Intracranial Hemorrhage and Early Mortality in Patients Receiving Extracorporeal Membrane Oxygenation for Severe Respiratory Failure

Abstract

Intracranial hemorrhage (ICH) is a serious complication in patients receiving veno-venous extracorporeal membrane oxygenation (VV-ECMO) and is associated with high mortality. It is unknown whether ICH may be a consequence of the ECMO or of an underlying disease. The authors first aimed to assess the incidence of ICH at initiation and during the course of VV-ECMO and its associated mortality. The second aim was to identify clinical and laboratory measures that could predict the development of ICH in severe respiratory failure. Data were collected from a total number of 165 patients receiving VV-ECMO from January, 2012 to December, 2016 in a single tertiary center and treated according to a single protocol. Only patients who had a brain computed tomography within 24 hours of initiation of ECMO ( = 149) were included for analysis. The prevalence and incidence of ICH at initiation and during the course of VV-ECMO (at median 9 days) were 10.7% (16/149) and 5.2% (7/133), respectively. Thrombocytopenia and reduced creatinine clearance (CrCL) were independently associated with increased risk of ICH on admission; odds ratio (95% confidence interval): 22.6 (2.6-99.5), and 10.8 (5.6-16.2). Only 30-day (not 180-day) mortality was significantly higher in patients with ICH on admission versus those without (37.5% [6/16] vs 16.4% [22/133]; = 0.03 and 43.7% [7/16] vs 26.3% [35/133]; = 0.15, respectively). Reduced CrCL and thrombocytopenia were associated with ICH at initiation of VV-ECMO. The higher incidence of ICH at initiation suggests it is more closely related to the severity of the underlying lung injury than to the VV-ECMO itself. ICH at VV-ECMO initiation was associated with early mortality.

Hematologic concerns in extracorporeal membrane oxygenation

“…Risk of intracranial hemorrhage was independently related to length of ventilation and admission fibrinogen level but not the use of ECMO. This same pattern of intracranial hemorrhage being related to severity of illness and patient factors, and not ECMO use, has been demonstrated in other studies 11 …”

Long-term pulmonary function and quality of life in adults after extracorporeal membrane oxygenation for respiratory failure

“…In the published literature, there's a large discrepancy between reported CVL prevalence when brain radiography is used when symptoms occur (5.3-5.4%; [83][84]) and routinely screened patients (16.4% in ECMO patients vs 7.6% in conventionally managed patients; [85]). The latter was supported in a recent study which reported CVL in 10.7% of ECMO patients upon admission, and a further 5.2% during ECMO treatment (86). Interestingly, the recent EOLIA RCT reported a similar haemorrhagic stroke prevalence in the ECMO (2%) compared to the non-ECMO group (4%), and significantly fewer ischemic strokes in the ECMO group (absolute risk reduction −5%, 95% CI −10% to -2%; [4]).…”

Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia

“…5 However, the lack of thrombocytopenia may be beneficial as we found this to be a risk factor for ICH. 5 The studies cited here have led to suggestions that DIC may be a useful prognostic marker, but the anticoagulation required for VV-ECMO and the activation of coagulation from artificial surfaces may confound interpretation. In particular, a sudden rise in D-dimer may be because of pump head thrombosis.…”