Study On The Relationship Between Coagulation Complications And Prognosis During Veno-arterial Extracorporeal Membrane Oxygenation After Cardiac Surgery In Childre

Background:Mortality and morbidity of children received veno-arterial extracorporeal membrane oxygenation(VA-ECMO)support after cardiac surgery remain high despite remarkable advances in medical management and devices.Comprehensive understanding of the risk factors before and during ECMO may help us take reasonable measures to improve prognosis.Few prediction scores for pediatric cardiac ECMO appear late and lack external validation.The purpose of this study was to describe outcomes and risk factors of applying VA-ECMO in the surgical pediatric population and to compare the effectiveness of three prediction scores.Methods:We retrospectively analyzed 85 consecutive pediatric patients(aged<18 years)who received post-cardiotomy VA-ECMO at Fuwai Hospital from January 2010 to December 2018.The patients in this cohort were divided into survivors group(n=40)and non-survivors group(n=45)according to in-hospital mortality.The baseline,pre-ECMO,and mid-ECMO clinical variables were compared to explore their impact on clinical outcome between the two groups.Results:Median(IQR)age at ECMO implantation in this cohort was 12.7(6.4,43.2)months,median weight was 8.5(6.0,12.8)kg,mean ECMO duration was 143.2±81.6 h and mean hospital length of stay was 48.4 ± 32.4 days.75 patients(88.2%)were indicated for post-cardiotomy cardiogenic shock.The successful ECMO weaning rate was 70.6%and in-hospital mortality was 52.9%.The most common diagnosis was transposition of great arteries(n=18,21.2%).It can be seen that ECMO implantation was later(P=0.045),extracorporeal cardiopulmonary resuscitation(ECPR)was performed more often(P=0.022),lactate pre-ECMO was higher(P=0.005)and acute kidney injury(AKI)pre-ECMO was more frequent(P=0.022)in non-survivors.During ECMO,AKI was the most common complication(n=64,75.3%).The incidence of thrombocytopenia(P<0.001),hemolysis(P=0.001),nosocomial infection(P=0.009)and neurological dysfunction(P=0.001)were positively correlated with in-hospital mortality.Multivariate logistic regression analysis showed that thrombocytopenia[odds ratio(OR)=10.358(2.557,41.962),P=0.001],hemolysis[OR=4.581(1.366,15.363),P=0.014]and nosocomial infection[OR=3.651(1.089,12.246),P=0.036]were positively correlated with in-hospital mortality.A further exploration of the children successfully weaned from ECMO was performed.It was found that compared with survivors,the incidence of thrombocytopenia(P=0.001),AKI pre-ECMO(P=0.003)and neurological dysfunction(P=0.010)were higher,ECMO duration was prolonged(P=0.044)in non-survivors.Multivariate Cox proportional hazard regression analysis presented that thrombocytopenia significantly increased the 180-day mortality[hazard ratio=3.970(1.522,10.356),P=0.005].Postcannulation pediatric survival after VA-ECMO(Pedi-SAVE))score accessing the entire ECMO process had the greatest area under receiver operator curve(AUROC)to predict in-hospital mortality,0.840(95%confidence interval[CI]:0.758-0.922).Pre-ECMO pediatric ECMO prediction(PEP)model could also predict in-hospital mortality[AUROC=0.720(95%CI:0.611-0.830)],and Precannulation Pedi-SAVE score had the poorest prediction[AUROC=0.530(95%CI:0.406-0.653)].Conclusion:VA-ECMO provides effective cardiopulmonary support for post-cardiotomy pediatric patients.Multiple factors had adverse effects on prognosis.Effective predictive models play an essential role in assessing risk and predicting prognosis.Therefore,patient selection and procedures from ECMO implantation to weaning need to be closely monitored and performed in a timely manner to improve outcome.Background:Hemostatic complications and the need for large amounts of blood products are major obstacles during veno-arterial extracorporeal membrane oxygenation(VA-ECMO).Additionally,the occurrence of coagulopathy after cardiopulmonary bypass(CPB)affects systemic heparinization in pediatric post-cardiotomy patients.This study compares hemostatic complications in pediatric post-cardiotomy VA-ECMO patients for failure to wean from CPB with those who received post-cardiotomy VA-ECMO for other indications,while also exploring the relationship between different stages-hemostatic complications and the timing of systemic heparinization.Methods:We retrospectively analyzed 146 pediatric patients who received post-cardiotomy VA-ECMO support(CPB-ECMO,n=96 vs.non-CPB-ECMO,n=50)from January 2005 to June 2020.Patients were divided into survivors(n=46)and non-survivors(n=50)according to in-hospital mortality in the CPB-ECMO group.We compared clinical outcomes between the groups,then examined the associations between the timing of systemic heparinization after ECMO implantation and different stages-hemostatic(bounded by first 48 hours after VA ECMO initiation)complications,in the CPB-ECMO group.Results:We found that the risk of early bleeding was significantly increased in patients who failed to wean from CPB(P=0.012).Re-exploration due to surgical or cannulation site bleeding was more common in the CPB-ECMO group(P=0.014).Multivariate logistic regression analysis showed that failure to wean from CPB correlated positively with bleeding during ECMO after adjusting for illness severity[odds ratio(OR)=2.613(1.268,5.383),P=0.009].Furthermore,the univariate logistic regression analysis demonstrated that early bleeding was associated with a 2-fold[OR=2.500(1.039,6.015),P=0.041]increased risk of in-hospital mortality and early hemolysis increased in-hospital by 3-fold[OR=3.189(1.046,9.724),P=0.041]in the CPB-ECMO group.Patients with early bleeding received larger amounts of red blood cell(P=0.009),platelet(P=0.029),and fresh frozen plasma(P=0.017),as well as more chest-tube drainage(P=0.001).Thus,they received significant delay in timing of systemic heparinization(P=0.002).The timing of systemic heparinization was 15.3(8.8,24.9)hours after ECMO implantation in the CPB-ECMO group.Spearman correlation analysis revealed significant relationships between peak plasma-free hemoglobin(r=0.259,P=0.011),circuit change time(r=-0.534,P=0.033),and unfractionated heparin(UFH)start time.A delayed systemic heparinization of 9.5 hours showed the best Youden index results and the overall greatest accuracy in predicting early hemolysis.Conclusions:A direct transition from CPB to ECMO in pediatric post-cardiotomy patients significantly increases early bleeding.Delayed systemic heparinization to reduce early bleeding has good discrimination for predicting early hemolysis in the CPB-ECMO group.Coagulopathy is complex in pediatric post-cardiotomy VA-ECMO patients who failed to wean from CPB,and,as such,it is extremely important to monitor coagulation-related indicators in multiple dimensions to determine the timing of systemic heparinization.