title: Activated partial thromboplastin time is a better trending tool in pediatric extracorporeal membrane oxygenation.
abstract: OBJECTIVE
  To determine whether activated partial thromboplastin times are a better heparin management tool than activated clotting times in pediatric extracorporeal membrane oxygenation.
  
  
  METHODS
  A single-center retrospective analysis of perfusion and patient records.
  
  
  METHODS
  Academic pediatric tertiary care center.
  
  
  METHODS
  Pediatric patients (<21 yrs old) requiring extracorporeal membrane oxygenation support initiated at Children's Hospital of Pittsburgh.
  
  
  METHODS
  None.
  
  
  RESULTS
  Point-of-care activated clotting time and activated partial thromboplastin time values, clinical laboratory activated partial thromboplastin time values, weight-normalized heparin administration (units/kg/hr), and reported outcomes were collected for pediatric patients treated for cardiac and/or respiratory failure with extracorporeal membrane oxygenation. Spearman's ranked correlations were performed for each coagulation test compared to heparin dosage. The Bland-Altman test was used to determine the validity of the point-of-care activated partial thromboplastin time. Hazard analysis was conducted for outcomes and complications for patients whose heparin management was based on the clinical laboratory activated partial thromboplastin time or the activated clotting time. Only the clinical laboratory activated partial thromboplastin time showed a correlation (ρ = 0.40 vs. ρ = -0.04 for activated clotting time) with the heparin administration (units/kg/hr). Point-of-care activated partial thromboplastin time and activated partial thromboplastin time values correlated well (ρ = 0.76), with <5% of samples showing a difference outside 2 SDs, but differences in their absolute values (Δactivated partial thromboplastin time = 100 secs) preclude them from being interchangeable measures. Furthermore, despite no effective change in the mean activated clotting time, cardiac patients showed a significantly improved correlation to heparin dose for all coagulation tests (e.g., point-of-care activated partial thromboplastin time ρ = 0.60). Management of patients with the clinical laboratory activated partial thromboplastin time did not significantly affect patient survival rates but did significantly reduce bleeding complications and significantly increased clotting in the extracorporeal membrane oxygenation circuit. A hazard analysis demonstrated that bleeding complications were associated with an increased risk of mortality, whereas clotting complications in the extracorporeal membrane oxygenation circuit were not.
  
  
  CONCLUSIONS
  The activated clotting time is not an accurate monitoring tool for heparin management in pediatricextracorporeal membrane oxygenation. The point-of-care activated partial thromboplastin time correlates well with the clinical laboratory activated partial thromboplastin time but cannot be substituted for the clinical laboratory activated partial thromboplastin time values. Management of pediatric extracorporeal membrane oxygenation patients with the clinical laboratory activated partial thromboplastin time reduced bleeding complications which are associated with increases in mortality.
authors.affiliation: Department of Cardiothoracic Surgery, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
authors.forename: Timothy M
authors.initials: TM
authors.lastname: Maul
authors.forename: Erin L
authors.initials: EL
authors.lastname: Wolff
authors.forename: Bradley A
authors.initials: BA
authors.lastname: Kuch
authors.forename: Adam
authors.initials: A
authors.lastname: Rosendorff
authors.forename: Victor O
authors.initials: VO
authors.lastname: Morell
authors.forename: Peter D
authors.initials: PD
authors.lastname: Wearden
mesh_terms: D000293:Adolescent; D000925:Anticoagulants / Q000008:administration & dosage*; D002648:Child; D002675:Child, Preschool; D015199:Extracorporeal Membrane Oxygenation / Q000009:adverse effects; D006333:Heart Failure / Q000628:therapy; D006470:Hemorrhage / Q000209:etiology / Q000517:prevention & control*; D006493:Heparin / Q000008:administration & dosage*; D006801:Humans; D007223:Infant; D010314:Partial Thromboplastin Time; D019095:Point-of-Care Systems; D012131:Respiratory Insufficiency / Q000628:therapy; D012189:Retrospective Studies; D018570:Risk Assessment; D018709:Statistics, Nonparametric; D014914:Whole Blood Coagulation Time
chemical_list: D000925:Anticoagulants; D006493:Heparin