Thromboelastography-guided management of coagulopathy in neonates with congenital diaphragmatic hernia supported by extracorporeal membrane oxygenation

Abstract

Purpose

Congenital diaphragmatic hernia (CDH) can cause severe hemodynamic deterioration requiring support with extracorporeal membrane oxygenation (ECMO). ECMO is associated with hemorrhagic and thromboembolic complications. In 2015, we standardized anti-coagulation management on ECMO, incorporating thromboelastography (TEG) as an adjunct to manage hemostasis of CDH patients. The purpose of this study is to evaluate our blood product utilization, choice of blood product use in response to abnormal TEG parameters, and the associated effect on bleeding and thrombotic complications.

Methods

We retrospectively reviewed all CDH neonates supported by ECMO between 2008 and 2018. Blood product administration, TEG data, and hemorrhagic and thrombotic complications data were collected. We divided subjects into two groups pre-2015 and post-2015.

Results

After 2015, platelet transfusion was administered for a low maximum amplitude (MA) more frequently (77% compared to 65%, p = 0.0007). Cryoprecipitate was administered less frequently for a low alpha-angle (28% compared to 41%, p = 0.0016). There was no difference in fresh frozen plasma use over time. After standardizing the use of TEG, we observed a significant reduction in hemothoraces (18% compared to 54%, p = 0.026).

Conclusion

Institutional standardization of anti-coagulation management of CDH neonates on ECMO, including the use of goal-directed TEG monitoring may lead to improved blood product utilization and a decrease in bleeding complications in neonates with CDH supported by ECMO.

Level of evidence/type of study

Level III, Retrospective comparative study

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Correspondence to Ryan C. Phillips.

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None of the authors hasa conflict of interest to disclose.

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All of the procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

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The study was evaluated and approved by the Colorado Multiple Institution Review Board (COMIRB), and a waiver of informed consent as obtained due to the retrospective nature of the study.

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John S. Kim and Ahmed I. Marwan are Co-senior authors.

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Phillips, R.C., Shahi, N., Leopold, D. et al. Thromboelastography-guided management of coagulopathy in neonates with congenital diaphragmatic hernia supported by extracorporeal membrane oxygenation. Pediatr Surg Int (2020). https://doi.org/10.1007/s00383-020-04694-0

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Keywords

  • Congenital diaphragmatic hernia
  • Extracorporeal membrane oxygenation
  • Neonatal
  • Coagulation
  • Hemorrhage