214 G . Budhu et al .: J Extra Corpor Technol 2024 , 56 , 211 – 215
TPE can induce severe coagulopathy if albumin is used for replacement instead of FFP , requiring close monitoring of coagulation factors .
In the cases presented , TPE was set up with the typical anticoagulant , citrate [ 17 ] in the blood-to-citrate ratio of 15:1 to achieve interface sooner . Subsequently , citrate was replaced by 0.9 % NaCl to minimize the risk of intracranial bleeding in already systemically heparinized patients . We also wanted to avoid hypocalcemia , a relatively frequent complication . In a study of 76 patients , out of which 53 were children , hypocalcemia was noted in 27.6 % of patients [ 7 ]. Our approach led to an overall reduction in the average TPE time without significant coagulation derangement , and the total citrate received was kept at a minimum . The TPE resulted in a sustained reduction of PFH and , thereby , in hemolysis and morbid sequelae . Though clinical outcomes were poor in both cases , the desired effect of reduction in hemolysis was achieved ( NB . data is accrued continuously ).
Given the wide range of incidence of ECMO-induced hemolysis , we interrogated the 2023 ELSO report with respect to infants ( defined as < 28 days old ) and found out that for the subpopulation with cardiac disease requiring ECMO , severe hemolysis ( defined as PFH > 100 ) was reported in 54 / 366 cases ( 14.8 %) with 28 % survival rate . In turn , for those with respiratory illnesses requiring ECMO , in the same time period , there were 67 / 475 cases of severe hemolysis ( 14.1 %), with a 43 % survival rate .
We conclude that TPE plays a role in managing severe ECMO-induced hemolysis and is feasible to be used in tandem with ECMO in infants and older children . In the absence of randomized studies to date , a database of patients experiencing ECMO-induced hemolysis should be set up , with the scope of creating clinical practice guidelines for adequate therapy . After ensuring cannulae are in the first line of therapy for severe correct position and void of thrombi or fibrin deposition , we could recommend TPE as the first line of therapy for severe ECMO-induced hemolysis . We also emphasize the importance of continuous monitoring of hemodynamics , urine output , ionized calcium , and blood gases during the procedure .
Acknowledgements We thank the Medical staff involved in the care of these patients .
Funding The authors received no funding to complete this research .
Conflicts of interest The authors declare no conflict of interest .
Data availability statement All pertinent data are included in the manuscript .
Author contribution statement
GB and KM-W – data analysis , creation of graphs , and manuscript preparation .
ARC – conceptualize and editing .
Ethics approval Ethics guidelines were respected in this case report .
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