Severe cholestasis in neonatal extracorporeal membrane oxygenation

Introduction: Cholestasis is a common complication of Extracorporeal Membrane Oxygenation (ECMO) secondary to patient physiology and circuit-induced factors. In our institution’s Neonatal Intensive Care Unit (NICU), we noted cases of severe cholestasis, with peak conjugated bilirubin levels much higher than previously reported in the literature. The objective of our study was to identify the contributing factors to the development of severe cholestasis in neonatal ECMO cases. Methods: Using our institutional ECMO database, all neonates who received ECMO at our institution were identified. A retrospective chart review was completed for a sample of 30 neonates. Univariate, multivariate, and logistic regression models were utilized. Results: Twenty percent of the patients in our study developed severe cholestasis (peak conjugated bilirubin > 10.0 mg/dL). Comparing the group of neonates that developed severe cholestasis to those who did not, we found that severe cholestasis was associated with the use of the Getinge Pediatric Quadrox-iD oxygenator. Mean plasma free hemoglobin levels were significantly higher in cases using pediatric oxygenators vs. adult (204.6 mg/dL vs. 110.4 mg/dL, p = 0.01). Longer ECMO courses and percent time within the ACT goal were also associated with severe cholestasis. Conclusion: Our study describes a cohort of neonatal ECMO cases complicated by severe cholestasis that was mediated by hemolysis due to circuit factors. In particular, circuit factors (the use of a pediatric oxygenator), longer duration of ECMO, and anticoagulation management were all significant factors. Future studies are needed to further elucidate the impact of these circuit factors and how they interplay with neonatal physiology.