title: Hemorrhagic complications in pediatric cardiac patients on extracorporeal membrane oxygenation: an analysis of the Extracorporeal Life Support Organization Registry.
abstract: OBJECTIVE
  To determine the prevalence of and risk factors for hemorrhagic complications in children with cardiac disease requiring extracorporeal membrane oxygenation.
  
  
  METHODS
  Retrospective review of the Extracorporeal Life Support Organization Registry (2002-2013).
  
  
  METHODS
  Participating Extracorporeal Life Support Organization centers.
  
  
  METHODS
  Patients less than 18 years old on extracorporeal membrane oxygenation.
  
  
  METHODS
  None.
  
  
  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.
authors: 1University of Michigan, Ann Arbor, MI. 2Toronto Hospital for Sick Children, Toronto, Canada. 3Boston Children's Hospital, Boston, MA.
authors: David K
authors: DK
authors: Werho
authors: Sara K
authors: SK
authors: Pasquali
authors: Sunkyung
authors: S
authors: Yu
authors: Janet
authors: J
authors: Donohue
authors: Gail M
authors: GM
authors: Annich
authors: Ravi R
authors: RR
authors: Thiagarajan
authors: Jennifer C
authors: JC
authors: Hirsch-Romano
authors: Michael G
authors: MG
authors: Gaies
mesh_terms: D000293:Adolescent; D006348:Cardiac Surgical Procedures / Q000009:adverse effects* / Q000401:mortality; D002315:Cardiopulmonary Bypass / Q000009:adverse effects / Q000379:methods; D002648:Child; D002675:Child, Preschool; D015199:Extracorporeal Membrane Oxygenation / Q000009:adverse effects* / Q000706:statistics & numerical data; D005260:Female; D006331:Heart Diseases / Q000401:mortality / Q000503:physiopathology / Q000601:surgery / Q000628:therapy*; D006470:Hemorrhage / Q000453:epidemiology* / Q000209:etiology; D017052:Hospital Mortality; D006801:Humans; D007223:Infant; D008297:Male; D011183:Postoperative Complications / Q000453:epidemiology*; D015995:Prevalence; D012042:Registries / Q000706:statistics & numerical data; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
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