Factors Associated with Bleeding and Thrombosis in Children Receiving Extracorporeal Membrane Oxygenation.
Extracorporeal membrane oxygenation (ECMO) is used for respiratory and cardiac failure in children but is complicated by bleeding and thrombosis.



(1) To measure the incidence of bleeding (blood loss requiring transfusion or intracranial hemorrhage) and thrombosis during ECMO support; (2) to identify factors associated with these complications; and (3) to determine the impact of these complications on patient outcome.



This was a prospective, observational cohort study in pediatric, cardiac, and neonatal intensive care units in eight hospitals, carried out from December 2012 to September 2014.



ECMO was used on 514 consecutive patients under age 19 years. Demographics, anticoagulation practices, severity of illness, circuitry components, bleeding, thrombotic events, and outcome were recorded. Survival was 54.9%. Bleeding occurred in 70.2%, including intracranial hemorrhage in 16%, and was independently associated with higher daily risk of mortality. Circuit component changes were required in 31.1%, and patient-related clots occurred in 12.8%. Laboratory sampling contributed to transfusion requirement in 56.6%, and was the sole reason for at least one transfusion in 42.2% of patients. Pump type was not associated with bleeding, thrombosis, hemolysis, or mortality. Hemolysis was predictive of subsequent thrombotic events. Neither hemolysis nor thrombotic events increased the risk of mortality.



The incidences of bleeding and thrombosis are high during ECMO support. Laboratory sampling is a major contributor to transfusion during ECMO. Strategies to reduce the daily risk of bleeding and thrombosis, and different thresholds for transfusion, may be appropriate subjects of future trials to improve outcomes of children requiring this supportive therapy.
1 Department of Child Health, Phoenix Children's Hospital, Phoenix, Arizona.
Heidi J
HJ
Dalton
2 Department of Pediatrics, University of Utah, Salt Lake City, Utah.
Ron
R
Reeder
1 Department of Child Health, Phoenix Children's Hospital, Phoenix, Arizona.
Pamela
P
Garcia-Filion
2 Department of Pediatrics, University of Utah, Salt Lake City, Utah.
Richard
R
Holubkov
3 Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
Robert A
RA
Berg
3 Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
Athena
A
Zuppa
4 Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, Michigan.
Frank W
FW
Moler
4 Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, Michigan.
Thomas
T
Shanley
1 Department of Child Health, Phoenix Children's Hospital, Phoenix, Arizona.
Murray M
MM
Pollack
5 Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Los Angeles, Los Angeles, California.
Christopher
C
Newth
6 Department of Pediatrics, Children's National Medical Center, Washington, DC.
John
J
Berger
6 Department of Pediatrics, Children's National Medical Center, Washington, DC.
David
D
Wessel
7 Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania.
Joseph
J
Carcillo
7 Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania.
Michael
M
Bell
8 Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan.
Sabrina
S
Heidemann
8 Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan.
Kathleen L
KL
Meert
9 Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, California.
Richard
R
Harrison
10 Department of Pediatrics, Washington University, St. Louis, Missouri; and.
Allan
A
Doctor
11 Pediatric Trauma and Critical Illness Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland.
Robert F
RF
Tamburro
2 Department of Pediatrics, University of Utah, Salt Lake City, Utah.
J Michael
JM
Dean
11 Pediatric Trauma and Critical Illness Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland.
Tammara
T
Jenkins
11 Pediatric Trauma and Critical Illness Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland.
Carol
C
Nicholson
D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D015199:Extracorporeal Membrane Oxygenation / Q000009:adverse effects*; D005260:Female; D006333:Heart Failure / Q000628:therapy*; D006461:Hemolysis; D006470:Hemorrhage / Q000453:epidemiology / Q000209:etiology*; D006801:Humans; D015994:Incidence; D007223:Infant; D008297:Male; D011446:Prospective Studies; D012131:Respiratory Insufficiency / Q000628:therapy*; D012189:Retrospective Studies; D013927:Thrombosis / Q000453:epidemiology / Q000209:etiology*
cardiorespiratory failure; extracorporeal life support; hemolysis; outcome; transfusion