Predictors of intracranial hemorrhage in adult patients on extracorporeal membrane oxygenation: an observational cohort study

Abstract

BackgroundIntracranial hemorrhage (ICH) is a recognized complication of adults treated with extracorporeal membrane oxygenation (ECMO) and is associated with increased morbidity and mortality. However, the predictors of ICH in this patient category are poorly understood. The purpose of this study was to identify predictors of ICH in ECMO-treated adult patients.MethodsWe conducted a retrospective review of adult patients (≥18 years) treated with ECMO at the Karolinska University Hospital (Stockholm, Sweden) between September 2005 and June 2016, excluding patients with ICH upon admission or those who were treated with ECMO for less than 12 h. In a comparative analysis, the primary end-points were the difference in baseline characteristics and predictors of hemorrhage occurrence (ICH vs. non-ICH cohorts). The secondary end-point was difference in mortality between groups. Paired testing and uni- and multivariate regression models were applied.ResultsTwo hundred and fifty-three patients were included, of which 54 (21%) experienced an ICH during ECMO treatment. The mortality for patients with ICH was 81% at 1 month and 85% at 6 months, respectively, compared to 28 and 33% in patients who did not develop ICH. When comparing ICH vs. non-ICH cohorts, pre-admission antithrombotic therapy (p = 0.018), high pre-cannulation Sepsis-related Organ Failure Assessment (SOFA) coagulation score (p = 0.015), low platelet count (p < 0.001), and spontaneous extracranial hemorrhage (p = 0.045) were predictors of ICH. In a multivariate regression model predicting ICH, pre-admission antithrombotic therapy and low platelet count demonstrated independent risk association. When comparing the temporal trajectories for coagulation variables in the days leading up to the detection of an ICH, plasma antithrombin significantly increased per patient over time (p = 0.014). No other temporal trajectories were found.ConclusionsICH in adult ECMO patients is associated with a high mortality rate and independently associated with pre-admission antithrombotic therapy and low platelet count, thus highlighting important areas of potential treatment strategies to prevent ICH development.Electronic supplementary materialThe online version of this article (doi:10.1186/s40560-017-0223-2) contains supplementary material, which is available to authorized users.

Predictors of complications associated with extracorporeal membrane oxygenation

“…Sandersjöo et al (27) There was a balance in the context of cardiac and pulmonary indications, as the proportion between ECMO VV (n=13; 68.42%) and ECMO VA (n=14; 73.68%) was approximated. The main clinical situations that required ECMO were cardiogenic shock, respiratory failure, and cardiorespiratory arrest (Chart 2).…”

“…Neurological complications were the most frequently investigated (seven studies) (17)(18)(21)(22)(23)27,30) , followed by hemorrhagic (three studies) (24,29,32) , kidney (two studies) (26,31) , infectious (two studies) (20,25) , and mechanical (one study) (16) complications. Other complications were identified in the studies and were categorized as "other": formation of a lymphocele (one study) (33) , thrombocytopenia (one study) (19) , and thrombosis or pulmonary thromboembolism (one study) (34) .…”

“…The frequent complications included: neurological (5.2%-15.1%) (17)(18)(21)(22)23,27,30) , bleeding (17%-80%) (24,29,32) , infection (21.4%-23.0%) (20,25) , kidney complications (48.8%-73%) (26,31) , lymphocele formation (16% in the total sample, in which 93.5% received heart transplants) (33) , thrombocytopenia (22%) (19) , and thrombosis or pulmonary thromboembolism (34) .…”

“…Nineteen predictors were identified for neurological complications: age (17) , CA pre-ECMO (17)(18) , use of inotropes during ECMO (17) , post-ECMO hypoglycemia (17) , dialysis during ECMO (17)(18) , plasma free hemoglobin >50mg/dL, cardiac tamponade, disseminated intravascular coagulopathy, creatinine> 3mg/dL or creatinine between 1.5-3.0mg/dL (17) , hyperbilirubinemia during ECMO (18) , high level of pre-ECMO lactic acid (21)(22) , lower pre-ECMO serum hemoglobin level (22) , interval between CA and ECMO (22) , thrombocytopenia (23,27) , reduced creatinine clearance (23) , pre-admission antithrombotic therapy (27) , kidney insufficiency at ICU admission, and low pre-ECMO PaCO 2 (30) . For bleeding complications, high previous aPTT (≥70 sec), elevated APACHE III score, and post-surgery ECMO (24) were some of the predictors identified.…”

“…Recent studies have shown that thrombocytopenia and impaired kidney function increase the risk of intracranial bleeding, especially subarachnoid hemorrhages. Therefore, evaluating each condition and considering preventive strategies, such as previous treatment of kidney function, can reduce the risk of bleeding during ECMO (23,27,30) .…”