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Patient-tailored platelet transfusion practices for children supported by extracorporeal membrane oxygenation
Ofer Schiller1,2, Giulia Pula3, Eran Shostak1,2
1Pediatric Cardiac Intensive Care Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.
Insights
A new platelet transfusion strategy for pediatric patients on extracorporeal membrane oxygenation (ECMO) significantly reduced platelet use. This patient-tailored approach, lowering transfusion thresholds, proved safe and effective in managing bleeding risks during ECMO therapy.
Area of Science:
- Pediatric Critical Care Medicine
- Hematology
- Cardiopulmonary Support
Background:
- Extracorporeal membrane oxygenation (ECMO) is a life-support therapy for critically ill children with heart or respiratory failure.
- ECMO often requires blood product transfusions, including platelets, to manage bleeding risks.
- Current guidelines typically recommend high platelet transfusion thresholds (80-100 × 10⁹/L) during ECMO.
Purpose of the Study:
- To evaluate the feasibility and safety of a restrictive, patient-tailored platelet transfusion policy during pediatric ECMO.
- To assess the impact of a dynamically lowered platelet threshold (around 20 × 10⁹/L) on transfusion rates and bleeding outcomes.
- To compare outcomes with traditional, higher platelet transfusion guidelines.
Main Methods:
- Retrospective evaluation of 229 pediatric patients supported with ECMO.
- Analysis of platelet transfusion policy, bleeding complications, and patient outcomes.
- Comparison of lowest platelet counts in patients with and without bleeding events.
Main Results:
- Over 97% of patients had platelet counts below 100 × 10⁹/L during ECMO.
- Platelets were transfused on only 28.5% of ECMO days, with 19.2% never requiring transfusion.
- The median lowest platelet count in bleeding patients (25 × 10⁹/L) was significantly lower than in non-bleeding patients (33 × 10⁹/L) (p < 0.001).
- Fewer platelet transfusions were administered without an increase in red blood cell transfusions or hemorrhagic complications.
Conclusions:
- A restrictive, patient-tailored platelet transfusion strategy is safe and feasible for pediatric ECMO patients.
- This approach significantly reduces platelet product utilization.
- The study suggests that lower median platelet counts are associated with bleeding, but the observed thresholds were below current recommendations.
Background And Objectives:
Extracorporeal membrane oxygenation (ECMO) serves as cardiopulmonary therapy in critically ill patients with respiratory/heart failure and often necessitates multiple blood product transfusions. The administration of platelet transfusions during ECMO is triggered by the presence or risk of significant bleeding. Most paediatric ECMO programmes follow guidelines that recommend a platelet transfusion threshold of 80-100 × 109/L. To reduce exposure to platelets, we developed a practice to dynamically lower the threshold to ~20 × 109/L. We describe our experience with patient-tailored platelet thresholds and related bleeding outcomes.
Materials And Methods:
We retrospectively evaluated our platelet transfusion policy, bleeding complications and patient outcome in 229 ECMO-supported paediatric patients in our unit.
Results:
We found that more than 97.4% of patients had a platelet count <100 × 109/L at some point during their ECMO course. Platelets were transfused only on 28.5% of ECMO days; and 19.2% of patients never required a platelet transfusion. The median lowest platelet count in children who had bleeding events was 25 × 109/L as compared to 33 × 109/L in children who did not bleed (p < 0.001). Our patients received fewer platelet transfusions and did not require more red blood cell transfusions, nor did they experience more haemorrhagic complications.
Conclusion:
We have shown that a restrictive, 'patient-tailored' rather than 'goal-directed' platelet transfusion policy is feasible and safe, which can greatly reduce the use of platelet products. Although there was a difference in the lowest platelet counts in children who bled versus those who did not, the median counts were much lower than current recommendations.
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