Melania Bembea, director of the extracorporeal membrane oxygenation (ECMO) program at Johns Hopkins Children’s Center, discusses ECMO hematologic emergencies, which was the subject of her presentation during the Hot Topics in ECMO session at the Eighth World Congress of Pediatric Cardiology and Cardiac Surgery. ECMO is a life support technology that provides extracorporeal support for infants, children and adults who are critically ill and who have with severe cardiopulmonary failure or cardiac arrest that is refractory to conventional therapies. Although this technology is life saving, it is has a high risk of adverse events. During the presentation, Bembea highlighted multiple strategies that can reduce hematologic emergencies during ECMO support, along with ongoing studies using novel transfusion strategies and innovative circuit modifications.
Hi, my name is Melania Pena. I'm an associate professor in the Department of Anesthesiology and Critical Care Medicine and the Department of Pediatrics at the Johns Hopkins University School of Medicine and Medical Director of the Johns Hopkins Children's Center at program or Extra Corporal Membrane oxygenation program at the World Congress of Pediatric cardiology and cardiac surgery that took place in Washington DC. I spoke on hematologic emergencies in ACMA during the hot topics in ACMA session. ACMA provides extra corporal life support for critically ill chi uh Children and adults with severe cardio pulmonary failure or cardiac arrest refractory to conventional therapies. While lifesaving ECMO is also fraught with a high risk of adverse events. As the patient's blood is exposed to the foreign materials of the ECMO circuit. It has the tendency to clot clot formation in the circuit can then lead to obstruction of ECMO flow, requiring emergent replacement of the ECMO circuit or clot dislodgement leading to embolic complications in the patient to avoid circuit clot formation. Most patients are maintained on a continuous infusion of an anti coagulant, either unfractionated heparin or a direct thrombin inhibitor such as valid with the dual risk for clot formation in the circuit and bleeding within the patient in the face of anticoagulation. Magic emergencies during ACMA support remain problematic. In a recent multi center pediatric acma cohort, the cumulative incidence of thrombotic and bleeding events during the ACMA course was 38% and 70% respectively. The most feared such events are those that affect the brain in the form of embolic stroke or intrarenal hemorrhage. When acute neurologic events take place, the risk of mortality increases by 89%. Clinicians are therefore required to very carefully adjust therapies and maintain a fine balance of hemostasis. By judicious use of red blood cells, platelets, um plasma and cry precipitate transfusions, selection of anticoagulant drugs and then close monitoring of their effect on coagulation, adjustment of ECMO flows to minimize turbulent flow and decrease shear around circuit connectors and preservation of vital uh organ function. The use of institutional transfusion and anti coagulation protocols using best practice guidelines, close multidisciplinary collaboration among ECMO team members, intensivist um hematologists, surgeons, bedside nurses, ECMO specialists, pharmacists uh to name a few as well as recent advances in technology in oxygenator and circuit surface manufacturing can all contribute to a lower rate of hematologic emergencies and ultimately improved outcomes for patients. It was exciting to discuss several of such strategies that have been shown to reduce the incidence of hematologic emergencies during acma support as well as ongoing studies using novel transfusion strategies and innovative circuit modifications that hold promise in improving um hemostasis and biocompatibility respectively. Thank you very much.