Skip to main content

Advertisement

SpringerLink
Log in

Thrombocytopenia and extracorporeal membrane oxygenation in adults with acute respiratory failure: a cohort study

  • Original
  • Published:
Intensive Care Medicine Aims and scope Submit manuscript

Abstract

Purpose

The association between extracorporeal membrane oxygenation (ECMO) use and the development of thrombocytopenia is widely presumed yet weakly demonstrated. We hypothesized that longer duration of ECMO support would be independently associated with worsened thrombocytopenia.

Methods

We performed a single-center retrospective cohort study of 100 adults who received ECMO for acute respiratory failure. We used generalized estimating equations to test the association between days on ECMO and daily percentage of platelets compared to the first post-cannulation platelet count. We constructed a multivariable logistic regression model with backwards stepwise elimination to identify clinical predictors of severe thrombocytopenia (≤50,000/μL) while on ECMO.

Results

Days on ECMO was not associated with a decrease in platelet count in the unadjusted analysis (β −0.85, 95 % CI −2.05 to 0.36), nor after considering and controlling for days hospitalized prior to ECMO, APACHE II score, platelet transfusions, and potential thrombocytopenia-inducing medications (β −0.83, 95 % CI −1.9 to 0.25). Twenty-two subjects (22 %) developed severe thrombocytopenia. The APACHE II score and platelet count at the time of cannulation predicted the development of severe thrombocytopenia. The odds of developing severe thrombocytopenia increased 35 % for every 5-point increase in APACHE II score (OR 1.35, 95 % CI 0.94–1.94) and increased 35 % for every 25,000/μL platelets below a mean at cannulation of 188,000/μL (OR 1.35, 95 % CI 1.10–1.64).

Conclusions

Duration of ECMO is not associated with the development of thrombocytopenia. The severity of critical illness and platelet count at the time of cannulation predict the development of severe thrombocytopenia while receiving ECMO for respiratory failure. Future studies should validate these findings, especially in cohorts with more venoarterial ECMO patients, and should characterize the association between thrombocytopenia and bleeding events while on ECMO.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Brodie D, Bacchetta M (2011) Extracorporeal membrane oxygenation for ARDS in adults. N Engl J Med 365:1905–1914

    Article  CAS  PubMed  Google Scholar 

  2. Abrams D, Brodie D (2013) Emerging indications for extracorporeal membrane oxygenation in adults with respiratory failure. Ann Am Thorac Soc 10:371–377

    Article  PubMed  Google Scholar 

  3. Brogan TV, Thiagarajan RR, Rycus PT, Bartlett RH, Bratton SL (2009) Extracorporeal membrane oxygenation in adults with severe respiratory failure: a multi-center database. Intensive Care Med 35:2105–2114

    Article  CAS  PubMed  Google Scholar 

  4. Roch A, Lepaul-Ercole R, Grisoli D, Bessereau J, Brissy O, Castanier M, Dizier S, Forel JM, Guervilly C, Gariboldi V, Collart F, Michelet P, Perrin G, Charrel R, Papazian L (2010) Extracorporeal membrane oxygenation for severe influenza A (H1N1) acute respiratory distress syndrome: a prospective observational comparative study. Intensive Care Med 36:1899–1905

    Article  PubMed  Google Scholar 

  5. Schmidt M, Tachon G, Devilliers C, Muller G, Hekimian G, Brechot N, Merceron S, Luyt CE, Trouillet JL, Chastre J, Leprince P, Combes A (2013) Blood oxygenation and decarboxylation determinants during venovenous ECMO for respiratory failure in adults. Intensive Care Med 39:838–846

    Article  CAS  PubMed  Google Scholar 

  6. Abrams D, Brodie D, Combes A (2013) What is new in extracorporeal membrane oxygenation for ARDS in adults? Intensive Care Med 39:2028–2030

    Article  PubMed  Google Scholar 

  7. Azoulay E, Citerio G, Bakker J, Bassetti M, Benoit D, Cecconi M, Curtis JR, Hernandez G, Herridge M, Jaber S, Joannidis M, Papazian L, Peters M, Singer P, Smith M, Soares M, Torres A, Vieillard-Baron A, Timsit JF (2014) Year in review in Intensive Care Medicine 2013: II. Sedation, invasive and noninvasive ventilation, airways, ARDS, ECMO, family satisfaction, end-of-life care, organ donation, informed consent, safety, hematological issues in critically ill patients. Intensive Care Med 40:305–319

    Article  PubMed  Google Scholar 

  8. Abrams D, Combes A, Brodie D (2014) Extracorporeal membrane oxygenation in cardiopulmonary disease in adults. J Am Coll Cardiol 63:2769–2778

    Article  PubMed  Google Scholar 

  9. Agerstrand CL, Burkart KM, Abrams DC, Bacchetta MD, Brodie D (2015) Blood conservation in extracorporeal membrane oxygenation for acute respiratory distress syndrome. Ann Thorac Surg 99:590–595

    Article  PubMed  Google Scholar 

  10. Paden ML, Rycus PT, Thiagarajan RR, Registry E (2014) Update and outcomes in extracorporeal life support. Semin Perinatol 38:65–70

    Article  PubMed  Google Scholar 

  11. Davies A, Jones D, Bailey M, Beca J, Bellomo R, Blackwell N, Forrest P, Gattas D, Granger E, Herkes R, Jackson A, McGuinness S, Nair P, Pellegrino V, Pettila V, Plunkett B, Pye R, Torzillo P, Webb S, Wilson M, Ziegenfuss M (2009) Extracorporeal membrane oxygenation for 2009 influenza A(H1N1) acute respiratory distress syndrome. JAMA 302:1888–1895

    Article  CAS  PubMed  Google Scholar 

  12. Pham T, Combes A, Roze H, Chevret S, Mercat A, Roch A, Mourvillier B, Ara-Somohano C, Bastien O, Zogheib E, Clavel M, Constan A, Marie Richard JC, Brun-Buisson C, Brochard L (2013) Extracorporeal membrane oxygenation for pandemic influenza A(H1N1)-induced acute respiratory distress syndrome: a cohort study and propensity-matched analysis. Am J Respir Crit Care Med 187:276–285

    Article  CAS  PubMed  Google Scholar 

  13. Weingart C, Lubnow M, Philipp A, Bein T, Camboni D, Muller T (2015) Comparison of coagulation parameters, anticoagulation, and need for transfusion in patients on interventional lung assist or veno-venous extracorporeal membrane oxygenation. Artif Organs 39:765–773

  14. Nair P, Davies AR, Beca J, Bellomo R, Ellwood D, Forrest P, Jackson A, Pye R, Seppelt I, Sullivan E, Webb S (2011) Extracorporeal membrane oxygenation for severe ARDS in pregnant and postpartum women during the 2009 H1N1 pandemic. Intensive Care Med 37:648–654

    Article  PubMed  Google Scholar 

  15. Zapol WM, Snider MT, Hill JD, Fallat RJ, Bartlett RH, Edmunds LH, Morris AH, Peirce EC 2nd, Thomas AN, Proctor HJ, Drinker PA, Pratt PC, Bagniewski A, Miller RG Jr (1979) Extracorporeal membrane oxygenation in severe acute respiratory failure. A randomized prospective study. JAMA 242:2193–2196

    Article  CAS  PubMed  Google Scholar 

  16. Morris AH, Wallace CJ, Menlove RL, Clemmer TP, Orme JF Jr, Weaver LK, Dean NC, Thomas F, East TD, Pace NL, Suchyta MR, Beck E, Bombino M, Sittig DF, Bohm S, Hoffmann B, Becks H, Butler S, Pearl J, Rasmusson B (1994) Randomized clinical trial of pressure-controlled inverse ratio ventilation and extracorporeal CO2 removal for adult respiratory distress syndrome. Am J Respir Crit Care Med 149:295–305

    Article  CAS  PubMed  Google Scholar 

  17. Combes A, Bacchetta M, Brodie D, Muller T, Pellegrino V (2012) Extracorporeal membrane oxygenation for respiratory failure in adults. Curr Opin Crit Care 18:99–104

    Article  PubMed  Google Scholar 

  18. Yeo HJ, Kim do H, Jeon D, Kim YS, Cho WH (2015) Low-dose heparin during extracorporeal membrane oxygenation treatment in adults. Intensive Care Med 41:2020–2021

    Article  PubMed  Google Scholar 

  19. Haneya A, Philipp A, Diez C, Ried M, Puehler T, Camboni D, Zausig Y, Lehle K, Schmid C (2009) Comparison of two different minimized extracorporeal circulation systems: hematological effects after coronary surgery. ASAIO J 55:592–597

    Article  PubMed  Google Scholar 

  20. Oliver WC (2009) Anticoagulation and coagulation management for ECMO. Semin Cardiothorac Vasc Anesth 13:154–175

    Article  PubMed  Google Scholar 

  21. Peek GJ, Firmin RK (1999) The inflammatory and coagulative response to prolonged extracorporeal membrane oxygenation. ASAIO J 45:250–263

    Article  CAS  PubMed  Google Scholar 

  22. Panigada M, Artoni A, Passamonti SM, Maino A, Mietto C, L’Acqua C, Cressoni M, Boscolo M, Tripodi A, Bucciarelli P, Gattinoni L, Martinelli I (2016) Hemostasis changes during veno-venous extracorporeal membrane oxygenation for respiratory support in adults. Minerva Anestesiol 82:170–179

  23. Glick D, Dzierba AL, Abrams D, Muir J, Eisenberger A, Diuguid D, Abel E, Agerstrand C, Bacchetta M, Brodie D (2015) Clinically suspected heparin-induced thrombocytopenia during extracorporeal membrane oxygenation. J Crit Care 30:1190–1194

    Article  PubMed  Google Scholar 

  24. Cuker A, Gimotty PA, Crowther MA, Warkentin TE (2012) Predictive value of the 4Ts scoring system for heparin-induced thrombocytopenia: a systematic review and meta-analysis. Blood 120:4160–4167

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  25. Laverdure F, Louvain-Quintard V, Kortchinsky T, Rezaiguia-Delclaux S, Imbert A, Stephan F (2016) PF4-heparin antibodies during ECMO: incidence, course, and outcomes. Intensive Care Med. doi:10.1007/s00134-016-4262-2

  26. Charlson ME, Pompei P, Ales KL, MacKenzie CR (1987) A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 40:373–383

    Article  CAS  PubMed  Google Scholar 

  27. Vincent JL, de Mendonca A, Cantraine F, Moreno R, Takala J, Suter PM, Sprung CL, Colardyn F, Blecher S (1998) Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: results of a multicenter, prospective study. Working group on “sepsis-related problems” of the European Society of Intensive Care Medicine. Crit Care Med 26:1793–1800

    Article  CAS  PubMed  Google Scholar 

  28. Schmidt M, Zogheib E, Roze H, Repesse X, Lebreton G, Luyt CE, Trouillet JL, Brechot N, Nieszkowska A, Dupont H, Ouattara A, Leprince P, Chastre J, Combes A (2013) The PRESERVE mortality risk score and analysis of long-term outcomes after extracorporeal membrane oxygenation for severe acute respiratory distress syndrome. Intensive Care Med 39:1704–1713

    Article  CAS  PubMed  Google Scholar 

  29. Meyer AD, Wiles AA, Rivera O, Wong EC, Freishtat RJ, Rais-Bahrami K, Dalton HJ (2012) Hemolytic and thrombocytopathic characteristics of extracorporeal membrane oxygenation systems at simulated flow rate for neonates. Pediatr Crit Care Med 13:e255–e261

    Article  PubMed  PubMed Central  Google Scholar 

  30. Steyerberg EW, Harrell FE Jr, Borsboom GJ, Eijkemans MJ, Vergouwe Y, Habbema JD (2001) Internal validation of predictive models: efficiency of some procedures for logistic regression analysis. J Clin Epidemiol 54:774–781

    Article  CAS  PubMed  Google Scholar 

  31. Weerasinghe A, Taylor KM (1998) The platelet in cardiopulmonary bypass. Ann Thorac Surg 66:2145–2152

    Article  CAS  PubMed  Google Scholar 

  32. Bonfiglio MF, Traeger SM, Kier KL, Martin BR, Hulisz DT, Verbeck SR (1995) Thrombocytopenia in intensive care patients: a comprehensive analysis of risk factors in 314 patients. Ann Pharmacother 29:835–842

    CAS  PubMed  Google Scholar 

  33. Crowther MA, Cook DJ, Meade MO, Griffith LE, Guyatt GH, Arnold DM, Rabbat CG, Geerts WH, Warkentin TE (2005) Thrombocytopenia in medical-surgical critically ill patients: prevalence, incidence, and risk factors. J Crit Care 20:348–353

    Article  PubMed  Google Scholar 

  34. Lee KH, Hui KP, Tan WC (1993) Thrombocytopenia in sepsis: a predictor of mortality in the intensive care unit. Singap Med J 34:245–246

    CAS  Google Scholar 

  35. Strauss R, Wehler M, Mehler K, Kreutzer D, Koebnick C, Hahn EG (2002) Thrombocytopenia in patients in the medical intensive care unit: bleeding prevalence, transfusion requirements, and outcome. Crit Care Med 30:1765–1771

    Article  PubMed  Google Scholar 

  36. Hui P, Cook DJ, Lim W, Fraser GA, Arnold DM (2011) The frequency and clinical significance of thrombocytopenia complicating critical illness: a systematic review. Chest 139:271–278

    Article  PubMed  Google Scholar 

  37. Schmidt M, Brechot N, Combes A (2015) Ten situations in which ECMO is unlikely to be successful. Intensive Care Med. doi:10.1007/s00134-015-4013-9

  38. Lubnow M, Philipp A, Dornia C, Schroll S, Bein T, Creutzenberg M, Diez C, Schmid C, Pfeifer M, Riegger G, Muller T, Lehle K (2014) D-dimers as an early marker for oxygenator exchange in extracorporeal membrane oxygenation. J Crit Care 29(473):e471–e475

    Google Scholar 

  39. Cheung PY, Sawicki G, Salas E, Etches PC, Schulz R, Radomski MW (2000) The mechanisms of platelet dysfunction during extracorporeal membrane oxygenation in critically ill neonates. Crit Care Med 28:2584–2590

    Article  CAS  PubMed  Google Scholar 

  40. Muller G, Flecher E, Lebreton G, Luyt CE, Trouillet JL, Brechot N, Schmidt M, Mastroianni C, Chastre J, Leprince P, Anselmi A, Combes A (2016) The ENCOURAGE mortality risk score and analysis of long-term outcomes after VA-ECMO for acute myocardial infarction with cardiogenic shock. Intensive Care Med 42:370–378

    Article  PubMed  Google Scholar 

Download references

Author information

Author notes

    Authors and Affiliations

    1. Division of Pulmonary and Critical Care, College of Physicians and Surgeons, Columbia University, New York, NY, USA

      Darryl Abrams, Matthew R. Baldwin, Cara Agerstrand & Daniel Brodie

    2. Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY, USA

      Matthew Champion

    3. Division of Hematology and Oncology, College of Physicians and Surgeons, Columbia University, New York, NY, USA

      Andrew Eisenberger

    4. Division of Thoracic Surgery, College of Physicians and Surgeons, Columbia University, New York, NY, USA

      Matthew Bacchetta

    Authors
    1. Darryl Abrams
      View author publications

      You can also search for this author in PubMed Google Scholar

    2. Matthew R. Baldwin
      View author publications

      You can also search for this author in PubMed Google Scholar

    3. Matthew Champion
      View author publications

      You can also search for this author in PubMed Google Scholar

    4. Cara Agerstrand
      View author publications

      You can also search for this author in PubMed Google Scholar

    5. Andrew Eisenberger
      View author publications

      You can also search for this author in PubMed Google Scholar

    6. Matthew Bacchetta
      View author publications

      You can also search for this author in PubMed Google Scholar

    7. Daniel Brodie
      View author publications

      You can also search for this author in PubMed Google Scholar

    Corresponding author

    Correspondence to Daniel Brodie.

    Ethics declarations

    Conflicts of interest

    Dr. Brodie is currently on the medical advisory boards of ALung Technologies and Kadence. All compensation for these activities is paid to Columbia University. All other authors have no conflicts of interest to report.

    Additional information

    M. Bacchetta and D. Brodie are co-senior authors.

    D. Abrams and M. R. Baldwin contributed equally to this work.

    Take-home message: This study demonstrates that in a large single-center cohort, duration of ECMO support was not associated with a decrease in platelet count, which is contrary to the generally held belief that thrombocytopenia is an inevitable consequence of ECMO use. Instead, the development of thrombocytopenia was associated with severity of illness and lower baseline platelet count, suggesting that the current paradigm, attributing thrombocytopenia to the use of ECMO over time, needs to be revisited.

    Electronic supplementary material

    Below is the link to the electronic supplementary material.

    Supplementary material 1 (DOCX 212 kb)

    Rights and permissions

    Reprints and permissions

    About this article

    Check for updates. Verify currency and authenticity via CrossMark

    Cite this article

    Abrams, D., Baldwin, M.R., Champion, M. et al. Thrombocytopenia and extracorporeal membrane oxygenation in adults with acute respiratory failure: a cohort study. Intensive Care Med 42, 844–852 (2016). https://doi.org/10.1007/s00134-016-4312-9

    Download citation

    • Received:

    • Accepted:

    • Published:

    • Issue Date:

    • DOI: https://doi.org/10.1007/s00134-016-4312-9

    Keywords

    Search

    Navigation