Role of therapeutic plasma exchange in management of hemolysis associated with extracorporeal membrane oxygenation in neonates with congenital diaphragmatic hernia: A case series

Plasma free hemoglobin (PFH) is a product of intravascular hemolysis associated with certain disease states as well as the shearing effects of mechanical support devices, such as extracorporeal membrane oxygenation (ECMO). There are detrimental effects of intravascular hemolysis secondary to ECMO including severe hyperbilirubinemia, thrombus within the ECMO circuit causing inability to provide adequate support, and as a result, a need for ECMO circuit exchanges. Neonates can experience renal failure, kernicterus, and other significant morbidities as a result of hemolysis secondary to ECMO. We present three cases of neonates with a gestational age of 35 to 37 weeks who had a left-sided CDH and were cannulated to VA-ECMO on the first day of life using an 8 French arterial cannula and a 10 French venous cannula. Within the first 10 days of the ECMO run all patients developed markedly elevated PFH of (peaks of 465, >500 and >500 mg/dl), and creatinine, and underwent therapeutic plasma exchange (TPE). TPE was done using frozen fresh plasma (FFP) replacement in line with the ECMO circuit. All patients showed a remarkable decrease in the PFH levels after the TPE treatment. The number of TPE rounds ranged from 1 to 6, depending on the evolution of the PFH levels. One patient developed hypocalcemia that resulted in decreased cardiac pulsatility during the first round of TPE that resolved with aggressive calcium repletion. The total duration of the ECMO runs ranged from 16 to 29 days. None of the patients required continuous renal replacement therapy. All patients were discharged home at ages ranging from 2 to 6 months. Mechanical cell hemolysis is a significant source of morbidity in neonatal patients on ECMO. This case series exemplifies a safe and impactful intervention to address hemolysis in a critically ill patient population