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Bleeding and thrombotic events in adults supported with venovenous extracorporeal membrane oxygenation: an ELSO registry analysis

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A Correction to this article was published on 18 January 2022

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Abstract

Purpose

This study aimed at analyzing the prevalence, mortality association, and risk factors for bleeding and thrombosis events (BTEs) among adults supported with venovenous extracorporeal membrane oxygenation (VV-ECMO).

Methods

We queried the Extracorporeal Life Support Organization registry for adults supported with VV-ECMO from 2010 to 2017. Multivariable logistic regression modeling was used to assess the association between BTEs and in-hospital mortality and the predictors of BTEs.

Results

Among 7579 VV-ECMO patients meeting criteria, 40.2% experienced ≥ 1 BTE. Thrombotic events comprised 54.9% of all BTEs and were predominantly ECMO circuit thrombosis. BTE rates decreased significantly over the study period (p < 0.001). The inpatient mortality rate was 34.9%. Bleeding events (1.69 [1.49–1.93]) were more strongly associated with in-hospital mortality than thrombotic events (1.23 [1.08–1.41]) p < 0.01 for both. The BTEs most strongly associated with mortality were ischemic stroke (4.50 [2.55–7.97]) and medical bleeding, including intracranial (5.71 [4.02–8.09]), pulmonary (2.02 [1.54–2.67]), and gastrointestinal (1.54 [1.2–1.98]) hemorrhage, all p < 0.01. Risk factors for bleeding included acute kidney injury and pre-ECMO vasopressor support and for thrombosis were higher weight, multisite cannulation, pre-ECMO arrest, and higher PaCO2 at ECMO initiation. Longer time on ECMO, younger age, higher pH, and earlier year of support were associated with bleeding and thrombosis.

Conclusions

Although decreasing over time, BTEs remain common during VV-ECMO and have a strong, cumulative association with in-hospital mortality. Thrombotic events are more frequent, but bleeding carries a higher risk of inpatient mortality. Differential risk factors for bleeding and thrombotic complications exist, raising the possibility of a tailored approach to VV-ECMO management.

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Availability of data and material

The datasets analyzed for this study are available from the Extracorporeal Life Support Organization via data acquisition request.

Change history

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Authors and Affiliations

  1. Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA

    Jose I. Nunez

  2. Department of Anesthesiology, Duke University Hospital, Durham, NC, USA

    Andre F. Gosling

  3. Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA

    Brian O’Gara & Shahzad Shaefi

  4. Smith Center for Cardiology Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA, USA

    Kevin F. Kennedy & E. Wilson Grandin

  5. Extracorporeal Life Support Organization, Ann Arbor, MI, USA

    Peter Rycus

  6. Division of Pulmonary and Critical Care Medicine, Columbia Presbyterian Medical Center, New York, NY, USA

    Darryl Abrams & Daniel Brodie

  7. Division of Cardiovascular Medicine, Section of Advanced Heart Failure, Department of Medicine, Beth Israel Deaconess Medical Center, 185 Pilgrim Road, DE-319, Boston, MA, 02215, USA

    A. Reshad Garan & E. Wilson Grandin

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Contributions

All authors contributed to the study conception and design. Material preparation and data analysis were performed by JIN, KK, AG, ARG, BO, and EWG. The first draft of the manuscript was written by JIN, AG, BO and EWG. Review and editing were performed by JIN, AG, KK, DA, DB, PR, BO, SS, ARG and EWG. All authors provided appropriate feedback and commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to E. Wilson Grandin.

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Conflicts of interest

JIN: no relationships with industry. AFG: no relationships with industry. BOG: consulting for Sedana Medical. KFK: no relationships with industry. DA: at-large member of the Steering Committee for the Extracorporeal Life Support Organization (ELSO). DB: receives research support from ALung Technologies. He has been on the medical advisory boards for Abiomed, Xenios, Medtronic, and Cellenkos. He is the President-elect of ELSO. PR: no relationships with industry. SS: No relationships with industry. ARG: receives research support from Abbott. EWG: ELSO Research Grant.

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Studies utilizing the ELSO database are exempt from Institutional Review Board approval due to the retrospective analysis of de-identified data.

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Nunez, J.I., Gosling, A.F., O’Gara, B. et al. Bleeding and thrombotic events in adults supported with venovenous extracorporeal membrane oxygenation: an ELSO registry analysis. Intensive Care Med 48, 213–224 (2022). https://doi.org/10.1007/s00134-021-06593-x

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