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Temporal trends and risk factors for bleeding and thrombosis in pediatric ECMO: A multicenter cohort study

Kevin J Doré1, Carlton M Kelly2, Timothy T Cornell1

  • 1Department of Pediatrics, Division of Critical Care Medicine, Stanford University School of Medicine, Stanford, CA, USA.

Perfusion
|July 31, 2025
PubMed

Insights

Bleeding and thrombosis are common in pediatric extracorporeal membrane oxygenation (ECMO) and their risks change over time. Prior bleeding or thrombosis influences future risk, suggesting dynamic anticoagulation strategies are needed for pediatric ECMO patients.

Area of Science:

  • Pediatric critical care medicine
  • Cardiovascular research
  • Hematology

Background:

  • Bleeding and thrombosis are significant complications in pediatric extracorporeal membrane oxygenation (ECMO), impacting patient outcomes.
  • The time-dependent nature and predictors of these events in pediatric ECMO are not fully understood.
  • Accurate risk assessment is crucial for managing anticoagulation and improving survival rates.

Purpose of the Study:

  • To evaluate clinical predictors of bleeding and thrombotic events in pediatric patients undergoing ECMO.
  • To analyze the time-to-event risks associated with bleeding and thrombosis during ECMO.
  • To identify factors influencing the evolving risk of these complications.

Main Methods:

  • Retrospective cohort study using the Pediatric ECMO Outcomes Registry (PEDECOR) from 2011 to 2024.
  • Included 1444 pediatric patients (≤18 years) on their first ECMO run.
  • Utilized time-varying Cox proportional hazards models to assess risk factors for bleeding and thrombosis.

Main Results:

  • Bleeding occurred in 65% of patients, with a median time to first event of 2 days; thrombosis occurred in 28%, with a median time of 3 days.
  • Prior thrombosis reduced early bleeding risk (HR: 0.39), but this effect reversed over time (crossover at 12.4 days).
  • Prior bleeding reduced early thrombosis risk (HR: 0.49), reversing over time (crossover at 4.3 days). Sepsis was linked to thrombosis; central cannulation, cardiac surgery, and non-pulmonary indications were linked to bleeding.

Conclusions:

  • Bleeding and thrombosis are frequent and dynamic risks during pediatric ECMO.
  • The interplay between prior bleeding/thrombosis and subsequent events changes over the ECMO course.
  • Findings support the need for adaptive anticoagulation strategies based on evolving patient risk profiles in pediatric ECMO.

Keywords:
anticoagulationbleedingextracorporeal membrane oxygenationthrombosistime-to-event analysis

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