Regular Article Correlation of thromboelastography with standard tests of anticoagulation in paediatric patients receiving extracorporeal life support D.C. Alexander a , W.W. Butt a,b , J.D. Best a , S.M. Donath a,b,c , P.T. Monagle a,b , L.S. Shekerdemian a,b,c, ⁎ a Intensive Care Unit, The Royal Children's Hospital, Melbourne, Australia b The Department of Paediatrics, University of Melbourne c The Murdoch Children's Research Institute, Melbourne, Australia abstract article info Article history: Received 6 November 2008 Received in revised form 2 June 2009 Accepted 3 June 2009 Available online 11 August 2009 Keywords: Thromboelastography Coagulation Paediatrics Extracorporeal life support Children requiring extracorporeal life support (ECLS) are at significant risk for thrombotic and haemorrhagic complications. Thromboelastography (TEG) is increasingly being used to assist in monitoring the coagulation status of critically ill patients. Its role in heparinised children receiving ECLS is unknown. Methods: A retrospective review of TEG in 27 children (mean age 2 years and 8 months) receiving ECLS in a tertiary paediatric intensive care unit between December 2006 and April 2008. Paired TEG (kaolin and heparinase) analysis was performed on 171 occasions. On all occasions activated partial thromboplastin time (APTT) and platelet count were performed within 4 hours of the TEG (mean 6.5 minutes after TEG). On 158 occasions, the activated clotting time (ACT) was measured simultaneously with TEG. Results: The TEG (kaolin) sample was not interpretable due to the heparin effect in 89 (52%) samples. There was a weak correlation between TEG (heparinase) variables and APTT, and between TEG and ACT with a stronger correlation between TEG (Maximum amplitude) and platelet count. Conclusion: TEG monitoring should always include paired samples in heparinised children on ECLS. In this heterogeneous population, weak, and moderate correlations exist between TEG and standard haematological tests. Prospective studies, with simultaneous sampling for TEG and conventional laboratory tests, must be performed in order to establish its absolute utility as a clinical tool in this population. © 2009 Elsevier Ltd. All rights reserved. Background Temporary extracorporeal life support (ECLS) incorporates both extracorporeal membrane oxygenation (ECMO) and ventricular assist device (VAD) support as treatment modalities for infants, children and adults with severe or life-threatening cardiorespiratory disease. ECLS has been performed in more than 500 children at The Royal Children's Hospital since the inception of the service in 1988. ECLS is associated with a high risk of thrombosis due to foreign material, turbulent flow as well as intrinsic abnormalities of coagula- tion related to the patients underlying disease process. In order to prevent thrombosis, all patients on ECLS receive systemic anti- coagulation. Unfractionated heparin (UFH) is the most widely used anticoagulant for patients requiring temporary ECLS. UFH has the advantages of a short half life (approximately 1 hour), reversibility (with protamine) and is easily available and inexpensive. Currently, the accurate and meaningful monitoring of heparin therapy and coagulation status on ECLS is predominantly through a number of bedside and laboratory tests, including activated clotting time (ACT), activated thromboplastin time (APTT), prothrombin time (PT), fibrinogen, and platelet count. Despite our best efforts, prevention of thrombosis is not always possible for patients on ECLS, and furthermore systemic anticoagulation brings with it a significant risk of haemorrhagic complications [1–3]. Over recent years, the thromboelastogram (TEG) has become more widely used as an adjunctive, point of care test of coagulation in patients receiving cardiopulmonary bypass or ECLS. Although ACT remains the most commonly used point-of-care investigation, TEG may offer more specific information relating to the coagulation cascade, and the patients overall coagulation status. TEG was introduced to the Intensive Care Unit at the Royal Children's Hospital, Melbourne, in late 2006. To date, it has only been used in an investigational role as its precise role in monitoring systemic anticoagulation on ECLS is currently unknown. This review of TEG in heparinised children on temporary ECLS is aimed at exploring its correlation with APTT, ACT, and platelet count and ultimately to be used as a template to better define a potential role in monitoring children on ECLS. In order to be consistent with our terminology, ACT, APTT, PT, Fibrinogen and Platelet count will be considered to be ‘standard’ laboratory haemostatic tests for the remainder of this review. Thrombosis Research 125 (2010) 387–392 ⁎ Corresponding author. Director of Intensive Care, The Royal Children's Hospital, Flemington Road, Melbourne, Australia. Tel.: +61 3 9345 5224; fax: +61 3 9345 6239. E-mail address: lara.shekerdemian@rch.org.au (L.S. Shekerdemian). 0049-3848/$ – see front matter © 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.thromres.2009.07.001 Contents lists available at ScienceDirect Thrombosis Research journal homepage: www.elsevier.com/locate/thromres