Short-term neurologic outcomes in pediatric extracorporeal membrane oxygenation are proportional to bleeding severity graded by a novel bleeding scale

Katherine Doane¹, Danielle Guffey², Laura L Loftis¹, Trung C Nguyen^{1

3}, Matthew A Musick¹, Amanda Ruth¹, Ryan D Coleman¹, Jun Teruya⁴, Christine Allen⁵, Melania M Bembea⁶, Brian Boville^{7

8}, Jamie Furlong-Dillard⁹, Santosh Kaipa¹⁰, Mara Leimanis^{7

8}, Matthew P Malone¹¹, Lindsey K Rasmussen¹², Ahmed Said¹³, Marie E Steiner¹⁴, Deanna T Tzanetos⁹, Heather Viamonte¹⁵, Linda Wallenkamp¹⁶, Arun Saini^{1

3}

Affiliations

¹ Division of Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA.
² Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, TX, USA.
³ Center for Translational Research on Inflammatory Diseases (CTRID), Michael E. DeBakey Veterans Affairs Medical Center (MEDVAMC), Houston, TX, USA.
⁴ Departments of Pathology & Immunology, Pediatrics, and Medicine, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA.
⁵ Division of Pediatric Critical Care, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
⁶ Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
⁷ Pediatric Critical Care Medicine Division, Helen DeVos Children's Hospital, Grand Rapids, MI, USA.
⁸ Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, East Lansing, MI, USA.
⁹ Division of Pediatric Critical Care Medicine, Department of Pediatrics, Norton Children's Hospital and University of Louisville School of Medicine, Louisville, KY, USA.
¹⁰ Department of Pediatrics, Children's Nebraska and University of Nebraska Medical Center, Omaha, NE, USA.
¹¹ Division of Critical Care Medicine, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AR, USA.
¹² Division of Pediatric Critical Care Medicine, Department of Pediatrics, Stanford University, Palo Alto, CA, USA.
¹³ Division of Pediatric Critical Care, Department of Pediatrics, Institute of Informatics, Data Science & Biostatistics (I2DB), Washington University in St. Louis School of Medicine, St. Louis, MO, USA.
¹⁴ Divisions of Hematology and Oncology and Critical Care, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA.
¹⁵ Divisions of Cardiology and Critical Care, Children's Healthcare of Atlanta and Emory University, Atlanta, GA, USA.
¹⁶ Children's Wisconsin and Medical College of Wisconsin, Milwaukee, WI, USA.

PMID: 39425501
PMCID: PMC12202819
DOI: 10.1177/02676591241293673

Short-term neurologic outcomes in pediatric extracorporeal membrane oxygenation are proportional to bleeding severity graded by a novel bleeding scale

Katherine Doane et al. Perfusion. 2025 Jul.

. 2025 Jul;40(5):1267-1276.

doi: 10.1177/02676591241293673. Epub 2024 Oct 18.

Authors

Affiliations

¹ Division of Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA.
² Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, TX, USA.
³ Center for Translational Research on Inflammatory Diseases (CTRID), Michael E. DeBakey Veterans Affairs Medical Center (MEDVAMC), Houston, TX, USA.
⁴ Departments of Pathology & Immunology, Pediatrics, and Medicine, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA.
⁵ Division of Pediatric Critical Care, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
⁶ Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
⁷ Pediatric Critical Care Medicine Division, Helen DeVos Children's Hospital, Grand Rapids, MI, USA.
⁸ Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, East Lansing, MI, USA.
⁹ Division of Pediatric Critical Care Medicine, Department of Pediatrics, Norton Children's Hospital and University of Louisville School of Medicine, Louisville, KY, USA.
¹⁰ Department of Pediatrics, Children's Nebraska and University of Nebraska Medical Center, Omaha, NE, USA.
¹¹ Division of Critical Care Medicine, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AR, USA.
¹² Division of Pediatric Critical Care Medicine, Department of Pediatrics, Stanford University, Palo Alto, CA, USA.
¹³ Division of Pediatric Critical Care, Department of Pediatrics, Institute of Informatics, Data Science & Biostatistics (I2DB), Washington University in St. Louis School of Medicine, St. Louis, MO, USA.
¹⁴ Divisions of Hematology and Oncology and Critical Care, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA.
¹⁵ Divisions of Cardiology and Critical Care, Children's Healthcare of Atlanta and Emory University, Atlanta, GA, USA.
¹⁶ Children's Wisconsin and Medical College of Wisconsin, Milwaukee, WI, USA.

PMID: 39425501
PMCID: PMC12202819
DOI: 10.1177/02676591241293673

Abstract

IntroductionThis study aimed to characterize the severity of bleeding and its association with short-term neurologic outcomes in pediatric ECMO.MethodsMulticenter retrospective cohort study of pediatric ECMO patients at 10 centers utilizing the Pediatric ECMO Outcomes Registry (PEDECOR) database from December 2013-February 2019. Subjects excluded were post-cardiac surgery patients and those with neonatal pathologies. A novel ECMO bleeding scale was utilized to categorize daily bleeding events. Poor short-term neurologic outcome was defined as an unfavorable Pediatric Cerebral Performance Category (PCPC) or Pediatric Overall Performance Category (POPC) (score of >3) at hospital discharge.ResultsThis study included 283 pediatric ECMO patients with a median (interquartile range [IQR]) age of 1.3 years [0.1, 9.0], ECMO duration of 5 days [3.0, 9.5], and 44.1% mortality. Unfavorable PCPC and POPC were observed in 48.4% and 51.3% of patients at discharge, respectively. Multivariable logistic regression analysis included patient's age, cannulation type, duration of ECMO, need for cardiopulmonary resuscitation, acute kidney injury, new infection, and vasoactive-inotropic score. As the severity of bleeding increased, there was a corresponding increase in the likelihood of poor neurologic recovery, shown by increasing odds of unfavorable neurologic outcome (PCPC), with an adjusted odds ratio (aOR) of 0.77 (confidence interval [CI] 0.36-1.62), 1.87 (0.54-6.45), 2.97 (1.32-6.69), and 5.56 (0.59-52.25) for increasing bleeding severity (grade 1 to 4 events, respectively). Similarly, unfavorable POPC aOR (CI) was 1.02 (0.48-2.17), 2.05 (0.63-6.70), 5.29 (2.12-13.23), and 5.11 (0.66-39.64) for bleeding grade 1 to 4 events.ConclusionShort-term neurologic outcomes in pediatric ECMO are proportional to the severity of bleeding events. Strategies to mitigate bleeding events could improve neurologic recovery in pediatric ECMO.

Keywords: anticoagulation; child; extracorporeal membrane oxygenation; hemorrhage; mortality; outcome.

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Conflict of interest statement

Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Jun Teruya: Evaheart member of DSMB and STAGO honoraria for presentation: Ahmed Said: supported by the Children’s Discovery Institute Faculty Development Award at Washington University in St. Louis: Marie Steiner: Teaching contract (managing coagulation) with Medtronic and study advisory board for Octapharma (AT in Adult CPB heparin resistance). All other authors report no conflicts of interest.

Figures

**Figure 1.**
Of all severe and catastrophic bleeding events, nearly half (42.6%) of the events were preceded by either mild (16.4%) or moderate (26.2%) clinical bleeding events 24 h prior to the severe or catastrophic bleeding event.

**Figure 2.**
The proportion of patients with unfavorable PCPC, unfavorable POPC, and in-hospital mortality increased with maximum bleeding severity during the ECMO course.

**Figure 3.**
In multivariable logistic regression, severity of bleeding events categorized by the TCH ECMO Bleeding Scale increased with the likelihood of in-hospital mortality and unfavorable PCPC and POPC at discharge in children requiring ECMO. PCPC: pediatric cerebral performance category; POPC: pediatric overall performance category; Yr: years of age; CPR: cardiopulmonary resuscitation; VIS: vasoactive inotrope score; OI: oxygenation index.

See this image and copyright information in PMC

References

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Short-term neurologic outcomes in pediatric extracorporeal membrane oxygenation are proportional to bleeding severity graded by a novel bleeding scale

Affiliations

Short-term neurologic outcomes in pediatric extracorporeal membrane oxygenation are proportional to bleeding severity graded by a novel bleeding scale

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

MeSH terms

LinkOut - more resources

Full Text Sources

Medical

Research Materials