Department of Cardiology, Boston Children's Hospital, Boston, MA.
Department of Pediatrics, Harvard Medical School, Boston, MA.
Pediatr Crit Care Med. 2021 Mar 1;22(3):241-250. doi: 10.1097/PCC.0000000000002657.
Patients undergoing extracorporeal membrane oxygenation are at high risk for bleeding and thrombotic complications. Current laboratory methods for assessing the coagulation system may be imprecise and complicate clinical decision-making. We hypothesize that thromboelastography may be more strongly associated with bleeding events than traditional methods and can aid extracorporeal membrane oxygenation coagulation management.
In a retrospective study, 40 patients with congenital heart disease requiring extracorporeal membrane oxygenation support yielded a total of 159 patient days of data for thromboelastography analysis.
Pediatric cardiac ICU at a single institution.
Pediatric patients (≤ 18 yr) with congenital heart disease requiring extracorporeal membrane oxygenation support.
None.
Thromboelastography was performed on whole blood samples collected 6-12 hours following extracorporeal membrane oxygenation initiation and daily for the duration of extracorporeal membrane oxygenation. Bleeding during each 24-hour period was defined as need for re-exploration or need for blood transfusion. Associations between thromboelastography variables and bleeding over each 24-hour period (bleeding vs nonbleeding days) were assessed using mixed effects logistic regression and classification and regression tree analysis.
Bleeding occurred in 25 patients (63%), contributing 87 bleeding days (55% extracorporeal membrane oxygenation days) for analysis. The probability of bleeding within the 24-hour period was not associated with activated partial thromboplastin time (p = 0.6) or anti-Xa levels (p = 0.3) on that day. The strongest correlate of bleeding was a maximum amplitude less than 55.4 mm on thromboelastography (odds ratio, 3.28; 95% CI, 1.63-6.60; p < 0.001). Bleeding occurred on 73% versus 35% of extracorporeal membrane oxygenation days for maximum amplitude less than 55.4 mm versus greater than or equal to 55.4 mm, respectively. Bleeding occurred on all days when a combination of maximum amplitude less than 55.4 mm and a reaction time greater than 12.9 minutes was present. The lowest risk of bleeding (28% of patient days) was associated with maximum amplitude greater than or equal to 55.4 mm and plasma fibrinogen greater than 345 mg/dL.
Thromboelastography-derived variables maximum amplitude and reaction time, along with plasma fibrinogen levels, can help predict bleeding events in children on extracorporeal membrane oxygenation support. Research based on larger patient samples is needed to confirm the specific thresholds identified for bleeding risk stratification for extracorporeal membrane oxygenation anticoagulation management.
接受体外膜肺氧合治疗的患者有发生出血和血栓并发症的高风险。目前评估凝血系统的实验室方法可能不够精确，并使临床决策复杂化。我们假设血栓弹性图与出血事件的相关性可能强于传统方法，并能辅助体外膜肺氧合的凝血管理。
在一项回顾性研究中，40 名患有先天性心脏病并需要体外膜肺氧合支持的患者共产生了 159 个患者天的血栓弹性图分析数据。
单一机构的儿科心脏重症监护病房。
需要体外膜肺氧合支持的患有先天性心脏病的儿科患者（≤18 岁）。
无。
在体外膜肺氧合启动后 6-12 小时采集全血样本进行血栓弹性图检查，并在体外膜肺氧合期间每天进行检查。在每个 24 小时期间发生的出血定义为需要再次探查或需要输血。使用混合效应逻辑回归和分类回归树分析评估血栓弹性图变量与每个 24 小时期间（出血与非出血日）出血之间的相关性。
25 名患者（63%）发生出血，其中 87 个出血日（55%为体外膜肺氧合日）用于分析。当天的活化部分凝血活酶时间（p=0.6）或抗-Xa 水平（p=0.3）与 24 小时内出血的概率无关。血栓弹性图上最大振幅小于 55.4 mm 是出血的最强相关因素（比值比，3.28；95%置信区间，1.63-6.60；p<0.001）。最大振幅小于 55.4 毫米的体外膜肺氧合日出血发生率为 73%，而最大振幅大于或等于 55.4 毫米的体外膜肺氧合日出血发生率为 35%。当最大振幅小于 55.4 毫米和反应时间大于 12.9 分钟的组合存在时，所有日子都会发生出血。最大振幅大于或等于 55.4 mm 和血浆纤维蛋白原大于 345 mg/dL 时，出血风险最低（28%的患者日）。
血栓弹性图衍生的变量最大振幅和反应时间，以及血浆纤维蛋白原水平，可帮助预测体外膜肺氧合支持患儿的出血事件。需要更大的患者样本研究来证实为体外膜肺氧合抗凝管理的出血风险分层确定的特定阈值。
