Incidence, kinetics, and clinical impact of thrombocytopenia in venovenous ECMO: insights from the multicenter observational PROTECMO study
Nina Buchtele, Kenichi A. Tanaka, Fabio Tuzzolino, Cara Agerstrand, Ali Ait Hssain, Jordi Riera, Peter Schellongowski, Matthieu Schmidt, Raj Ramanan, Martin Balík, Lars Mikael Broman, Nicolò Rizzitello, Konstanty Szułdrzyński, Whitney D. Gannon, Vito Fanelli, Brian Trethowan, Hergen Buscher, Huda Alfoudri, Marco Giani, Alain Combes, Giacomo Grasselli, Roberto Lorusso, Antonio Arcadipane, Daniel Brodie, Gennaro Martucci, PROTECMO Study group, Marco Barbara, Paolo Capuano, Claudia Costantino, Gennaro Martucci, Nicolò Rizzitello, Monica Rizzo, Matteo Rossetti, Antonio Pesenti, Matteo Brioni, Gennaro De Pascale, Luca Montini, Giuseppe Foti, Emanuele Rezoagli, Luca Brazzi, Pierfrancesco Curcio, Eugenio Garofalo, Luis Martin-Villen, Raquel Garcìa-Álvarez, Marta Lopez Sanchez, Nuno Principe, Violeta Chica Saez, Juan Ignacio Chico, Vanesa Gomez, Joaquin Colomina-Climent, Andres Francisco Pacheco, Camilo Bonilla, Eduard Argudo, María Martínez-Martínez, María Martínez-Pla, Pau Torrella, Bet Gallart, Vojka Gorjup, Julien Goutay, Duburcq Thibault, Mariusz Kowalewski, Philipp Eller, Elisabeth Lobmeyr, Peter Schellongowski, Silvia Mariani, Marco Vito Ranieri, Pavel Suk, Michal Maly, Jakob Forestier, Nicolò Rizzitello, Marco Barbara, Monica Rizzo, Tyler Holsworth, Alexis Serra, Darryl Abrams, Yiorgos Alexandros Cavayas, Ali Tabatabai, Jay Menaker, Samuel Galvagno, Whitney D Gannon, Todd W Rice, Wilson E Grandin, Jose Nunez, Collette Cheplic, Ryan Rivosecchi, Harikesh Subramanian, Young-Jae Cho, Sarah Buabbas, Kyeongman Jeon, Ming Chit Kwan, Hend Sallam, Joy Ann Villanueva, Jeffrey Aliudin, Kota Hoshino, Yoshitaka Hara, Kollengode Ramanathan, Graeme Maclaren
Abstract
Thrombocytopenia is a recognized risk factor for bleeding during extracorporeal membrane oxygenation (ECMO). This study determines the incidence, risk factors, and clinical relevance of thrombocytopenia and platelet transfusions during venovenous (VV) ECMO. The multicenter, prospective observational PROTECMO study included 652 adult patients who received VV ECMO for respiratory failure. Thrombocytopenia was classified as mild (100–149·109/L), moderate (50–99·109/L), or severe (< 50·109/L). Bleeding events were evaluated using a modified Bleeding Academy Research Consortium score. Cox proportional hazards and logistic regression analyses were done to identify predictors, and quantify the association between platelet counts and bleeding risk. A total of 182 patients (27.9%) had thrombocytopenia at baseline (mild in 14.7%, moderate in 8.7%, and severe in 4.4%). Thrombocytopenia during ECMO, at least once in 80.2% of patients, was mild in 21.3% of cases, moderate in 32.2%, and severe in 26.7%. A 10·109/L decrease in platelet count was associated with a 3.7% (95% CI: 2.4–5.0%) increase in risk of bleeding. There was no strong evidence of nonlinear relationship within the platelet count range between 25,000 and 300,000. This relation remained consistent across all ECMO weeks. Mild thrombocytopenia increased the risk of experiencing a bleeding event by 61% (hazard ratio (HR) 1.611, 95% CI 1.230–2.109, p = 0.0005), while moderate and severe thrombocytopenia increased the risk by roughly 90% (moderate: HR 1.944 (CI 1.484–2.545), p < 0.0001; severe: HR 1.876 (CI 1.275–2.7680), p = 0.0014). The risk for thrombocytopenia < 100·109/L during ECMO significantly increased with ICU days prior to ECMO start, postoperative admission, immunocompromised state, renal replacement therapy, septic shock, low hemoglobin, and circuit exchange. Thrombocytopenia is highly prevalent in VV ECMO, and associated with a significant increase in the risk of bleeding, and a reduction in 6-month survival, particularly at platelet counts below 100·109/L. Further research is needed to better define the outcomes associated with specific thresholds for transfusion of platelets.