Original article
Adult cardiac
Bleeding, Transfusion, and Mortality on Extracorporeal Life Support: ECLS Working Group on Thrombosis and Hemostasis

Presented at the Thirty-seventh Annual Meeting of the Society of Cardiovascular Anesthesiologists, Washington, DC, April 11–15, 2015.
https://doi.org/10.1016/j.athoracsur.2015.07.046Get rights and content

Background

Bleeding may occur frequently during adult extracorporeal life support; however, there are no detailed investigations of bleeding events, red blood cell transfusion, and their impact on mortality. The purpose of our study was to characterize the incidence of bleeding and red blood cell transfusion during adult extracorporeal life support and examine the impact on mortality.

Methods

We performed a retrospective analysis of adult extracorporeal life support patients over approximately a 3-year period. The incidence of bleeding events and transfusions were recorded. Unadjusted and adjusted multivariate logistic regression analyses were performed to estimate the odds of inhospital mortality among patients with bleeding and for each red blood cell unit transfused. Ninety-day survival was compared between patients who bled and those who did not.

Results

Serious bleeding events occurred in 74 of 132 patients (56.1%), and the rate of bleeding was 10 events per 100 days. The crude odds ratio for inhospital mortality in patients who bled was 2.22 (95% confidence interval [CI]: 1.00 to 4.94, p = 0.05); and for each unit of red blood cells transfused, it was 1.03 (95% CI: 1.01 to 1.04, p = 0.005). The adjusted odds ratios for bleeding and red blood cell transfusions were 0.90 (95% CI: 0.37 to 2.19, p = 0.82) and 1.03 (95% CI: 1.00 to 1.06, p = 0.04). There was a trend toward decreased 90-day survival among patients who bled compared with patients who did not (46.7% versus 64.9%, p = 0.08).

Conclusions

Bleeding and red blood cell transfusion occur frequently during adult extracorporeal life support, but only the amount of red blood cell transfusion is associated with inhospital mortality after controlling for confounding variables.

Section snippets

Subjects

The Institutional Review Board at the University of Maryland, Baltimore, approved the study. Data were collected using electronic medical records, the institutional Extracorporeal Life Support Organization (ELSO) database, and scanned hospital records. All adult patients who had ECLS between March 1, 2010, and August 15, 2013, were included.

Demographic Data and Comorbidities

For all subjects we recorded age, sex, diabetes mellitus, hypertension, baseline right ventricular function (defined as none, mild, moderate, or severe

Patient Characteristics

Patient characteristics are listed in Table 1. Of the 132 patients, 40.9% required VA ECLS, 48.5% required VV ECLS, and 10.6% required both modalities. The most common diagnosis was adult respiratory distress syndrome, and the median number of ECLS days for the cohort was 7. Patients who had a serious bleeding event during ECLS were older (p = 0.004). They were also more likely to be male, have chronic hypertension, have postcardiotomy shock, have central cannulation, and have VA ECLS compared

Comment

Coagulation management during ECLS is challenging because patients require systemic anticoagulation therapy to prevent thrombosis but it puts them at risk for serious bleeding events. Currently, anticoagulation therapy protocols for ECLS are highly variable among ECLS centers [15]. There is also a large amount of variability in transfusion practice and coagulation management among individual patients at a particular center [16]. In addition to systemic anticoagulation therapy, multifactorial

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