Quantifiable Bleeding in Children Supported by Extracorporeal Membrane Oxygenation and Outcome

Abstract

Objectives: To evaluate the association between bleeding from chest tubes and clinical outcomes in children supported by extracorporeal membrane oxygenation.

Design: Secondary analysis of a large observational cohort study.

Setting: Eight pediatric institutions within the Eunice Kennedy Shriver National Institute of Child Health and Human Development's Collaborative Pediatric Critical Care Research Network.

Patients: Critically ill children supported by extracorporeal membrane oxygenation.

Interventions: None.

Measurements and main results: Daily chest tube bleeding, results from hemostatic assays, transfusion volumes, 90-day PICU-free days, and mortality were collected prospectively by trained bedside extracorporeal membrane oxygenation specialists and research coordinators. Extracorporeal membrane oxygenation was employed in the care of 514 consecutive patients. Sixty percent of patients had at least one episode of chest tube bleeding (median chest tube blood volume over the entire extracorporeal membrane oxygenation course was 123 mL/kg [interquartile range, 47-319 mL/kg]). Twenty-six percent had at least 1 day of bleeding from the chest tube greater than 100 mL/kg/d. The number of days with chest tube bleeding greater than 60 mL/kg/d was independently associated with increased in-hospital mortality (adjusted odds ratio, 1.43; 95% CI, 1.05-1.97; p = 0.02) and decreased PICU-free days (beta coefficient, -4.2; 95% CI, -7.7 to -0.6; p = 0.02). The total amount of bleeding from chest tube were independently associated with increased mortality (per mL/kg/extracorporeal membrane oxygenation run; adjusted odds ratio, 1.002; 95% CI, 1.000-1.003; p = 0.04). Fibrinogen, weight, indication for extracorporeal membrane oxygenation, and need for hemodialysis were independently associated with chest tube bleeding, whereas platelet count, coagulation tests, heparin dose, and thrombotic events were not.

Conclusions: In children supported by extracorporeal membrane oxygenation, chest tube bleeding above 60 mL/kg/d was independently associated with worse clinical outcome. Low fibrinogen was independently associated with chest tube bleeding, whereas platelet count and hemostatic tests were not. Further research is needed to evaluate if interventions to prevent or stop chest tube bleeding influence the clinical outcome.

Figure 1:

Adjusted odds ratio of mortality according to chest tube bleeding above a certain threshold. Patients were grouped according to any day with bleeding above the noted thresholds. The diamonds represent the adjusted odds ratio and the horizontal lines represent the 95% confidence interval around the odds ratio.

Figure 2:

Adjusted Beta coefficient for 90-day PICU-free days according to chest tube bleeding above a certain threshold. Patients were grouped according to any day with bleeding above the noted thresholds. The diamonds represent the adjusted Beta coefficient and the horizontal lines represent the 95% confidence interval around the Beta coefficient.

Figure 3:

Association between daily fibrinogen levels and daily chest tube bleeding, in mL/kg (R = −0.13).