Major Bleeding in Adults Undergoing Peripheral Extracorporeal Membrane Oxygenation (ECMO): Prognosis and Predictors

Abstract

Background. Major bleeding has been a common and serious complication with poor outcomes in ECMO patients. With a novel, less-invasive cannulation approach and closer coagulation monitoring regime, the incidence of major bleeding is currently not determined yet. Our study aims to examine the incidence of major bleeding, its determinants, and association with mortality in peripheral-ECMO patients. Method. We conducted a single-center retrospective study on adult patients undergoing peripheral-ECMO between January 2019 and January 2020 at a tertiary referral hospital. Determinants of major bleeding were defined by logistic regression analysis. Risk factors of in-hospital mortality were determined by Cox proportional hazard regression analysis. Results. Major bleeding was reported in 33/105 patients (31.4%) and was associated with higher in-hospital mortality [adjusted hazard ratio (aHR) 3.56, 95% confidence interval (CI) 1.63–7.80, p < 0.001 ). There were no significant difference in age, sex, ECMO indications, ECMO modality, pre-ECMO APACHE-II and SOFA scores between two groups with and without major bleeding. Only APTT >72 seconds [adjusted odds ratio (aOR) 7.10, 95% CI 2.60–19.50, p < 0.001 ], fibrinogen <2 g/L [aOR = 7.10, 95% CI 2.60–19.50, p < 0.001 ], and ACT >220 seconds [aOR = 3.9, 95% CI 1.20–11.80, p = 0.017 ] on days with major bleeding were independent predictors. Conclusions. In summary, major bleeding still had a fairly high incidence and poor outcome in peripheral-ECMO patients. APTT > 72 seconds, fibrinogen < 2 g/L were the strongest predicting factors for major bleeding events.

Transarterial embolization to treat a massive hemothorax during mechanical circulatory support via puncturing of the extracorporeal membrane oxygenation circuit

“…Anticoagulation measures are necessary during MCS management, as the most common complication is bleeding. Major bleeding occurs in 31% of patients who undergo ECMO, [ 6 ] 31% of patients on Impella, and 16% of patients receiving IABP [ 7 ]. Furthermore, bleeding complications are significantly more common during ECPELLA compared to either ECMO or Impella alone [ 8 , 9 ].…”

Blood Coagulation and Beyond: Position Paper from the Fourth Maastricht Consensus Conference on Thrombosis

“…Patients undergoing ECMO support are predisposed to bleeding through various mechanisms, and these can be classified into patient, treatments, and circuit related. Many factors that may place patients undergoing ECMO at higher risk of bleeding have been identified (194), including underlying critical conditions prompting ECMO initiation, comorbidities, multiorgan dysfunction, and the technology itself (194)(195)(196). The contact between the patient's blood with the ECMO circuit and the systemic inflammatory response syndrome (SIRS) lead to activation of the coagulation cascade, with effects on fibrinolysis, thrombin formation, and platelet function (194,197,198).…”

Update on Anticoagulation Strategies in Patients with ECMO—A Narrative Review

“…The rationale behind this precise anticoagulation titration is to keep the fragile balance between the two extreme situations. While bleeding and thrombosis remain common complications in ECMO patients, haemorrhagic events substantially influence mortality (emphasising fatal intra-cranial bleeding) [ 10 , 41 ]. According to the systematic review of Abruzzo et al, early computed tomography (CT) diagnosis of deep venous thrombosis was obtained in a number of patients as high as 71.4%, and pulmonary embolism was observed in 16.2% of the patients [ 14 ].…”