Background/Objective: There is limited literature documenting bleeding patterns in pediatric post-cardiotomy patients on extracorporeal life support (ECLS). This retrospective review details bleeding complications and identifies risk factors for bleeding in these patients.
Methods: Records from 145 patients were reviewed. Patients were divided into excessive (E) and non-excessive (NE) bleeding groups based on blood loss.
Results: Excessive bleeding occurred predominantly from 0-6h. Longer CPB duration (NE=174±8min; E=212±16; p=0.02) and lower platelet counts (NE=104.8±50K; E=84.3±41K; p=0.01) were associated with excessive bleeding during the first 6h (p=0.005). Use of intraoperative protamine with normal platelets was associated with decreased bleeding from 7-12h post-ECLS (p=0.002). Most mediastinal exploration occurred >49h post-ECLS, with decreased bleeding post-exploration in E patients.
Conclusions: The majority of pediatric post-cardiotomy ECLS bleeding occurs early after support initiation. Longer CPB time and thrombocytopenia increased bleeding 0-6h post-ECLS. Since early bleeding may be coagulopathic in origin, an approach to minimize bleeding includes protamine administration and aggressive blood product replacement with target platelet counts of 100-120K. Surgical exploration should follow if additional hemostasis is necessary.
Chaturvedi D. , Macrae D., Brown KL, et al. Cardiac ECMO for biventricular hearts after paediatric open heart surgery. Heart2004; 90: 545-551.
3.
Kern FH, Morana NJ, Sears JJ, et al. Coagulation defects in neonates during cardiopulmonary bypass . Ann Thorac Surg1992; 54: 541-546.
4.
Williams G., Bratton S., Ramamoorthy C.Factors associated with blood loss and blood product transfusions: a multivariate analysis in children after open-heart surgery. Anesth Analg1999; 89: 57-64.
5.
McEwan A.Aspects of bleeding after cardiac surgery in children. Pediatric Anesthesia2007; 17: 1126-1133.
6.
D’Errico C., Shayevitz JR, Martindale, SJAge-related differences in heparin sensitivity and heparin-protamine interactions in cardiac surgery patients. J Cardiothorac and Vasc Anesth1996; 10: 451-457.
7.
Sell L., Cullen M., Whittlesey GC, et al. Hemorrhagic complications during extracorporeal membrane oxygenation: prevention and treatment. J Pediatr Surg1986 ; 21: 1087-1091.
8.
Williams G., Bratton S., Riley E., Ramamoorthy C.Coagulation tests during cardiopulmonary bypass correlate with blood loss in children undergoing cardiac surgery. J Cardiothorac Vasc Anesth1999; 13: 398-404.
9.
Miller BE, Mochizuki T., Levy JH, et al. Predicting and treating coagulopathies after cardiopulmonary bypass in children. Anesth Analg1997; 85: 1196-1202.
10.
Mochizuki T. , Olson PJ, Szlam F., Ramsay JG, Levy JHProtamine reversal of heparin affects platelet aggregation and activated clotting time after cardiopulmonary bypass. Anesth Analg1998; 87: 781-785.
11.
Codispoti M. , Mankad P.Management of anticoagulation and its reversal during paediatric cardiopulmonary bypass: a review of current UK practice . Perfusion2000; 15: 191-201.
12.
Alsoufi B., Shen I., KaramlouT, et al. Extracorporeal life support in neonates, infants and children after repair of congenital heart disease: modern era results in a single institution. Ann Thorac Surg 2005; 80(1): 15-21.
13.
Meliones JN, Custer JR, Snedecor S., Moler FW, O’Rourke PP, Delius REExtracorporeal life support for cardiac assist in pediatric patients. Review of ELSO Registry data. Circulation1991; 84(5 Suppl): III168-172.
14.
Morris MC, Ittenbach RF, Godinez RI, et al. Risk factors for mortality in 137 pediatric cardiac intensive care unit patients managed with extracorporeal membrane oxygenation. Crit Care Med2004; 32: 1061-1069.
15.
Walters HL, Hakimi M., Rice MD, Lyons JM, Whittlesey GC, Klein MDPediatric cardiac surgical ECMO: multivariate analysis of risk factors for hospital death. Ann Thorac Surg1995; 60: 329-337.
16.
Berger A., Wollenek G., Hermon M., Burda G.Excessive bleeding on extracorporeal membrane oxygenation after surgical repair of Type I truncus arteriosus: a case report. Artificial Organs1999; 23: 1033-1035.
