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RBC Transfusion Practice in Pediatric Extracorporeal Membrane Oxygenation Support.

ABSTRACT: OBJECTIVES:To determine RBC transfusion practice and relationships between RBC transfusion volume and mortality in infants and children treated with extracorporeal membrane oxygenation. DESIGN:Secondary analysis of a multicenter prospective observational 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:Patients age less than 19 years old treated with extracorporeal membrane oxygenation at a participating center. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:Clinical data and target hemoglobin or hematocrit values (if set) were recorded daily by trained bedside extracorporeal membrane oxygenation specialists and research coordinators. Laboratory values, including hemoglobin and hematocrit, were recorded daily using the value obtained closest to 8:00 AM. RBC transfusion was recorded as total daily volume in mL/kg. Multivariable logistic regression was used to determine the relationship between RBC transfusion volume and hospital mortality, accounting for potential confounders. Average goal hematocrits varied across the cohort with a range of 27.5-41.3%. Overall, actual average daily hematocrit was 36.8%, and average RBC transfusion volume was 29.4?mL/kg/d (17.4-49.7?mL/kg/d) on extracorporeal membrane oxygenation. On multivariable analysis, each additional 10?mL/kg/d of RBC transfusion volume was independently associated with a 9% increase in odds of hospital mortality (adjusted odds ratio, 1.09 [1.02-1.16]; p = 0.009). CONCLUSIONS:In this multicenter cohort of pediatric extracorporeal membrane oxygenation patients, daily hematocrit levels were maintained at normal or near-normal values and RBC transfusion burden was high. RBC transfusion volume was independently associated with odds of mortality. Future clinical studies to identify optimum RBC transfusion thresholds for pediatric extracorporeal membrane oxygenation are urgently needed.

SUBMITTER: Muszynski JA

PROVIDER: S-EPMC6085106 | biostudies-literature | 2018 Jun

REPOSITORIES: biostudies-literature

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RBC Transfusion Practice in Pediatric Extracorporeal Membrane Oxygenation Support.

Muszynski Jennifer A JA Reeder Ron W RW Hall Mark W MW Berg Robert A RA Shanley Thomas P TP Newth Christopher J L CJL Pollack Murray M MM Wessel David D Carcillo Joseph J Harrison Rick R Meert Kathleen L KL Dean J Michael JM Jenkins Tammara T Tamburro Robert F RF Dalton Heidi J HJ

Critical care medicine 20180601 6

<h4>Objectives</h4>To determine RBC transfusion practice and relationships between RBC transfusion volume and mortality in infants and children treated with extracorporeal membrane oxygenation.<h4>Design</h4>Secondary analysis of a multicenter prospective observational study.<h4>Setting</h4>Eight pediatric institutions within the Eunice Kennedy Shriver National Institute of Child Health and Human Development's Collaborative Pediatric Critical Care Research Network.<h4>Patients</h4>Patients age l ...[more]

PMID: 29517551

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Project description:ObjectiveTo describe factors associated with platelet transfusion during pediatric extracorporeal membrane oxygenation and the relationships among platelet transfusion, complications, and mortality.DesignSecondary analysis of data collected prospectively by the Collaborative Pediatric Critical Care Research Network between December 2012 and September 2014.SettingEight Collaborative Pediatric Critical Care Research Network-affiliated hospitals.PatientsAge less than 19 years old and treated with extracorporeal membrane oxygenation.InterventionsNone.Measurements and main resultsOf 511 children, 496 (97.1%) received at least one platelet transfusion during extracorporeal membrane oxygenation. Neonatal age, venoarterial extracorporeal membrane oxygenation, and various acute and chronic diagnoses were associated with increased average daily platelet transfusion volume (milliliters per kilogram body weight). On multivariable analysis, average daily platelet transfusion volume was independently associated with mortality (per 1?mL/kg; odds ratio, 1.05; CI, 1.03-1.08; p < 0.001), whereas average daily platelet count was not (per 1?×?10/L up to 115?×?10/L; odds ratio, 1.00; CI, 0.98-1.01; p = 0.49). Variables independently associated with increased daily bleeding risk included increased platelet transfusion volume on the previous extracorporeal membrane oxygenation day, a primary cardiac indication for extracorporeal membrane oxygenation, adolescent age, and an acute diagnosis of congenital cardiovascular disease. Variables independently associated with increased daily thrombotic risk included increased platelet transfusion volume on the previous extracorporeal membrane oxygenation day and venoarterial extracorporeal membrane oxygenation. Variables independently associated with decreased daily thrombotic risk included full-term neonatal age and an acute diagnosis of airway abnormality.ConclusionsPlatelet transfusion was common in this multisite pediatric extracorporeal membrane oxygenation cohort. Platelet transfusion volume was associated with increased risk of mortality, bleeding, and thrombosis.

Project description:ObjectivesTo present recommendations and supporting literature for RBC transfusions in critically ill children supported with extracorporeal membrane oxygenation, ventricular assist devices, or renal replacement therapy.DesignConsensus conference series of international, multidisciplinary experts in RBC transfusion management of critically ill children.MethodsThe panel of 38 experts developed evidence-based, and when evidence was lacking, expert-based clinical recommendations as well as research priorities for RBC transfusions in critically ill children. The extracorporeal membrane oxygenation/ventricular assist device/renal replacement therapy subgroup included six experts. We conducted electronic searches of the PubMed, EMBASE, and Cochrane Library databases from 1980 to May 2017, using medical subject heading terms and text words to define concepts of RBC transfusion, extracorporeal membrane oxygenation, ventricular assist device, and renal replacement therapy. We used a standardized data extraction form to construct evidence tables and graded the evidence using the Grading of Recommendations Assessment, Development, and Evaluation system. Recommendations developed and supporting literature were reviewed and scored by all panel members. Agreement was obtained using the Research and Development/UCLA Appropriateness Method.ResultsFor inpatients requiring extracorporeal membrane oxygenation, ventricular assist device, or renal replacement therapy support, there was expert agreement (> 80%) on five good practice statements aimed to improve accuracy and uniform reporting of RBC transfusion data in pediatric extracorporeal membrane oxygenation, ventricular assist device, and renal replacement therapy studies and quality improvement projects; four clinical recommendations of physiologic metrics and biomarkers of oxygen delivery, in addition to hemoglobin concentration, to guide RBC transfusion, acknowledging insufficient evidence to recommend specific RBC transfusion strategies; and eight research recommendations.ConclusionsFurther research surrounding indications, risks, benefits, and alternatives to RBC transfusion in children on extracorporeal devices is clearly needed. Using a structured literature review and grading process, the Transfusion and Anemia Expertise Initiative panel concluded that there is currently insufficient evidence to recommend specific RBC transfusion variables in children requiring extracorporeal membrane oxygenation, ventricular assist device, or renal replacement therapy support.

Project description:Background: Extracorporeal membrane oxygenation (ECMO) treatment alleviates systemic cardiorespiratory failure. However, it is unclear whether ECMO also improves microcirculatory function, as the microcirculation can be disturbed despite normal systemic hemodynamics. We therefore aimed to study the sublingual microcirculation (SMC) throughout neonatal and pediatric ECMO treatment. We hypothesized that the SMC improves after starting ECMO, that the SMC differs between venovenous (VV) and venoarterial (VA) ECMO, and that insufficient recovery of microcirculatory disturbances during ECMO predicts mortality. Methods: This single-center prospective longitudinal observational study included 34 consecutive children (April 2016-September 2018). The SMC was assessed daily with a handheld vital microscope (integrated with incident dark field illumination) before, during, and after ECMO. Validated parameters of vessel density, perfusion, and flow quality were assessed for all vessels (diameter <100 μm) and small vessels (<20 μm). Linear mixed models and logistic regression models were built to assess changes over time and identify significant covariates. Using ROC curves, the predictive values of microcirculatory parameters were assessed for mortality on ECMO and overall mortality. Results: The study population comprised 34 patients (median age 0.27 years, 16 neonates, 16 females). Twelve patients were treated with VV and 22 with VA ECMO. Twelve patients died during ECMO (stopped due to futility) and 3 died after ECMO but before discharge. Microcirculatory parameters did not change significantly before, during or after ECMO. Except between microcirculatory flow index (MFI) and mean arterial pressure (MAP), no significant associations were found between microcirculatory parameters and global systemic hemodynamics. The probability of an undisturbed MFI (>2.6) increased with higher MAP (OR: 1.050, 95%CI: 1.008-1.094). Microcirculatory parameters did not significantly differ between VV and VA ECMO or between survivors and non-survivors. None of the microcirculatory parameters could predict mortality on ECMO or overall mortality. Conclusion: In this heterogeneous study population, we were not able to demonstrate an effect of ECMO on the sublingual microcirculation. Microcirculatory parameters did not change throughout ECMO treatment and did not differ between VV and VA ECMO or between survivors and non-survivors. Future research should focus on determining which neonatal and pediatric ECMO patients would benefit from microcirculatory monitoring and how.

Project description:ObjectivesExtracorporeal membrane oxygenation has been used to support children who fail to wean from cardiopulmonary bypass after pediatric cardiac surgery, but little is known about outcomes. We aimed to describe epidemiology and extracorporeal membrane oxygenation factors associated with inhospital mortality in these patients.DesignRetrospective multicenter registry-based cohort study.SettingInternational pediatric extracorporeal membrane oxygenation centers.PatientsChildren less than 18 years old supported with extracorporeal membrane oxygenation for failure to wean from cardiopulmonary bypass after cardiac surgery during 2000-2016 and reported to Extracorporeal Life Support Organization's registry.InterventionNone.Measurements and main resultsThe primary outcome measure was inhospital mortality. Cardiac surgical procedural complexity was assigned using risk adjustment in congenital heart surgery-1. Multivariable logistic regression was used to identify factors independently associated with the primary outcome. We included 2,322 patients, with a median age of 26 days (interquartile range, 7-159); 47% underwent complex surgical procedures (risk adjustment in congenital heart surgery 4-6 categories). Inhospital mortality was 55%. The multivariable model evaluating associations with inhospital mortality showed noncardiac congenital anomalies (odds ratio, 1.78; CI, 1.36-2.32), comorbidities (odds ratio, 1.59; CI, 1.30-1.94), preoperative cardiac arrest (odds ratio, 1.67; CI, 1.20-2.34), preoperative mechanical ventilation greater than 24 hours (odds ratio, 1.49; CI, 1.21-1.84), preoperative bicarbonate administration (odds ratio, 1.42; CI, 1.08-1.86), longer cardiopulmonary bypass time (> 251 min; odds ratio, 1.50; CI, 1.13-1.99), complex surgical procedures (odds ratio, 1.43; CI, 1.13-1.81), longer extracorporeal membrane oxygenation duration (> 104 hr, odds ratio, 1.54; CI, 1.17-2.02), and extracorporeal membrane oxygenation complications increased the odds of inhospital mortality. Age greater than 26 days (odds ratio, 0.56; CI, 0.42-0.75) reduced the odds of mortality.ConclusionsChildren supported with extracorporeal membrane oxygenation for failure to wean from cardiopulmonary bypass after cardiac surgery are at high risk of mortality (55%). Younger patients, those with congenital abnormalities and comorbidities, undergoing complex procedures, requiring longer cardiopulmonary bypass, and experiencing extracorporeal membrane oxygenation complications and longer extracorporeal membrane oxygenation duration have higher mortality risk. These data can help assessing prognosis in this high-risk population.

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RBC Transfusion Practice in Pediatric Extracorporeal Membrane Oxygenation Support.

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RBC Transfusion Practice in Pediatric Extracorporeal Membrane Oxygenation Support.

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