Use of rotational thromboelastometry to predict hemostatic complications in pediatric patients undergoing extracorporeal membrane oxygenation: A retrospective cohort study.

BACKGROUND: The incidence of hemostatic complications in pediatric patients undergoing extracorporeal membrane oxygenation (ECMO) is high. The optimal anticoagulation strategy in children undergoing ECMO is unknown. OBJECTIVES: To study the association between hemostatic complications, coagulation tests, and clinical parameters in pediatric patients undergoing ECMO and their effect on survival. METHODS: We performed a retrospective cohort study of pediatric patients undergoing centrifugal pump ECMO. Collected data included patient characteristics, risk factors, and coagulation test results. Statistical analysis was done using logistic regression analysis for repeated measurements. Dependent variables were thrombosis and bleeding, independent variables were rotational thromboelastometry (ROTEM), activated partial thromboplastin time (aPTT) and antifactor-Xa assay (aXa) results, ECMO duration, age <29 days, sepsis and surgery. RESULTS: Seventy-three patients with 623 ECMO days were included. Cumulative incidences of thrombosis and bleeding were 43.5% (95% confidence interval [CI], 26.0%-59.8%) and 25.4% (95% CI, 13.4%-39.3%), respectively. A lower maximum clot firmness of intrinsic ROTEM (INTEM; odds ratio [OR], 0.946; 95% CI, 0.920-0.969), extrinsic ROTEM (OR, 0.945; 95% CI, 0.912-0.973), and INTEM with heparinase (OR, 0.936; 95% CI, 0.896-0.968); higher activated partial thromboplastin time aPTT; OR, 1.020; 95% CI, 1.006-1.024) and age <29 days (OR, 2.900; 95% CI, 1.282-6.694); surgery (OR, 4.426; 95% CI, 1.543-12.694); and longer ECMO duration (OR, 1.149; 95% CI, 1.022-1.292) significantly increased thrombotic risk. Surgery (OR, 2.698; 95% CI, 1.543-12.694) and age <29 days (OR 2.242, 95% CI 1.282-6.694) were significantly associated with major bleeding. Patients with hemostatic complications had significantly decreased survival to hospital discharge (P = .009). CONCLUSION: The results of this study help elucidate the role of ROTEM, aPTT, anti-factor Xa, and clinical risk factors in predicting hemostatic complications in pediatric patients undergoing ECMO.

Risk Factors of Impaired Neuropsychologic Outcome in School-Aged Survivors of Neonatal Critical Illness.

OBJECTIVE: Until now, long-term outcome studies have focused on general cognitive functioning and its risk factors following neonatal extracorporeal membrane oxygenation and/or congenital diaphragmatic hernia. However, it is currently unknown which neuropsychological domains are most affected in these patients and which clinical variables can be used to predict specific neuropsychological problems. This study aimed to identify affected neuropsychological domains and its clinical determinants in survivors of neonatal extracorporeal membrane oxygenation and/or congenital diaphragmatic hernia. DESIGN: Prospective follow-up study. SETTING: Tertiary university hospital. PATIENTS: Sixty-five 8-year-old survivors of neonatal extracorporeal membrane oxygenation and/or congenital diaphragmatic hernia. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Intelligence, attention, memory, executive functioning and visuospatial processing were evaluated using validated tests and compared with Dutch reference data. Assessed risk factors of outcome were illness severity indicators, number of anesthetic procedures in the first year of life, and growth at 1 year. Patients had average intelligence (mean intelligence quotient ± SD, 95 ± 16), but significantly poorer sustained attention (mean z score ± SD, -2.73 ± 2.57), verbal (immediate, -1.09 ± 1.27; delayed, -1.14 ± 1.86), and visuospatial memory (immediate, -1.48 ± 1.02; delayed, -1.57 ± 1.01; recognition, -1.07 ± 3.10) than the norm. Extracorporeal membrane oxygenation-treated congenital diaphragmatic hernia patients had significantly lower mean intelligence quotient (84 ± 12) than other neonatal extracorporeal membrane oxygenation patients (94 ± 10) and congenital diaphragmatic hernia patients not treated with extracorporeal membrane oxygenation (100 ± 20). Maximum vasoactive-inotropic score was negatively associated with delayed verbal (B = -0.02; 95% CI, -0.03 to -0.002; p = 0.026) and visuospatial memory (B = -0.01; 95% CI, -0.02 to -0.001; p = 0.024). CONCLUSIONS: We found memory and attention deficits in 8-year-old neonatal extracorporeal membrane oxygenation and congenital diaphragmatic hernia survivors. The maximum dose of vasoactive medication was negatively associated with verbal and visuospatial memory, which may suggest an effect of early cerebral hypoperfusion in determining these abnormalities.

Eficácia e segurança do tramadol versus morfina na dor pós-operatória moderada e severa com especial atençäo à depressäo respiratória / Efficacy and safety of tramadol versus morphine for moderate and severe postoperative pain with special regard to respiratory depression

A eficácia analgésica e a segurança do tramadol e da morfina foram comparadas em um estudo randomizado e duplo-cego realizado em 150 mulheres após cirurgia ginecológica. Se necessário, as pacientes poderiam receber até três doses intravenosas ou de 50 mg de tramadol ou de 5 mg de morfina dentro de um período de 6 horas. A intensidade da dor (escore de resposta verbal) foi registrada antes da administraçäo e 0,5 1, 2, 3, 5 e 6 horas depois da dose inicial; nestes períodos o alívio da dor também foi monitorada continuamente através de pulso-oximetria por ao mínimo 30 minutos depois de cada administraçäo. Em 13,3 por cento do grupo morfina (mas em nenhuma do grupo tramadol) a saturaçäo transcutânea de oxigênio na artéria radial diminuiu para menos de 86 por cento, em 50 por cento destas pacientes a reduçäo já ocorreu depois da primeira dose de 5mg de morfina. Ambas as drogas produziram uma analgesia aceitável e näo foram observados efeitos adversos clinicamente significativos. Pela demonstraçäo da ausência de depressäo respiratória clinicamente relevante com o tramadol nós enfatizamos a sua segurança no alívio da dor pós-operatória