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Mortality and Factors Associated With Hemorrhage During Pediatric Extracorporeal Membrane Oxygenation
Conor P O'Halloran1, Kristofer G Andren2, Jessica Mecklosky2
1Department of Pediatrics, Boston Children's Hospital, Boston, MA.
Insights
Bleeding during pediatric extracorporeal membrane oxygenation (ECMO) is linked to central cannulation, older age, low platelets, and high lactate. Frequent bleeding increases mortality and dependence on technology.
Area of Science:
- Pediatric critical care medicine
- Cardiovascular surgery
- Neonatology
Background:
- Extracorporporeal membrane oxygenation (ECMO) is a life-support measure for critically ill children.
- Bleeding complications are a significant concern during pediatric ECMO, impacting patient outcomes.
- Identifying factors associated with bleeding is crucial for improving ECMO management.
Purpose of the Study:
- To quantify the incidence of bleeding days in pediatric patients undergoing ECMO.
- To identify clinical and laboratory factors associated with bleeding events during ECMO.
- To evaluate the impact of bleeding on patient outcomes, including mortality and hospital-free days.
Main Methods:
- Retrospective cohort study of 122 children receiving ECMO for >12 hours.
- Bleeding days defined by specific hemorrhage types or interventions.
- Logistic regression analysis to identify factors associated with bleeding.
Main Results:
- Bleeding days occurred in 16% of ECMO-patient-days, with 50% of patients experiencing bleeding by day 4.
- Factors associated with bleeding included central cannulation (OR 2.58), older age (OR 1.31/week), higher lactate (OR 1.08/mmol/L), and lower platelets (OR 0.87/25,000 cells/μL).
- Increased bleeding frequency correlated with fewer ventilator-free/hospital-free days and higher in-hospital mortality.
Conclusions:
- Central cannulation, older age, low platelets, and high lactate are significant risk factors for bleeding during pediatric ECMO.
- Frequent bleeding events during ECMO are associated with worse clinical outcomes, including increased mortality and prolonged technological dependence.
- These findings highlight the need for vigilant monitoring and potential interventions to mitigate bleeding risk in pediatric ECMO patients.
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.
