Minimizing bleeding associated with mechanical circulatory support following pediatric heart surgery☆

McMullan, D. Michael; Emmert, Jennifer A.; Permut, Lester C.; Mazor, Robert; Jeffries, Howard E.; Parrish, Andrea Rae; Baden, H; Cohen, Gordon

doi:10.1016/j.ejcts.2010.07.027

Cited by 26 publications

(23 citation statements)

References 24 publications

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“…The frequency of children with complex congenital heart disease or cardiomyopathies requiring ECMO has increased steadily over the past decade (4, 5), and those placed on ECMO after cardiac surgery already have disturbed coagulation pathways and additional surgical sites, factors that have been hypothesized to confer a greater propensity toward bleeding than other ECMO populations (6). Severe bleeding can make ongoing support impossible and may contribute directly to perioperative mortality (7). Therefore, a deeper understanding of the epidemiology and risk factors leading to hemorrhage in pediatric patients with cardiac disease on ECMO is crucial to improving care in this growing population.…”

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confidence: 99%

Hemorrhagic Complications in Pediatric Cardiac Patients on Extracorporeal Membrane Oxygenation

Werho

Pasquali

et al. 2015

Pediatric Critical Care Medicine

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Objectives To determine the prevalence of and risk factors for hemorrhagic complications in children with cardiac disease requiring extracorporeal membrane oxygenation. Design Retrospective review of the Extracorporeal Life Support Organization Registry (2002–2013). Setting Participating Extracorporeal Life Support Organization centers. Patients Patients less than 18 years old on extracorporeal membrane oxygenation. Interventions None. Measurements and Main Results Of 21,845 patients requiring extracorporeal membrane oxygenation during the study period, 8,905 (41%) had cardiac disease, and 79% of whom (6,995) had cardiac surgery. Hemorrhagic complications occurred in 8,480 patients (39% of overall cohort), with higher rates in cardiac versus noncardiac patients (49% vs 32%; p < 0.0001) related to cannulation and surgical site bleeding. Cardiac surgical patients had higher rates of hemorrhage compared with cardiac medical patients (57% vs 38%; p < 0.0001), and cardiac patients with hemorrhage had higher extracorporeal membrane oxygenation mortality compared with those without (42% vs 22% in medical patients and 34% vs 20% in surgical patients; both p < 0.0001). In multivariable analysis in both the cardiac medical and surgical groups, hemorrhage risk was higher in children greater than 1 year old and in patients with longer extracorporeal membrane oxygenation duration. Additional independent risk factors for hemorrhage in cardiac surgical patients included pre-extracorporeal membrane oxygenation mediastinal exploration (odds ratio, 3.6; 95% CI, 2.1–6.3), Society of Thoracic Surgeons morbidity category 4–5 (odds ratio, 1.2; 95% CI, 1.03–1.5), cannulation less than 24 hours after surgery (odds ratio, 1.6; 95% CI, 1.3–1.9), and longer cardiopulmonary bypass time (≥ 282 min [upper quartile]; odds ratio, 1.5; 95% CI, 1.3–1.9). Conclusions In this large, multicenter analysis, hemorrhagic complications occurred in nearly half of children with heart disease on extracorporeal membrane oxygenation and were associated with a significant mortality risk. Several factors were associated with hemorrhagic complications in cardiac surgical patients including pre-extracorporeal membrane oxygenation mediastinal exploration, greater surgical complexity, early postoperative cannulation, and longer bypass times. Whether these risks can be mitigated by modifying or delaying systemic anticoagulation requires further investigation.

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confidence: 99%

Hemorrhagic Complications in Pediatric Cardiac Patients on Extracorporeal Membrane Oxygenation

Werho

Pasquali

et al. 2015

Pediatric Critical Care Medicine

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“…As other methods, a heparin‐coated ECMO circuit was assembled and incorporated a nonmembrane oxygenator and shorter circuit length. This reduces circuit thrombosis by decreasing circuit transit time and areas of stasis within the oxygenator, so it can be used without additional heparin (16). These may contribute to reduction of the bleeding complications.…”

Section: Discussionmentioning

confidence: 99%

The Impact of Extracorporeal Membrane Oxygenation on Survival in Pediatric Patients With Respiratory and Heart Failure: Review of Our Experience

Goto

Suzuki

et al. 2011

Artificial Organs

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Extracorporeal membrane oxygenation (ECMO) is widely used for circulatory support in pediatric cardiac patients with low cardiac output and hypoxemia. We retrospectively evaluated the efficacy of ECMO support for respiratory and heart failure in infants and children. From April 2002 to February 2011, 14 patients aged 19 days to 20 years old (average 44 months), with body weight 2.6 kg to 71 kg (median 14.1 kg), underwent ECMO support for failing cardiac function, hypoxemia, and low cardiac output syndrome. In 12 patients, ECMO was introduced after operation for congenital heart disease (four with complete repair including Fontan circulation, and eight with palliative repair). In one patient, ECMO was introduced after partial pulmonary resection for congenital cystic adenomatoid malformation because of respiratory failure. ECMO was introduced in a patient with severe heart failure caused by fulminant myocarditis. Patients' demographics, duration of extracorporeal membrane oxygenation, additional support, and outcomes were analyzed. Ten patients (71%) were successfully weaned from ECMO, and eight patients (57%) were discharged from the hospital. The mean duration of ECMO support was 332 h (range 11-2030 h). Although management of the ECMO circuit, including anticoagulation (activated clotting time: 150-250), was conducted following the institutional practice guidelines, it was difficult to control the bleeding. Seven patients required renal replacement therapy during ECMO support using peritoneal dialysis or continuous hemodiafiltration. Five patients had additional operative procedures: systemic-pulmonary shunt in two, bidirectional Glenn takedown with right modified Blalock-Taussig shunt, total cavopulmonary connection takedown, and redo ECMO in one patient each. The patient who had the longest ECMO support for respiratory failure due to acute respiratory distress syndrome after lung surgery was successfully weaned from ECMO because high-frequency oscillation (HFO) improved respiratory function. ECMO for heart and respiratory failure in infants and children is effective and allows time for recovery of cardiac dysfunction and acute hypoxic insult. The long-term ECMO support for over 2000 h was very rare, but it was possible to wean this patient from ECMO using HFO.

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“…This is because when blood is exposed to the non-biologic surfaces of a circuit, a complex biologic response is initiated involving both the coagulation pathway and the inflammatory response pathway (2). The tubing of the circuit can be coated with a biocompatible lining to reduce the systemic inflammatory response and risk of thrombosis and bleeding (3), although no coating to date has been shown to eliminate this reaction completely. Shorter tubing may also optimize venous drainage, as there is less resistance to blood flow (4).…”

Section: Ecmo Circuit Designmentioning

confidence: 99%

Extracorporeal Membrane Oxygenation Circuitry

Lequier

Horton

McMullan

et al. 2013

Pediatric Critical Care Medicine

147

100

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The extracorporeal membrane oxygenation (ECMO) circuit is made of a number of components that have been customized to provide adequate tissue oxygen delivery in patients with severe cardiac and/or respiratory failure for a prolonged period of time (days to weeks). A standard ECMO circuit consists of a mechanical blood pump, gas exchange device, and a heat exchanger all connected together with circuit tubing. ECMO circuits can vary from simple to complex and may include a variety of blood flow and pressure monitors, continuous oxyhemoglobin saturation monitors, circuit access sites and a bridge connecting the venous access and arterial infusion limbs of the circuit. Significant technical advancements have been made in the equipment available for short and long term ECMO applications. Contemporary ECMO circuits have greater biocompatibility and allow for more prolonged cardiopulmonary support time, while minimizing the procedure-related complications of bleeding, thrombosis and other physiologic derangements that were so common with the early application of ECMO. Modern era ECMO circuitry and components are simpler, safer, more compact and can be used across a wide variety of patient sizes from neonates to adults.

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Minimizing bleeding associated with mechanical circulatory support following pediatric heart surgery☆

Cited by 26 publications

References 24 publications

Hemorrhagic Complications in Pediatric Cardiac Patients on Extracorporeal Membrane Oxygenation

Hemorrhagic Complications in Pediatric Cardiac Patients on Extracorporeal Membrane Oxygenation

The Impact of Extracorporeal Membrane Oxygenation on Survival in Pediatric Patients With Respiratory and Heart Failure: Review of Our Experience

Extracorporeal Membrane Oxygenation Circuitry

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