Optimizing Congenital Diaphragmatic Hernia Repair on ECMO: Evaluating the Risk of Bleeding
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Nicholas Schmoke, Anna Rose, Christopher Nemeh, Yeu Sanz Wu, Pengchen Wang, Paul Kurlansky, Cindy Neunert, William Middlesworth, Vincent Duron
Background: Institutions lack consensus on the management of patients with congenital diaphragmatic hernia (CDH) who are repaired on extracorporeal membrane oxygenation (ECMO). Our study aimed to evaluate risk factors associated with bleeding complications in patients with CDH repaired on ECMO.
Methods: A single-institution retrospective review evaluated all patients with CDH who underwent on-ECMO repair between January 2005 and December 2023. A significant bleeding complication post-repair was defined as bleeding necessitating re-operation. The association between preoperative factors and bleeding complications was evaluated.
Results: Forty-six patients were included. Bleeding complications developed in 11/46 (24%) patients. Birthweight (2.5 vs. 3.2 kg, p = 0.02), platelet count <100/mm3 (64% vs. 29%, p = 0.04), elevated blood urea nitrogen (BUN; 24.5 vs. 17.5 mg/dL, p = 0.05), and older age at repair (8 vs. 5 days, p = 0.04) were associated with bleeding. In univariate analysis, patients with platelets under 100/mm3 were more likely to develop a bleeding complication (OR = 4.4, p = 0.04). Patients who experienced a significant bleeding event experienced increased ECMO days (12 vs. 7 days, p < 0.01), ventilator days (31 vs. 18 days, p < 0.05), and lower survival to discharge (36% vs. 74%, p = 0.03).
Conclusion: Among CDH patients undergoing repair on ECMO, those with lower birth weight, platelet counts under 100/mm3, elevated BUN, and older age at repair had an increased risk of a significant bleeding complication, resulting in more ECMO and ventilator days and higher mortality. Patients undergoing on-ECMO repair should have platelet count transfused to greater than 100/mm3. Patients at high risk for bleeding may benefit from early repair on ECMO.
Transcript
What risk factors are associated with bleeding complications and patients on the on-eckmon congenital diaphragmatic herniar repair? I'm Alex Halpern, research fellow from Children's National, and this is an article that you should know. Smoke at all performed a single institution in retrospective analysis of all patients who underwent on-eckmonocidial repair between 2005 and 2023 to try and answer this question. They identified 46 patients. Eleven patients had bleeding complications. Low birth weight, platelet count less than 100, elevated BUN, and older age-ever pair were associated with bleeding. Patients who experienced the bleeding complication had more days on eckmon, more days on the ventilator, and a lower survival at discharge. So it seems like patients undergoing on-eckmonocidial repair may benefit from an earlier repair instead of their platelets greater than 100 to help prevent bleeding complications. Does this information change your practice? Let us know what you think in the comments below.