A total of 65 patients were included, with 33 aPTT patients and 32 anti-Xa patients, representing 39 UFH orders in each group. Baseline characteristics were similar between groups, with an overall mean age of 1.4 years and mean weight of 6.7 kg. The anti-Xa cohort demonstrated a statistically significantly higher percentage of time in therapeutic range compared with the aPTT group (50.3% vs 26.9%, p = 0.002). The anti-Xa group also demonstrated a trend toward decreased time to first therapeutic value compared with aPTT (14 vs 23.2 hours, p = 0.12). Two patients in each group experienced new or worsening thrombosis. Six patients in the aPTT cohort experienced bleeding. CONCLUSIONS This study demonstrated greater time was spent within therapeutic range for children receiving UFH monitored with anti-Xa compared with aPTT. Future studies should assess clinical outcomes in a larger population.
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Affiliation(s)
- Richard J. Haftmann
- Department of Pharmacy Services (RJH, BAH), University of California, Davis Health, Sacramento, CA
| | - Erika May Pineda
- Department of Pharmacy Services (EMP), Children's Hospital of Philadelphia, Philadelphia, PA
| | - Brent A. Hall
- Department of Pharmacy Services (RJH, BAH), University of California, Davis Health, Sacramento, CA
| | - Machelle D. Wilson
- Department of Public Health Sciences (MDW), Division of Biostatistics, Clinical and Translational Science Center, University of California, Davis Health, Sacramento, CA
| | - Stephanie N. Mateev
- Department of Pediatrics, Division of Pediatric Critical Care (SNM), University of California, Davis Health, Sacramento, CA
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2
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Male C. Anticoagulation in Pediatric Patients. Hamostaseologie 2022; 42:46-53. [PMID: 35042258 DOI: 10.1055/a-1703-0821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Special aspects of anticoagulation in children include the different epidemiology of thrombosis, developmental changes in the coagulation system, age-dependent pharmacokinetics of anticoagulants, risk of bleeding, and practical hurdles to anticoagulation. The classical anticoagulants so far used in children have several limitations, resulting in the need for regular monitoring. The pharmacological properties of direct oral anticoagulants (DOACs) and the special challenges of anticoagulation in children make the DOACs particularly attractive for children. All DOACs have pediatric development programs, targeting various indications for prevention and treatment of thrombosis. Child-appropriate formulations have been developed, age-specific dosing information generated, and safety and efficacy evaluated in ongoing phase 3 trials. Rivaroxaban and dabigatran have already been authorized for children for treatment of acute venous thrombosis and for extended secondary prevention. Their safety and efficacy have been demonstrated comparable to that of standard-of-care anticoagulants, without need for monitoring. Further studies are ongoing, which are expected to lead to pediatric authorizations of DOACs for primary venous thromboembolic event prevention in some high-risk settings. More real-life data will be necessary from postmarketing studies and registries to complement the evidence base for DOAC use in children, particularly in the youngest age groups and special disease populations.
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Affiliation(s)
- Christoph Male
- Department of Paediatrics, Medical University of Vienna, Vienna, Austria
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3
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Male C, Monagle P, Albisetti M, Brandão LR, Young G. Direct Oral Anticoagulants: Overcoming the Challenges of Managing Venous Thromboembolism in Children. J Pediatr 2022; 240:14-23. [PMID: 34687696 DOI: 10.1016/j.jpeds.2021.09.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 09/15/2021] [Accepted: 09/16/2021] [Indexed: 12/16/2022]
Affiliation(s)
- Christoph Male
- Department of Pediatrics, Medical University of Vienna, Vienna, Austria.
| | - Paul Monagle
- Royal Children's Hospital, Murdoch Children's Research Institute, University of Melbourne, Melbourne, Australia; Australia and Kids Cancer Centre, Sydney Children's Hospital, Sydney, Australia
| | - Manuela Albisetti
- Division of Hematology, University Children's Hospital of Zurich, Zurich, Switzerland
| | - Leonardo R Brandão
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Guy Young
- Children's Hospital Los Angeles, University of Southern California, Keck School of Medicine, Los Angeles, CA
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4
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Kunwar S, Alam M, Ezekwueme F, Yasir M, Lawrence JA, Shah S, Gordon DK. Diagnostic Scores and Treatment Options for Acute Disseminated Intravascular Coagulation in Children. Cureus 2021; 13:e17682. [PMID: 34513536 PMCID: PMC8415803 DOI: 10.7759/cureus.17682] [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: 06/28/2021] [Accepted: 09/02/2021] [Indexed: 11/07/2022] Open
Abstract
Disseminated intravascular coagulation (DIC) is a thrombo-hemorrhagic condition that commonly accompanies life-threatening illnesses in children and is associated with significant morbidity and mortality. Treatment of underlying conditions, hemodynamic support, and replacement therapy with blood components is the mainstay of DIC management. Limited research studies have supported the use of antithrombin (AT), recombinant thrombomodulin (rTM), and protein C concentrates (PrCC). Although there have been several studies and advancements in the DIC treatment in adults, data in pediatric patients are limited, and the consensus is lacking. Evidence validating the use of diagnostic scoring systems in the pediatric population is also limited. Since the hemostatic system differs significantly in children, especially in neonates, management of DIC is also different in children from that of adults, and there is a dire need for good quality research studies in this aspect. We reviewed more than 100 articles in PubMed, Cochrane database, and Google Scholar. This traditional review article discusses different scoring systems for diagnosing DIC in pediatric patients, and different pharmacological treatment options for acute DIC in this population. This study mainly focuses on papers published from 1990 to 2021 and includes papers in all languages involving humans only.
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Affiliation(s)
- Saru Kunwar
- Internal Medicine/Pediatrics, California Institute of Behavioral Neurosciences & Psychology, California, USA
| | - Mohammad Alam
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, California, USA
| | - Francis Ezekwueme
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, California, USA
| | - Muhammad Yasir
- Emergency Medicine, California Institute of Behavioral Neurosciences & Psychology, California, USA
| | - Jannel A Lawrence
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, California, USA
| | - Sunil Shah
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, California, USA
| | - Domonick K Gordon
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, California, USA
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5
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Doshi BS, Ellison AM. Diagnosis and Management of Pediatric Venous Thromboembolism: New Therapies on the Horizon. Pediatr Emerg Care 2021; 37:273-279. [PMID: 33903287 DOI: 10.1097/pec.0000000000002431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT The incidence of venous thromboembolism (VTE) is increasing in pediatric patients. Prompt recognition and evaluation of VTE in young patients could prevent significant morbidity or mortality. In contrast to VTE in adults, current treatment guidelines are largely based on expert opinion as limited randomized controlled trial data exist about the appropriate management in pediatric patients with traditional anticoagulants. However, recently approved direct-acting oral anticoagulants in adults are also being investigated in pediatric VTE and these data could inform future evidence-based treatment principles. Thus, healthcare providers must be well informed about the management of pediatric VTE and the data from these trials to date. This continuing medical education article will provide a summary of management of pediatric VTE with particular emphasis on emerging direct-acting oral anticoagulants.
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7
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Saini S, Folta AN, Harsh KL, Stanek JR, Dunn AL, O'Brien SH, Kumar R. Anti-Factor Xa-Based Monitoring of Unfractionated Heparin: Clinical Outcomes in a Pediatric Cohort. J Pediatr 2019; 209:212-219.e1. [PMID: 30961988 DOI: 10.1016/j.jpeds.2019.02.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 12/11/2018] [Accepted: 02/12/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To assess clinical outcomes in children treated with unfractionated heparin and monitored using an anti-factor Xa (Anti-FXa)-based nomogram. We also sought to assess the correlation between activated partial thromboplastin time (APTT) and Anti-FXa. STUDY DESIGN This was a single-center, observational cohort study conducted over a 20-month period that included all pediatric patients (<21 years) who received therapeutic unfractionated heparin and were monitored using an anti-FXa-based nomogram. RESULTS In total, 95 patients met prespecified inclusion criteria, and 1098 pairs of APTT and Anti-FXa measurements were performed. The median unfractionated heparin dose required to reach therapeutic Anti-FXa goal was significantly greater in infants compared with older children (P <.0001). The median time to achieve therapeutic Anti-FXa was 10 hours (range 2-96 hours) and was significantly shorter in patients who received a bolus compared with those who did not (P = .03). Five (5.3%) major bleeding events were noted. Age, peak Anti-FXa, peak APTT, lowest platelet count, and fibrinogen were not predictive of major and clinically relevant nonmajor bleeds. Moderate correlation between the APTT and Anti-FXa (r = 0.75; 95% CI 0.72-0.77) assays was appreciated. CONCLUSIONS Using an anti-FXa-based nomogram to monitor unfractionated heparin in children is feasible. Although moderate correlation was observed between the APTT and Anti-FXa assays, the APTT frequently overestimated heparin activity. Safety and efficacy of an Anti-FXa nomogram needs further validation.
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Affiliation(s)
- Surbhi Saini
- Division of Pediatric Hematology/Oncology/BMT, PennState Health Children's Hospital, Hershey, PA; Department of Pediatrics, Penn State University College of Medicine, Hershey, PA
| | - Ashley N Folta
- Division of Pediatric Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, OH
| | - Katherine L Harsh
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
| | - Joseph R Stanek
- Division of Pediatric Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, OH
| | - Amy L Dunn
- Division of Pediatric Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
| | - Sarah H O'Brien
- Division of Pediatric Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
| | - Riten Kumar
- Division of Pediatric Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH.
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8
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Heizer J, Schardt T, Murphy M, Branchford B. Unfractionated heparin dosing requirements in the presence of inflammation during the first six months of life. Thromb Res 2019; 177:17-22. [DOI: 10.1016/j.thromres.2019.02.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 02/17/2019] [Accepted: 02/22/2019] [Indexed: 11/30/2022]
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Abstract
Replantation and revascularization in the pediatric extremity has unique challenges that provide a fertile field of research and clinical experience. Children regenerate peripheral nerves rapidly, resulting in good sensory and motor function. They adapt well to functional deficits and mismatch errors of reinnervation. The technical aspects of microsurgical care in children can be challenging because the structures are small. Additional technical challenges include preservation of growth centers, prevention of vasospasm, protection of the reconstruction, and psychosocial care. Despite these challenges, children show excellent functional outcomes with minimal complications.
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Affiliation(s)
- Amir H Taghinia
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Enders 1, Boston, MA 02115, USA.
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10
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Erol S, Aydın B, Cinar HG, Yoldas T, Zenciroglu A. Arterial Thrombosis Secondary to Cardiac Catheterization in Neonates. DICLE MEDICAL JOURNAL 2019. [DOI: 10.5798/dicletip.534847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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11
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Dressler A, Benninger F, Trimmel-Schwahofer P, Gröppel G, Porsche B, Abraham K, Mühlebner A, Samueli S, Male C, Feucht M. Efficacy and tolerability of the ketogenic diet versus high-dose adrenocorticotropic hormone for infantile spasms: A single-center parallel-cohort randomized controlled trial. Epilepsia 2019; 60:441-451. [DOI: 10.1111/epi.14679] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 01/29/2019] [Accepted: 01/29/2019] [Indexed: 01/01/2023]
Affiliation(s)
- Anastasia Dressler
- Department of Pediatrics and Adolescent Health; Medical University of Vienna; Vienna Austria
| | - Franz Benninger
- Department of Child and Adolescent Psychiatry; Medical University of Vienna; Vienna Austria
| | | | - Gudrun Gröppel
- Department of Pediatrics and Adolescent Health; Medical University of Vienna; Vienna Austria
| | - Barbara Porsche
- Department of Pediatrics and Adolescent Health; Medical University of Vienna; Vienna Austria
| | - Klaus Abraham
- Department of Pediatrics and Adolescent Health; Medical University of Vienna; Vienna Austria
| | - Angelika Mühlebner
- Department of Pediatrics and Adolescent Health; Medical University of Vienna; Vienna Austria
| | - Sharon Samueli
- Department of Pediatrics and Adolescent Health; Medical University of Vienna; Vienna Austria
| | - Christoph Male
- Department of Pediatrics and Adolescent Health; Medical University of Vienna; Vienna Austria
| | - Martha Feucht
- Department of Pediatrics and Adolescent Health; Medical University of Vienna; Vienna Austria
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12
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Male C, Thom K, O'Brien SH. Direct oral anticoagulants: What will be their role in children? Thromb Res 2019; 173:178-185. [DOI: 10.1016/j.thromres.2018.06.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 06/16/2018] [Accepted: 06/26/2018] [Indexed: 01/01/2023]
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13
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Monagle P, Newall F. Management of thrombosis in children and neonates: practical use of anticoagulants in children. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2018; 2018:399-404. [PMID: 30504338 PMCID: PMC6245972 DOI: 10.1182/asheducation-2018.1.399] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Venous thrombosis (VTE) in children and neonates presents numerous management challenges. Although increasing in frequency, VTE in children and neonates is still uncommon compared with adults. The epidemiology of VTE is vastly different in neonates vs children vs adolescents vs adults. In reality, pediatric thrombosis should be viewed as a multitude of rare diseases (eg, renal vein thrombosis, spontaneous thrombosis, catheter-related thrombosis, cerebral sinovenous thrombosis), all requiring different approaches to diagnosis and with different short- and long-term consequences, but linked by the use of common therapeutic agents. Further, children have fundamentally different physiology in terms of blood flow, developmental hemostasis, and, likely, endothelial function. The American Society of Hematology 2017 Guidelines for Management of Venous Thromboembolism: Treatment of Pediatric VTE provides up-to-date evidence-based guidelines related to treatment. Therefore, this article will focus on the practical use of therapeutic agents in the management of pediatric VTE, especially unfractionated heparin, low-molecular-weight heparin, and oral vitamin K antagonists, as the most common anticoagulants used in children. Direct oral anticoagulants (DOACs) remain in clinical trials in children and should not be used outside of formal trials for the foreseeable future.
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Affiliation(s)
- Paul Monagle
- Department of Clinical Haematology, Royal Children’s Hospital, Haematology Research Murdoch Children’s Research Institute, Department of Paediatrics, University of Melbourne, and
| | - Fiona Newall
- Department of Clinical Haematology, Royal Children’s Hospital, Haematology Research Murdoch Children’s Research Institute, School of Nursing, University of Melbourne, Melbourne, VIC, Australia
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14
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Deshaies C, Poirier N, Khairy P. An evidence-based standardized protocol for anticoagulation following congenital heart surgery. Transl Pediatr 2018; 7:369-371. [PMID: 30460190 PMCID: PMC6212385 DOI: 10.21037/tp.2018.07.04] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Affiliation(s)
| | - Nancy Poirier
- CHU Sainte-Justine, Université de Montréal, Montreal, Canada.,Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Paul Khairy
- CHU Sainte-Justine, Université de Montréal, Montreal, Canada.,Montreal Heart Institute, Université de Montréal, Montreal, Canada
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15
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Maas H, Gropper S, Huang F, Stangier J, Tartakovsky I, Brueckmann M, Halton JML, Mitchell LG. Anticoagulant Effects of Dabigatran in Paediatric Patients Compared with Adults: Combined Data from Three Paediatric Clinical Trials. Thromb Haemost 2018; 118:1625-1636. [PMID: 30112751 PMCID: PMC6202931 DOI: 10.1055/s-0038-1668132] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Physiological age-related changes in the haemostatic and coagulation systems result in differing anticoagulant assay responses to standard anticoagulants. Therefore, we investigated the response of anticoagulant assays to dabigatran etexilate (DE) in children compared with adults. OBJECTIVE This article assesses the relationship between plasma dabigatran concentration and coagulation assay results across age groups in children and adults. PATIENTS AND METHODS Data from three clinical trials in which children received DE following standard of care for venous thromboembolism were compared with data from adult clinical trials. The effects of dabigatran concentration on diluted thrombin time (dTT), ecarin clotting time (ECT) and activated partial thromboplastin time (aPTT) were analysed graphically and with modelling. RESULTS The concentration-dTT relationships were consistent in children across all ages and adults in the graphical analysis. For ECT and aPTT, relationships based on ratios over baseline were similar across all ages; absolute clotting times showed that the same exposure resulted in longer clotting times in some of the children aged < 1 year versus adults. Modelling showed concentration-clotting time relationships for all three assays were largely comparable between adults and children, except in those aged < 2 months, in whom there was a slight upward shift in ECT and aPTT relative to adults. CONCLUSION Results suggest that developmental haemostatic changes will have little impact on response to DE. However, further paediatric clinical trials assessing the relationship between coagulation assay responses and clinical outcomes will be needed to confirm this finding.
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Affiliation(s)
- Hugo Maas
- Translational Medicine and Clinical Pharmacology, Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Savion Gropper
- Clinical Development and Medical Affairs, Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Fenglei Huang
- Translational Medicine and Clinical Pharmacology, Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, Connecticut, United States
| | - Joachim Stangier
- Translational Medicine and Clinical Pharmacology, Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Igor Tartakovsky
- Clinical Development and Medical Affairs, Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Martina Brueckmann
- Clinical Development and Medical Affairs, Boehringer Ingelheim International GmbH, Ingelheim, Germany.,Faculty of Medicine Mannheim, Department of Medicine I, University of Heidelberg, Mannheim, Germany
| | - Jacqueline M L Halton
- Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Lesley G Mitchell
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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16
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Comparison between activated clotting time and anti-activated factor X activity for the monitoring of unfractionated heparin therapy in patients with aortic aneurysm undergoing an endovascular procedure. J Vasc Surg 2018; 68:400-407. [DOI: 10.1016/j.jvs.2017.11.079] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 11/27/2017] [Indexed: 12/17/2022]
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17
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Moore EF, Pak J, Jefferis-Kirk C, Armatage A, Kronmal RA, Salerno JC, Files MD. Development and Implementation of a Standardized Heparin Protocol for Left-Sided Pediatric Electrophysiology Procedures. Pediatr Cardiol 2018; 39:941-947. [PMID: 29500504 DOI: 10.1007/s00246-018-1843-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 02/23/2018] [Indexed: 11/29/2022]
Abstract
Heparin is used to decrease the risk of thromboembolic complications during electrophysiology studies (EPS); however, there is wide practice variation and minimal evidence to guide heparin dosing, particularly in pediatric patients. This study retrospectively analyzed heparin dosing and response, measured via activated clotting time (ACT), in patients undergoing EPS and used these data (pre-protocol cohort, n = 40), as well as guidance from available literature to implement a standardized heparin protocol (phase 1, n = 43). We utilized quality improvement methodology to refine this protocol (phase 2, n = 40) to improve therapeutic heparin response. Prior to the protocol, patients achieved therapeutic ACT levels (250-350 s) only 35% of the time which improved to 60% during phase 1 (p < 0.05) and to 73% during phase 2 (p < 0.001 compared to pre-protocol). There were no thromboses or significant adverse events in any group. These results demonstrate the effectiveness of a standardized heparin protocol in achieving effective antithrombotic therapy during left-sided pediatric EPS.
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Affiliation(s)
- Emily F Moore
- Division of Cardiology and Cardiac Surgery, Heart Center at Seattle Children's Hospital, 4800 Sand Point way NE Mail Stop RC 2.820, Seattle, WA, 98105, USA.
| | - Jennifer Pak
- Department of Pharmacy, Seattle Children's Hospital, 4800 Sand Point Way NE, Mail stop BM.5.420, Seattle, WA, 98105, USA
| | - Christa Jefferis-Kirk
- Department of Pharmacy, Seattle Children's Hospital, 4800 Sand Point Way NE, Mail stop BM.5.420, Seattle, WA, 98105, USA
| | - Arlene Armatage
- Division of Cardiology and Cardiac Surgery, Heart Center at Seattle Children's Hospital, 4800 Sand Point way NE Mail Stop RC 2.820, Seattle, WA, 98105, USA
| | - Richard A Kronmal
- Department of Biostatistics, Collaborative Health Studies Coordinating Center, University of Washington, Bldg. 29, 6200 NE 74th St., Seattle, WA, 98115, USA
| | - Jack C Salerno
- Division of Pediatric Cardiology, Department of Pediatrics, University of Washington, 1959 NE Pacific St., Health Sciences Bldg., Seattle, WA, 98195, USA
| | - Matthew D Files
- Division of Pediatric Cardiology, Department of Pediatrics, University of Washington, 1959 NE Pacific St., Health Sciences Bldg., Seattle, WA, 98195, USA
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18
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Newall F, Branchford B, Male C. Anticoagulant prophylaxis and therapy in children: current challenges and emerging issues. J Thromb Haemost 2018; 16:196-208. [PMID: 29316202 DOI: 10.1111/jth.13913] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
This review is aimed at describing the unique challenges of anticoagulant prophylaxis and treatment in children, and highlighting areas for research for improving clinical outcomes of children with thromboembolic disease. The evidence presented demonstrates the challenges of advancing the evidence base informing optimal management of thromboembolic disease in children. Recent observational studies have identified risk factors for venous thromboembolism in children, but there are few interventional studies assessing the benefit-risk balance of using thromboprophylaxis in risk-stratified clinical subgroups. A risk level-based framework is proposed for administering mechanical and pharmacological thromboprophylaxis. More research is required to refine the assignment of risk levels. The anticoagulants currently used predominantly in children are unfractionated heparin, low molecular weight heparin, and vitamin K antagonists. There is a paucity of robust evidence on the age-specific pharmacology of these agents, and their efficacy and safety for prevention and treatment of thrombosis in children. The available literature is heterogeneous, reflecting age-specific differences, and the various clinical settings for anticoagulation in children. Monitoring assays and target ranges are not well established. Nevertheless, weight-based dosing appears to achieve acceptable outcomes in most indications. Given the limitations of the classical anticoagulants for children, there is great interest in the direct oral anticoagulants (DOACs), whose properties appear to be particularly suitable for children. All DOACs currently approved for adults have Pediatric Investigation Plans ongoing or planned. These are generating age-specific formulations and systematic dosing information. The ongoing pediatric studies still have to establish whether DOACs have a positive benefit-risk balance in the various pediatric indications and age groups.
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Affiliation(s)
- F Newall
- Clinical Haematology & Nursing Research, Royal Children's Hospital, Haematology Research Group, Murdoch Childrens Research Institute and Departments of Paediatrics and Nursing, The University of Melbourne, Melbourne, Australia
| | - B Branchford
- Department of Pediatrics, Section of Hematology/Oncology/Bone Marrow Transplant and the Hemophilia and Thrombosis Center, School of Medicine and Center for Cancer and Blood Disorders, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - C Male
- Haemostasis and Thrombosis Unit, Department of Paediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
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19
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Silvey M, Brandão LR. Risk Factors, Prophylaxis, and Treatment of Venous Thromboembolism in Congenital Heart Disease Patients. Front Pediatr 2017; 5:146. [PMID: 28674685 PMCID: PMC5476169 DOI: 10.3389/fped.2017.00146] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 06/09/2017] [Indexed: 01/19/2023] Open
Abstract
Congenital heart disease (CHD) is a common condition in the pediatric population, affecting up to 1% of all live births (i.e., around 40,000 newborns/year in the United States). Although CHD does have a wide range of severity, by the age of 5 years approximately 80% of patients will require at least one surgical intervention to achieve a complete/palliative cardiac repair. Today, in light of their much-improved surgical survival, the care of these patients focuses on morbidity prevention and/or treatment. One such morbidity has been the increased frequency of thrombotic occlusions [e.g., cardioembolic arterial ischemic strokes; arterial, cardiac, and/or newly created shunt thrombosis; venous thromboembolism (VTE)]. Patients with CHD are at high risk of developing thrombosis due to the disruption of blood flow, CHD-related coagulopathy, inflammation, and/or platelet activation secondary to extracorporeal circulation support required during open-heart surgery or as a bridge to recovery, which can increase thrombus formation. In this article, we will discuss how the coagulation system is altered in patients with CHD in regard to the patient's anatomy, procedures they undergo to correct their congenital heart defect, and other risk factors that may increase their thrombotic risk, focusing on VTE. We will also discuss the most recently published reports pertaining to guidelines on prophylaxis and treatment of VTE in this population. Finally, we will briefly address the long-term VTE outcomes for patients with CHD.
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Affiliation(s)
- Michael Silvey
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO, United States
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Hanslik A, Kitzmüller E, Tran US, Thom K, Karapetian H, Prutsch N, Voitl J, Michel-Behnke I, Newall F, Male C. Anti-activated factor II assay for monitoring unfractionated heparin in children: results of the HEARTCAT study. J Thromb Haemost 2017; 15:38-46. [PMID: 27736032 DOI: 10.1111/jth.13539] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Indexed: 11/30/2022]
Abstract
Essentials Unfractionated heparin has variable effects in children and therefore, monitoring is essential. A randomized controlled trial substudy investigating an anti-IIa assay in children was conducted. Anti-IIa values are lower in younger children, an effect more pronounced at low-dose heparin. Heparin effect on Xa and IIa is not equal, particularly in infants and after high-dose heparin. SUMMARY Background Unfractionated heparin (UFH) is used for the prophylaxis and treatment of thrombosis in children. Laboratory monitoring of UFH is needed to prevent over-anticoagulation or under-anticoagulation. Objectives To investigate the association between UFH dose and UFH effect as monitored with the anti-activated factor II (FIIa) assay, the relationship between anti-FIIa and anti-activated factor X (FXa) effects, and the influence of patient age and other factors on UFH effect. Patients and methods This was a randomized controlled trial in children during cardiac catheterization, comparing high-dose UFH (100 units kg-1 bolus) with low-dose UFH (50 units kg-1 bolus). Blood samples were drawn at baseline, and after 30 min, 60 min, and 90 min. For the purpose of this study, 49 children and 117 blood samples were evaluated. Results The anti-FIIa assay discriminated well between high-dose and low-dose UFH. Multiple regression demonstrated significant influences of UFH dose and age on anti-FIIa levels. Younger children had lower anti-FIIa levels than older children, an effect that was more pronounced with low-dose UFH. Anti-FXa/anti-FIIa ratios were equal with low-dose UFH. However, anti-FXa levels were relatively increased over anti-FIIa levels in infants and after high-dose UFH bolus administration. Conclusion The UFH effect on anti-FIIa levels is lower in infants than in older children. This influence of age appears to be dose-dependent, being more pronounced with low-dose UFH. Anti-FXa and anti-FIIa levels are not equal, particularly in infants and after high-dose UFH. Monitoring UFH solely with anti-FXa assays may not be sufficient in children, and the anti-FIIa assay may provide important complementary information.
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Affiliation(s)
- A Hanslik
- Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - E Kitzmüller
- Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - U S Tran
- School of Psychology, University of Vienna, Vienna, Austria
| | - K Thom
- Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - H Karapetian
- Anesthesia and Intensive Care Medicine, Sozialmedizinisches Zentrum Ost, Vienna, Austria
| | - N Prutsch
- Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - J Voitl
- Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - I Michel-Behnke
- Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - F Newall
- Clinical Haematology & Nursing Research, Royal Children's Hospital, Melbourne, Australia
- Haematology Research Group, Murdoch Children's Research Institute and Departments of Paediatrics and Nursing, The University of Melbourne, Melbourne, Australia
| | - C Male
- Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
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Ass. Prof. Dr. Andreas Hanslik ist Researcher of the Month Dezember 2016. Wien Klin Wochenschr 2016; 128:930-931. [PMID: 27924455 DOI: 10.1007/s00508-016-1151-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Toulon P. Developmental hemostasis: laboratory and clinical implications. Int J Lab Hematol 2016; 38 Suppl 1:66-77. [DOI: 10.1111/ijlh.12531] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 04/21/2016] [Indexed: 11/28/2022]
Affiliation(s)
- P. Toulon
- Laboratoire d'Hématologie; Faculté de Médecine; Université Nice Sophia-Antipolis; Nice France
- CHU; Hôpital Pasteur; Service d'Hématologie Biologique; Nice France
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