Coagulations Studies Do Not Correlate With Each Other or With Hematologic Complications During Pediatric Extracorporeal Membrane Oxygenation.

OBJECTIVES: Anticoagulation plays a key role in the management of children supported with extracorporeal membrane oxygenation. However, the ideal strategy for monitoring anticoagulation remains unclear. Our objective was to evaluate the utility of laboratory measures of anticoagulation in pediatric extracorporeal membrane oxygenation. DESIGN: Retrospective cohort study. SETTING: Quaternary care academic children's hospital. PATIENTS: Children in a noncardiac PICU cannulated to extracorporeal membrane oxygenation in 2010-2016. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Demographic data, laboratory values, and heparin doses were extracted from the enterprise data warehouse. Primary diagnoses, indications for cannulation, hemorrhagic and thrombotic complications, and survival outcomes were abstracted from the local registry used for Extracorporeal Life Support Organization reporting. Statistical models accounting for repeated measures using generalized estimating equations were constructed to evaluate correlations between heparin doses and laboratory values; among laboratory values; and between heparin dose or laboratory values and clinical outcomes. One hundred thirty-three unique patients-78 neonates and 55 older patients-were included in the study. There was no significant association between antifactor Xa level, activated partial thromboplastin time, activated clotting time, or heparin dose with hemorrhage or thrombosis (odds ratio ≅ 1 for all associations). There was weak-to-moderate correlation between antifactor Xa, activated partial thromboplastin time, and activated clotting time in both neonates and older pediatric patients (R2 < 0.001 to 0.456). Heparin dose correlated poorly with laboratory measurements in both age groups (R2 = 0.010-0.063). CONCLUSIONS: In children supported with extracorporeal membrane oxygenation, heparin dose correlates poorly with common laboratory measures of anticoagulation, and these laboratory measures correlate poorly with each other. Neither heparin dose nor laboratory measures correlate with hemorrhage or thrombosis. Further work is needed to identify better measures of anticoagulation in order to minimize morbidity and mortality associated with extracorporeal membrane oxygenation.

Mortality and Factors Associated With Hemorrhage During Pediatric Extracorporeal Membrane Oxygenation.

OBJECTIVES: To quantify and identify factors associated with bleeding events during pediatric extracorporeal membrane oxygenation. DESIGN: Retrospective cohort study with primary outcome of bleeding days on extracorporeal membrane oxygenation. SETTING: Single tertiary care children's hospital. SUBJECTS: One-hundred twenty-two children supported with extracorporeal membrane oxygenation for greater than 12 hours during January 2015 through December 2016. INTERVENTIONS: Bleeding days were identified if mediastinal or cannula site exploration, activated factor VII administration, gastrointestinal, pulmonary, or intracranial hemorrhages occurred. Logistic regression was used to assess factors associated with bleeding days. MEASUREMENTS AND MAIN RESULTS: Study population was identified from institutional extracorporeal membrane oxygenation database. Clinical, laboratory, and survival data were obtained from medical records. Only data from patients' first extracorporeal membrane oxygenation run were used. One-hundred twenty-two patients with median age of 17 weeks (interquartile range, 1-148 wk) were analyzed. Congenital heart disease (n = 56, 46%) was the most common diagnosis. Bleeding days comprised 179 (16%) of the 1,121 observed extracorporeal membrane oxygenation-patient-days. By extracorporeal membrane oxygenation day 4, 50% of users had experienced a bleeding day. Central rather than peripheral cannulation (odds ratio, 2.58; 95% CI, 1.47-4.52; p < 0.001), older age (odds ratio, 1.31 per increased week; 95% CI, 1.14-1.52; p < 0.001), higher lactate (odds ratio, 1.08 per 1 mmol/L increase; 95% CI, 1.05-1.12; p < 0.001), and lower platelets (odds ratio, 0.87 per 25,000 cell/µL increase; 95% CI, 0.77-0.99; p = 0.005) were associated with bleeding days. Patients who experienced more frequent bleeding (> 75th percentile) had fewer ventilator-free and hospital-free days in the 60 days after cannulation (0 vs 31; p = 0.002 and 0 vs 0; p = 0.008) and higher in-hospital mortality (68 vs 34%; p < 0.001). CONCLUSIONS: Central cannulation, older age, low platelets, and high lactate are associated with bleeding days during pediatric extracorporeal membrane oxygenation. Patients who bleed more frequently during extracorporeal membrane oxygenation have higher in-hospital mortality, longer technological dependence, and reduced hospital-free days.