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Risk factors associated with intracranial hemorrhage in neonates with persistent pulmonary hypertension on ECMO
Sule Doymaz1, Marcia Zinger2, Todd Sweberg2
1Pediatric Critical Care Division, Cohen Children's Medical Center of New York, New Hyde Park, NY 11040 USA ; Department of Pediatrics and Division of Pediatric Intensive Care Unit, SUNY DOWNSTATE Medical Center, 450 Clarkson Ave, Brooklyn, NY 11203 USA.
Insights
Low fibrinogen and platelet levels increase the risk of intracranial hemorrhage (ICH) in infants with persistent pulmonary hypertension (PPHN) receiving extracorporeal membrane oxygenation (ECMO) support. Maintaining normal levels is crucial for preventing ICH.
Area of Science:
- Pediatric Critical Care Medicine
- Neonatology
- Cardiovascular Research
Background:
- Persistent pulmonary hypertension of the newborn (PPHN) affects up to 40% of infants and often requires extracorporeal membrane oxygenation (ECMO) when conventional therapies fail.
- Extracorporeal membrane oxygenation (ECMO) is a life-saving intervention for severe PPHN but carries significant risks, including intracranial hemorrhage (ICH).
Purpose of the Study:
- To identify risk factors associated with intracranial hemorrhage (ICH) in infants diagnosed with persistent pulmonary hypertension (PPHN) who require extracorporeal membrane oxygenation (ECMO) support.
- To inform clinical management strategies aimed at reducing the incidence of ICH in this vulnerable patient population.
Main Methods:
- A case-control study was conducted in a pediatric intensive care unit (PICU) involving 32 infants with PPHN requiring ECMO.
- Evaluated patients with and without ICH for various factors including coagulation parameters (fibrinogen, platelets, ACT, aPTT, PT, INR), vital signs (MAP), and pre-ECMO illness severity.
Main Results:
- Low fibrinogen levels (115 ± 13 mg/dL) and low platelet counts (37.4 ± 18.3 Thousand/μL) were significantly associated with a higher incidence of ICH (p=0.009 and p=0.005, respectively).
- Elevated mean arterial pressure (MAP) (69 ± 4.34 mmHg) was also observed in patients who experienced ICH (p=0.006).
Conclusions:
- Low fibrinogen levels and low platelet counts are identified as significant risk factors for intracranial hemorrhage (ICH) in infants with PPHN undergoing ECMO.
- Maintaining normal fibrinogen and platelet counts during ECMO support is critical for preventing ICH in PPHN patients.
- This study is the first to highlight low fibrinogen levels as a specific risk factor for ICH in this population.
Background:
Up to 40% of infants with persistent pulmonary hypertension (PPHN) remains refractory to conventional therapies, and extracorporeal membrane oxygenation (ECMO) is offered as an effective support for this group. However, ECMO is a highly invasive and risky procedure with devastating complications such as intracranial hemorrhage (ICH). In this study, we aimed to determine the risk factors for ICH in infants with PPHN.
Methods:
A case-control study of patients admitted to the pediatric intensive care unit (PICU) with PPHN requiring ECMO support was conducted. The study was carried out at a 25-bed PICU in large urban tertiary care children's hospital. A total number of 32 subjects were studied. Patients with and without ICH during ECMO were evaluated for activated clotting time (ACT), heparin dosing, platelet count, coagulation profile such as activated partial thromboplastin time (aPTT), prothrombin time (PT), international normalized ratio (INR), fibrinogen level, vital signs including heart rate and mean arterial pressure (MAP), transfusion history, gestational age, and severity of pre-ECMO illness as possible risk factors.
Results:
Low fibrinogen level (115 ± 13 mg/dl) and low platelet counts (37.4 ± 18.3 Thousand/μl) were associated with higher incidence of ICH (p = 0.009 and p = 0.005, respectively). Elevated MAP (69 ± 4.34 mmHg) was also noticed in ICH patients (p = 0.006).
Conclusions:
Results demonstrated that low fibrinogen level and low platelet count were associated with ICH in PPHN patients on ECMO. While on ECMO support, maintaining fibrinogen and platelet counts within normal ranges seems crucial to prevent ICH in PPHN patients. This is the first report identifying low fibrinogen level among the risk factors for ICH in infants with PPHN on ECMO support.
