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Hemolysis in Pediatric Patients Receiving Centrifugal-Pump Extracorporeal Membrane Oxygenation: Prevalence, Risk Factors, and Outcomes*

Lou, Song MD1,2; MacLaren, Graeme MBBS, FCCM1,3,4; Best, Derek RN, BSCN, BN1; Delzoppo, Carmel BappSc1; Butt, Warwick MBBS, FRACP, FCICM1,4,5

doi: 10.1097/CCM.0000000000000128
Pediatric Critical Care

Objectives: To explore the prevalence and risk factors for hemolysis in children receiving extracorporeal membrane oxygenation and examine the relationship between hemolysis and adverse outcomes.

Design: Retrospective, single-center study.

Setting: Tertiary PICU.

Patients: Two hundred seven children receiving extracorporeal membrane oxygenation.

Interventions: None.

Measurements and Main Results: Plasma-free hemoglobin was tested daily and hemolysis was diagnosed based on peak plasma-free hemoglobin as mild (< 0.5 g/L), moderate (0.5–1.0 g/L), or severe (> 1.0 g/L). Gender, age, weight, diagnosis, oxygenator type, cannulation site, mean venous inlet pressure, mean pump speed, mean flow, and visible clots in the extracorporeal membrane oxygenation circuit were entered into the ordered logistic regression model to identify risk factors of hemolysis. Complications and clinical outcomes were compared across four hemolysis groups. Of the 207 patients, 69 patients (33.3%; 95% CI, 27.0–40.2%) did not have hemolysis, 98 patients (47.3%; 95% CI, 40.4–54.4%) had mild hemolysis, 26 patients (12.5%; 95% CI, 8.4–17.9%) had moderate hemolysis, and 14 patients (6.8%; 95% CI, 3.7–11.1%) had severe hemolysis with a median peak plasma-free hemoglobin of 1.51 g/L (1.18–2.05 g/L). The independent risk factors for hemolysis during extracorporeal membrane oxygenation were use of Quadrox D (odds ratio, 7.25; 95% CI, 3.10–16.95; p < 0.001) or Lilliput (odds ratio, 37.32; 95% CI, 8.95–155.56; p < 0.001) oxygenators, mean venous inlet pressure (odds ratio, 0.95; 95% CI, 0.91–0.98; p = 0.002), and mean pump speed (odds ratio, 2.89; 95% CI, 1.36–6.14; p = 0.006). Patients with hemolysis were more likely to experience a longer extracorporeal membrane oxygenation run and require more blood products. After controlling for age, weight, pediatric index of mortality 2, and diagnosis, patients with severe hemolysis were more likely to die in the ICU (odds ratio, 5.93; 95% CI, 1.64–21.43; p = 0.007) and in hospital (odds ratio, 6.34; 95% CI, 1.71–23.54; p = 0.006).

Conclusions: Hemolysis during extracorporeal membrane oxygenation with centrifugal pumps was common and associated with a number of adverse outcomes. Risk factors for hemolysis included oxygenator types, mean venous inlet pressure, and mean pump speed. Further studies are warranted comparing pump types while controlling both physical and nonphysical confounders.

1Paediatric Intensive Care Unit, Royal Children’s Hospital, Melbourne, Australia.

2Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People’s Republic of China.

3Cardiothoracic Intensive Care Unit, National University Health System, Singapore.

4Department of Paediatrics, University of Melbourne, Melbourne, Australia.

5Murdoch Children's Research Institute, Melbourne, Australia.

* See also p. 1314.

This work was performed at the Royal Children’s Hospital, Melbourne, Australia.

The authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: gmaclaren@iinet.net.au

© 2014 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins