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          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Heparin dose &#40;IU&#47;kg&#47;h&#41; and values corresponding to aPTT &#40;seconds&#41; and antiXa &#40;IU&#47;ml&#41; during ECMO &#40;mean and standard deviation&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Extracorporeal membrane oxygenation &#40;ECMO&#41; is a circulatory support technique associated with a high risk of complications &#8211; the most frequent being of a hemodynamic&#44; neurological and hematological nature&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">1&#8211;4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The most important hematological complications consist of bleeding and thromboembolism&#44;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">4&#8211;7</span></a> which are responsible for up to 30&#8211;40&#37; of all deaths among patients subjected to ECMO&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">8&#44;9</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Bleeding is the most frequent and serious complication in children subjected to ECMO&#44; particularly in neonates and in surgical patients&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">10</span></a> Anticoagulation with heparin&#44; needed to prevent thrombus formation&#44; increases the risk of bleeding&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">11</span></a> It is also common to detect thrombocytopenia resulting from the activation and depletion of platelets due to multiple causes&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">1</span></a> For these reasons&#44; children subjected to ECMO receive numerous blood transfusions&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The primary objective of this study was to analyze the incidence and factors predisposing to hematological complications and the transfusion requirements in children subjected to ECMO&#46; The secondary objective was to examine the relationship between these complications and mortality and the duration of admission to the Pediatric Intensive Care Unit &#40;PICU&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Patients and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">A retrospective study was made of a prospective database including all children under 18 years of age subjected to ECMO between September 2006 and November 2015&#46; There were no exclusion criteria&#46; The study was approved by the Local Ethics Committee&#46; In all cases ECMO involved the use of a centrifugal pump &#40;Rotaflow&#44; Maquet<span class="elsevierStyleSup">&#174;</span>&#41; and a hollow polymethylpentene fiber oxygenator &#40;Quadrox&#44; Maquet<span class="elsevierStyleSup">&#174;</span>&#41;&#46; In the case of patients weighing under 15<span class="elsevierStyleHsp" style=""></span>kg&#44; we used a Quadrox-iD Pediatr<span class="elsevierStyleSup">&#174;</span> oxygenator with a membrane surface of 0&#46;8<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> and a priming volume of 81<span class="elsevierStyleHsp" style=""></span>ml allowing a blood flow of between 0&#46;2 and 2&#46;8<span class="elsevierStyleHsp" style=""></span>l&#47;min&#46; In the case of patients weighing over 15<span class="elsevierStyleHsp" style=""></span>kg we used the Quadrox-D<span class="elsevierStyleSup">&#174;</span> model with a membrane surface of 1&#46;8<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> and a priming volume of 250<span class="elsevierStyleHsp" style=""></span>ml allowing a blood flow of between 0&#46;5 and 7<span class="elsevierStyleHsp" style=""></span>l&#47;min&#46; There were two types of pediatric circuits&#58; 1&#47;4<span class="elsevierStyleHsp" style=""></span>in&#46; &#40;neonates and nursing infants&#41; and 3&#47;8<span class="elsevierStyleHsp" style=""></span>in&#46; Fig&#46; 1 of the supplementary material schematically shows the circuit used&#46; Cervical cannulation was the option of choice&#46; Transthoracic cannulation was decided in cases where extracorporeal life support could not be suspended after surgery&#44; in patients with recent sternotomy&#44; and in situations of extreme emergency&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Anticoagulation was provided with sodium heparin in continuous infusion at a dose of 10&#8211;50<span class="elsevierStyleHsp" style=""></span>IU&#47;kg<span class="elsevierStyleHsp" style=""></span>h<span class="elsevierStyleSup">&#8722;1</span>&#46; The control of anticoagulation and modification of the heparin dose throughout the study was based on the combined use of activated coagulation time &#40;ACT&#41; at the patient bedside every 30&#8211;60<span class="elsevierStyleHsp" style=""></span>min&#44; activated partial thromboplastin time &#40;aPTT&#41; &#40;measured at least once a day&#41; and the levels of antifactor Xa &#40;antiXa&#41;&#44; which were used as reference value&#46; We recorded data referred to the patient &#40;age&#44; weight&#44; diagnosis&#41;&#44; ECMO &#40;indication&#44; type and duration&#41;&#44; anticoagulation &#40;heparin dose&#41;&#44; the hematological and coagulation parameters &#40;hemoglobin &#91;Hb&#93;&#44; platelets&#44; international normalized ratio &#91;INR&#93;&#44; ACT&#44; aPTT&#44; fibrinogen&#44; antiXa&#44; free Hb&#41;&#44; the administration of transfusions &#40;packed red cells&#44; plasma and platelets&#41; and the clinical course &#40;bleeding complications&#44; thrombosis&#44; hemolysis&#44; duration of admission to the PICU&#44; survival&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Significant bleeding was defined as any bleeding causing a decrease in hemoglobin of over 2<span class="elsevierStyleHsp" style=""></span>g&#47;dl in 24<span class="elsevierStyleHsp" style=""></span>h&#44; or which required transfusion&#46; Significant hematological alterations requiring blood product transfusions were defined as Hb<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>9<span class="elsevierStyleHsp" style=""></span>g&#47;dl&#44; platelets<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>100&#44;000&#47;mm<span class="elsevierStyleSup">3</span>&#44; INR and aPTT alteration<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>2 times the control level&#44; and fibrinogen<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>150<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#46; These values were regarded as general indicators of transfusion&#44; but the decision was made on an individualized basis in each patient&#44; taking into account the clinical condition&#44; bleeding volume and hematological alterations&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The study was divided into two equal periods in order to analyze the possible existence of differences in the course of the study&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The statistical analysis of the data was carried out using the SPSS version 21&#46;0 statistical package&#46; Quantitative variables with a normal distribution were reported as the mean and standard deviation &#40;SD&#41;&#44; while those exhibiting a non-normal distribution were reported as the median and interquartile range &#40;IQR&#41; &#40;p25&#8211;p75&#41;&#46; Qualitative variables were reported as percentages&#46; The chi-squared test or Fisher exact test was used for the comparison of qualitative variables&#44; while quantitative variables were compared by the Student&#39;s <span class="elsevierStyleItalic">t</span>-test and Wilcoxon rank-sign test&#44; according to whether or not the data exhibited a normal distribution&#46; Multivariate logistic regression analysis was performed to assess the association between each of the factors and the need for packed red cell&#44; platelet and plasma transfusions&#46; Statistical significance was considered for <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Results</span><p id="par0050" class="elsevierStylePara elsevierViewall">The study comprised a total of 100 patients &#40;67&#37; males&#41; with a median age of 11 months &#40;IQR 4&#8211;66 months&#41; and a median weight of 7&#46;4<span class="elsevierStyleHsp" style=""></span>kg &#40;IQR 4&#46;8&#8211;16&#46;8<span class="elsevierStyleHsp" style=""></span>kg&#41;&#46; The diagnosis was heart disease in 94 patients &#40;64 were in the postoperative period of heart surgery&#41;&#44; respiratory failure in 5 patients and septic shock in one&#46; The indication of ECMO was the impossibility of suspending extracorporeal life support in 27 patients&#44; postoperative low cardiac output in 23 cases&#44; non-postoperative severe heart failure in 18 patients&#44; cardiac arrest in 12 and refractory arrhythmias in 7 patients&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Venoarterial ECMO was used in 98 patients and venovenous ECMO in two cases&#46; Cervical cannulas were placed in 55 patients and transthoracic cannulas in 30&#44; while both types of cannulation were used in 15 cases&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> summarizes the general patient data&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Evolution of the hematological and coagulation parameters</span><p id="par0060" class="elsevierStylePara elsevierViewall">Hemoglobin decreased progressively up until day 7&#44; and recovered thereafter&#46; Statistically significant differences were only observed among the hemoglobin levels at 24<span class="elsevierStyleHsp" style=""></span>h&#44; 72<span class="elsevierStyleHsp" style=""></span>h and 5 days &#40;Fig&#46; 2 of the supplementary material&#41;&#46; The platelet counts decreased up until day 7 and remained stable thereafter&#46; There were significant differences between the baseline platelet count and the counts during the rest of the clinical course &#40;Fig&#46; 3 of the supplementary material&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The INR was initially prolonged but gradually normalized over time &#40;Fig&#46; 4 of the supplementary material&#41;&#44; while fibrinogen remained within normal ranges in most of the patients from the start of ECMO &#40;data not shown&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Ten percent of the patients presented hemoglobin<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>9<span class="elsevierStyleHsp" style=""></span>g&#47;dl&#59; 30&#37; had a platelet count of<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>100&#44;000&#47;mm<span class="elsevierStyleSup">3</span>&#59; 19&#37; showed INR<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>2&#59; and 11&#37; presented fibrinogen<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>150<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Anticoagulation</span><p id="par0075" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> shows the heparin dose and values corresponding to aPTT and antiXa&#46; A gradual increase in heparin requirements was observed during ECMO&#46; The aPTT values increased early after the start of anticoagulation and remained high over the entire time course&#46; Only 22&#46;2&#37; of the patients had antiXa within therapeutic ranges on the first day &#8211; this objective being reached on day 5 of ECMO&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Bleeding</span><p id="par0080" class="elsevierStylePara elsevierViewall">Bleeding was recorded in 52 patients in the first 24<span class="elsevierStyleHsp" style=""></span>h and in 76 patients in the global course of treatment&#46; Another 39 patients required revision surgery due to bleeding&#46; The most frequent location of bleeding was the mediastinum &#40;34 patients&#41;&#44; with resulting tamponade in 15 patients&#46; Diffuse bleeding was observed in 14 patients&#44; another 14 suffered lung bleeding&#44; 6 presented peri-cannula bleeding&#44; 5 digestive bleeding&#44; and three suffered cerebral hemorrhage&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The incidence of bleeding in the first 24<span class="elsevierStyleHsp" style=""></span>h among the patients in the postoperative period of surgery &#40;67&#46;2&#37;&#41; was significantly higher than in the rest of the children &#40;25&#37;&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Those patients with fibrinogen<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>150<span class="elsevierStyleHsp" style=""></span>mg&#47;dl and a platelet count<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>100&#44;000&#47;mm<span class="elsevierStyleSup">3</span> had a higher incidence of initial bleeding &#40;81&#46;8&#37; and 66&#46;7&#37;&#41; than those with fibrinogen<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>150 and platelets<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>100&#44;000&#47;mm<span class="elsevierStyleSup">3</span> &#40;48&#46;3&#37; and 45&#46;7&#37;&#41;&#44; but the differences failed to reach statistical significance &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;053 and <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;080&#44; respectively&#41;&#46; There were no significant differences in the incidence of bleeding at the start of ECMO between the children with INR<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>2 &#40;52&#46;6&#37;&#41; and those with INR<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>2 &#40;51&#46;9&#37;&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Transfusions</span><p id="par0095" class="elsevierStylePara elsevierViewall">In the first 24<span class="elsevierStyleHsp" style=""></span>h of ECMO&#44; 85 patients received red cell transfusions&#44; 78 received platelet infusions&#44; and 83 received plasma&#46; The red cell transfusion volume during the first three days of ECMO was 34&#46;4<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#47;day &#40;SD 31&#46;1&#41;&#44; the platelet volume was 21&#46;1<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#47;day &#40;SD 19&#46;1&#41;&#44; and the plasma volume was 26&#46;6<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#47;day &#40;SD 24&#46;8&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The children in the postoperative period of heart surgery&#44; those in which ECMO was indicated due to the impossibility of suspending extracorporeal life support&#44; those with initial bleeding&#44; and the children requiring revision surgery needed significantly greater transfusion volumes &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">The multivariate logistic regression analysis showed the factors significantly associated to a need for packed red cell transfusions to be the impossibility of suspending extracorporeal life support as an indication of ECMO &#40;odds ratio &#91;OR&#93; 23&#46;43&#59; 95&#37; confidence interval &#91;95&#37;CI&#93;&#58; 6&#46;05&#8211;40&#46;80&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;009&#41; and transthoracic cannulation &#40;OR 21&#46;10&#59; 95&#37;CI&#58; 6&#46;08&#8211;36&#46;11&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;007&#41;&#46; In the multivariate analyses of the need for platelet and plasma transfusions&#44; none of the studied factors reached statistical significance&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">There were no significant differences in the incidence of hematological alterations or in the transfusion needs between the two periods of the study &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Thromboembolic phenomena</span><p id="par0115" class="elsevierStylePara elsevierViewall">Fourteen thromboembolic events were recorded&#46; The location was peripheral in 6 patients&#44; with acral zone embolism&#46; These 6 patients died under conditions of multiorgan failure&#46; Three patients suffered cerebral thromboembolism&#44; with secondary infarction&#59; one of these patients died&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The ultrasound controls made due to malfunctioning of the ECMO circuit diagnosed a right atrial thrombus&#44; a thrombus in the inferior vena cava&#44; and another in the aorta&#46; One of these patents suffered pulmonary embolism&#46; Peritoneal embolism was suspected in one subject due to suspected intestinal ischemia&#46; Five patients suffered a second thromboembolic event&#46; Twenty-one patients developed thrombi in the oxygenator&#46; In 10 of them thrombosis affected the arterial side of the oxygenator or caused it to malfunction &#8211; thereby requiring replacement of the circuit&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Hemolysis</span><p id="par0125" class="elsevierStylePara elsevierViewall">The evolution of the free hemoglobin levels is reported in Fig&#46; 5 of the supplementary material&#46; Excessive hemolysis &#40;free Hb<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>50<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41; was observed in 33 patients&#46; The mean time from the start of ECMO to the appearance of hemolysis was 3&#46;9 days &#40;SD 2&#41;&#46; Five circuit replacements were required because of hemolysis&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The patients with hemolysis were younger and weighed less than the rest&#58; 20&#46;1 months &#40;SD 35&#46;3&#41; versus 46&#46;9 months &#40;SD 55&#46;4&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;013&#41; and 7&#46;7<span class="elsevierStyleHsp" style=""></span>kg &#40;SD 5&#46;9&#41; versus 16&#46;4<span class="elsevierStyleHsp" style=""></span>kg &#40;SD 18&#46;4&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41;&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">No relationship was observed between hemolysis and the number of revolutions used ECMO&#46; Blood flow in the children with hemolysis was lower than in those without hemolysis &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Clinical course</span><p id="par0140" class="elsevierStylePara elsevierViewall">Extracorporeal membrane oxygenation could be suspended in 76 patients &#40;due to clinical improvement in 61 cases&#44; bleeding in one&#44; conversion to a ventricular assist system in 7&#44; and heart transplantation in 7&#41;&#46; The duration of ECMO was 5&#46;5 days &#40;IQR 3&#8211;9 days&#41;&#46; In total&#44; 52 patients were still alive at discharge from hospital&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The duration of admission to the PICU was 21 days &#40;IQR 10&#8211;38 days&#41;&#46; There were no significant differences in the duration of admission to the PICU between the patients with initial bleeding &#40;40&#46;2 days&#59; SD 25&#46;1&#41; and the rest &#40;49&#46;6 days&#59; SD 44&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;385&#41;&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Forty-eight percent of the children died&#58; 56&#37; of those under one year of age and 40&#37; of those over this age &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;161&#41;&#46; Mortality among the children with bleeding at the start of ECMO &#40;57&#46;6&#37;&#41; was significantly greater than in the rest of the patients &#40;37&#46;5&#37;&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;048&#41;&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Mortality among the children with coagulation disorders was greater than in the rest&#44; though the differences were not statistically significant&#58; INR<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>2 &#40;63&#46;2&#37; versus 44&#46;4&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;202&#41;&#44; fibrinogen<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>150<span class="elsevierStyleHsp" style=""></span>mg&#47;dl &#40;72&#46;7&#37; versus 44&#46;9&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;112&#41; and &#60;100&#44;000<span class="elsevierStyleHsp" style=""></span>platelets&#47;mm<span class="elsevierStyleSup">3</span> &#40;56&#46;7&#37; versus 44&#46;3&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;282&#41;&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Lastly&#44; mortality among the patients who were in the postoperative period of heart surgery &#40;53&#46;1&#37;&#41; was greater than in the rest &#40;39&#37;&#41;&#44; though the difference failed to reach statistical significance &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;213&#41;&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Discussion</span><p id="par0165" class="elsevierStylePara elsevierViewall">The results of our study show that hematological alterations are very frequent in children subjected to ECMO&#44; and are associated to important transfusion requirements&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">The incidence of bleeding in our study was higher than that reported in the ELSO registry&#44;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">2&#44;4</span></a> though we included any type of bleeding and the percentage of postsurgery patients was very high&#46; This could partially account for the observed differences&#46; In the present study the coagulation disorders and transfusion requirements remained stable in the two periods of the study&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Some authors have suggested that only bleeding requiring transfusion should be regarded as a bleeding complication&#46; Other investigators propose classification of bleeding into mild &#40;between 10 and 20<span class="elsevierStyleHsp" style=""></span>ml&#47;kg in 24<span class="elsevierStyleHsp" style=""></span>h&#41; or intense &#40;&#62;20<span class="elsevierStyleHsp" style=""></span>ml&#47;kg in 24<span class="elsevierStyleHsp" style=""></span>h&#44; with a drop in hemoglobin of 2<span class="elsevierStyleHsp" style=""></span>g&#47;l in 24<span class="elsevierStyleHsp" style=""></span>h&#44; involvement of the brain&#44; lungs or retroperitoneum&#44; or a need for surgery&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">12</span></a> Bleeding volume was not recorded in our study&#44; but 39&#37; of the patients required revision surgery&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">The cause of bleeding in patients with ECMO is probably multifactorial&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">2</span></a> On one hand&#44; the underlying disease&#44; surgery&#44; drug use and multiorgan failure usually present in these children alter the coagulation mechanisms&#46; On the other hand&#44; the ECMO machine and system produce inflammation&#44; platelet activation<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">1&#44;8&#44;13</span></a> and the consumption of coagulation factors&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">3</span></a> Lastly&#44; treatment with heparin is another cause of bleeding&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">An important decrease in platelet count is observed in children and adults subjected to ECMO&#44; and frequent transfusions are required&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">1&#44;13&#8211;15</span></a> The etiology underlying thrombocytopenia is probably multifactorial &#40;infection&#44; bleeding&#44; transfusion and platelet depletion in the ECMO circuit&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">8</span></a> We recorded a significant decrease in platelet count &#40;from 186&#44;500 to 105&#44;700&#47;mm<span class="elsevierStyleSup">3</span>&#41; in the first 24<span class="elsevierStyleHsp" style=""></span>h of treatment&#46; This figure persisted in the course of treatment&#44; with periodic platelet transfusions&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Bleeding&#44; platelet activation and the consumption of coagulation factors explain the hematological alterations found in these patients and the need for blood product transfusions&#46; In our study&#44; the factors associated to an increased need for blood product transfusions were the postoperative period of heart surgery&#44; bleeding at the start of ECMO&#44; and the need for revision surgery&#46; Other authors have reported similar findings&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">16&#44;17</span></a> In the logistic regression analysis&#44; the factors found to be significantly correlated to the need for packed red cell transfusions were the impossibility of suspending extracorporeal circulation and transthoracic cannulation&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">There is no clear evidence regarding the indications of transfusions in children subjected to ECMO&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">12</span></a> Most authors propose keeping the hematocrit at 35&#37;&#44; with a broad transfusion indication range of between 25 and 40&#37;&#44; and the platelet count at 100&#44;000&#47;mm<span class="elsevierStyleSup">3</span>&#44; with a transfusion indication range of between 50&#44;000 and 200&#44;000&#47;mm<span class="elsevierStyleSup">3</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">12</span></a> These transfusion criteria are similar to those used in our series&#46; Further studies are needed to determine whether a more restrictive transfusion policy could reduce the volume of transfusions without placing the patient at risk&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Heparin response is highly variable and changing over time&#44; and it is difficult to keep the circuit free of thrombi without increasing the risk of bleeding&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">18</span></a> A number of studies have reported a greater correlation between heparin levels and antiXa than with ACT or aPTT&#44;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">8&#44;19</span></a> and the antiXa levels moreover are not affected by acute phase reactants such as fibrinogen and factor <span class="elsevierStyleSmallCaps">vii</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">8</span></a> Other studies have reported a lesser need for blood sampling&#44; a decrease in blood product transfusions&#44; and fewer both thrombotic and bleeding complications when using antiXa as part of the coagulation monitoring protocol&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">19</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">In our study we used ACT for monitoring anticoagulation at the patient bedside&#44; and aPTT and antiXa for the daily control of anticoagulation&#46; Our reference parameter for the control of anticoagulation was antiXa&#46; However&#44; since this parameter cannot be determined on an emergency basis in our hospital&#44; use was made of ACT for the hourly regulation of heparin dosing&#44; and aPTT was used to assess the need for plasma transfusion&#46; The antiXa levels initially were maintained below the therapeutic range in most of the patients with respect to the use of lower heparin doses to reduce bleeding&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Some investigators have reported that the use of lower heparin doses for keeping aPTT between 1&#46;5 and 2 times the control level results in a lesser incidence of bleeding without incrementing thromboembolic events<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">16</span></a> though large comparative trials are needed to confirm these results&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">Thromboembolic events occur as a consequence of contact between the blood and non-endothelial surfaces&#44; triggering an inflammatory response with the activation of coagulation&#46; In our study&#44; 14 patients suffered some thromboembolic event&#44; with peripheral thrombi being the most frequent presentation&#46; The 6 patients that presented these events died under conditions of multiorgan failure probably related to disseminated intravascular coagulation &#40;DIC&#41;&#46; In the ELSO registry&#44; the central nervous system was the most commonly affected territory&#44; with 5&#37; of the children suffering cerebral infarction&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">4</span></a> This is consistent with our own findings &#40;3&#37;&#41;&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Thrombi in the oxygenator were recorded in 21 patients &#8211; this being the most common location of thrombosis within the circuit&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">3&#44;6&#44;20</span></a> The figure is similar to those reported by other authors&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">3&#44;20</span></a> Thrombi on the arterial side of the oxygenator are the most important risk factor for thromboembolism&#46; In this regard&#44; careful and continuous circuit monitoring is required by the medical and nursing staff&#44; with close control of anticoagulation&#46; The appearance of thrombi in the post-oxygenator circuit requires circuit replacement in order to avoid embolisms&#46; This situation occurred in 10 of our patients&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">In our study&#44; 33&#37; of the patients presented hemolysis &#8211; this figure being significantly lower than the 66&#37; reported by Lou et al&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">21</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall">Hemolysis is a complication of mechanical support secondary to increased shear stress caused by the pump and which can lead to acute renal failure and multiorgan failure&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">3</span></a> The negative pressure drop across the oxygenator membrane can also produce a suction effect with cavitation and red cell damage&#46; On the other hand&#44; the use of high revolution settings has also been related to hemolysis&#59; as a result&#44; when free hemoglobin starts to rise in blood&#44; it is advisable where possible to reduce the revolutions per minute &#40;rpm&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">3</span></a> In children with hemolysis&#44; Lou et al&#46; found the rpm setting and flow to be greater than in patients without hemolysis&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">21</span></a> However&#44; no relationship between rpm and hemolysis was observed in our study&#44; and surprisingly the blood flow was lower in the children with hemolysis than in those without&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">On the other hand&#44; in our series hemolysis was greater in the children of younger age and lower weight&#44; in coincidence with the observations of Lou et al&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">21</span></a></p><p id="par0240" class="elsevierStylePara elsevierViewall">The survival rate at hospital discharge in our study &#40;52&#37;&#41; was very similar to that reported by the ELSO registry in cardiac pediatric patients &#40;51&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">4</span></a></p><p id="par0245" class="elsevierStylePara elsevierViewall">Bleeding is the main cause of mortality in patients subjected to ECMO&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">3&#44;6</span></a> In our case&#44; mortality among the children with bleeding at the start of ECMO &#40;57&#46;6&#37;&#41; was significantly greater than in the rest of the patients &#40;37&#46;5&#37;&#41;&#44; in coincidence with the findings of the ELSO registry&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">2&#44;6</span></a> Major bleeding can contribute to the appearance of organic complications and increases coagulopathy&#44; generating a vicious circle of coagulopathy-bleeding-transfusions that proves very difficult to control&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">The median duration of ECMO support in our study &#40;5&#46;5 days&#41; was similar to that reported in the ELSO registry among children with cardiac indications for extracorporeal support &#40;6&#46;3 days&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">4</span></a></p><p id="par0255" class="elsevierStylePara elsevierViewall">The median duration of stay in the PICU among the patients requiring ECMO was 21 days&#44; and the presence of bleeding was not associated to longer admission&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">Our study has a number of limitations&#46; Firstly&#44; it is a single-center trial conducted in a heart surgery reference center&#44; and our data are not fully extrapolatable to other centers in which ECMO is used in other types of patients&#46; Secondly&#44; the study involves a retrospective analysis of a registry with a long duration &#8211; a fact that increases the difficulty of adequately collecting all the variables and the risk of bias&#59; full homogeneity of the transfusion criteria cannot be ensured&#44; and causal relationships cannot be established&#46;</p><p id="par0265" class="elsevierStylePara elsevierViewall">Lastly&#44; bleeding volume was not quantified and the hematological parameters were influenced by the number of transfusions received by the patients&#46; In our study we did not record the values of the hematological parameters before and after each transfusion&#44; which would have been of help in assessing the impact of the transfusions&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">Our results show hematological and coagulation disorders to be frequent in the children subjected to ECMO&#44; with a high incidence of bleeding and the need for numerous transfusions&#46;</p><p id="par0275" class="elsevierStylePara elsevierViewall">The patients in the postoperative period of surgery&#44; those with bleeding at the start of ECMO&#44; and those needing revision surgery required a greater volume of transfusions &#8211; though no causal relationship can be established in this regard&#46; The children with bleeding at the start of ECMO showed higher mortality but not a longer PICU stay&#46; The present study may serve as a basis for the development of specific transfusion protocols in children subjected to ECMO and for the design of multicenter studies seeking to determine whether heparin-impregnated circuits&#44; lesser anticoagulation&#44; and a more restricted transfusion policy are able to reduce the risk of bleeding and thromboembolic complications in children subjected to ECMO&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">19</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Financial support</span><p id="par0280" class="elsevierStylePara elsevierViewall">The authors have received no financial support for carrying out this study&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Authorship&#47;collaborations</span><p id="par0285" class="elsevierStylePara elsevierViewall">MJS&#58; conception and design of the study&#59; data collection&#44; analysis and interpretation&#59; critical review of the text&#59; and approval of the definitive version of the manuscript&#46;</p><p id="par0290" class="elsevierStylePara elsevierViewall">CG&#58; data collection&#44; analysis and interpretation&#59; drafting of the text&#59; and approval of the definitive version of the manuscript&#46;</p><p id="par0295" class="elsevierStylePara elsevierViewall">IM&#58; data collection&#44; analysis and interpretation&#59; drafting of the text&#59; and approval of the definitive version of the manuscript&#46;</p><p id="par0300" class="elsevierStylePara elsevierViewall">VM&#58; data collection&#44; analysis and interpretation&#59; drafting of the text&#59; and approval of the definitive version of the manuscript&#46;</p><p id="par0305" class="elsevierStylePara elsevierViewall">PS&#58; data collection&#44; analysis and interpretation&#59; drafting of the text&#59; and approval of the definitive version of the manuscript&#46;</p><p id="par0310" class="elsevierStylePara elsevierViewall">AS&#58; conception and design of the study&#59; data collection&#44; analysis and interpretation&#59; critical review of the text&#59; and approval of the definitive version of the manuscript&#46;</p><p id="par0315" class="elsevierStylePara elsevierViewall">JLH&#58; conception and design of the study&#59; analysis and interpretation of the data&#59; drafting of the text&#59; and approval of the definitive version of the manuscript&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Conflicts of interest</span><p id="par0320" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To analyze the hematological complications and need for transfusions in children receiving extracorporeal life support &#40;ECLS&#41;&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Design</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A retrospective study was carried out&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Setting</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A pediatric intensive care unit&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Patients</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Children under 18 years of age subjected to ECLS between September 2006 and November 2015&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Interventions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">None&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Variables of interest</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Patient and ECLS characteristics&#44; anticoagulation&#44; hematological and coagulation parameters&#44; transfusions and clinical course&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A total of 100 patients &#40;94 with heart disease&#41; with a median age of 11 months were studied&#46; Seventy-six patients presented bleeding&#46; The most frequent bleeding point was the mediastinum and 39 patients required revision surgery&#46; In the first 3<span class="elsevierStyleHsp" style=""></span>days&#44; 97&#37; of the patients required blood transfusion &#40;34&#46;4<span class="elsevierStyleHsp" style=""></span>ml&#47;kg per day&#41;&#44; 94&#37; platelets &#40;21&#46;1<span class="elsevierStyleHsp" style=""></span>ml&#47;kg per day&#41; and 90&#37; plasma &#40;26&#46;6<span class="elsevierStyleHsp" style=""></span>ml&#47;kg per day&#41;&#46; Patients who were in the postoperative period&#44; those who were bleeding at the start of ECLS&#44; those requiring revision surgery&#44; those who could not suspend extracorporeal circulation&#44; and those subjected to transthoracic cannulation required a greater volume of transfusions than the rest of the patients&#46; Thromboembolism occurred in 14 patients and hemolysis in 33 patients&#46; Mortality among the children who were bleeding at the start of ECLS &#40;57&#46;6&#37;&#41; was significantly higher than in the rest of the patients &#40;37&#46;5&#37;&#41; &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;048&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Children subjected to ECLS present high blood product needs&#46; The main factors related to transfusions were the postoperative period&#44; bleeding at the start of ECLS&#44; revision surgery&#44; transthoracic cannulation&#44; and the impossibility of suspending extracorporeal circulation&#46; Children with bleeding suffered greater mortality than the rest of the patients&#46;</p></span>"
        "secciones" => array:8 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objectives"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Design"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Setting"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Patients"
          ]
          4 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Interventions"
          ]
          5 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Variables of interest"
          ]
          6 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Results"
          ]
          7 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusions"
          ]
        ]
      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Objetivos</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Analizar las complicaciones hematol&#243;gicas y las necesidades transfusionales en ni&#241;os tratados con oxigenaci&#243;n por membrana extracorp&#243;rea &#40;ECMO&#41;&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Dise&#241;o</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo&#46;</p></span> <span id="abst0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">&#193;mbito</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Unidad de cuidados intensivos pedi&#225;tricos&#46;</p></span> <span id="abst0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Pacientes</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Ni&#241;os menores de 18 a&#241;os tratados con ECMO entre septiembre de 2006 y noviembre de 2015&#46;</p></span> <span id="abst0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Intervenciones</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Ninguna&#46;</p></span> <span id="abst0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Variables de inter&#233;s</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Caracter&#237;sticas cl&#237;nicas&#44; de la ECMO&#44; anticoagulaci&#243;n&#44; par&#225;metros hematol&#243;gicos y de coagulaci&#243;n&#44; transfusiones y evoluci&#243;n cl&#237;nica&#46;</p></span> <span id="abst0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Resultados</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Se estudiaron 100 pacientes con una mediana de edad de 11 meses&#46; Presentaron sangrado 76&#59; el mediastino fue la localizaci&#243;n m&#225;s frecuente&#59; 39 precisaron revisi&#243;n quir&#250;rgica&#46; En los primeros 3 d&#237;as de ECMO&#44; el 97&#37; de los pacientes precisaron transfusi&#243;n de hemat&#237;es &#40;34&#44;4 ml&#47;kg al d&#237;a&#41;&#44; el 94&#37; plaquetas &#40;21&#44;1<span class="elsevierStyleHsp" style=""></span>ml&#47;kg al d&#237;a&#41; y el 90&#37; plasma &#40;26&#44;6<span class="elsevierStyleHsp" style=""></span>ml&#47;kg al d&#237;a&#41;&#46; Los pacientes posquir&#250;rgicos&#44; con imposibilidad de salida de la circulaci&#243;n extracorp&#243;rea&#44; los que presentaron sangrado al inicio de la ECMO&#44; los que precisaron revisi&#243;n quir&#250;rgica y los que tuvieron canulaci&#243;n transtor&#225;cica requirieron mayor volumen de transfusiones&#46; Se produjeron tromboembolias en 14 pacientes y hem&#243;lisis en 33&#46; La mortalidad de los ni&#241;os que presentaron sangrado al inicio de ECMO &#40;57&#44;6&#37;&#41; fue significativamente mayor que la del resto &#40;37&#44;5&#37;&#41; &#40;p&#160;&#61;&#160;0&#44;048&#41;&#46;</p></span> <span id="abst0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusiones</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Los ni&#241;os tratados con ECMO presentan una elevada incidencia de sangrado y precisan un gran volumen de transfusiones&#46; El postoperatorio de cirug&#237;a&#44; el sangrado al inicio de la ECMO&#44; la necesidad de revisi&#243;n quir&#250;rgica&#44; la imposibilidad de salida de la circulaci&#243;n extracorp&#243;rea y la canulaci&#243;n transtor&#225;cica se asocian a un mayor volumen de transfusiones&#46; Los ni&#241;os que sangraron al inicio de la ECMO presentaron mayor mortalidad&#46;</p></span>"
        "secciones" => array:8 [
          0 => array:2 [
            "identificador" => "abst0045"
            "titulo" => "Objetivos"
          ]
          1 => array:2 [
            "identificador" => "abst0050"
            "titulo" => "Dise&#241;o"
          ]
          2 => array:2 [
            "identificador" => "abst0055"
            "titulo" => "&#193;mbito"
          ]
          3 => array:2 [
            "identificador" => "abst0060"
            "titulo" => "Pacientes"
          ]
          4 => array:2 [
            "identificador" => "abst0065"
            "titulo" => "Intervenciones"
          ]
          5 => array:2 [
            "identificador" => "abst0070"
            "titulo" => "Variables de inter&#233;s"
          ]
          6 => array:2 [
            "identificador" => "abst0075"
            "titulo" => "Resultados"
          ]
          7 => array:2 [
            "identificador" => "abst0080"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Santiago MJ&#44; G&#243;mez C&#44; Maga&#241;a I&#44; Mu&#241;oz V&#44; Saiz P&#44; S&#225;nchez A&#44; et al&#46; Complicaciones hematol&#243;gicas en ni&#241;os tratados con oxigenaci&#243;n por membrana extracorp&#243;rea&#46; Med Intensiva&#46; 2019&#59;43&#58;281&#8211;289&#46;</p>"
      ]
    ]
    "apendice" => array:1 [
      0 => array:1 [
        "seccion" => array:1 [
          0 => array:4 [
            "apendice" => "<p id="par0335" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article&#58;<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary data"
            "identificador" => "sec0080"
          ]
        ]
      ]
    ]
    "multimedia" => array:6 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 2126
            "Ancho" => 2322
            "Tamanyo" => 173375
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Heparin dose &#40;IU&#47;kg&#47;h&#41; and values corresponding to aPTT &#40;seconds&#41; and antiXa &#40;IU&#47;ml&#41; during ECMO &#40;mean and standard deviation&#41;&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Table "
            "rol" => "short"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">ECC&#58; extracorporeal circulation&#59; IQR&#58; interquartile range&#46;</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7&#46;4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4&#46;8&#8211;16&#46;8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;27&#8211;0&#46;65&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Indication</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Non-postoperative low output&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Postoperative low output&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hypoxemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No suspension of ECC&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cardiac arrest&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>arrhythmia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Immediate postoperative period of heart surgery</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Type of ECMO</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Venoarterial&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">98&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Venovenous&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Type of cannulation</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cervical&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">55&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Transthoracic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Both&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Red cells &#40;ml&#47;kg&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Platelets &#40;ml&#47;kg&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Plasma &#40;ml&#47;kg&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">M</span> &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">M</span> &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">M</span> &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Postoperative</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Yes&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">42&#46;2 &#40;34&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&#46;4 &#40;21&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;005&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&#46;6 &#40;27&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;020&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21 &#40;18&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#46;1 &#40;12&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&#46;3 &#40;17&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">No suspension of ECC</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Yes&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">59&#46;8 &#40;36&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;750&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bleeding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;420&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Revision surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;075&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Activated factor VII&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">33&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;340&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  \t\t\t\t">0&#46;980&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Platelet transfusion &#40;ml&#47;kg&#47;day&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;980&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t">Plasma transfusion &#40;ml&#47;kg&#47;day&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">26&#46;5 &#40;29&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">25&#46;4 &#40;19&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;890&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Hemolysis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">No hemolysis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Hemolysis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">No hemolysis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">8<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">M</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#46;333&#46;2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#46;478&#46;1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">349&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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        "titulo" => "Acknowledgements"
        "texto" => "<p id="par0325" class="elsevierStylePara elsevierViewall">The authors are grateful to the medical and nursing staff of the PICU&#44; the Pediatric Cardiology Section and Pediatric Heart Surgery&#44; the perfusion nurses&#44; and the Department of Hematology of Hospital General Universitario Gregorio Mara&#241;&#243;n&#44; for their collaboration in the care of the children subjected to ECMO&#46;</p>"
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