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Transfusion Thresholds for Adult Respiratory Extracorporeal Life Support: An Expert Consensus Document.

ABSTRACT: Severe acute respiratory distress syndrome (ARDS) can complicate novel pandemic coronavirus disease (COVID-19). Extracorporeal life support (ECLS) represents the final possible rescue strategy. Variations in practice, combined with a paucity of rigourous guidelines, may complicate blood-product resource availability and allocation during a pandemic. We conducted a literature review around venovenous extracorporeal membrane oxygenation (VV-ECMO) transfusion practices for platelets, packed red blood cells, fresh frozen plasma, prothrombin complex concentrate, and antithrombin. Pertinent society guidelines were examined, and the practice of Canadian ECLS experts was sampled through an environmental scan. This paper represents a synthesis of these explorations, combined with input from the Canadian Cardiovascular Critical Care (CANCARE) Society, Canadian Society of Cardiac Surgeons, and the Canadian Critical Care Society. We offer a pragmatic guidance document for restrictive transfusion thresholds in nonbleeding patients on VV-ECMO, which may attenuate transfusion-related complications and simultaneously shield national blood product inventory from strain during pandemic-induced activation of the National Plan for the Management of Shortages of Labile Blood Components.

SUBMITTER: Singh G

PROVIDER: S-EPMC7319637 | biostudies-literature | 2020 Sep

REPOSITORIES: biostudies-literature

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Transfusion Thresholds for Adult Respiratory Extracorporeal Life Support: An Expert Consensus Document.

Singh Gurmeet G Nahirniak Susan S Arora Rakesh R Légaré Jean-François JF Kanji Hussein D HD Nagpal Dave D Lamarche Yoan Y Fan Eddy E Singh Parhar Ken Kuljit KK

The Canadian journal of cardiology 20200626 9

Severe acute respiratory distress syndrome (ARDS) can complicate novel pandemic coronavirus disease (COVID-19). Extracorporeal life support (ECLS) represents the final possible rescue strategy. Variations in practice, combined with a paucity of rigourous guidelines, may complicate blood-product resource availability and allocation during a pandemic. We conducted a literature review around venovenous extracorporeal membrane oxygenation (VV-ECMO) transfusion practices for platelets, packed red blo ...[more]

PMID: 32599018

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Project description:RationaleExtracorporeal life support (ECLS) for acute respiratory failure has increased as a result of technological advancements and promising results from recent studies as compared with historical trials.ObjectivesSystematically review the effect of ECLS compared with mechanical ventilation on mortality, length of stay, and adverse events in respiratory failure.MethodsData sources included were MEDLINE, EMBASE, and CENTRAL (through to October 2013). Any randomized controlled trial (RCT) or observational study comparing ECLS to mechanical ventilation in adults was used. Two authors independently abstracted the data. Our primary outcome was mortality. Secondary outcomes included intensive care unit length of stay, hospital length of stay, and adverse events. A sensitivity analysis was performed restricted to RCTs and quasi-RCTs, and a number of predefined subgroups were identified to explore heterogeneity.Measurements and main resultsTen studies (four RCTs, six observational studies, 1,248 patients) were included. There was no significant difference in hospital mortality with ECLS as compared with mechanical ventilation (risk ratio [RR], 1.02; 95% confidence interval [CI], 0.79-1.33; I(2) = 77%). When restricted to venovenous ECLS studies of randomized trials and quasi-randomized trials (three studies; 504 patients), there was a decrease in mortality with ECLS compared with mechanical ventilation (RR, 0.64; 95% CI, 0.51-0.79; I(2) = 15%). There were insufficient study-level data to evaluate most secondary outcomes. Bleeding was significantly greater in the ECLS group (RR, 11.44; 95% CI, 3.11-42.06; I(2) = 0%). In the H1N1 subgroup (three studies; 364 patients), ECLS was associated with significantly lower hospital mortality (RR, 0.62; 95% CI, 0.45-0.8; I(2) = 25%).ConclusionsECLS was not associated with a mortality benefit in patients with acute respiratory failure. However, a significant mortality benefit was seen when restricted to higher-quality studies of venovenous ECLS. Patients with H1N1-acute respiratory distress syndrome represent a subgroup that may benefit from ECLS. Future studies are needed to confirm the efficacy of ECLS as well as the optimal configuration, indications, and timing for adult patients with respiratory failure.

Project description: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.

Dataset Information

Transfusion Thresholds for Adult Respiratory Extracorporeal Life Support: An Expert Consensus Document.

Publications

Transfusion Thresholds for Adult Respiratory Extracorporeal Life Support: An Expert Consensus Document.

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