title: Risk factors associated with intracranial hemorrhage in neonates with persistent pulmonary hypertension on ECMO.
abstract: BACKGROUND
  Up to 40% of infants with persistent pulmonary hypertension (PPHN) remains refractory to conventional therapies, and extracorporeal membrane oxygenation (ECMO) is offered as an effective support for this group. However, ECMO is a highly invasive and risky procedure with devastating complications such as intracranial hemorrhage (ICH). In this study, we aimed to determine the risk factors for ICH in infants with PPHN.
  
  
  METHODS
  A case-control study of patients admitted to the pediatric intensive care unit (PICU) with PPHN requiring ECMO support was conducted. The study was carried out at a 25-bed PICU in large urban tertiary care children's hospital. A total number of 32 subjects were studied. Patients with and without ICH during ECMO were evaluated for activated clotting time (ACT), heparin dosing, platelet count, coagulation profile such as activated partial thromboplastin time (aPTT), prothrombin time (PT), international normalized ratio (INR), fibrinogen level, vital signs including heart rate and mean arterial pressure (MAP), transfusion history, gestational age, and severity of pre-ECMO illness as possible risk factors.
  
  
  RESULTS
  Low fibrinogen level (115 ± 13 mg/dl) and low platelet counts (37.4 ± 18.3 Thousand/μl) were associated with higher incidence of ICH (p = 0.009 and p = 0.005, respectively). Elevated MAP (69 ± 4.34 mmHg) was also noticed in ICH patients (p = 0.006).
  
  
  CONCLUSIONS
  Results demonstrated that low fibrinogen level and low platelet count were associated with ICH in PPHN patients on ECMO. While on ECMO support, maintaining fibrinogen and platelet counts within normal ranges seems crucial to prevent ICH in PPHN patients. This is the first report identifying low fibrinogen level among the risk factors for ICH in infants with PPHN on ECMO support.
authors.affiliation: Pediatric Critical Care Division, Cohen Children's Medical Center of New York, New Hyde Park, NY 11040 USA ; Department of Pediatrics and Division of Pediatric Intensive Care Unit, SUNY DOWNSTATE Medical Center, 450 Clarkson Ave, Brooklyn, NY 11203 USA.
authors.forename: Sule
authors.initials: S
authors.lastname: Doymaz
authors.affiliation: Pediatric Critical Care Division, Cohen Children's Medical Center of New York, New Hyde Park, NY 11040 USA.
authors.forename: Marcia
authors.initials: M
authors.lastname: Zinger
authors.affiliation: Pediatric Critical Care Division, Cohen Children's Medical Center of New York, New Hyde Park, NY 11040 USA.
authors.forename: Todd
authors.initials: T
authors.lastname: Sweberg
keywords: ECMO; Hypertension; Intracranial hemorrhage; Neonates; Pulmonary