Epidemiology of the Use of Hemostatic Agents in Children Supported by Extracorporeal Membrane Oxygenation: A Pediatric Health Information System Database Study.

Marianne E Nellis,Oliver Karam,Ljiljana V Vasovic,Ruchika Goel

doi:10.3389/fped.2021.673613

Abstract

Objectives: Children supported by extracorporeal membrane oxygenation (ECMO) are at high risk of bleeding. Though practitioners often prescribe blood components and/or medications to prevent or treat bleeding, the utilization of these hemostatic measures in children is not well-understood. We sought to evaluate the use of hemostatic blood products (platelet, plasma and cryoprecipitate transfusions) and medications [aminocaproic acid, tranexamic acid (TXA) and Factor VIIa] in children supported by ECMO.Design: Retrospective observational study using the Pediatric Health Information System (PHIS) database from 2011-2017.Setting: Fifty-one U.S. children's hospitals.Patients: Children (aged 0–18 years) supported by ECMO.Interventions: None.Measurements and Main Results: ECMO was employed in the care of 7,910 children for a total of 56,079 ECMO days. Fifty-five percent of the patients were male with a median (IQR) age of 0 (0–2) years. The median (IQR) length of ECMO was 5 (2–9) days with a hospital mortality rate of 34%. Platelets were transfused on 49% of ECMO days, plasma on 33% of ECMO days and cryoprecipitate on 17% of ECMO days. Twenty-two percent of children received TXA with the majority receiving it on the first day of ECMO and the use of TXA increased during the 6-year period studied (p < 0.001). Seven percent of children received aminocaproic acid and 3% received Factor VIIa.Conclusions: Children supported by ECMO are exposed to a significant number of hemostatic blood products. Antifibrinolytics, in particular TXA, are being used more frequently. Given the known morbidity and mortality associated with hemostatic blood products, studies are warranted to evaluate the effectiveness of hemostatic strategies.

Highlights

Ill children have a significant risk of developing clinically significant bleeding due to underlying organ dysfunction and possible bone marrow suppression and/or consumptive coagulopathies [1]
We sought to evaluate the utilization patterns of hemostatic blood products and medications (TXA, aminocaproic acid, and Factor VIIa) in children supported by extracorporeal membrane oxygenation (ECMO) using a large administrative database
There were initially 9,192 children supported by ECMO identified within the database

Summary

Introduction

Ill children have a significant risk of developing clinically significant bleeding due to underlying organ dysfunction and possible bone marrow suppression and/or consumptive coagulopathies [1]. In a cohort of 514 children supported by ECMO at eight children’s hospitals in the US, bleeding occurred in over 70% of patients and was independently associated with mortality [4, 5]. Bleeding in children supported by ECMO has been associated with fewer ventilator-free days and hospital-free days [6]. In the same cohort described above examining the use of plasma and platelet transfusions, only one-quarter of the ECMO days were free from the transfusion of either blood product [7]. Small epidemiologic reports have estimated that children supported by ECMO receive on average 75 mL/kg of plasma transfusions and 90 mL/kg of platelet transfusions during their hospital stay [8]. No large-scale studies on blood product utilization in this vulnerable patient population have been reported

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