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Epidemiology of Hemostatic Transfusions in Children Supported by Extracorporeal Membrane Oxygenation
Oliver Karam1, Ruchika Goel2,3, Heidi Dalton4
1Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Hospital of Richmond at VCU, Richmond, VA.
Insights
Hemostatic transfusions like platelets and plasma are frequently given to children on extracorporeal membrane oxygenation (ECMO), often without clear links to lab results. Further research is needed to optimize these transfusion strategies in pediatric critical care.
Area of Science:
- Pediatric Critical Care Medicine
- Hematology
- Extracorporeal Life Support
Background:
- Hemostatic transfusions are common in critically ill children on extracorporeal membrane oxygenation (ECMO).
- Understanding the epidemiology and drivers of these transfusions is crucial for optimizing patient care.
Purpose of the Study:
- To evaluate the epidemiology of hemostatic transfusions (plasma, platelets, cryoprecipitate) in pediatric patients supported by ECMO.
- To identify factors associated with the administration of these transfusions.
Main Methods:
- Secondary analysis of a large observational cohort study.
- Involved 514 critically ill children across eight pediatric institutions.
- Examined daily transfusion doses and associations with clinical and laboratory parameters.
Main Results:
- Platelets transfused on 68% of ECMO days, plasma on 34%, and cryoprecipitate on 14%.
- Transfusion doses were associated with bleeding but not consistently with standard hemostatic testing.
- Platelet dose linked to chest tube output and bleeding, plasma dose to chest tube output and ACT, cryoprecipitate dose to younger age.
Conclusions:
- Most hemostatic transfusions in pediatric ECMO patients were associated with bleeding but not laboratory hemostatic tests.
- Current transfusion strategies may require further evaluation for appropriateness.
- Further studies are warranted to refine transfusion protocols in this vulnerable population.
Objective:
To evaluate the epidemiology of hemostatic transfusions (plasma, platelet, and cryoprecipitate) in children supported by extracorporeal membrane oxygenation.
Design:
Secondary analysis of a large observational cohort study.
Setting:
Eight pediatric institutions within the Eunice Kennedy Shriver National Institute of Child Health and Human Development's Collaborative Pediatric Critical Care Research Network.
Patients:
Critically ill children supported by extracorporeal membrane oxygenation.
Interventions:
None.
Measurements And Main Results:
Extracorporeal membrane oxygenation was used in the care of 514 consecutive children. Platelets were transfused on 68% of extracorporeal membrane oxygenation days, plasma on 34% of the days on extracorporeal membrane oxygenation, and cryoprecipitate on 14%. Only 24% of the days on extracorporeal membrane oxygenation were free of any hemostatic transfusions. Daily platelet transfusion dose was independently associated with chest tube output (p < 0.001), other bleeding requiring RBC transfusion (p = 0.03), and daily set platelet goal (p = 0.009), but not with total platelet count (p = 0.75). Daily plasma transfusion dose was independently associated with chest tube output (p < 0.001), other bleeding requiring RBC transfusion (p = 0.01), activated clotting time (p = 0.001), and antithrombin levels (p = 0.02), but not with international normalized ratio (p = 0.99) or activated partial thromboplastin time (p = 0.29). Daily cryoprecipitate transfusion dose was independently associated with younger age (p = 0.009), but not with chest tube bleeding (p = 0.18), other bleeding requiring RBC transfusion (p = 0.75), fibrinogen level (p = 0.67), or daily fibrinogen goal (p = 0.81).
Conclusions:
Platelets were transfused on two third of the days on extracorporeal membrane oxygenation, plasma on one third, and cryoprecipitate on one sixth of the days. Although most hemostatic transfusions were independently associated with bleeding, they were not independently associated with the majority of hemostatic testing. Further studies are warranted to evaluate the appropriateness of these transfusion strategies.
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