Plasma Free Hemoglobin Is an Independent Predictor of Mortality among Patients on Extracorporeal Membrane Oxygenation Support

Hesham R Omar, Mehdi Mirsaeidi, Stephanie Socias, Collin Sprenker, Christiano Caldeira, Enrico M Camporesi, Devanand Mangar, Hesham R Omar, Mehdi Mirsaeidi, Stephanie Socias, Collin Sprenker, Christiano Caldeira, Enrico M Camporesi, Devanand Mangar

Abstract

Background: Hemolysis is common in all extracorporeal circuits as evident by the elevated plasma free hemoglobin (PFHb) level. We investigated whether increased hemolysis during extracorporeal membrane oxygenation (ECMO) is an independent mortality predictor.

Methods: We performed a retrospective observational study of consecutive subjects who received ECMO at a tertiary care facility from 2007-2013 to investigate independent predictors of in-hospital mortality. We examined variables related to patient demographics, comorbidities, markers of hemolysis, ECMO characteristics, transfusion requirements, and complications. 24-hour PFHb > 50 mg/dL was used as a marker of severe hemolysis.

Results: 154 patients received ECMO for cardiac (n = 115) or pulmonary (n = 39) indications. Patients' mean age was 51 years and 75.3% were males. Compared to nonsurvivors, survivors had lower pre-ECMO lactic acid (p = 0.026), lower 24-hour lactic acid (p = 0.023), shorter ECMO duration (P = 0.01), fewer RBC transfusions on ECMO (p = 0.008) and lower level of PFHb 24-hours post ECMO implantation (p = 0.029). 24-hour PFHb > 50 mg/dL occurred in 3.9 % versus 15.5% of survivors and nonsurvivors, respectively, p = 0.002. A Cox proportional hazard analysis identified PFHb > 50 mg/dL 24-hours post ECMO as an independent predictor of mortality (OR= 3.4, 95% confidence interval: 1.3 - 8.8, p = 0.011).

Conclusion: PFHb > 50 mg/dL checked 24-hour post ECMO implantation is a useful tool to predict mortality. We propose the routine checking of PFHb 24-hours after ECMO initiation for early identification and treatment of the cause of hemolysis.

Conflict of interest statement

Competing Interests: The authors would like to declare that authors Enrico M. Camporesi and Collin Sprenker are affiliated with Florida Gulf to Bay Anesthesiology Associates (FGTBA). However, this institution has not played any role in the design or funding of the manuscript. This does not alter the authors' adherence to PLOS ONE policies on sharing data and materials.

Figures

Fig 1. Cox proportional hazard method analysis…
Fig 1. Cox proportional hazard method analysis of predictors of in-hospital mortality for patients receiving extracorporeal membrane oxygenation at Tampa General Hospital from 2007–2013.
Fig 2. Kaplan-Meier cumulative survival curve comparing…
Fig 2. Kaplan-Meier cumulative survival curve comparing subjects with plasma free Hb>50 mg/dL or
Fig 3. Kaplan-Meier cumulative survival curve comparing…
Fig 3. Kaplan-Meier cumulative survival curve comparing subjects with plasma free Hb>50 mg/dL or

References

    1. Peek GJ, Mugford M, Tiruvoipati R, Wilson A, Allen E, Thalanany MM, et al. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet. 2009. October 17;374(9698):1351–63. 10.1016/S0140-6736(09)61069-2
    1. Conrad SA, Rycus PT, Dalton H. Extracorporeal Life Support registry report 2004. ASAIO J.2005;51:4–10.
    1. Lin CY, Tsai FC, Tian YC, Jenq CC, Chen YC, Fang JT, et al. Evaluation of outcome scoring systems for patients on extracorporeal membrane oxygenation. Ann Thorac Surg. 2007. October;84(4):1256–62.
    1. Lin CY, Chen YC, Tsai FC, Tian YC, Jenq CC, et al. RIFLE classification is predictive of short-term prognosis in critically ill patients with acute renal failure supported by extracorporeal membrane oxygenation. Nephrol Dial Transplant.2006;21:2867–2873.
    1. Chen YC, Tsai FC, Chang CH, Lin CY, Jenq CC, Juan KC, et al. Prognosis of patients on extracorporeal membrane oxygenation: the impact of acute kidney injury on mortality. Ann Thorac Surg. 2011. January;91(1):137–42. 10.1016/j.athoracsur.2010.08.063
    1. Rastan AJ, Dege A, Mohr M, Doll N, Falk V, Walther T, et al. Early and late outcomes of 517 consecutive adult patients treated with extracorporeal membrane oxygenation for refractory postcardiotomy cardiogenic shock. J Thorac Cardiovasc Surg. 2010;139(2):302–11. 10.1016/j.jtcvs.2009.10.043
    1. Aubron C, Cheng AC, Pilcher D, Leong T, Magrin G, Cooper DJ, et al. Factors associated with outcomes of patients on extracorporeal membrane oxygenation support: a 5-year cohort study. Crit Care. 2013;17(2):R73 10.1186/cc12681
    1. Kielstein JT, Heiden AM, Beutel G, Gottlieb J, Wiesner O, Hafer C, et al. Renal function and survival in 200 patients undergoing ECMO therapy. Nephrol Dial Transplant. 2013;28(1):86–90. 10.1093/ndt/gfs398
    1. Smith A, Hardison D, Bridges B, Pietsch J. Red blood cell transfusion volume among patients receiving extracorporeal membrane oxygenation. Perfusion. 2013;28(1):54–60. 10.1177/0267659112457969
    1. Kawahito S, Maeda T, Motomura T, Ishitoya H, Takano T, Nonaka K, et al. Hemolytic characteristics of oxygenators during clinical extracorporeal membrane oxygenation. ASAIO J. 2002. Nov-Dec;48(6):636–9.
    1. Meyer AD, Wiles AA, Rivera O, Wong EC, Freishtat RJ, Rais-Bahrami K, et al.Hemolytic and thrombocytopathic characteristics of extracorporeal membrane oxygenation systems at simulated flow rate for neonates. Pediatr Crit Care Med. 2012;13(4):e255–61. 10.1097/PCC.0b013e31823c98ef
    1. Toomasian JM, Bartlett RH. Hemolysis and ECMO pumps in the 21st Century.Perfusion. 2011;26(1):5–6. 10.1177/0267659110396015
    1. Gbadegesin R, Zhao S, Charpie J, Brophy PD, Smoyer WE, Lin JJ. Significance of hemolysis on extracorporeal life support after cardiac surgery in children. Pediatr Nephrol. 2009. March;24(3):589–95. 10.1007/s00467-008-1047-z
    1. Rother RP, Bell L, Hillmen P, Gladwin MT. The clinical sequelae of intravascular hemolysis and extracellular plasma hemoglobin: a novel mechanism of human disease. J Am Med Assoc. 2005;293:1653–62.
    1. Vermeulen Windsant IC, Hanssen SJ, Buurman WA, Jacobs MJ. Cardiovascular surgery and organ damage: time to reconsider the role of hemolysis. J Thorac Cardiovasc Surg. 2011;142:1–11. 10.1016/j.jtcvs.2011.02.012
    1. Cruz-Landeira A, Bal MJ, Lopez-Rivadulla M. Determination of methemoglobin and total hemoglobin in toxicological studies by derivative spectrophotometry. J Anal Toxicol.2002;26:67–72.
    1. Guidelines General All ECLS Version1.1.pdf. Accessed 11/5/2014
    1. Chen YS, Chao A, Yu HY, Ko WJ, Wu IH, Chen RJ. Analysis and results of prolonged resuscitation in cardiac arrest patients rescued by extracorporeal membrane oxygenation. J Am Coll Cardiol. 2003. January 15;41(2):197–203.
    1. Wu MY, Lin PJ, Tsai FC, Haung YK, Liu KS, Tsai FC. Impact of preexisting organ dysfunction on extracorporeal life support for non-postcardiotomy cardiopulmonary failure. Resuscitation. 2008. Oct;79(1):54–60. 10.1016/j.resuscitation.2008.05.002
    1. Vercaemst L. Hemolysis in cardiac surgery patients undergoing cardiopulmonary bypass: a review in search of a treatment algorithm. J Extra Corpor Technol. 2008;40(4):257–67.
    1. Jeffers A, Gladwin MT, Kim-Shapiro DB. Computation of plasma hemoglobin nitric oxide scavenging in haemolytic anaemias.Free Radic Biol Med. 2006;41:1557–65.
    1. Mumby S, Koh TW, Pepper JR, Gutteridge JM. Risk of iron overload is decreased in beating heart coronary artery surgery compared to conventional bypass. Biochim Biophys Acta. 2001. November 29;1537(3):204–10.
    1. Davis C, Kausz A, Zager R, Kharasch E, Cochran R. Acute renal failure after CPB is related to decreased serum ferritin levels. J Am Soc Nephrol. 1999;10:2396–402.
    1. An Y, Xiao YB, Zhong QJ. Hyperbilirubinemia after extracorporeal circulation surgery: a recent and prospective study. World J Gastroenterol. 2006. November 7;12(41):6722–6.
    1. Watanabe N, Sakota D, Ochuchi K, Takatani S. Deformability of red blood cells and its relation to blood trauma in rotary blood pumps.Artif Organs. 2007;31:352–8.
    1. Bennett M, Horton S, Thuys C, Augustin S, Rosenberg M, Brizard C. Pump-induced haemolysis: a comparison of short-term ventricular assist devices. Perfusion. 2004; 19:107–111.
    1. Bottrell S, Bennett M, Augustin S, Thuys C, Schultz B, Horton A, et al. comparison study of haemolysis production in three contemporary centrifugal pumps. Perfusion. 2014;29(5):411–6. 10.1177/0267659113509000
    1. Lawson DS, Ing R, Cheifetz IM, Walczak R, Craig D, Schulman S, et al. Hemolytic characteristics of three commercially available centrifugal blood pumps. Pediatr Crit Care Med. 2005;6(5):573–7.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe