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Hemolysis During Pediatric Extracorporeal Membrane Oxygenation

Associations With Circuitry, Complications, and Mortality

Dalton, Heidi J., MD1; Cashen, Katherine, DO2; Reeder, Ron W., PhD3; Berg, Robert A., MD4; Shanley, Thomas P., MD5; Newth, Christopher J. L., MD6; Pollack, Murray M., MD7; Wessel, David, MD7; Carcillo, Joseph, MD8; Harrison, Rick, MD9; Dean, J. Michael, MD2; Meert, Kathleen L., MD2 for the Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network (CPCCRN)

doi: 10.1097/PCC.0000000000001709
Extracorporeal Support

Objectives: To describe factors associated with hemolysis during pediatric extracorporeal membrane oxygenation and the relationships between hemolysis, complications, and mortality.

Design: Secondary analysis of data collected prospectively by the Collaborative Pediatric Critical Care Research Network between December 2012 and September 2014.

Setting: Three Collaborative Pediatric Critical Care Research Network-affiliated hospitals.

Patients: Age less than 19 years and treated with extracorporeal membrane oxygenation.

Interventions: None.

Measurements and Main Results: Hemolysis was defined based on peak plasma free hemoglobin levels during extracorporeal membrane oxygenation and categorized as none (< 0.001 g/L), mild (0.001 to < 0.5 g/L), moderate (0.5 to < 1.0 g/L), or severe (≥ 1.0 g/L). Of 216 patients, four (1.9%) had no hemolysis, 67 (31.0%) had mild, 51 (23.6%) had moderate, and 94 (43.5%) had severe. On multivariable analysis, variables independently associated with higher daily plasma free hemoglobin concentration included the use of in-line hemofiltration or other continuous renal replacement therapy, higher hemoglobin concentration, higher total bilirubin concentration, lower mean heparin infusion dose, lower body weight, and lower platelet count. Using multivariable Cox modeling, daily plasma free hemoglobin was independently associated with development of renal failure during extracorporeal membrane oxygenation (defined as creatinine > 2 mg/dL [> 176.8 μmol/L] or use of in-line hemofiltration or continuous renal replacement therapy) (hazard ratio, 1.04; 95% CI, 1.02–1.06; p < 0.001), but not mortality (hazard ratio, 1.01; 95% CI, 0.99–1.04; p = 0.389).

Conclusions: Hemolysis is common during pediatric extracorporeal membrane oxygenation. Hemolysis may contribute to the development of renal failure, and therapies used to manage renal failure such as in-line hemofiltration and other forms of continuous renal replacement therapy may contribute to hemolysis. Hemolysis was not associated with mortality after controlling for other factors. Monitoring for hemolysis should be a routine part of extracorporeal membrane oxygenation practice, and efforts to reduce hemolysis may improve patient care.

1Department of Pediatrics, Inova Fairfax Hospital, Falls Church, VA.

2Division of Critical Care, Department of Pediatrics, Children’s Hospital of Michigan/Wayne State University, Detroit, MI.

3Department of Pediatrics, University of Utah, Salt Lake City, UT.

4Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, Philadelphia, PA.

5Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago/Northwestern University Feinberg School of Medicine, Chicago, IL.

6Department of Anesthesiology and Critical Care Medicine, Children’s Hospital Los Angeles, Los Angeles, CA.

7Department of Pediatrics, Children’s National Medical Center, Washington, DC.

8Department of Critical Care Medicine, Children’s Hospital of Pittsburgh, Pittsburgh, PA.

9Department of Pediatrics, Mattel Children’s Hospital UCLA, Los Angeles, CA.

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Supported, in part, by the following cooperative agreements from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services: U10HD050096, U10HD049981, U10HD049983, U10HD050012, U10HD063108, U10HD063106, U10HD063114, and U01HD049934. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Drs. Dalton’s, Reeder’s, Berg’s, Shanley’s, Wessel’s, Harrison’s, Dean’s, and Meert’s institutions received funding from the National Institutes of Health (NIH). Drs. Dalton, Reeder, Berg, Shanley, Newth, Pollack, Wessel, Carcillo, Harrison, Dean, and Meert received support for article research from the NIH. Dr. Dalton received funding from Innovative Extracorporeal membrane oxygenation (ECMO) Concepts and Maquet speakers bureau, and she disclosed off-label product use of ECMO equipment. Dr. Shanley received funding from Springer Publishing, Pediatric Academic Societies Operating and Executive Committees, and International Pediatric Research Fund. Dr. Newth received funding from Philips Research North American (consulting services for data analysis). Dr. Carcillo’s institution received funding from the National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network U10. Dr. Cashen has disclosed that she does not have any potential conflicts of interest.

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©2018The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies