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Prophylactic Transfusion Strategies in Children Supported by Extracorporeal Membrane Oxygenation: The Pediatric
Marianne E Nellis1, Katie M Moynihan1,2,3,4,5,6,7,8,9,10,11,12,13,14, Steven R Sloan5
1Division of Pediatric Critical Care Medicine, Department of Pediatrics, NY Presbyterian Hospital-Weill Cornell Medicine, New York, NY.
Insights
Despite frequent transfusions in pediatric extracorporeal membrane oxygenation (ECMO) patients, evidence-based guidelines for prophylactic transfusions are lacking. This study aimed to develop consensus-based recommendations for transfusion strategies in neonates and children on ECMO.
Area of Science:
- Pediatric critical care medicine
- Hematology
- Transfusion medicine
Background:
- Pediatric patients on extracorporeal membrane oxygenation (ECMO) often receive prophylactic blood product transfusions.
- Current transfusion strategies lack robust evidence-based guidelines.
- The Pediatric ECMO Anticoagulation CollaborativE initiated a consensus process to address this gap.
Purpose of the Study:
- To derive systematic-review informed, modified Delphi consensus recommendations for prophylactic transfusions in neonates and children supported with ECMO.
- To establish evidence-based and expert-based guidelines for transfusion practices in pediatric ECMO.
Main Methods:
- A comprehensive literature search was conducted across major databases (PubMed, EMBASE, Cochrane Library) from 1988 to 2021.
- A modified Delphi process involving 48 experts was employed over two years to build consensus.
- Recommendations were informed by systematic review data and expert opinion, with consensus defined as >80% agreement.
Main Results:
- Two good practice statements, four weak recommendations, and three expert consensus statements were developed.
- The consensus process addressed prophylactic transfusion strategies for pediatric ECMO patients.
- Evidence evaluation used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.
Conclusions:
- There is a significant lack of evidence to support evidence-based prophylactic transfusion strategies in pediatric ECMO patients.
- Consensus-based recommendations were established to guide clinical practice in the absence of definitive evidence.
- Further research is needed to develop robust, evidence-based transfusion guidelines for this vulnerable population.
Objectives:
To derive systematic-review informed, modified Delphi consensus regarding prophylactic transfusions in neonates and children supported with extracorporeal membrane oxygenation (ECMO) from the Pediatric ECMO Anticoagulation CollaborativE.
Data Sources:
A structured literature search was performed using PubMed, EMBASE, and Cochrane Library (CENTRAL) databases from January 1988 to May 2020, with an update in May 2021.
Study Selection:
Included studies assessed use of prophylactic blood product transfusion in pediatric ECMO.
Data Extraction:
Two authors reviewed all citations independently, with a third independent reviewer resolving conflicts. Thirty-three references were used for data extraction and informed recommendations. Evidence tables were constructed using a standardized data extraction form.
Measurements And Main Results:
The evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation system. Forty-eight experts met over 2 years to develop evidence-informed recommendations and, when evidence was lacking, expert-based consensus statements or good practice statements for prophylactic transfusion strategies for children supported with ECMO. A web-based modified Delphi process was used to build consensus via the Research And Development/University of California Appropriateness Method. Consensus was based on a modified Delphi process with agreement defined as greater than 80%. We developed two good practice statements, 4 weak recommendations, and three expert consensus statements.
Conclusions:
Despite the frequency with which pediatric ECMO patients are transfused, there is insufficient evidence to formulate evidence-based prophylactic transfusion strategies.
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