Hemorrhagic complications in pediatric cardiac patients on extracorporeal membrane oxygenation: an analysis of the Extracorporeal Life Support Organization Registry

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.

Figure 1

Prevalence of hemorrhage in different patient groups, categorized by complication type. Values are expressed as the percentage of patients within each cohort who experienced a hemorrhagic complication during their extracorporeal membrane oxygenation hospitalization (*p < 0.05; **p < 0.0001). A, Cardiac versus noncardiac patients. Dark bars represent cardiac patients (n = 8,905); light bars represent noncardiac patients (n = 12,940). B, Structural heart disease versus nonstructural cardiac patients. Dark bars represent structural heart disease patients (n = 7,277); light bars represent nonstructural heart disease patients (n = 1,406). C, Cardiac patients by age group. Dark bars represent neonates 0–28 d old (n = 4,170); light bars represent infants 29–365 d old (n = 2,642); medium bars represent children greater than 1 yr old to less than 18 yr old (n = 2,093). D, Cardiac surgical versus cardiac medical patients, after exclusion of extracorporeal cardiopulmonary resuscitation and pulmonary patients. Dark bars represent cardiac surgical patients (n = 3,517); light bars represent cardiac medical patients (n = 1,196). GI = Gastrointestinal.