Predictive factors of bleeding events in adults undergoing extracorporeal membrane oxygenation
Identifieur interne : 000A20 ( Pmc/Curation ); précédent : 000A19; suivant : 000A21Predictive factors of bleeding events in adults undergoing extracorporeal membrane oxygenation
Auteurs : Cécile Aubron [Australie, France] ; Joris Depuydt [Australie, Belgique] ; François Belon [France] ; Michael Bailey [Australie] ; Matthieu Schmidt [Australie, France] ; Jayne Sheldrake [Australie] ; Deirdre Murphy [Australie] ; Carlos Scheinkestel [Australie] ; D Jamie Cooper [Australie] ; Gilles Capellier [France] ; Vincent Pellegrino [Australie] ; David Pilcher [Australie] ; Zoe Mcquilten [Australie]Source :
- Annals of Intensive Care [ 2110-5820 ] ; 2016.
Abstract
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.
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.
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,
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.
Url:
DOI: 10.1186/s13613-016-0196-7
PubMed: 27714705
PubMed Central: 5053950
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<author><name sortKey="Bailey, Michael" sort="Bailey, Michael" uniqKey="Bailey M" first="Michael" last="Bailey">Michael Bailey</name>
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<author><name sortKey="Schmidt, Matthieu" sort="Schmidt, Matthieu" uniqKey="Schmidt M" first="Matthieu" last="Schmidt">Matthieu Schmidt</name>
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<country xml:lang="fr">France</country>
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<author><name sortKey="Sheldrake, Jayne" sort="Sheldrake, Jayne" uniqKey="Sheldrake J" first="Jayne" last="Sheldrake">Jayne Sheldrake</name>
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<author><name sortKey="Murphy, Deirdre" sort="Murphy, Deirdre" uniqKey="Murphy D" first="Deirdre" last="Murphy">Deirdre Murphy</name>
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<country xml:lang="fr">Australie</country>
<wicri:regionArea>School of Public Health and Preventive Medicine, Monash University, Melbourne</wicri:regionArea>
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<author><name sortKey="Scheinkestel, Carlos" sort="Scheinkestel, Carlos" uniqKey="Scheinkestel C" first="Carlos" last="Scheinkestel">Carlos Scheinkestel</name>
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<country xml:lang="fr">Australie</country>
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<country xml:lang="fr">Australie</country>
<wicri:regionArea>School of Public Health and Preventive Medicine, Monash University, Melbourne</wicri:regionArea>
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<author><name sortKey="Cooper, D Jamie" sort="Cooper, D Jamie" uniqKey="Cooper D" first="D Jamie" last="Cooper">D Jamie Cooper</name>
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<country xml:lang="fr">Australie</country>
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</affiliation>
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<country xml:lang="fr">Australie</country>
<wicri:regionArea>The Intensive Care Unit, The Alfred Hospital, Melbourne</wicri:regionArea>
</affiliation>
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<author><name sortKey="Capellier, Gilles" sort="Capellier, Gilles" uniqKey="Capellier G" first="Gilles" last="Capellier">Gilles Capellier</name>
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<country xml:lang="fr">France</country>
<wicri:regionArea>The Intensive Care Unit, Jean Minjoz Hospital, 25030 Besançon</wicri:regionArea>
</affiliation>
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<author><name sortKey="Pellegrino, Vincent" sort="Pellegrino, Vincent" uniqKey="Pellegrino V" first="Vincent" last="Pellegrino">Vincent Pellegrino</name>
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<country xml:lang="fr">Australie</country>
<wicri:regionArea>The Intensive Care Unit, The Alfred Hospital, Melbourne</wicri:regionArea>
</affiliation>
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<country xml:lang="fr">Australie</country>
<wicri:regionArea>School of Public Health and Preventive Medicine, Monash University, Melbourne</wicri:regionArea>
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<author><name sortKey="Pilcher, David" sort="Pilcher, David" uniqKey="Pilcher D" first="David" last="Pilcher">David Pilcher</name>
<affiliation wicri:level="1"><nlm:aff id="Aff1">The Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia</nlm:aff>
<country xml:lang="fr">Australie</country>
<wicri:regionArea>The Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne</wicri:regionArea>
</affiliation>
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<country xml:lang="fr">Australie</country>
<wicri:regionArea>The Intensive Care Unit, The Alfred Hospital, Melbourne</wicri:regionArea>
</affiliation>
</author>
<author><name sortKey="Mcquilten, Zoe" sort="Mcquilten, Zoe" uniqKey="Mcquilten Z" first="Zoe" last="Mcquilten">Zoe Mcquilten</name>
<affiliation wicri:level="1"><nlm:aff id="Aff1">The Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia</nlm:aff>
<country xml:lang="fr">Australie</country>
<wicri:regionArea>The Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne</wicri:regionArea>
</affiliation>
<affiliation wicri:level="1"><nlm:aff id="Aff2">The Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia</nlm:aff>
<country xml:lang="fr">Australie</country>
<wicri:regionArea>The Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne</wicri:regionArea>
</affiliation>
</author>
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<series><title level="j">Annals of Intensive Care</title>
<idno type="eISSN">2110-5820</idno>
<imprint><date when="2016">2016</date>
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<front><div type="abstract" xml:lang="en"><sec><title>Background</title>
<p>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.</p>
</sec>
<sec><title>Methods</title>
<p>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.</p>
</sec>
<sec><title>Results</title>
<p>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, <italic>P</italic>
= 0.03]. Higher activated partial thromboplastin time (aPTT) [adjusted odds ratio (OR) 3.00, 95 % CI 1.64–5.47, <italic>P</italic>
< 0.01], APACHE III score [adjusted OR 1.01, 95 % CI 1.01–1.02, <italic>P</italic>
= 0.01] and ECMO following surgery [adjusted OR 3.04, 95 % CI 1.62–5.69, <italic>P</italic>
< 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.</p>
</sec>
<sec><title>Conclusions</title>
<p>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.</p>
</sec>
</div>
</front>
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</TEI>
<pmc article-type="research-article"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">Ann Intensive Care</journal-id>
<journal-id journal-id-type="iso-abbrev">Ann Intensive Care</journal-id>
<journal-title-group><journal-title>Annals of Intensive Care</journal-title>
</journal-title-group>
<issn pub-type="epub">2110-5820</issn>
<publisher><publisher-name>Springer Paris</publisher-name>
<publisher-loc>Paris</publisher-loc>
</publisher>
</journal-meta>
<article-meta><article-id pub-id-type="pmid">27714705</article-id>
<article-id pub-id-type="pmc">5053950</article-id>
<article-id pub-id-type="publisher-id">196</article-id>
<article-id pub-id-type="doi">10.1186/s13613-016-0196-7</article-id>
<article-categories><subj-group subj-group-type="heading"><subject>Research</subject>
</subj-group>
</article-categories>
<title-group><article-title>Predictive factors of bleeding events in adults undergoing extracorporeal membrane oxygenation</article-title>
</title-group>
<contrib-group><contrib contrib-type="author" corresp="yes"><name><surname>Aubron</surname>
<given-names>Cécile</given-names>
</name>
<address><phone>+61 2 98 34 71 81</phone>
<email>Cecile.aubron@chu-brest.fr</email>
<email>cecile.aubron@monash.edu</email>
</address>
<xref ref-type="aff" rid="Aff1">1</xref>
<xref ref-type="aff" rid="Aff2">2</xref>
<xref ref-type="aff" rid="Aff7">7</xref>
<xref ref-type="aff" rid="Aff8">8</xref>
</contrib>
<contrib contrib-type="author"><name><surname>DePuydt</surname>
<given-names>Joris</given-names>
</name>
<address><email>jorisdepuydt@telenet.be</email>
</address>
<xref ref-type="aff" rid="Aff3">3</xref>
<xref ref-type="aff" rid="Aff4">4</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Belon</surname>
<given-names>François</given-names>
</name>
<address><email>fbelon@chu-besancon.fr</email>
</address>
<xref ref-type="aff" rid="Aff5">5</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Bailey</surname>
<given-names>Michael</given-names>
</name>
<address><email>michael.bailey@monash.edu</email>
</address>
<xref ref-type="aff" rid="Aff1">1</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Schmidt</surname>
<given-names>Matthieu</given-names>
</name>
<address><email>matthieuschmidt@yahoo.fr</email>
</address>
<xref ref-type="aff" rid="Aff1">1</xref>
<xref ref-type="aff" rid="Aff9">9</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Sheldrake</surname>
<given-names>Jayne</given-names>
</name>
<address><email>Ja.Sheldrake@alfred.org.au</email>
</address>
<xref ref-type="aff" rid="Aff3">3</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Murphy</surname>
<given-names>Deirdre</given-names>
</name>
<address><email>deirdre8murphy@gmail.com</email>
</address>
<xref ref-type="aff" rid="Aff3">3</xref>
<xref ref-type="aff" rid="Aff6">6</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Scheinkestel</surname>
<given-names>Carlos</given-names>
</name>
<address><email>cd@scheinkestel.com.au</email>
</address>
<xref ref-type="aff" rid="Aff3">3</xref>
<xref ref-type="aff" rid="Aff6">6</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Cooper</surname>
<given-names>D Jamie</given-names>
</name>
<address><email>jamie.cooper@monash.edu</email>
</address>
<xref ref-type="aff" rid="Aff1">1</xref>
<xref ref-type="aff" rid="Aff3">3</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Capellier</surname>
<given-names>Gilles</given-names>
</name>
<address><email>gilles.capellier@univ-fcomte.fr</email>
</address>
<xref ref-type="aff" rid="Aff5">5</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Pellegrino</surname>
<given-names>Vincent</given-names>
</name>
<address><email>V.Pellegrino@alfred.org.au</email>
</address>
<xref ref-type="aff" rid="Aff3">3</xref>
<xref ref-type="aff" rid="Aff6">6</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Pilcher</surname>
<given-names>David</given-names>
</name>
<address><email>D.Pilcher@alfred.org.au</email>
</address>
<xref ref-type="aff" rid="Aff1">1</xref>
<xref ref-type="aff" rid="Aff3">3</xref>
</contrib>
<contrib contrib-type="author"><name><surname>McQuilten</surname>
<given-names>Zoe</given-names>
</name>
<address><email>zoe.mcquilten@monash.edu</email>
</address>
<xref ref-type="aff" rid="Aff1">1</xref>
<xref ref-type="aff" rid="Aff2">2</xref>
</contrib>
<aff id="Aff1"><label>1</label>
The Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia</aff>
<aff id="Aff2"><label>2</label>
The Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia</aff>
<aff id="Aff3"><label>3</label>
The Intensive Care Unit, The Alfred Hospital, Melbourne, Australia</aff>
<aff id="Aff4"><label>4</label>
University Hospital of Antwerp, 2000 Antwerp, Belgium</aff>
<aff id="Aff5"><label>5</label>
The Intensive Care Unit, Jean Minjoz Hospital, 25030 Besançon, France</aff>
<aff id="Aff6"><label>6</label>
School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia</aff>
<aff id="Aff7"><label>7</label>
Medical Intensive Care Unit, Centre Hospitalier Régional et Universitaire de Brest, site La Cavale Blanche, Bvd Tanguy Prigent, 29609 Brest Cedex, France</aff>
<aff id="Aff8"><label>8</label>
LUBEM, EA 3882 - Université de Bretagne Occidentale, 29 200 Brest, France</aff>
<aff id="Aff9"><label>9</label>
Medical Intensive Care Unit, iCAN, Institute of Cardiometabolism and Nutrition, Hôpital de la Pitié–Salpetrière, Assistance Publique–Hôpitaux de Paris, Paris, France</aff>
</contrib-group>
<pub-date pub-type="epub"><day>6</day>
<month>10</month>
<year>2016</year>
</pub-date>
<pub-date pub-type="pmc-release"><day>6</day>
<month>10</month>
<year>2016</year>
</pub-date>
<pub-date pub-type="collection"><year>2016</year>
</pub-date>
<volume>6</volume>
<elocation-id>97</elocation-id>
<history><date date-type="received"><day>21</day>
<month>7</month>
<year>2016</year>
</date>
<date date-type="accepted"><day>18</day>
<month>9</month>
<year>2016</year>
</date>
</history>
<permissions><copyright-statement>© The Author(s) 2016</copyright-statement>
<license license-type="OpenAccess"><license-p><bold>Open Access</bold>
This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by/4.0/">http://creativecommons.org/licenses/by/4.0/</ext-link>
), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.</license-p>
</license>
</permissions>
<abstract id="Abs1"><sec><title>Background</title>
<p>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.</p>
</sec>
<sec><title>Methods</title>
<p>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.</p>
</sec>
<sec><title>Results</title>
<p>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, <italic>P</italic>
= 0.03]. Higher activated partial thromboplastin time (aPTT) [adjusted odds ratio (OR) 3.00, 95 % CI 1.64–5.47, <italic>P</italic>
< 0.01], APACHE III score [adjusted OR 1.01, 95 % CI 1.01–1.02, <italic>P</italic>
= 0.01] and ECMO following surgery [adjusted OR 3.04, 95 % CI 1.62–5.69, <italic>P</italic>
< 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.</p>
</sec>
<sec><title>Conclusions</title>
<p>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.</p>
</sec>
</abstract>
<kwd-group xml:lang="en"><title>Keywords</title>
<kwd>Extra corporeal membrane oxygenation</kwd>
<kwd>Critically ill patients</kwd>
<kwd>Haemorrhage</kwd>
<kwd>Bleeding</kwd>
<kwd>Anticoagulation</kwd>
<kwd>Coagulopathy</kwd>
<kwd>Thromboembolic events</kwd>
</kwd-group>
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