Budhu Gail, Morris-Whyte Kaydeen, Constantinescu Alexandru R
Pediatric Residency Program, Joe DiMaggio Children's Hospital, Memorial Healthcare System, 1005 Joe DiMaggio Dr. Hollywood, FL 33021, USA.
Division of Pediatric Nephrology, Joe DiMaggio Children's Hospital, 1131 N35th Ave, Hollywood, FL 33021, USA - Charles E. Schmidt College of Medicine at Florida Atlantic University, 777 Glades Rd BC-71, Boca Raton, FL 33431, USA.
J Extra Corpor Technol. 2024 Dec;56(4):211-215. doi: 10.1051/ject/2024032. Epub 2024 Dec 20.
Intravascular hemolysis is a known complication of extracorporeal membrane oxygenation (ECMO). Characterized by elevated plasma-free hemoglobin (PFH), intravascular hemolysis is associated with cytotoxic effects leading to renal replacement therapy (RRT), longer ECMO runs, and mortality. Therapeutic plasma exchange (TPE) in tandem with ECMO was described as a therapy for various pathologic conditions, but there are no Extracorporeal Life Support Organization (ELSO) guidelines for the treatment of ECMO-induced hemolysis. We describe the use of TPE in the management of severe ECMO-induced hemolysis.
Two-term neonates receiving veno-arterial (VA) ECMO developed severe PFH, with peak values over 500 mg/dL. TPE was performed in tandem with the ECMO circuit. Packed red cells were used to prime the TPE circuit, and citrate anticoagulation was added to establish the interface, which could not be achieved with existing heparin in the ECMO circuit. Therapy was completed with saline solution as a decoy for citrate, to avoid hypocalcemia and intracranial bleeding. Plasma volume was replaced by fresh frozen plasma (FFP).
In one patient PFH fell to 120 mg/dL, but rebounded to close to 500 mg/dL, only to stabilize between 210 and 300 mg/dL after the second TPE. He was liberated from ECMO, but could not survive a respiratory decompensation. The other patient's PFH improved to 360 mg/dL after one TPE and continued to decline to 120 mg/dL over the ensuing days. Despite that improvement, care was withdrawn.
TPE is effective in decreasing the burden of PFH and is well tolerated in tandem with ECMO, and a database of infants with ECMO-induced hemolysis needs to be created to assess the current practice and establish clinical guidelines for its most appropriate therapy.
血管内溶血是体外膜肺氧合（ECMO）已知的并发症。血管内溶血以血浆游离血红蛋白（PFH）升高为特征，与细胞毒性作用相关，可导致肾脏替代治疗（RRT）、ECMO运行时间延长及死亡。治疗性血浆置换（TPE）联合ECMO被描述为针对各种病理状况的一种治疗方法，但体外生命支持组织（ELSO）尚无关于ECMO所致溶血治疗的指南。我们描述了TPE在严重ECMO所致溶血管理中的应用。
两名接受静脉-动脉（VA）ECMO的足月新生儿出现严重PFH，峰值超过500mg/dL。TPE与ECMO回路同时进行。用浓缩红细胞预充TPE回路，并添加枸橼酸盐抗凝以建立界面，而ECMO回路中现有的肝素无法实现这一点。用生理盐水作为枸橼酸盐的诱饵完成治疗，以避免低钙血症和颅内出血。用新鲜冰冻血浆（FFP）替代血浆量。
一名患者的PFH降至120mg/dL，但反弹至接近500mg/dL，在第二次TPE后才稳定在210至300mg/dL之间。他脱离了ECMO，但未能在呼吸失代偿中存活。另一名患者在一次TPE后PFH改善至360mg/dL，并在随后几天继续降至120mg/dL。尽管有改善，但仍停止了治疗。
TPE可有效减轻PFH负担，与ECMO联合应用耐受性良好，需要建立一个ECMO所致溶血婴儿的数据库，以评估当前的实践并制定其最恰当治疗的临床指南。
