Clinical Features and Risk Factors Analysis for Hemorrhage in Adults on ECMO

Abstract

Background: The use of extracorporeal membrane oxygenation (ECMO) to support critically ill patients with cardiorespiratory dysfunction has increased over the last decades. However, hemorrhagic complications occur frequently during ECMO support, and this has a significant impact on morbidity and mortality. Thus, this study aimed to identify the risk factors for hemorrhage in patients receiving ECMO.Methods: Our retrospective study included 60 patients, who were admitted to the Taihe Hospital in Shiyan City, Hubei Province, China from February 2017 to October 2020. About 18 patients developed hemorrhagic complications, and 42 patients did not demonstrate such complications. Data regarding patient demography, laboratory tests, and clinical manifestations prior to ECMO were collected to analyze their clinical features. Univariable and multivariable logistic analyses were used to explore the risk factors for hemorrhage in adults on ECMO. The receiver operating characteristic (ROC) curve was used to evaluate the predictive value of the binary logistic model. The amount of blood transfusions was compared between the two groups, and the activated partial thromboplastin time (APTT), platelet count, and hemoglobin level before the initiation of ECMO.Results: Logistic analysis showed that a longer duration of ECMO support, higher APTT, and lower platelet count prior to ECMO were independent risk factors for hemorrhage in adults on ECMO. In addition, we found that the cannula site was the most common bleeding site. Most bleeding events occurred within the first 3 days of ECMO therapy. After the ECMO initiation, APTT was prolonged while the platelet count and hemoglobin levels were decreased. The amount of blood transfusion was significantly higher in the hemorrhage group than in the non-hemorrhage group.Conclusions: Clinicians should evaluate the risk of hemorrhage based on the coagulation function of patients, underlying disease, and the duration of ECMO support. In the first 3 days during ECMO support, special attention should be given to the cannula site, mucosal, and dermal regions, and digestive tract to detect any signs of hemorrhage. Moreover, increasing the platelet count transfusion threshold and accurately determining the amount of blood transfusion required may prevent bleeding events.

Bleeding and thrombotic events in post-cardiotomy extracorporeal life support

“…In line with this finding, ECLS duration has been identified as a risk factor for HRAE in a large Extracorporeal Life Support Organization Registry analysis (mixed cohort including 17.7% post-cardiotomy patients) [ 4 ]. The duration of ECLS as a risk factor for haemorrhage has also been a ubiquitous finding in prior studies with non-PC [ 17 ] and PC patients [ 8 ].…”

Risk Factors for Bleeding in Coronavirus Disease 2019 Patients on Extracorporeal Membrane Oxygenation and Effects of Transcatheter Arterial Embolization for Hemostasis

“…Ischemia-reperfusion-related damage is thought to be the main cause of gastrointestinal hemorrhage during ECMO support [13,26]. When patients are in the state of ischemia and hypoxia, the blood redistributes and stress ulcers occur in the gastrointestinal tract due to the insufficient blood supply, decreased mucosal blood flow, ischemia, and reperfusion injury [13]. This stress ulceration can progress and erode larger vessels, resulting in gastrointestinal bleeding [13].…”

“…The nonbleeding group comprised the remaining 19 patients without apparent bleeding events. Patients with hemorrhages at cannula insertion sites, surgical incisions, and dermal or mucosal regions were included in the nonbleeding group because those bleeding sites could be treated by pausing anticoagulant administration and astriction without a blood transfusion [13]. ICU physicians decided to perform CT examination when they suspected a progression of anemia based on blood tests, sudden or continuous decrease in blood pressure, or lack of response to blood transfusions.…”

Anticoagulation Management in High Bleeding-Risk ECMO in Adults

“…Bleeding is a frequent complication of ECMO, with a reported incidence ranging from 27 to 60%. In adult patients with ECMO, the risk factors for bleeding have been identified: postsurgical (especially postcardiotomy) ECMO, recent trauma, type of cannulation (surgical, especially intrathoracic, and arterial at increased risk), ECMO duration, pre-ECMO coagulation abnormalities, and on-ECMO aPTT (>72 s), fibrinogen (<2 g/L), and platelets count (<38,000/mm 3 ) ( 3 , 4 ). The clinical spectrum of ECMO bleeding includes intracranial hemorrhage, surgical site bleeding, gastrointestinal and pulmonary hemorrhage, and cannulation site bleeding.…”