Predictive factors of bleeding events in adults undergoing extracorporeal membrane oxygenation

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Abstract

Background: Bleeding is the most frequent complication associated with extracorporeal membrane oxygenation (ECMO) support in critically ill patients. Nonetheless, risk factors for bleeding have been poorly described especially those associated with coagulation anomalies and anticoagulant therapy during ECMO support. The aim of this study is to describe bleeding complications in critically ill patients undergoing ECMO and to identify risk factors for bleeding events. Methods: We retrospectively analysed ICU charts of adults who received either veno-venous (VV) or veno-arterial (VA) ECMO support in two participating ICUs between 2010 and 2013. Characteristics of patients with and without bleeding complications, as per the Extracorporeal Life Support Organisation (ELSO) definition, were compared, and the impact of bleeding complications on patient outcomes was assessed using survival analysis. Variables that were independently associated with bleeding, including daily clinical and biological variables during ECMO courses, were modelled. Results: Of the 149 ECMO episodes (111 VA ECMO and 38 VV ECMO) performed in 147 adults, 89 episodes (60 %) were complicated by at least one bleeding event. The most common bleeding sources were: ECMO cannula (37 %), haemothorax or cardiac tamponade (17 %) and ear–nose and throat (16 %). Intra-cranial haemorrhage occurred in five (2.2 %) patients. Bleeding complications were independently associated with worse survival [adjusted hazard ratio (HR) 2.17, 95 % confidence interval (CI) 1.07–4.41, P = 0.03]. Higher activated partial thromboplastin time (aPTT) [adjusted odds ratio (OR) 3.00, 95 % CI 1.64–5.47, P < 0.01], APACHE III score [adjusted OR 1.01, 95 % CI 1.01–1.02, P = 0.01] and ECMO following surgery [adjusted OR 3.04, 95 % CI 1.62–5.69, P < 0.01] were independently associated with greater risk of bleeding occurrence. A similar association between bleeding and higher aPTT was found when non-post-surgical VA ECMO was considered separately. Conclusions: Bleeding events based on the ELSO bleeding definition occurred in more than 60 % of ECMO episodes and were associated with hospital mortality. We identified higher aPTT prior bleeding as an independent risk factor for bleeding event, suggesting that better control of the aPTT (through a better control of either coagulopathy or anticoagulation) may improve patients’ outcome.

Original languageEnglish
Article number97
JournalAnnals of Intensive Care
Volume6
Issue number1
DOIs
Publication statusPublished - 1 Dec 2016

Keywords

  • Anticoagulation
  • Bleeding
  • Coagulopathy
  • Critically ill patients
  • Extra corporeal membrane oxygenation
  • Haemorrhage
  • Thromboembolic events

Cite this

@article{57293a67b8a9465db86c5dea0b613297,
title = "Predictive factors of bleeding events in adults undergoing extracorporeal membrane oxygenation",
abstract = "Background: Bleeding is the most frequent complication associated with extracorporeal membrane oxygenation (ECMO) support in critically ill patients. Nonetheless, risk factors for bleeding have been poorly described especially those associated with coagulation anomalies and anticoagulant therapy during ECMO support. The aim of this study is to describe bleeding complications in critically ill patients undergoing ECMO and to identify risk factors for bleeding events. Methods: We retrospectively analysed ICU charts of adults who received either veno-venous (VV) or veno-arterial (VA) ECMO support in two participating ICUs between 2010 and 2013. Characteristics of patients with and without bleeding complications, as per the Extracorporeal Life Support Organisation (ELSO) definition, were compared, and the impact of bleeding complications on patient outcomes was assessed using survival analysis. Variables that were independently associated with bleeding, including daily clinical and biological variables during ECMO courses, were modelled. Results: Of the 149 ECMO episodes (111 VA ECMO and 38 VV ECMO) performed in 147 adults, 89 episodes (60 {\%}) were complicated by at least one bleeding event. The most common bleeding sources were: ECMO cannula (37 {\%}), haemothorax or cardiac tamponade (17 {\%}) and ear–nose and throat (16 {\%}). Intra-cranial haemorrhage occurred in five (2.2 {\%}) patients. Bleeding complications were independently associated with worse survival [adjusted hazard ratio (HR) 2.17, 95 {\%} confidence interval (CI) 1.07–4.41, P = 0.03]. Higher activated partial thromboplastin time (aPTT) [adjusted odds ratio (OR) 3.00, 95 {\%} CI 1.64–5.47, P < 0.01], APACHE III score [adjusted OR 1.01, 95 {\%} CI 1.01–1.02, P = 0.01] and ECMO following surgery [adjusted OR 3.04, 95 {\%} CI 1.62–5.69, P < 0.01] were independently associated with greater risk of bleeding occurrence. A similar association between bleeding and higher aPTT was found when non-post-surgical VA ECMO was considered separately. Conclusions: Bleeding events based on the ELSO bleeding definition occurred in more than 60 {\%} of ECMO episodes and were associated with hospital mortality. We identified higher aPTT prior bleeding as an independent risk factor for bleeding event, suggesting that better control of the aPTT (through a better control of either coagulopathy or anticoagulation) may improve patients’ outcome.",
keywords = "Anticoagulation, Bleeding, Coagulopathy, Critically ill patients, Extra corporeal membrane oxygenation, Haemorrhage, Thromboembolic events",
author = "Cecile Aubron and Joris DePuydt and Fran{\cc}ois Belon and Michael Bailey and Matthieu Schmidt and Jayne Sheldrake and Deirdre Murphy and Carlos Scheinkestel and Cooper, {D Jamie} and Gilles Capellier and Vincent Pellegrino and David Pilcher and Zoe McQuilten",
year = "2016",
month = "12",
day = "1",
doi = "10.1186/s13613-016-0196-7",
language = "English",
volume = "6",
journal = "Annals of Intensive Care",
issn = "2110-5820",
publisher = "Springer-Verlag London Ltd.",
number = "1",

}

Predictive factors of bleeding events in adults undergoing extracorporeal membrane oxygenation. / Aubron, Cecile; DePuydt, Joris; Belon, François; Bailey, Michael; Schmidt, Matthieu; Sheldrake, Jayne; Murphy, Deirdre; Scheinkestel, Carlos; Cooper, D Jamie; Capellier, Gilles; Pellegrino, Vincent; Pilcher, David; McQuilten, Zoe.

In: Annals of Intensive Care, Vol. 6, No. 1, 97, 01.12.2016.

Research output: Contribution to journalArticleResearchpeer-review

TY - JOUR

T1 - Predictive factors of bleeding events in adults undergoing extracorporeal membrane oxygenation

AU - Aubron, Cecile

AU - DePuydt, Joris

AU - Belon, François

AU - Bailey, Michael

AU - Schmidt, Matthieu

AU - Sheldrake, Jayne

AU - Murphy, Deirdre

AU - Scheinkestel, Carlos

AU - Cooper, D Jamie

AU - Capellier, Gilles

AU - Pellegrino, Vincent

AU - Pilcher, David

AU - McQuilten, Zoe

PY - 2016/12/1

Y1 - 2016/12/1

N2 - Background: Bleeding is the most frequent complication associated with extracorporeal membrane oxygenation (ECMO) support in critically ill patients. Nonetheless, risk factors for bleeding have been poorly described especially those associated with coagulation anomalies and anticoagulant therapy during ECMO support. The aim of this study is to describe bleeding complications in critically ill patients undergoing ECMO and to identify risk factors for bleeding events. Methods: We retrospectively analysed ICU charts of adults who received either veno-venous (VV) or veno-arterial (VA) ECMO support in two participating ICUs between 2010 and 2013. Characteristics of patients with and without bleeding complications, as per the Extracorporeal Life Support Organisation (ELSO) definition, were compared, and the impact of bleeding complications on patient outcomes was assessed using survival analysis. Variables that were independently associated with bleeding, including daily clinical and biological variables during ECMO courses, were modelled. Results: Of the 149 ECMO episodes (111 VA ECMO and 38 VV ECMO) performed in 147 adults, 89 episodes (60 %) were complicated by at least one bleeding event. The most common bleeding sources were: ECMO cannula (37 %), haemothorax or cardiac tamponade (17 %) and ear–nose and throat (16 %). Intra-cranial haemorrhage occurred in five (2.2 %) patients. Bleeding complications were independently associated with worse survival [adjusted hazard ratio (HR) 2.17, 95 % confidence interval (CI) 1.07–4.41, P = 0.03]. Higher activated partial thromboplastin time (aPTT) [adjusted odds ratio (OR) 3.00, 95 % CI 1.64–5.47, P < 0.01], APACHE III score [adjusted OR 1.01, 95 % CI 1.01–1.02, P = 0.01] and ECMO following surgery [adjusted OR 3.04, 95 % CI 1.62–5.69, P < 0.01] were independently associated with greater risk of bleeding occurrence. A similar association between bleeding and higher aPTT was found when non-post-surgical VA ECMO was considered separately. Conclusions: Bleeding events based on the ELSO bleeding definition occurred in more than 60 % of ECMO episodes and were associated with hospital mortality. We identified higher aPTT prior bleeding as an independent risk factor for bleeding event, suggesting that better control of the aPTT (through a better control of either coagulopathy or anticoagulation) may improve patients’ outcome.

AB - Background: Bleeding is the most frequent complication associated with extracorporeal membrane oxygenation (ECMO) support in critically ill patients. Nonetheless, risk factors for bleeding have been poorly described especially those associated with coagulation anomalies and anticoagulant therapy during ECMO support. The aim of this study is to describe bleeding complications in critically ill patients undergoing ECMO and to identify risk factors for bleeding events. Methods: We retrospectively analysed ICU charts of adults who received either veno-venous (VV) or veno-arterial (VA) ECMO support in two participating ICUs between 2010 and 2013. Characteristics of patients with and without bleeding complications, as per the Extracorporeal Life Support Organisation (ELSO) definition, were compared, and the impact of bleeding complications on patient outcomes was assessed using survival analysis. Variables that were independently associated with bleeding, including daily clinical and biological variables during ECMO courses, were modelled. Results: Of the 149 ECMO episodes (111 VA ECMO and 38 VV ECMO) performed in 147 adults, 89 episodes (60 %) were complicated by at least one bleeding event. The most common bleeding sources were: ECMO cannula (37 %), haemothorax or cardiac tamponade (17 %) and ear–nose and throat (16 %). Intra-cranial haemorrhage occurred in five (2.2 %) patients. Bleeding complications were independently associated with worse survival [adjusted hazard ratio (HR) 2.17, 95 % confidence interval (CI) 1.07–4.41, P = 0.03]. Higher activated partial thromboplastin time (aPTT) [adjusted odds ratio (OR) 3.00, 95 % CI 1.64–5.47, P < 0.01], APACHE III score [adjusted OR 1.01, 95 % CI 1.01–1.02, P = 0.01] and ECMO following surgery [adjusted OR 3.04, 95 % CI 1.62–5.69, P < 0.01] were independently associated with greater risk of bleeding occurrence. A similar association between bleeding and higher aPTT was found when non-post-surgical VA ECMO was considered separately. Conclusions: Bleeding events based on the ELSO bleeding definition occurred in more than 60 % of ECMO episodes and were associated with hospital mortality. We identified higher aPTT prior bleeding as an independent risk factor for bleeding event, suggesting that better control of the aPTT (through a better control of either coagulopathy or anticoagulation) may improve patients’ outcome.

KW - Anticoagulation

KW - Bleeding

KW - Coagulopathy

KW - Critically ill patients

KW - Extra corporeal membrane oxygenation

KW - Haemorrhage

KW - Thromboembolic events

UR - http://www.scopus.com/inward/record.url?scp=84990851935&partnerID=8YFLogxK

U2 - 10.1186/s13613-016-0196-7

DO - 10.1186/s13613-016-0196-7

M3 - Article

VL - 6

JO - Annals of Intensive Care

JF - Annals of Intensive Care

SN - 2110-5820

IS - 1

M1 - 97

ER -