The early decline in platelet count is associated with increased adverse outcomes in non heparin-induced thrombocytopenia pediatric patients undergoing VA-ECMO

Abstract

Introduction

The impact of non heparin-induced thrombocytopenia on the clinical outcomes for pediatric cardiac surgery patients who required veno-arterial extracorporeal membrane support (VA-ECMO) for failure to wean from cardiopulmonary bypass (CPB) is uncertain. This study aimed to investigate the relationship between thrombocytopenia and prognosis in these patients.

Methods

This retrospective study enrolled 96 pediatric patients (age < 18) who received VA-ECMO directly transitioned from CPB at Fuwai Hospital from January 2010 to June 2020. The association between relative decrease in platelet count (△PLT) post-ECMO 24 h and clinical outcomes was explored.

Results

There were significant differences in Post-ECMO 24 h platelet counts, platelet count nadir, and duration of platelet decline between the survivors and non-survivors in CPB-ECMO groups. A positive correlation was found between △PLT post-ECMO 24 h and plasma-free hemoglobin (pFHb) (p = .014, r = 0.305), peak serum creatinine (p = .016, r = 0.299), peak AST (p = .014, r = 0.302), duration of platelet transfusion (p = .032, r = 0.270),The △PLT post-ECMO 24 h had predictive value on in-hospital mortality [(p < .001, AUROC = 0.781 (95% CI: 0.670–0.892)], massive bleeding (p = .001, AUROC 95% CI: 0.627–0.870), hemolysis (p = .046, AUROC 95% CI: 0.510–0.780), and nosocomial infection (p = .020, AUROC 95% CI: 0.536–0.801). Multivariate logistic regression showed that △PLT post-ECMO 24 h was associated with in-hospital mortality and hemolysis.

Conclusions

The relative early decrease in platelet count 24 h following transition to ECMO is associated with increased patient mortality, and is positively associated with adverse outcomes in pediatric cardiac surgery patients transferred from CPB to ECMO. Moreover, this decline rate can predict in-hospital survival, major bleeding, hemolysis, and hospital-acquired infections.

Keywords

thrombocytopenia cardiopulmonary bypass venoarterial extracorporeal membrane oxygenation pediatrics cardiac surgical procedures

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References

Ijsselstijn

Schiller

Holder

, et al. Extracorporeal life support organization (ELSO) guidelines for follow-up after neonatal and pediatric extracorporeal membrane oxygenation. ASAIO J Am Soc Artif Intern Organs 1992 2021; 67: 955–963.

Jiritano

Serraino

Ten Cate

, et al. Platelets and extra-corporeal membrane oxygenation in adult patients: a systematic review and meta-analysis. Intensive Care Med 2020; 46: 1154–1169.

Sokolovic

Pratt

Vukicevic

, et al. Platelet count trends and prevalence of heparin-induced thrombocytopenia in a cohort of extracorporeal membrane oxygenator patients. Crit Care Med 2016; 44: e1031–e1037.

Kohs

TCL

Liu

Raghunathan

, et al. Severe thrombocytopenia in adults undergoing extracorporeal membrane oxygenation is predictive of thrombosis. Platelets 2022; 33: 570–576.

Abrams

Baldwin

Champion

, et al. Thrombocytopenia and extracorporeal membrane oxygenation in adults with acute respiratory failure: a cohort study. Intensive Care Med 2016; 42: 844–852.

Griffin

Bronsert

Reece

, et al. Thrombocytopenia after cardiopulmonary bypass is associated with increased morbidity and mortality. Ann Thorac Surg 2020; 110(1): 50–57.

Jin

Feng

Zhao

, et al. Outcomes and factors associated with early mortality in pediatric postcardiotomy veno-arterial extracorporeal membrane oxygenation. Artif Organs 2021; 45: 6–14.

Jin

Cui

Zhang

, et al. Hemostatic complications and systemic heparinization in pediatric post-cardiotomy veno-arterial extracorporeal membrane oxygenation failed to wean from cardiopulmonary bypass. Transl Pediatr 2022; 11: 1458–1469.

Fried

Masoumi

Takeda

, et al. How I approach weaning from venoarterial ECMO. Crit Care 2020; 24: 307.

10.

Schulman

Kearon

Subcommittee on Control of Anticoagulation of the Scientific and Standardization Committee of the International Society on Thrombosis and Haemostasis . Definition of major bleeding in clinical investigations of antihemostatic medicinal products in non-surgical patients. J Thromb Haemostasis 2005; 3: 692–694.

11.

Levey

Eckardt

K-U

Tsukamoto

, et al. Definition and classification of chronic kidney disease: a position statement from kidney disease: improving Global Outcomes (KDIGO). Kidney Int 2005; 67: 2089–2100.

12.

Favaloro

Lippi

. Translational aspects of developmental hemostasis: infants and children are not miniature adults and even adults may be different. Ann Transl Med 2017; 5: 212.

13.

Thomas

Kostousov

Teruya

. Bleeding and thrombotic complications in the use of extracorporeal membrane oxygenation. Semin Thromb Hemost 2018; 44: 20–29.

14.

Cheung

Sawicki

Salas

, et al. The mechanisms of platelet dysfunction during extracorporeal membrane oxygenation in critically ill neonates. Crit Care Med 2000; 28: 2584–2590.

15.

Kertai

Zhou

Karhausen

, et al. Platelet counts, acute kidney injury, and mortality after coronary artery bypass grafting surgery. Anesthesiology 2016; 124: 339–352.

16.

Thielmann

Bunschkowski

Tossios

, et al. Perioperative thrombocytopenia in cardiac surgical patients - incidence of heparin-induced thrombocytopenia, morbidities and mortality. Eur J Cardio Thorac Surg 2010; 37: 1391–1395.

17.

Wang

Shao

, et al. The relative early decrease in platelet count is associated with mortality in post-cardiotomy patients undergoing venoarterial extracorporeal membrane oxygenation. Front Med 2021; 8: 733946.

18.

Caprarola

Carroll

, et al. Pediatric ECMO: unfavorable outcomes are associated with inflammation and endothelial activation. Pediatr Res 2022; 92: 549–556.

19.

Murphy

Hockings

Andrews

, et al. Extracorporeal membrane oxygenation-hemostatic complications. Transfus Med Rev 2015; 29: 90–101.

20.

Tang

Zhang

W-T

Zhang

, et al. Prevalence of hematologic complications on extracorporeal membranous oxygenation in critically ill pediatric patients: a systematic review and meta-analysis. Thromb Res 2023; 222: 75–84.

21.

Maul

Herrera

. Coagulation and hemolysis complications in neonatal ECLS: role of devices. Semin Fetal Neonatal Med 2022; 27: 101405.

22.

Delvasto-Nuñez

Jongerius

Zeerleder

. It takes two to thrombosis: hemolysis and complement. Blood Rev 2021; 50: 100834.

23.

Aubron

DePuydt

Belon

, et al. Predictive factors of bleeding events in adults undergoing extracorporeal membrane oxygenation. Ann Intensive Care 2016; 6: 97.

24.

Masi

Gendreau

Moyon

, et al. Bleeding complications, coagulation disorders, and their management in acute myocardial infarction-related cardiogenic shock rescued by veno-arterial ECMO: a retrospective cohort study. J Crit Care 2024; 82: 154771.

25.

Martucci

Giani

Schmidt

, et al. Anticoagulation and bleeding during veno-venous extracorporeal membrane oxygenation: insights from the PROTECMO study. Am J Respir Crit Care Med 2024; 209(4): 417–426.

26.

Cholette

Muszynski

Ibla

, et al. Plasma and platelet transfusions strategies in neonates and children undergoing cardiac surgery with cardiopulmonary bypass or neonates and children supported by extracorporeal membrane oxygenation: from the transfusion and anemia EXpertise initiative-control/avoidance of bleeding. Pediatr Crit Care Med 2022; 23: e25–e36.

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