Elena Ashikhmina1, Sameh Said2, Mark M Smith3, Vilmarie Rodriguez4, William C Oliver3, Gregory A Nuttall3, Joseph A Dearani2, Hartzell V Schaff2. 1. Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota. Electronic address: ashikhmina.elena@mayo.edu. 2. Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota. 3. Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota. 4. Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota.
Abstract
BACKGROUND: After decades of practice of pediatric cardiac surgery, postoperative bleeding due to the immaturity of hemostasis, hemodilution, and hypothermia remains a concern. Recently, a new approach for adult coagulopathy after bypass has emerged. Prothrombin complex concentrates (PCCs), designed to treat bleeding in hemophilia patients, are safely and efficiently used off label for hemorrhage after bypass. However, optimal dosing, indications and contraindications, and laboratory tests to assess the efficacy of PCC use in children have not yet been established. This literature review outlines the challenges of bypass-related coagulopathy, the pharmacology, and the experience in use of PCCs, with a focus on their potential in pediatric cardiac surgery. METHODS: After a thorough literature search of MEDLINE, Scopus, and Ovid databases using the term "prothrombin complex concentrate AND pediatric," 23 relevant articles were selected. RESULTS: The data supporting successful use of PCCs in acquired coagulopathy after cardiac surgery in adults have been increasing. Although small volume, low immunogenicity, efficiency, and speed in correcting coagulopathy are attractive qualities of PCCs for pediatric practice, current evidence is only anecdotal. The main concerns are unknown dosing regimens, the inability to closely monitor the effects of PCCs in real time, and a possibility of thrombotic complications, which can be particularly devastating in young congenital cardiac patients whose lives frequently depend upon the patency of artificial shunts. CONCLUSIONS: Extensive, high-quality research is warranted to fill in the gaps of knowledge regarding using PCCs in pediatric cardiac practice.
BACKGROUND: After decades of practice of pediatric cardiac surgery, postoperative bleeding due to the immaturity of hemostasis, hemodilution, and hypothermia remains a concern. Recently, a new approach for adult coagulopathy after bypass has emerged. Prothrombin complex concentrates (PCCs), designed to treat bleeding in hemophiliapatients, are safely and efficiently used off label for hemorrhage after bypass. However, optimal dosing, indications and contraindications, and laboratory tests to assess the efficacy of PCC use in children have not yet been established. This literature review outlines the challenges of bypass-related coagulopathy, the pharmacology, and the experience in use of PCCs, with a focus on their potential in pediatric cardiac surgery. METHODS: After a thorough literature search of MEDLINE, Scopus, and Ovid databases using the term "prothrombin complex concentrate AND pediatric," 23 relevant articles were selected. RESULTS: The data supporting successful use of PCCs in acquired coagulopathy after cardiac surgery in adults have been increasing. Although small volume, low immunogenicity, efficiency, and speed in correcting coagulopathy are attractive qualities of PCCs for pediatric practice, current evidence is only anecdotal. The main concerns are unknown dosing regimens, the inability to closely monitor the effects of PCCs in real time, and a possibility of thrombotic complications, which can be particularly devastating in young congenital cardiac patients whose lives frequently depend upon the patency of artificial shunts. CONCLUSIONS: Extensive, high-quality research is warranted to fill in the gaps of knowledge regarding using PCCs in pediatric cardiac practice.