Risk factors for intracranial hemorrhage in the extracorporeal membrane oxygenation patient

The need for cardiopulmonary resuscitation and repeated correction of persistent acidosis identifies extracorporeal membrane oxygenation patients more likely to develop an intracranial hemorrhage. The objective of this study was to identify risk factors for an intracranial hemorrhage (ICH) in infants on extracorporeal membrane oxygenation (ECMO). This study was a retrospective-matched, case-controlled study of infants with ICH on ECMO compared with infants without ICH on ECMO. Data collected included patient demographics, ventilator parameters, blood gases, coagulation parameters, the need for cardiopulmonary resuscitation (CPR), neurologic findings, and outcome. The Neonatal Intensive Care Nursery at Kosair Children's Hospital in Louisville, Ky., was the setting. Twenty-three infants who developed an ICH (excluding subarachnoid hemorrhage) on ECMO were matched with a control group of 23 infants without an ICH on ECMO. The presence of acidosis (pH < 7.19 or HCO3 < 17; p < 0.01 and p < 0.05, respectively) and the need for CPR (heart rate < or = 80 or mean blood pressure < or = 30 mm Hg, p < 0.003) shortly before or during cannulation correlated with the development of an ICH in infants on ECMO. The infants with an ICH required more frequent platelet transfusions (p < 0.005), had difficulty maintaining activated clotting times (ACTs) within a normal range (p < 0.03), and had abnormal neurologic examinations shortly before or after the ICH was detected with head ultrasound. The ultrasound was obtained as soon as possible after a change in the neurologic status. The need for CPR and repeated correction of persistent acidosis before or during cannulation identifies ECMO patients more likely to develop an ICH. We found that elevated ACTs and low platelet counts requiring transfusion showed a statistical association with the development of an ICH. Daily head ultrasounds and frequent neurologic checks are thus valuable tools in assessing the ECMO patient who demonstrates difficulty in maintaining coagulation values in the normal range or who requires frequent platelet transfusions.