Factors associated with bleeding and thrombosis in children receiving extracorporeal membrane oxygenation

Heidi J. Dalton*, Ron Reeder, Pamela Garcia-Filion, Richard Holubkov, Robert A. Berg, Athena Zuppa, Frank W. Moler, Thomas Shanley, Murray Pollack, Christopher Newth, John Berger, David Wessel, Joseph Carcillo, Michael Bell, Sabrina Heidemann, Kathleen L. Meert, Richard Harrison, Allan Doctor, Robert F. Tamburro, J. Michael DeanTammara Jenkins, Carol Nicholson

*Corresponding author for this work

Research output: Contribution to journalArticle

30 Citations (Scopus)

Abstract

Rationale: Extracorporeal membrane oxygenation (ECMO) is used for respiratory and cardiac failure in children but is complicated by bleeding and thrombosis. Objectives: (1) To measure the incidence of bleeding (blood loss requiring transfusion or intracranial hemorrhage) and thrombosis during ECMO support; (2) to identify factors associated with these complications; and (3) to determine the impact of these complications on patient outcome. Methods: This was a prospective, observational cohort study in pediatric, cardiac, and neonatal intensive care units in eight hospitals, carried out from December 2012 to September 2014. Measurements and Main Results: ECMO was used on 514 consecutive patients under age 19 years. Demographics, anticoagulation practices, severity of illness, circuitry components, bleeding, thrombotic events, and outcome were recorded. Survival was 54.9%. Bleeding occurred in 70.2%, including intracranial hemorrhage in 16%, and was independently associated with higher daily risk of mortality. Circuit component changes were required in 31.1%, and patient-related clots occurred in 12.8%. Laboratory sampling contributed to transfusion requirement in 56.6%, and was the sole reason for at least one transfusion in 42.2% of patients. Pump type was not associated with bleeding, thrombosis, hemolysis, or mortality. Hemolysis was predictive of subsequent thrombotic events. Neither hemolysis nor thrombotic events increased the risk of mortality. Conclusions: The incidences of bleeding and thrombosis are high during ECMO support. Laboratory sampling is a major contributor to transfusion during ECMO. Strategies to reduce the daily risk of bleeding and thrombosis, and different thresholds for transfusion, may be appropriate subjects of future trials to improve outcomes of children requiring this supportive therapy.

Original languageEnglish (US)
Pages (from-to)762-771
Number of pages10
JournalAmerican journal of respiratory and critical care medicine
Volume196
Issue number6
DOIs
StatePublished - Sep 15 2017

Fingerprint

Extracorporeal Membrane Oxygenation
Thrombosis
Hemorrhage
Hemolysis
Intracranial Hemorrhages
Mortality
Intracranial Thrombosis
Pediatric Intensive Care Units
Neonatal Intensive Care Units
Incidence
Respiratory Insufficiency
Observational Studies
Cohort Studies
Heart Failure
Demography
Survival

Keywords

  • Cardiorespiratory failure
  • Extracorporeal life support
  • Hemolysis
  • Outcome
  • Transfusion

ASJC Scopus subject areas

  • Pulmonary and Respiratory Medicine
  • Critical Care and Intensive Care Medicine

Cite this

Dalton, Heidi J. ; Reeder, Ron ; Garcia-Filion, Pamela ; Holubkov, Richard ; Berg, Robert A. ; Zuppa, Athena ; Moler, Frank W. ; Shanley, Thomas ; Pollack, Murray ; Newth, Christopher ; Berger, John ; Wessel, David ; Carcillo, Joseph ; Bell, Michael ; Heidemann, Sabrina ; Meert, Kathleen L. ; Harrison, Richard ; Doctor, Allan ; Tamburro, Robert F. ; Dean, J. Michael ; Jenkins, Tammara ; Nicholson, Carol. / Factors associated with bleeding and thrombosis in children receiving extracorporeal membrane oxygenation. In: American journal of respiratory and critical care medicine. 2017 ; Vol. 196, No. 6. pp. 762-771.
@article{cfe204afa2c44f2baa742cf6daf507b6,
title = "Factors associated with bleeding and thrombosis in children receiving extracorporeal membrane oxygenation",
abstract = "Rationale: Extracorporeal membrane oxygenation (ECMO) is used for respiratory and cardiac failure in children but is complicated by bleeding and thrombosis. Objectives: (1) To measure the incidence of bleeding (blood loss requiring transfusion or intracranial hemorrhage) and thrombosis during ECMO support; (2) to identify factors associated with these complications; and (3) to determine the impact of these complications on patient outcome. Methods: This was a prospective, observational cohort study in pediatric, cardiac, and neonatal intensive care units in eight hospitals, carried out from December 2012 to September 2014. Measurements and Main Results: ECMO was used on 514 consecutive patients under age 19 years. Demographics, anticoagulation practices, severity of illness, circuitry components, bleeding, thrombotic events, and outcome were recorded. Survival was 54.9{\%}. Bleeding occurred in 70.2{\%}, including intracranial hemorrhage in 16{\%}, and was independently associated with higher daily risk of mortality. Circuit component changes were required in 31.1{\%}, and patient-related clots occurred in 12.8{\%}. Laboratory sampling contributed to transfusion requirement in 56.6{\%}, and was the sole reason for at least one transfusion in 42.2{\%} of patients. Pump type was not associated with bleeding, thrombosis, hemolysis, or mortality. Hemolysis was predictive of subsequent thrombotic events. Neither hemolysis nor thrombotic events increased the risk of mortality. Conclusions: The incidences of bleeding and thrombosis are high during ECMO support. Laboratory sampling is a major contributor to transfusion during ECMO. Strategies to reduce the daily risk of bleeding and thrombosis, and different thresholds for transfusion, may be appropriate subjects of future trials to improve outcomes of children requiring this supportive therapy.",
keywords = "Cardiorespiratory failure, Extracorporeal life support, Hemolysis, Outcome, Transfusion",
author = "Dalton, {Heidi J.} and Ron Reeder and Pamela Garcia-Filion and Richard Holubkov and Berg, {Robert A.} and Athena Zuppa and Moler, {Frank W.} and Thomas Shanley and Murray Pollack and Christopher Newth and John Berger and David Wessel and Joseph Carcillo and Michael Bell and Sabrina Heidemann and Meert, {Kathleen L.} and Richard Harrison and Allan Doctor and Tamburro, {Robert F.} and Dean, {J. Michael} and Tammara Jenkins and Carol Nicholson",
year = "2017",
month = "9",
day = "15",
doi = "10.1164/rccm.201609-1945OC",
language = "English (US)",
volume = "196",
pages = "762--771",
journal = "American Journal of Respiratory and Critical Care Medicine",
issn = "1073-449X",
publisher = "American Thoracic Society",
number = "6",

}

Dalton, HJ, Reeder, R, Garcia-Filion, P, Holubkov, R, Berg, RA, Zuppa, A, Moler, FW, Shanley, T, Pollack, M, Newth, C, Berger, J, Wessel, D, Carcillo, J, Bell, M, Heidemann, S, Meert, KL, Harrison, R, Doctor, A, Tamburro, RF, Dean, JM, Jenkins, T & Nicholson, C 2017, 'Factors associated with bleeding and thrombosis in children receiving extracorporeal membrane oxygenation', American journal of respiratory and critical care medicine, vol. 196, no. 6, pp. 762-771. https://doi.org/10.1164/rccm.201609-1945OC

Factors associated with bleeding and thrombosis in children receiving extracorporeal membrane oxygenation. / Dalton, Heidi J.; Reeder, Ron; Garcia-Filion, Pamela; Holubkov, Richard; Berg, Robert A.; Zuppa, Athena; Moler, Frank W.; Shanley, Thomas; Pollack, Murray; Newth, Christopher; Berger, John; Wessel, David; Carcillo, Joseph; Bell, Michael; Heidemann, Sabrina; Meert, Kathleen L.; Harrison, Richard; Doctor, Allan; Tamburro, Robert F.; Dean, J. Michael; Jenkins, Tammara; Nicholson, Carol.

In: American journal of respiratory and critical care medicine, Vol. 196, No. 6, 15.09.2017, p. 762-771.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Factors associated with bleeding and thrombosis in children receiving extracorporeal membrane oxygenation

AU - Dalton, Heidi J.

AU - Reeder, Ron

AU - Garcia-Filion, Pamela

AU - Holubkov, Richard

AU - Berg, Robert A.

AU - Zuppa, Athena

AU - Moler, Frank W.

AU - Shanley, Thomas

AU - Pollack, Murray

AU - Newth, Christopher

AU - Berger, John

AU - Wessel, David

AU - Carcillo, Joseph

AU - Bell, Michael

AU - Heidemann, Sabrina

AU - Meert, Kathleen L.

AU - Harrison, Richard

AU - Doctor, Allan

AU - Tamburro, Robert F.

AU - Dean, J. Michael

AU - Jenkins, Tammara

AU - Nicholson, Carol

PY - 2017/9/15

Y1 - 2017/9/15

N2 - Rationale: Extracorporeal membrane oxygenation (ECMO) is used for respiratory and cardiac failure in children but is complicated by bleeding and thrombosis. Objectives: (1) To measure the incidence of bleeding (blood loss requiring transfusion or intracranial hemorrhage) and thrombosis during ECMO support; (2) to identify factors associated with these complications; and (3) to determine the impact of these complications on patient outcome. Methods: This was a prospective, observational cohort study in pediatric, cardiac, and neonatal intensive care units in eight hospitals, carried out from December 2012 to September 2014. Measurements and Main Results: ECMO was used on 514 consecutive patients under age 19 years. Demographics, anticoagulation practices, severity of illness, circuitry components, bleeding, thrombotic events, and outcome were recorded. Survival was 54.9%. Bleeding occurred in 70.2%, including intracranial hemorrhage in 16%, and was independently associated with higher daily risk of mortality. Circuit component changes were required in 31.1%, and patient-related clots occurred in 12.8%. Laboratory sampling contributed to transfusion requirement in 56.6%, and was the sole reason for at least one transfusion in 42.2% of patients. Pump type was not associated with bleeding, thrombosis, hemolysis, or mortality. Hemolysis was predictive of subsequent thrombotic events. Neither hemolysis nor thrombotic events increased the risk of mortality. Conclusions: The incidences of bleeding and thrombosis are high during ECMO support. Laboratory sampling is a major contributor to transfusion during ECMO. Strategies to reduce the daily risk of bleeding and thrombosis, and different thresholds for transfusion, may be appropriate subjects of future trials to improve outcomes of children requiring this supportive therapy.

AB - Rationale: Extracorporeal membrane oxygenation (ECMO) is used for respiratory and cardiac failure in children but is complicated by bleeding and thrombosis. Objectives: (1) To measure the incidence of bleeding (blood loss requiring transfusion or intracranial hemorrhage) and thrombosis during ECMO support; (2) to identify factors associated with these complications; and (3) to determine the impact of these complications on patient outcome. Methods: This was a prospective, observational cohort study in pediatric, cardiac, and neonatal intensive care units in eight hospitals, carried out from December 2012 to September 2014. Measurements and Main Results: ECMO was used on 514 consecutive patients under age 19 years. Demographics, anticoagulation practices, severity of illness, circuitry components, bleeding, thrombotic events, and outcome were recorded. Survival was 54.9%. Bleeding occurred in 70.2%, including intracranial hemorrhage in 16%, and was independently associated with higher daily risk of mortality. Circuit component changes were required in 31.1%, and patient-related clots occurred in 12.8%. Laboratory sampling contributed to transfusion requirement in 56.6%, and was the sole reason for at least one transfusion in 42.2% of patients. Pump type was not associated with bleeding, thrombosis, hemolysis, or mortality. Hemolysis was predictive of subsequent thrombotic events. Neither hemolysis nor thrombotic events increased the risk of mortality. Conclusions: The incidences of bleeding and thrombosis are high during ECMO support. Laboratory sampling is a major contributor to transfusion during ECMO. Strategies to reduce the daily risk of bleeding and thrombosis, and different thresholds for transfusion, may be appropriate subjects of future trials to improve outcomes of children requiring this supportive therapy.

KW - Cardiorespiratory failure

KW - Extracorporeal life support

KW - Hemolysis

KW - Outcome

KW - Transfusion

UR - http://www.scopus.com/inward/record.url?scp=85029670756&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85029670756&partnerID=8YFLogxK

U2 - 10.1164/rccm.201609-1945OC

DO - 10.1164/rccm.201609-1945OC

M3 - Article

C2 - 28328243

AN - SCOPUS:85029670756

VL - 196

SP - 762

EP - 771

JO - American Journal of Respiratory and Critical Care Medicine

JF - American Journal of Respiratory and Critical Care Medicine

SN - 1073-449X

IS - 6

ER -