The Use of Antifactor Xa Assays in a Comprehensive Pediatric Extracorporeal Membrane Oxygenation Anticoagulation Protocol is Associated with Increased Survival and Significant Blood Product Cost-Savings

Shawn B. Sood; Louisa Anne Walker; Rangaraj Ramanujam; Daphne Hardison; Jennifer Andrews; Andrew H. Smith; Brian C. Bridges

doi:10.1055/s-0041-1726455

Journal of Pediatric Intensive Care, Table of Contents

J Pediatr Intensive Care 2022; 11(04): 341-348
DOI: 10.1055/s-0041-1726455

Original Article

The Use of Antifactor Xa Assays in a Comprehensive Pediatric Extracorporeal Membrane Oxygenation Anticoagulation Protocol is Associated with Increased Survival and Significant Blood Product Cost-Savings

Shawn B. Sood

¹Division of Pediatric Critical Care Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Tennessee, United States

,

Louisa Anne Walker

²Department of Pediatrics, Vanderbilt University School of Medicine, Tennessee, United States

,

Rangaraj Ramanujam

³Owen Graduate School of Management, Vanderbilt University, Tennessee, United States

,

Daphne Hardison

⁴Monroe Carell Jr. Children's Hospital, Vanderbilt University, Tennessee, United States

,

Jennifer Andrews

⁵Division of Pediatric Hematology/Oncology, Department of Pediatrics, Vanderbilt University School of Medicine, Tennessee, United States

⁶Division of Transfusion Medicine, Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Tennessee, United States

,

Andrew H. Smith

¹Division of Pediatric Critical Care Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Tennessee, United States

⁷Thomas P. Graham Jr. Division of Pediatric Cardiology, Monroe Carell Jr. Children's Hospital at Vanderbilt and Vanderbilt University School of Medicine, Tennessee, United States

,

Brian C. Bridges

¹Division of Pediatric Critical Care Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Tennessee, United States

› Author Affiliations

Abstract

We augmented our standard extracorporeal membrane oxygenation laboratory protocol to include antifactor Xa assays, thromboelastography, and antithrombin measurements. We performed a retrospective chart review to determine outcomes for patients placed on extracorporeal membrane oxygenation (ECMO) prior to and after the initiation of our anticoagulation laboratory protocol. A total of 663 consecutive ECMO runs were evaluated from January 1, 2007 to June 30, 2018. Of these patients, 252 were on ECMO prior to initiation of the anticoagulation laboratory protocol on September 1, 2011, and 411 patients were on ECMO after initiation of the protocol. There were no major changes to our extracorporeal membrane oxygenation circuit or changes to our transfusion threshold during this continuous study period. Transfusion utilization data revealed statistically significant decreases in almost all blood components, and a savings in blood component inflation-adjusted acquisition costs of 31% bringing total blood product cost-savings to $309,905 per year. In addition, there was an increase in survival to hospital discharge from 45 to 56% associated with the initiation of the protocol (p = 0.004). Our data indicate that implementation of a standardized ECMO anticoagulation protocol, which titrates unfractionated heparin infusions based on antifactor Xa assays, is associated with reduced blood product utilization, significant blood product cost savings, and increased patient survival. Future prospective evaluation is needed to establish an antifactor Xa assay-driven ECMO anticoagulation strategy as both clinically superior and cost-effective.

Keywords

antifactor Xa - antithrombin - extracorporeal membrane oxygenation - hemorrhagic - heparin

Full Text

References

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