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Published on: January 17, 2025
Anticoagulation-Free Pediatric Extracorporeal Membrane Oxygenation: Single-Center Retrospective Study
Edon J Rabinowitz1,2,3,4, Megan T Danzo3,4, Mark J Anderson5,4
1Division of Pediatric Critical Care Medicine, Washington University School of Medicine in St Louis and St Louis Children's Hospital, St Louis, MO.
Insights
Pediatric extracorporeal membrane oxygenation (ECMO) can be safely used without anticoagulation for limited periods in high-risk bleeding patients, showing low thrombosis rates. Further studies are needed to define safe anticoagulation-free time limits.
Area of Science:
- Pediatric critical care medicine
- Cardiovascular research
- Extracorporeal life support
Background:
- Anticoagulation management is critical during pediatric extracorporeal membrane oxygenation (ECMO).
- Limited data exists on the safety and efficacy of anticoagulation-free periods in pediatric ECMO.
- Understanding thrombosis and hemorrhage risks is essential for optimizing patient outcomes.
Purpose of the Study:
- To analyze hemorrhage and thrombosis data in pediatric patients undergoing anticoagulation-free ECMO.
- To identify patient and ECMO characteristics associated with thrombotic events during anticoagulation-free periods.
Main Methods:
- Retrospective cohort study of pediatric patients (0-18 years) on ECMO with an initial anticoagulation-free period of ≥6 hours.
- Utilized American Thoracic Society definitions for hemorrhage and thrombosis.
- Evaluated patient demographics, ECMO parameters, and thrombotic/hemorrhagic events.
Main Results:
- Thirty-five patients met inclusion criteria; 8% experienced thrombotic events during the anticoagulation-free period.
- Increased red blood cell (RBC) transfusion needs correlated with longer anticoagulation-free periods (p=0.03).
- Anticoagulation-free thrombotic events were associated with younger age, lower weight, lower ECMO flow rate, and longer anticoagulation-free duration.
Conclusions:
- Limited anticoagulation-free ECMO is feasible in selected high-risk pediatric bleeding patients with a low frequency of thrombosis.
- Further multicenter studies are required to establish safe anticoagulation-free time limitations based on patient and ECMO variables.
Objectives:
To analyze hemorrhage and thrombosis data related to anticoagulation-free pediatric extracorporeal membrane oxygenation (ECMO).
Design:
Retrospective cohort study.
Settings:
High-volume ECMO single institution data.
Patients:
Children (0-18 yr) supported with ECMO (>24 hr) with initial anticoagulation-free period of greater than or equal to 6 hours.
Interventions:
None.
Measurements And Main Results:
Utilizing consensus American Thoracic Society definitions for hemorrhage and thrombosis on ECMO, we evaluated thrombosis and associated patient and ECMO characteristics during anticoagulation-free period. Thirty-five patients met inclusion criteria from 2018 to 2021 having a median age (interquartile range [IQR]) of 13.5 months (IQR, 3-91 mo), median ECMO duration of 135 hours (IQR, 64-217 hr), and 964 anticoagulation-free hours. Increased RBC transfusion needs were associated with longer anticoagulation-free periods ( p = 0.03). We identified 20 thrombotic events: only four during the anticoagulation-free period and occurring in three of 35 (8%) patients. Compared with those without thrombotic events, anticoagulation-free clotting events were associated with younger age (i.e., 0.3 mo [IQR, 0.2-0.3 mo] vs 22.9 mo [IQR, 3.6-112.9 mo]; p = 0.02), lower weight (2.7 kg [IQR, 2.7-3.25 kg] vs 13.2 kg [5.9-36.4 kg]; p = 0.006), support with lower median ECMO flow rate (0.5 kg [IQR, 0.45-0.55 kg] vs 1.25 kg [IQR, 0.65-2.5 kg]; p = 0.04), and longer anticoagulation-free ECMO duration (44.5 hr [IQR, 40-85 hr] vs 17.6 hr [IQR, 13-24.1]; p = 0.008).
Conclusions:
In selected high-risk-for-bleeding patients, our experience is that we can use ECMO in our center for limited periods without systemic anticoagulation, with lower frequency of patient or circuit thrombosis. Larger multicentered studies are required to assess weight, age, ECMO flow, and anticoagulation-free time limitations that are likely to pose risk for thrombotic events.
