Ankola Ashish A, Bailly David K, Reeder Ron W, Cashen Katherine, Dalton Heidi J, Dolgner Stephen J, Federman Myke, Ghassemzadeh Rod, Himebauch Adam S, Kamerkar Asavari, Koch Josh, Kohne Joseph, Lewen Margaret, Srivastava Neeraj, Willett Renee, Alexander Peta M A
Department of Pediatrics, Divisions of Critical Care and Cardiology, Baylor College of Medicine, Houston, TX, United States.
Department of Pediatrics, Division of Pediatric Critical Care, University of Utah, Salt Lake City, UT, United States.
Front Cardiovasc Med. 2022 Jan 13;8:812881. doi: 10.3389/fcvm.2021.812881. eCollection 2021.
Bleeding is a common complication of extracorporeal membrane oxygenation (ECMO) for pediatric cardiac patients. We aimed to identify anticoagulation practices, cardiac diagnoses, and surgical variables associated with bleeding during pediatric cardiac ECMO by combining two established databases, the Collaborative Pediatric Critical Care Research Network (CPCCRN) Bleeding and Thrombosis in ECMO (BATE) and the Extracorporeal Life Support Organization (ELSO) Registry. All children (<19 years) with a primary cardiac diagnosis managed on ECMO included in BATE from six centers were analyzed. ELSO Registry criteria for bleeding events included pulmonary or intracranial bleeding, or red blood cell transfusion >80 ml/kg on any ECMO day. Bleeding odds were assessed on ECMO Day 1 and from ECMO Day 2 onwards with multivariable logistic regression. There were 187 children with 114 (61%) bleeding events in the study cohort. Biventricular congenital heart disease (94/187, 50%) and cardiac medical diagnoses (75/187, 40%) were most common, and 48 (26%) patients were cannulated directly from cardiopulmonary bypass (CPB). Bleeding events were not associated with achieving pre-specified therapeutic ranges of activated clotting time (ACT) or platelet levels. In multivariable analysis, elevated INR and fibrinogen were associated with bleeding events (OR 1.1, CI 1.0-1.3, = 0.02; OR 0.77, CI 0.6-0.9, = 0.004). Bleeding events were also associated with clinical site (OR 4.8, CI 2.0-11.1, < 0.001) and central cannulation (OR 1.75, CI 1.0-3.1, = 0.05) but not with cardiac diagnosis, surgical complexity, or cannulation from CPB. Bleeding odds on ECMO day 1 were increased in patients with central cannulation (OR 2.82, 95% CI 1.15-7.08, = 0.023) and those cannulated directly from CPB (OR 3.32, 95% CI 1.02-11.61, = 0.047). Bleeding events in children with cardiac diagnoses supported on ECMO were associated with central cannulation strategy and coagulopathy, but were not modulated by achieving pre-specified therapeutic ranges of monitoring assays.
出血是小儿心脏患者体外膜肺氧合（ECMO）治疗过程中的常见并发症。我们旨在通过合并两个已建立的数据库，即协作儿科重症护理研究网络（CPCCRN）的ECMO出血与血栓形成（BATE）数据库和体外生命支持组织（ELSO）注册数据库，来确定与小儿心脏ECMO治疗期间出血相关的抗凝措施、心脏诊断及手术变量。对来自六个中心纳入BATE数据库的所有接受ECMO治疗且主要诊断为心脏疾病的儿童（<19岁）进行了分析。ELSO注册数据库中出血事件的标准包括肺出血或颅内出血，或在任何ECMO治疗日红细胞输注量>80 ml/kg。在ECMO治疗第1天以及从第2天起，采用多变量逻辑回归评估出血几率。研究队列中有187名儿童，其中114例（61%）发生出血事件。双心室先天性心脏病（94/187，50%）和心脏内科诊断（75/187，40%）最为常见，48例（26%）患者直接从体外循环（CPB）插管。出血事件与达到活化凝血时间（ACT）或血小板水平的预先设定治疗范围无关。在多变量分析中，INR升高和纤维蛋白原升高与出血事件相关（比值比1.1，置信区间1.0 - 1.3，P = 0.02；比值比0.77，置信区间0.6 - 0.9，P = 0.004）。出血事件还与临床治疗地点（比值比4.8，置信区间2.0 - 11.1，P < 0.001）和中心插管（比值比1.75，置信区间1.0 - 3.1，P = 0.05）相关，但与心脏诊断、手术复杂性或从CPB插管无关。中心插管患者（比值比2.82，95%置信区间1.15 - 7.08，P = 0.023）以及直接从CPB插管的患者（比值比3.32，95%置信区间1.02 - 11.61，P = 0.047）在ECMO治疗第1天的出血几率增加。接受ECMO支持的心脏诊断患儿的出血事件与中心插管策略和凝血病相关，但不受监测指标预先设定治疗范围的调节。
