Mortality and Factors Associated With Hemorrhage During Pediatric Extracorporeal Membrane Oxygenation

Abstract

Objectives: To quantify and identify factors associated with bleeding events during pediatric extracorporeal membrane oxygenation. Design: Retrospective cohort study with primary outcome of bleeding days on extracorporeal membrane oxygenation. Setting: Single tertiary care children’s hospital. Subjects: One-hundred twenty-two children supported with extracorporeal membrane oxygenation for greater than 12 hours during January 2015 through December 2016. Interventions: Bleeding days were identified if mediastinal or cannula site exploration, activated factor VII administration, gastrointestinal, pulmonary, or intracranial hemorrhages occurred. Logistic regression was used to assess factors associated with bleeding days. Measurements and Main Results: Study population was identified from institutional extracorporeal membrane oxygenation database. Clinical, laboratory, and survival data were obtained from medical records. Only data from patients’ first extracorporeal membrane oxygenation run were used. One-hundred twenty-two patients with median age of 17 weeks (interquartile range, 1–148 wk) were analyzed. Congenital heart disease (n = 56, 46%) was the most common diagnosis. Bleeding days comprised 179 (16%) of the 1,121 observed extracorporeal membrane oxygenation-patient-days. By extracorporeal membrane oxygenation day 4, 50% of users had experienced a bleeding day. Central rather than peripheral cannulation (odds ratio, 2.58; 95% CI, 1.47–4.52; p < 0.001), older age (odds ratio, 1.31 per increased week; 95% CI, 1.14–1.52; p < 0.001), higher lactate (odds ratio, 1.08 per 1 mmol/L increase; 95% CI, 1.05–1.12; p < 0.001), and lower platelets (odds ratio, 0.87 per 25,000 cell/μL increase; 95% CI, 0.77–0.99; p = 0.005) were associated with bleeding days. Patients who experienced more frequent bleeding (> 75th percentile) had fewer ventilator-free and hospital-free days in the 60 days after cannulation (0 vs 31; p = 0.002 and 0 vs 0; p = 0.008) and higher in-hospital mortality (68 vs 34%; p < 0.001). Conclusions: Central cannulation, older age, low platelets, and high lactate are associated with bleeding days during pediatric extracorporeal membrane oxygenation. Patients who bleed more frequently during extracorporeal membrane oxygenation have higher in-hospital mortality, longer technological dependence, and reduced hospital-free days.

Effect of Acute Limb Ischemia on the Mortality of Patients with Extracorporeal Membrane Oxygenation Established by Femoral Vein-Arterial Catheterization and Analysis of Related Risk Factors

“…The association between vascular complications and mortality has not been fully established, some studies have not established the association between ALI and mortality, and there is a wide range of opinions about what factors affect mortality in ECMO patients. There is also a wide variety of literature with conflicting conclusions and no guideline conclusion or expert consensus [ 21 – 24 ].…”

Epidemiology of the Use of Hemostatic Agents in Children Supported by Extracorporeal Membrane Oxygenation: A Pediatric Health Information System Database Study

“…Fifty-five percent of the patients were male with a median (IQR) age of 0 (0-2) years. The median (IQR) length of ECMO was 5 (2)(3)(4)(5)(6)(7)(8)(9) days with a hospital mortality rate of 34%. Platelets were transfused on 49% of ECMO days, plasma on 33% of ECMO days and cryoprecipitate on 17% of ECMO days.…”

“…In a cohort of 514 children supported by ECMO at eight children's hospitals in the US, bleeding occurred in over 70% of patients and was independently associated with mortality ( 4 , 5 ). In addition, bleeding in children supported by ECMO has been associated with fewer ventilator-free days and hospital-free days ( 6 ).…”

Impact of Lactate Clearance on Early Outcomes in Pediatric ECMO Patients

“…Currently, approximately 2-3% of all neonatal and pediatric patients undergoing cardiac surgery for congenital heart defect need post-surgical extracorporeal membrane oxygenation (ECMO) support [1]. There are various determination methods for insufficient tissue perfusion, such as measurement of lactate level, mixed venous oxygen saturation (ScVO2), blood pressure, urine output, use of regional near-infrared spectroscopy (NIRS), and inotrope requirement at any time point of ECMO therapy [2]. Nonetheless, the value of these means is quite limited in complex ECMO settings.…”

“…Nonetheless, the value of these means is quite limited in complex ECMO settings. In addition, only a few previous studies showed that measurement of blood lactate clearance can be proportional to tissue oxygen demand and thus be a reliable prognostic predictor for outcomes [2,3]. High lactate values can predict occurrence of multiorgan failure and inadequate tissue perfusion [3][4][5].…”