Online Clinical Investigations

Epidemiology of Hemostatic Transfusions in Children Supported by Extracorporeal Membrane Oxygenation

Karam, Oliver MD, PhD¹; Goel, Ruchika MD, MPH^2,3; Dalton, Heidi MD⁴; Nellis, Marianne E. MD, MS⁵

¹Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Richmond at VCU, Richmond, VA.

²Division of Hematology/Oncology, Simmons Cancer Institute at SIU School of Medicine, Springfield, IL.

³Department of Pathology, Johns Hopkins University, Baltimore, MD.

⁴Adult and Pediatric ECLS, INOVA Fairfax Hospital, Falls Church, VA.

⁵Division of Pediatric Critical Care Medicine, Department of Pediatrics, Weill Cornell Medicine, New York, NY.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).

The Collaborative Pediatric Critical Care Research Network was funded by the National Institute of Child Health and Human Development.

Dr. Dalton disclosed off-label product use of extracorporeal membrane oxygenation (ECMO), and she received funding from Innovative ECMO Concepts. The remaining authors have disclosed that they do not have any potential conflicts of interest.

This article was prepared using the Bleeding and Thrombosis During ECMO (BATE) Study Data Set obtained from the Collaborative Pediatric Critical Care Research Network Data Coordinating Center, and it does not necessarily reflect the opinions or views of the BATE investigators or the National Institute of Child Health and Human Development.

For information regarding this article, E-mail: [email protected]

Critical Care Medicine 48(8):p e698-e705, August 2020. | DOI: 10.1097/CCM.0000000000004417

Abstract

Objective:

To evaluate the epidemiology of hemostatic transfusions (plasma, platelet, and cryoprecipitate) in children supported by extracorporeal membrane oxygenation.

Design:

Secondary analysis of a large observational cohort 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:

Critically ill children supported by extracorporeal membrane oxygenation.

Interventions:

None.

Measurements and Main Results:

Extracorporeal membrane oxygenation was used in the care of 514 consecutive children. Platelets were transfused on 68% of extracorporeal membrane oxygenation days, plasma on 34% of the days on extracorporeal membrane oxygenation, and cryoprecipitate on 14%. Only 24% of the days on extracorporeal membrane oxygenation were free of any hemostatic transfusions. Daily platelet transfusion dose was independently associated with chest tube output (p < 0.001), other bleeding requiring RBC transfusion (p = 0.03), and daily set platelet goal (p = 0.009), but not with total platelet count (p = 0.75). Daily plasma transfusion dose was independently associated with chest tube output (p < 0.001), other bleeding requiring RBC transfusion (p = 0.01), activated clotting time (p = 0.001), and antithrombin levels (p = 0.02), but not with international normalized ratio (p = 0.99) or activated partial thromboplastin time (p = 0.29). Daily cryoprecipitate transfusion dose was independently associated with younger age (p = 0.009), but not with chest tube bleeding (p = 0.18), other bleeding requiring RBC transfusion (p = 0.75), fibrinogen level (p = 0.67), or daily fibrinogen goal (p = 0.81).

Conclusions:

Platelets were transfused on two third of the days on extracorporeal membrane oxygenation, plasma on one third, and cryoprecipitate on one sixth of the days. Although most hemostatic transfusions were independently associated with bleeding, they were not independently associated with the majority of hemostatic testing. Further studies are warranted to evaluate the appropriateness of these transfusion strategies.

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Epidemiology of Hemostatic Transfusions in Children Supported by Extracorporeal Membrane Oxygenation