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Anticoagulation monitoring during pediatric ECMO : which is the best method?
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Objetivos: Durante a Oxigenação por Membrana Extracorporal (ECMO) domina um estado pró-coagulante, determinando o uso de anticoagulação, sendo a heparina não fracionada (UFH) o anticoagulante de escolha. A dificuldade no controlo da dose de heparina, para prevenir eventos hemorrágicos ou trombóticos, estabelece a necessidade da existência de um método confiável e amplamente disponível para monitorizar a anticoagulação. O objetivo deste estudo é avaliar a relação entre a dose de heparina e o tempo de coagulação activada (ACT), o Tempo de Tromboplastina Parcial Ativada (aPTT) e o Anti-Factor Xa.
Métodos: Foi realizado um estudo prospetivo observacional na Unidade de Cuidados Intensivos Pediátricos (PICU) de um hospital universitário. Em todos os pacientes pediátricos sob ECMO durante um período de seis meses (Julho a Dezembro 2022) registou-se simultaneamente o valor de UFH e de Anti-Xa, ACT e aPTT. Para comparar os diferentes métodos utilizou-se o coeficiente de correlação de Spearman e de Pearson.
Resultados: Durante o período do estudo, obtiveram-se 61 amostras de sangue de 6 pacientes diferentes. Os estudos de correlação revelaram uma correlação moderada mas estatisticamente significativa entre aPTT e Anti-Xa (r=0,540; p<0,001), mas nenhuma correlação foi encontrada entre ACT e Anti-Xa (r=-0,172; p= NS). Encontrou-se uma forte correlação entre a dose de UFH e o Anti-Xa (r = 0,729; p < 0,001), uma correlação moderada mas significativa entre a dose de UFH e o aPTT (r = 0,537; p < 0,001), e nenhuma correlação foi encontrada com o ACT (r = -0,118; p = NS).
Conclusões: Estes resultados sugerem que apesar do Anti-Xa continuar a ser o método preferencial para o controlo da dose de UFH, o aPTT pode ser uma alternativa viável. Assim, sugerimos utilizar o Anti-Xa e aPTT para monitorizar a atividade da UFH e o ACT para avaliar a coagulação.
Objectives: During ExtraCorporeal Membrane Oxygenation (ECMO), a procoagulant state is dominant, determining the use of anticoagulation, with unfractionated heparin (UFH) being the anticoagulant of choice in most ECMO centers. The fine balance between bleeding and thrombosis establishes the need for a reliable and widely available method for anticoagulation monitoring. This study's primary goal is to assess the relationship between heparin dose and activated clotting time (ACT), activated Partial Thromboplastin Clotting Time (aPTT) and Anti-Xa, a direct measurement of heparin activity. Methods: A prospective observational study was conducted in a pediatric intensive care unit (PICU) at a university-affiliated hospital. Daily measurements of Anti-Xa, ACT, and aPTT were simultaneously performed and recorded along with UFH levels in all pediatric patients under ECMO, during a six-month period (July to December 2022). Spearman's rank correlation coefficient and Pearson's correlation coefficient were used to compare the different methods. Results: During the study period, 61 blood samples were obtained from six patients. Comparison of aPTT and ACT with Anti-Xa revealed a significant but moderate correlation between aPTT and Anti-Xa (r=0,540; p<0,001), but no correlation was found between ACT and Anti-Xa (r=-0,172; p=NS). A moderate but statistically significant correlation was found between heparin dose and aPTT (r = 0.537; p < 0.001), and a strong correlation was observed between heparin dose and Anti-Xa (r = 0.729; p < 0.001), while no correlation was found with ACT (r = -0.118; p = NS). Conclusions: These results suggest that while Anti-Xa remains the preferred method for managing UFH activity, aPTT can serve as a viable alternative. Our recommendation is to use Anti-Xa and aPTT for monitoring UFH activity and ACT for evaluating coagulation status.
Objectives: During ExtraCorporeal Membrane Oxygenation (ECMO), a procoagulant state is dominant, determining the use of anticoagulation, with unfractionated heparin (UFH) being the anticoagulant of choice in most ECMO centers. The fine balance between bleeding and thrombosis establishes the need for a reliable and widely available method for anticoagulation monitoring. This study's primary goal is to assess the relationship between heparin dose and activated clotting time (ACT), activated Partial Thromboplastin Clotting Time (aPTT) and Anti-Xa, a direct measurement of heparin activity. Methods: A prospective observational study was conducted in a pediatric intensive care unit (PICU) at a university-affiliated hospital. Daily measurements of Anti-Xa, ACT, and aPTT were simultaneously performed and recorded along with UFH levels in all pediatric patients under ECMO, during a six-month period (July to December 2022). Spearman's rank correlation coefficient and Pearson's correlation coefficient were used to compare the different methods. Results: During the study period, 61 blood samples were obtained from six patients. Comparison of aPTT and ACT with Anti-Xa revealed a significant but moderate correlation between aPTT and Anti-Xa (r=0,540; p<0,001), but no correlation was found between ACT and Anti-Xa (r=-0,172; p=NS). A moderate but statistically significant correlation was found between heparin dose and aPTT (r = 0.537; p < 0.001), and a strong correlation was observed between heparin dose and Anti-Xa (r = 0.729; p < 0.001), while no correlation was found with ACT (r = -0.118; p = NS). Conclusions: These results suggest that while Anti-Xa remains the preferred method for managing UFH activity, aPTT can serve as a viable alternative. Our recommendation is to use Anti-Xa and aPTT for monitoring UFH activity and ACT for evaluating coagulation status.
Descrição
Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2023
Palavras-chave
Oxigenação por membrana extracorporal (ECMO) Heparina Monitorização da anticoagulação Anti-factor Xa Tempo de coagulação activada (ACT) Pediatria