1. Fausat Bello Perfusion Technology Rush University PEDIATRIC ECMO: A SURVEY OF ANTICOAGULATION MONITORING PRACTICES

2. Disclosures  I have no disclosures

3. Why am I here?  The objective of this talk is to review: The history of pediatric ECMO and ACT usage. Review the literature on monitoring modalities of pediatric anticoagulation. Reveal the preliminary results of my survey.

4. Extracorporeal Membrane Oxygenation

5. ECMO Complications  Patient Related Anticoagulation Neurological Infectious End Organ Damage  Device Related

6. Blood Surface Interfacing Annich, G., & Adachi, I. (2013). Anticoagulation for pediatric mechanical circulatory support. Pediatric Critical Care Medicine : A Journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies, 14 (5 Suppl 1), S37-42.

7. Coagulation Cascade David Lillicrap; Nigel Key; Michael Makris; Denise O'Shaughnessy (2009). Practical Hemostasis and Thrombosis. Wiley-Blackwell. pp. 1–5.

8. Pediatric Hemostasis Procoagulants Clot Inhibitors Fibrinolytic Degradation Inhibitors  2 macroglobulin  Protein C,S ***  antithrombin  thrombin  PAI  II, VII,IX,X,XI,XII ***  plasminogen  tPA Platelets

9. ECMO Complications Baird, C. W., Zurakowski, D., Robinson, B., Gandhi, S., Burdis-Koch, L., Tamblyn, J., et al. (2007). Anticoagulation and pediatric extracorporeal membrane oxygenation: Impact of activated clotting time and heparin dose on survival. The Annals of Thoracic Surgery, 83 (3), 912-9; discussion 919-20.

10. Anticoagulants  Heparin is the primary anticoagulant of choice for pediatric patients undergoing extracorporeal membrane oxygenation.  Mechanism of action: Indirect thrombin inhibitor that couple and potentiates the action of antithrombin III

11.  Limitations Narrow therapeutic window of adequate anticoagulation without bleeding Highly variable dose-response Solution?

12. Monitoring patterns for Anticoagulation Baird, C. W., Zurakowski, D., Robinson, B., Gandhi, S., Burdis-Koch, L., Tamblyn, J., et al. (2007). Anticoagulation and pediatric extracorporeal membrane oxygenation: Impact of activated clotting time and heparin dose on survival. The Annals of Thoracic Surgery, 83 (3), 912-9; discussion 919-20.

13. Monitoring Practices 1966-2006

14. Activated Clotting Time  Described by Hattersly 1966  Proven correlation with weight normalized heparin dosing….in adults

15. Factors affecting ACT results  Patient Related Factors Platelet count Fibrinogen Antithrombin III levels Hemodilution  Technically Related Factors Agitator and timers Lack of a single sample precision Venous vs. Arterial blood Smaller sample volumes Temperature and timing of ACT levels Uncertainty of results for ACT levels less than 250

16. ACT tests alone cannot provide proper titration of heparin and thus be the test used to monitor anticoagulation alone.

17. Monitoring Practices 2007-

18. TEG

19. Anti-Factor Xa

21. Phase 3?  Multi-modality testing...

22. Objective  The objective of my study is to examine: Current status of anticoagulation monitoring practices Relationship between monitoring modalities, heparin dosing and the perfusionist role in the solution.

23. Do you employ extracorporeal membrane oxygenation (ECMO) for patients between the ages of 0-18? (n=65)

24. Does your institution have a written anticoagulation management (frequency of testing and/or guidelines for heparin dosing) protocols for ECMO? (n=65)

25. If Yes, is your institution’s protocol specific to the population under the age of 18? (n=65)

26. Check all monitoring modalities used to asses proper anticoagulation at your institution. (n=65)

27. Select the single test one should use in the absence of all other tests to monitor and measure anticoagulation for pediatric ECMO patients. (n=65)

28. How satisfied are you with your institutions monitoring protocol in decreasing hemorrhagic/thrombotic complications. (n=65)

29. Conclusion

30. Fausat_bello@rush.edu