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Blood product transfusion and mortality in neonatal extracorporeal membrane oxygenation.

ABSTRACT: BACKGROUND:Neonates receiving extracorporeal membrane oxygenation (ECMO) support are transfused large volumes of red blood cells (RBCs) and platelets (PLTs). Transfusions are often administered in response to specific, but largely unstudied thresholds. The aim of this study is to examine the relationship between RBC and PLT transfusion rates and mortality in neonates receiving ECMO support. STUDY DESIGN AND METHODS:We retrospectively examined outcomes of neonates receiving ECMO support in the neonatal intensive care unit (NICU) for respiratory failure between 2010 and 2016 at a single quaternary-referral NICU. We examined the association between RBC and PLT transfusion rate (mL per kg per day) and in-hospital mortality, adjusting for confounding by using a validated composite baseline risk score (Neo-RESCUERS). RESULTS:Among the 110 neonates receiving ECMO support, in-hospital mortality was 28%. The median RBC transfusion rate (mL/kg/d) after cannulation was greater among non-survivors, compared to survivors: 12.4 (IQR 9.3-16.2) versus 7.3 (IQR 5.1-10.3), p?

SUBMITTER: Keene SD

PROVIDER: S-EPMC7433883 | biostudies-literature | 2020 Feb

REPOSITORIES: biostudies-literature

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Blood product transfusion and mortality in neonatal extracorporeal membrane oxygenation.

Keene Sarah D SD Patel Ravi Mangal RM Stansfield Brian K BK Davis Joel J Josephson Cassandra D CD Winkler Anne M AM

Transfusion 20191214 2

<h4>Background</h4>Neonates receiving extracorporeal membrane oxygenation (ECMO) support are transfused large volumes of red blood cells (RBCs) and platelets (PLTs). Transfusions are often administered in response to specific, but largely unstudied thresholds. The aim of this study is to examine the relationship between RBC and PLT transfusion rates and mortality in neonates receiving ECMO support.<h4>Study design and methods</h4>We retrospectively examined outcomes of neonates receiving ECMO su ...[more]

PMID: 31837026

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Project description:ObjectiveExtracorporeal membrane oxygenation, an accepted rescue therapy for refractory cardiopulmonary failure, requires a complex multidisciplinary approach and advanced technology. Little is known about the relationship between a center's case volume and patient mortality. The purpose of this study was to analyze the relationship between hospital extracorporeal membrane oxygenation annual volume and in-hospital mortality and assess if a minimum hospital volume could be recommended.DesignRetrospective cohort study.SettingA retrospective cohort admitted to children's hospitals in the Pediatric Health Information System database from 2004 to 2011 supported with extracorporeal membrane oxygenation was identified. Indications were assigned based on patient age (neonatal vs pediatric), diagnosis, and procedure codes. Average hospital annual volume was defined as 0-19, 20-49, or greater than or equal to 50 cases per year. Maximum likelihood estimates were used to assess minimum annual case volume.PatientsA total of 7,322 pediatric patients aged 0-18 were supported with extracorporeal membrane oxygenation and had an indication assigned.InterventionsNone.Measurements and main resultsAverage hospital extracorporeal membrane oxygenation volume ranged from 1 to 58 cases per year. Overall mortality was 43% but differed significantly by indication. After adjustment for case-mix, complexity of cardiac surgery, and year of treatment, patients treated at medium-volume centers (odds ratio, 0.86; 95% CI, 0.75-0.98) and high-volume centers (odds ratio, 0.75; 95% CI, 0.63-0.89) had significantly lower odds of death compared with those treated at low-volume centers. The minimum annual case load most significantly associated with lower mortality was 22 (95% CI, 22-28).ConclusionsPediatric centers with low extracorporeal membrane oxygenation average annual case volume had significantly higher mortality and a minimum volume of 22 cases per year was associated with improved mortality. We suggest that this threshold should be evaluated by additional study.

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.

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 achieve optimal hemostatic balance in patients on extracorporeal membrane oxygenation (ECMO), a liberal transfusion practice is currently applied despite clear evidence. We aimed to give an overview of the current use of plasma, fibrinogen concentrate, tranexamic acid (TXA), and prothrombin complex concentrate (PCC) in patients on ECMO.DesignA prespecified subanalysis of a multicenter retrospective study. Venovenous (VV)-ECMO and venoarterial (VA)-ECMO are analyzed as separate populations, comparing patients with and without bleeding and with and without thrombotic complications.SettingSixteen international ICUs.PatientsAdult patients on VA-ECMO or VV-ECMO.InterventionsNone.Measurements and main resultsOf 420 VA-ECMO patients, 59% (n = 247) received plasma, 20% (n = 82) received fibrinogen concentrate, 17% (n = 70) received TXA, and 7% of patients (n = 28) received PCC. Fifty percent of patients (n = 208) suffered bleeding complications and 27% (n = 112) suffered thrombotic complications. More patients with bleeding complications than patients without bleeding complications received plasma (77% vs. 41%, p < 0.001), fibrinogen concentrate (28% vs 11%, p < 0.001), and TXA (23% vs 10%, p < 0.001). More patients with than without thrombotic complications received TXA (24% vs 14%, p = 0.02, odds ratio 1.75) in VA-ECMO, where no difference was seen in VV-ECMO. Of 205 VV-ECMO patients, 40% (n = 81) received plasma, 6% (n = 12) fibrinogen concentrate, 7% (n = 14) TXA, and 5% (n = 10) PCC. Thirty-nine percent (n = 80) of VV-ECMO patients suffered bleeding complications and 23% (n = 48) of patients suffered thrombotic complications. More patients with than without bleeding complications received plasma (58% vs 28%, p < 0.001), fibrinogen concentrate (13% vs 2%, p < 0.01), and TXA (11% vs 2%, p < 0.01).ConclusionsThe majority of patients on ECMO receive transfusions of plasma, procoagulant products, or antifibrinolytics. In a significant part of the plasma transfused patients, this was in the absence of bleeding or prolonged international normalized ratio. This poses the question if these plasma transfusions were administered for another indication or could have been avoided.

Dataset Information

Blood product transfusion and mortality in neonatal extracorporeal membrane oxygenation.

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Blood product transfusion and mortality in neonatal extracorporeal membrane oxygenation.

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