Pediatric Critical Care Medicine:
March 2015 - Volume 16 - Issue 3 - p 276–288
doi: 10.1097/PCC.0000000000000345
Extracorporeal Support
Hemorrhagic Complications in Pediatric Cardiac Patients on Extracorporeal Membrane Oxygenation: An Analysis of the Extracorporeal Life Support Organization Registry
Werho, David K. MD; Pasquali, Sara K. MD, MHS; Yu, Sunkyung MS; Donohue, Janet MPH; Annich, Gail M. MD; Thiagarajan, Ravi R. MBBS, MPH; Hirsch-Romano, Jennifer C. MD
Abstract
Objectives: To determine the prevalence of and risk factors for hemorrhagic complications in children with cardiac disease requiring extracorporeal membrane oxygenation.
Design: Retrospective review of the Extracorporeal Life Support Organization Registry (2002–2013).
Setting: Participating Extracorporeal Life Support Organization centers.
Patients: Patients less than 18 years old on extracorporeal membrane oxygenation.
Interventions: None.
Measurements and Main Results: Of 21,845 patients requiring extracorporeal membrane oxygenation during the study period, 8,905 (41%) had cardiac disease, and 79% of whom (6,995) had cardiac surgery. Hemorrhagic complications occurred in 8,480 patients (39% of overall cohort), with higher rates in cardiac versus noncardiac patients (49% vs 32%; p < 0.0001) related to cannulation and surgical site bleeding. Cardiac surgical patients had higher rates of hemorrhage compared with cardiac medical patients (57% vs 38%; p < 0.0001), and cardiac patients with hemorrhage had higher extracorporeal membrane oxygenation mortality compared with those without (42% vs 22% in medical patients and 34% vs 20% in surgical patients; both p < 0.0001). In multivariable analysis in both the cardiac medical and surgical groups, hemorrhage risk was higher in children greater than 1 year old and in patients with longer extracorporeal membrane oxygenation duration. Additional independent risk factors for hemorrhage in cardiac surgical patients included pre-extracorporeal membrane oxygenation mediastinal exploration (odds ratio, 3.6; 95% CI, 2.1–6.3), Society of Thoracic Surgeons morbidity category 4–5 (odds ratio, 1.2; 95% CI, 1.03–1.5), cannulation less than 24 hours after surgery (odds ratio, 1.6; 95% CI, 1.3–1.9), and longer cardiopulmonary bypass time (≥ 282 min [upper quartile]; odds ratio, 1.5; 95% CI, 1.3–1.9).
Conclusions: In this large, multicenter analysis, hemorrhagic complications occurred in nearly half of children with heart disease on extracorporeal membrane oxygenation and were associated with a significant mortality risk. Several factors were associated with hemorrhagic complications in cardiac surgical patients including pre-extracorporeal membrane oxygenation mediastinal exploration, greater surgical complexity, early postoperative cannulation, and longer bypass times. Whether these risks can be mitigated by modifying or delaying systemic anticoagulation requires further investigation.