Clinical and pathophysiologic aspects of ECMO-associated hemorrhagic complications

Abstract

Extracorporeal membrane oxygenation (ECMO) is increasingly used to treat severe cases of acute respiratory or cardiac failure. Hemorrhagic complications represent one of the most common complications during ECMO, and can be life threatening. The purpose of this study was to elucidate pathophysiological mechanisms of ECMO-associated hemorrhagic complications and their impact on standard and viscoelastic coagulation tests. The study cohort included 27 patients treated with VV-ECMO or VA-ECMO. Hemostasis was evaluated using standard coagulation tests and viscoelastic parameters investigated with rotational thromboelastometry. Anticoagulation and hemorrhagic complications were analyzed for up to seven days depending on ECMO duration. Hemorrhagic complications developed in 16 (59%) patients. There were 102 discrete hemorrhagic episodes among 116 24-hour-intervals, of which 27% were considered to be clinically significant. The highest number of ECMO-associated hemorrhages occurred on the 2 nd and 3 rd day of treatment. Respiratory tract bleeding was the most common hemorrhagic complication, occurring in 62% of the 24hour intervals. All 24-hours-intervals were divided into two groups: "with bleeding" and "without bleeding". The probability of hemorrhage was significantly associated with abnormalities of four parameters: increased international normalized ratio (INR, sensitivity 71%, specificity 94%), increased prothrombin time (PT, sensitivity 90%, specificity 72%), decreased intrinsic pathway maximal clot firmness (MCFin, sensitivity 76%, specificity 89%), and increased extrinsic pathway clot formation time (CFTex, sensitivity 77%, specificity 87%). In conclusions, early ECMO-associated hemorrhagic complications are related to one traditional and two novel viscoelastic coagulation abnormalities: PT/INR elevation, reduced maximum clot firmness due to intrinsic pathway dysfunction (MCFin), and prolonged clot formation time due to extrinsic pathway dysfunction (CFTex). When managing hemostasis during ECMO, derangements in PT/INR, MCFin and CFT ex should be focused on.

Efficacy and safety of ECG‐synchronized pulsatile extracorporeal membrane oxygenation in the clinical setting: The SynCor Trial

“…Popugaev et al identified the highest number of bleeding events to occur on the second or third day of treatment. 28 Hence median duration of mechanical circulatory support was 1.0 h in HRPCI-and 63.0 h in CS-patients, this suffices as an explanation for differences in transfusion in our study. Anemia in patients with acute coronary syndrome or undergoing PCI is associated with adverse outcomes.…”

“…14.7% of the patients in the HRPCI and 23.1% in the CS group received more than two units of RBC during the study‐period. Popugaev et al identified the highest number of bleeding events to occur on the second or third day of treatment 28 . Hence median duration of mechanical circulatory support was 1.0 h in HRPCI‐ and 63.0 h in CS‐patients, this suffices as an explanation for differences in transfusion in our study.…”

HEROES V‐V—HEmorRhagic cOmplications in Veno‐Venous Extracorporeal life Support—Development and internal validation of multivariable prediction model in adult patients

“…[7][8][9] Bleeding represents the most frequently reported adverse event during ECLS. 10 The pathophysiology of bleeding while on ECLS is complex, although not completely understood, 11 is likely multifactorial, depending on the exposure to artificial surfaces and anticoagulation. Underlying patients' primary diagnoses and/or comorbidities, such as vasculitis or trauma, may contribute to an increased risk of bleeding.…”

“…Bleeding complications remain frequent with high morbidity and mortality 11,15–20 . The reported incidence of bleeding complications ranges between 24% and 56% 18,21,22 .…”

“…14 Bleeding complications remain frequent with high morbidity and mortality. 11,[15][16][17][18][19][20] The reported incidence of bleeding complications ranges between 24% and 56%. 18,21,22 The management of these complications is complex, involving transfusion support and interventions to control bleeding.…”