TY - JOUR
T1 - Blood product transfusion and mortality in neonatal extracorporeal membrane oxygenation
AU - Keene, Sarah D.
AU - Patel, Ravi Mangal
AU - Stansfield, Brian K.
AU - Davis, Joel
AU - Josephson, Cassandra D.
AU - Winkler, Anne M.
N1 - Funding Information:
RBC and PLT transfusion rates are associated with in‐hospital mortality among neonates receiving ECMO. These data provide a basis for future studies evaluating more restrictive transfusion practices for neonates receiving ECMO support. Work was performed at Emory University School of Medicine and Childrenʼs Healthcare of Atlanta—Egleston campus. We have no disclaimers. Funding : We received no specific financial support for this work. Disclosures : The authors declare that they have no conflicts of interest relevant to the manuscript submitted to TRANSFUSION. Dr. Annie Winkler is an employee at Instrumentation Laboratory but there is no direct relationship to any of the data presented. The findings and conclusions in this abstract are those of the authors and do not necessarily represent the views of the NIH. Grant Support : R.M.P. received salary support from the National Heart Lung Blood Institute (NHLBI) under award K23 HL128942 and C.D.J. received support from the NHLBI under award P01 HL086773. The NIH had no role in: 1) study design; 2) the collection, analysis, and interpretation of data; 3) the writing of the report; and 4) the decision to submit the paper for publication. Guidelines provided by the Extracorporeal Life Support Organization (ELSO) recommend the maintenance of a target hematocrit (Hct) of 40% for neonatal ECMO patients, which typically leads to recurring red blood cell (RBC) transfusions. Overall, there exists an absence of data from clinical trials examining transfusion practices in critically ill term neonates, including those supported by ECMO. Thus, appropriate thresholds for RBC transfusion are uncertain, with many ECMO centers using center‐specific thresholds for transfusions in response to studies reporting associations between a greater transfusion volume and increased morbidity and mortality in this population. In addition, recent studies suggest that a more restrictive approach may be safe and adequately support neonates undergoing ECMO support. Blood transfusion is a frequent and necessary practice in neonates receiving extracorporeal membrane oxygenation (ECMO) due to frequent laboratory sampling, clinical bleeding, and the need to support tissue oxygen delivery. Bleeding complications on ECMO are an important and frequent source of mortality and this leads to higher thresholds for platelet transfusion for patients undergoing ECMO support as compared to other critically ill patients. ELSO recommends maintenance of a platelet threshold of 100,000/μL, which is above common thresholds for other critically ill populations. However, a recently published clinical trial in preterm infants showed that a lower platelet transfusion of 25,000/μL in preterm infants, compared to 50,000/μL, improved survival without increased bleeding, suggesting that more restrictive platelet transfusion practices could be used safely in critically‐ill neonates. Unfortunately, data regarding platelet transfusion thresholds and bleeding risk in neonatal ECMO is poorly defined. Similarly, platelet transfusions are commonly administered due to persistent consumption of platelets in the neonatal ECMO circuits coupled with the patientʼs underlying disease process. Thus, we examined the relationship between RBC and platelet transfusions and in‐hospital mortality in a population of neonates undergoing ECMO for hypoxic respiratory failure, while controlling for baseline risk of the population using a validated risk score. Overall, the lack of data to support RBC and platelet transfusions during neonatal ECMO has led to variability in clinical practice and uncertainty surrounding best practices.
Publisher Copyright:
© 2019 AABB
PY - 2020/2/1
Y1 - 2020/2/1
N2 - 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 < 0.001. Similarly, PLT transfusion rate was greater among non-survivors: 22.9 (9.3-16.2) versus 12.1 (8.4-20.1), p = 0.02. After adjusting for baseline mortality risk, both RBC transfusion (adjusted relative risk per 5 mL/kg/d increase: 1.33; 95% CI 1.05-1.69, p = 0.02) and PLT transfusion (adjusted relative risk per 5 mL/kg/d increase: 1.12; 95% CI 1.02-1.23, p = 0.02) were both associated with in-hospital mortality. CONCLUSIONS: RBC and PLT transfusion rates are associated with in-hospital mortality among neonates receiving ECMO. These data provide a basis for future studies evaluating more restrictive transfusion practices for neonates receiving ECMO support.
AB - 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 < 0.001. Similarly, PLT transfusion rate was greater among non-survivors: 22.9 (9.3-16.2) versus 12.1 (8.4-20.1), p = 0.02. After adjusting for baseline mortality risk, both RBC transfusion (adjusted relative risk per 5 mL/kg/d increase: 1.33; 95% CI 1.05-1.69, p = 0.02) and PLT transfusion (adjusted relative risk per 5 mL/kg/d increase: 1.12; 95% CI 1.02-1.23, p = 0.02) were both associated with in-hospital mortality. CONCLUSIONS: RBC and PLT transfusion rates are associated with in-hospital mortality among neonates receiving ECMO. These data provide a basis for future studies evaluating more restrictive transfusion practices for neonates receiving ECMO support.
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U2 - 10.1111/trf.15626
DO - 10.1111/trf.15626
M3 - Article
C2 - 31837026
AN - SCOPUS:85076747347
SN - 0041-1132
VL - 60
SP - 262
EP - 268
JO - Transfusion
JF - Transfusion
IS - 2
ER -