J Extra Corpor Technol 2024 , 56 , 211 – 215 Ó The Author ( s ), published by EDP Sciences , 2024 https :// doi . org / 10.1051 / ject / 2024032
Available online at : ject . edpsciences . org
CASE REPORT
Plasmapheresis for extracorporeal membrane oxygenation ( ECMO ) -induced hemolysis in infants
Gail Budhu ( MD ) 1 , Kaydeen Morris-Whyte ( MD ) 1 , and Alexandru R . Constantinescu ( MD ) 2 , 3 ,*
1 Pediatric Residency Program , Joe DiMaggio Children ' s Hospital , Memorial Healthcare System , 1005 Joe DiMaggio Dr . Hollywood , FL 33021 , USA 2 Division of Pediatric Nephrology , Joe DiMaggio Children ’ s Hospital , 1131 N35th Ave , Hollywood , FL 33021 , USA 3 Charles E . Schmidt College of Medicine at Florida Atlantic University , 777 Glades Rd BC-71 , Boca Raton , FL 33431 , USA
Received 5 July 2024 , Accepted 28 October 2024
Abstract – Background : Intravascular hemolysis is a known complication of extracorporeal membrane oxygenation ( ECMO ). Characterized by elevated plasma-free hemoglobin ( PFH ), intravascular hemolysis is associated with cytotoxic effects leading to renal replacement therapy ( RRT ), longer ECMO runs , and mortality . Therapeutic plasma exchange ( TPE ) in tandem with ECMO was described as a therapy for various pathologic conditions , but there are no Extracorporeal Life Support Organization ( ELSO ) guidelines for the treatment of ECMO-induced hemolysis . We describe the use of TPE in the management of severe ECMO-induced hemolysis . Methods : Two-term neonates receiving veno-arterial ( VA ) ECMO developed severe PFH , with peak values over 500 mg / dL . TPE was performed in tandem with the ECMO circuit . Packed red cells were used to prime the TPE circuit , and citrate anticoagulation was added to establish the interface , which could not be achieved with existing heparin in the ECMO circuit . Therapy was completed with saline solution as a decoy for citrate , to avoid hypocalcemia and intracranial bleeding . Plasma volume was replaced by fresh frozen plasma ( FFP ). Results : In one patient PFH fell to 120 mg / dL , but rebounded to close to 500 mg / dL , only to stabilize between 210 and 300 mg / dL after the second TPE . He was liberated from ECMO , but could not survive a respiratory decompensation . The other patient ’ s PFH improved to 360 mg / dL after one TPE and continued to decline to 120 mg / dL over the ensuing days . Despite that improvement , care was withdrawn . Conclusion : TPE is effective in decreasing the burden of PFH and is well tolerated in tandem with ECMO , and a database of infants with ECMO-induced hemolysis needs to be created to assess the current practice and establish clinical guidelines for its most appropriate therapy .
Key words : Therapeutic plasma exchange ( TPE ), ECMO-induced hemolysis , Infants .
Overview / Introduction
Extracorporeal membrane oxygenation ( ECMO ) is a lifesaving modality , being used more frequently nowadays in patient management due to its significant advances in quality , convenience , and accessibility . One of the major complications is intravascular hemolysis , which contributes to higher morbidity and mortality rates [ 1 ]. This is characterized by an increase in plasma-free hemoglobin ( PFH , in mg / dL ), more frequently seen in children , to levels of 100 – 500 ( in up to 47.3 % ( mild hemolysis ), 500 – 1,000 in 12.6 – 23.6 % ( moderate hemolysis ) and levels > 1,000 mg / dL in 6.8 – 43.5 % ( severe hemolysis ) [ 1 ], lactate dehydrogenase ( LDH ) or total bilirubin ( TB ) [ 2 , 3 ]. Various factors have been identified to contribute to hemolysis in these patients , including the presence of thrombi
* Corresponding author : aconstantinescu @ mhs . net within the circuit , high negative inlet pressure , excessive pump speed , shear stress exerted on red blood cells , and high-velocity flows through small cannulae [ 1 , 2 ]. Additionally , oxygenatorrelated factors such as cavitation , pressure fluctuations , and the duration of ECMO support , also play a role [ 1 – 5 ]. The most frequently encountered cause of hemolysis is thrombosis of the pump head , with experts recommending replacing it or replacing the entire ECMO circuit as the initial step [ 6 ]. However , there are no Extracorporeal Life Support Organization ( ELSO ) guidelines for the treatment of ECMO-induced hemolysis . Most care in pediatrics is off-label , universally accepted guidelines do not exist for most of our treatments . The problem is even more challenging in infants due to their small size and increased risk of intracranial hemorrhage . The following two cases illustrate instances in which hemolysis occurred and was significantly reduced by therapeutic plasma exchange ( TPE ). Plasma exchange is a therapeutic procedure involving
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