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Alexander PMA, Bembea MM, Cashen K, Cheifetz IM, Dalton HJ, Himebauch AS, Karam O, Moynihan KM, Nellis ME, Ozment C, Raman L, Rintoul NE, Said AS, Saini A, Steiner ME, Thiagarajan RR, Watt K, Willems A, Zantek ND, Barbaro RP, Steffen K, Vogel AM, Almond C, Anders MM, Annich GM, Brandão LR, Chandler W, Delaney M, DiGeronimo R, Emani S, Gadepalli SK, Garcia AV, Haileselassie B, Hyslop R, Kneyber MCJ, Baumann Kreuziger L, Le J, Loftis L, McMichael ABV, McMullan DM, Monagle P, Nicol K, Paden ML, Patregnani J, Priest J, Raffini L, Ryerson LM, Sloan SR, Teruya J, Yates AR, Gehred A, Lyman E, Muszynski JA. Executive Summary: The Pediatric Extracorporeal Membrane Oxygenation Anticoagulation CollaborativE (PEACE) Consensus Conference. Pediatr Crit Care Med 2024; 25:643-675. [PMID: 38959353 PMCID: PMC11216385 DOI: 10.1097/pcc.0000000000003480] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
OBJECTIVES To present recommendations and consensus statements with supporting literature for the clinical management of neonates and children supported with extracorporeal membrane oxygenation (ECMO) from the Pediatric ECMO Anticoagulation CollaborativE (PEACE) consensus conference. DATA SOURCES Systematic review was performed using PubMed, Embase, and Cochrane Library (CENTRAL) databases from January 1988 to May 2021, followed by serial meetings of international, interprofessional experts in the management ECMO for critically ill children. STUDY SELECTION The management of ECMO anticoagulation for critically ill children. DATA EXTRACTION Within each of eight subgroup, two authors reviewed all citations independently, with a third independent reviewer resolving any conflicts. DATA SYNTHESIS A systematic review was conducted using MEDLINE, Embase, and Cochrane Library databases, from January 1988 to May 2021. Each panel developed evidence-based and, when evidence was insufficient, expert-based statements for the clinical management of anticoagulation for children supported with ECMO. These statements were reviewed and ratified by 48 PEACE experts. Consensus was obtained using the Research and Development/UCLA Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. We developed 23 recommendations, 52 expert consensus statements, and 16 good practice statements covering the management of ECMO anticoagulation in three broad categories: general care and monitoring; perioperative care; and nonprocedural bleeding or thrombosis. Gaps in knowledge and research priorities were identified, along with three research focused good practice statements. CONCLUSIONS The 91 statements focused on clinical care will form the basis for standardization and future clinical trials.
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Affiliation(s)
- Peta M A Alexander
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Katherine Cashen
- Department of Pediatrics, Duke Children's Hospital, Duke University, Durham, NC
| | - Ira M Cheifetz
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Heidi J Dalton
- Department of Pediatrics, INOVA Fairfax Medical Center, Falls Church, VA
| | - Adam S Himebauch
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
| | - Oliver Karam
- Division of Critical Care Medicine, Children's Hospital of Richmond at VCU, Richmond, VA
- Division of Critical Care Medicine, Yale School of Medicine, New Haven, CT
| | - Katie M Moynihan
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA
- Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Marianne E Nellis
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, New York Presbyterian Hospital-Weill Cornell, New York, NY
| | - Caroline Ozment
- Division of Critical Care Medicine, Department of Pediatrics, Duke University and Duke University Health System, Durham, NC
| | - Lakshmi Raman
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Natalie E Rintoul
- Department of Pediatrics, Division of Neonatology, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Ahmed S Said
- Division of Pediatric Critical Care, Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
| | - Arun Saini
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Marie E Steiner
- Department of Pediatrics, Divisions of Hematology and Critical Care, University of Minnesota, Minneapolis, MN
| | - Ravi R Thiagarajan
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Kevin Watt
- Division of Clinical Pharmacology, Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Ariane Willems
- Pediatric Intensive Care Unit, Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
| | - Nicole D Zantek
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN
| | - Ryan P Barbaro
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, MI
| | - Katherine Steffen
- Department of Pediatrics (Pediatric Critical Care Medicine), Stanford University, Palo Alto, CA
| | - Adam M Vogel
- Departments of Surgery and Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Christopher Almond
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, CA
| | - Marc M Anders
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Gail M Annich
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Leonardo R Brandão
- Department of Pediatrics, The Hospital for Sick Children, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Wayne Chandler
- Department of Laboratories, Seattle Children's Hospital, Seattle, WA
| | - Megan Delaney
- Division of Pathology and Lab Medicine and Transfusion Medicine, Children's National Hospital, Washington, DC
- Departments of Pathology and Pediatrics, The George Washington University Health Sciences, Washington, DC
| | - Robert DiGeronimo
- Department of Pediatrics, Division of Neonatology, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
| | - Sitaram Emani
- Department of Cardiovascular Surgery, Boston Children's Hospital, and Department of Surgery, Harvard Medical School, Boston, MA
| | - Samir K Gadepalli
- Division of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Alejandro V Garcia
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Robert Hyslop
- Heart Institute, Children's Hospital of Colorado, Aurora, CO
| | - Martin C J Kneyber
- Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Lisa Baumann Kreuziger
- Versiti Blood Research Institute and Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - Jennifer Le
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA
| | - Laura Loftis
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Ali B V McMichael
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
- Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ
| | - D Michael McMullan
- Division of Pediatric Cardiac Surgery, Seattle Children's Hospital, Seattle, WA
| | - Paul Monagle
- University of Melbourne, and Kids Cancer Centre Sydney Children's Hospital, and Murdoch Children's Research Institute, and Royal Children's Hospital Melbourne Australia, Melbourne, VIC, Australia
| | - Kathleen Nicol
- Department of Pathology, Nationwide Children's Hospital, Columbus, OH
| | - Matthew L Paden
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Jason Patregnani
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Barbara Bush Children's Hospital, Portland, ME
| | - John Priest
- Department of Respiratory Care, Boston Children's Hospital, Boston MA
| | - Leslie Raffini
- Department of Pediatrics, Division of Hematology, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Lindsay M Ryerson
- Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada
| | - Steven R Sloan
- Department of Laboratory Medicine, Boston Children's Hospital, Boston, MA
- CSL Behring, King of Prussia, PA
| | - Jun Teruya
- Division of Transfusion Medicine and Coagulation, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Andrew R Yates
- Department of Pediatrics, Divisions of Cardiology and Critical Care Medicine, Nationwide Children's Hospital and the Ohio State University College of Medicine, Columbus, OH
| | - Alison Gehred
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital Columbus, Columbus, OH
| | - Elizabeth Lyman
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital Columbus, Columbus, OH
| | - Jennifer A Muszynski
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital and The Ohio State University of Medicine, Columbus, OH
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Martinez MJ, Romero T, Federman MD. Comparison of red blood cell transfusions and hemostatic transfusions and their relation to thromboses in pediatric patients receiving extracorporeal membrane oxygenation therapy. Perfusion 2024:2676591241260185. [PMID: 38850510 DOI: 10.1177/02676591241260185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2024]
Abstract
OBJECTIVE To evaluate the association of RBC transfusions with thrombosis in pediatric patients on extracorporeal membrane oxygenation (ECMO) and compare this with the transfusion of other blood products and their association with thrombosis. METHODS This was a secondary analysis of the Bleeding and Thrombosis during ECMO (BATE) study, which was a multicenter prospective observational study involving patients less than 19 years of age treated with ECMO. RESULTS 514 patients were analyzed, of which 282 (55%) were neonates (≤31 days) and 302 (58.7%) were male. When analyzing the entire cohort independently of other blood products, each 10 mL/kg of packed red blood cells (PRBCs) was associated with a 1.0% increase in the average number of thromboses (1.010; 1.008,1.013; p < .001). In neonates, each 10 mL/kg of PRBC was associated with a 0.9% increase in the average number of thromboses (1.009; 1.003,1.013; p < .001). In pediatric patients, each 10 mL/kg of PRBC was associated with a 1.2% increase in the average number of thromboses (1.012; 1.008,1.012; p < .001). The percent increase in the average number of thromboses was similar between PRBCs, platelets, and FFP, but increased significantly with cryoprecipitate. CONCLUSIONS RBC transfusions and hemostatic transfusions are likely associated with thromboses in pediatric patients on ECMO.
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Affiliation(s)
- Michael J Martinez
- Department of Pediatrics, Division of Cardiology, Hassenfeld Children's Hospital at NYU, New York, NY, USA
| | - Tahmineh Romero
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Myke D Federman
- Department of Pediatrics, Division of Critical Care Medicine, Mattel Children's Hospital at UCLA, Los Angeles, CA, USA
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Kim J, Yeo HJ, Cho WH, Lee HJ. Predictors of mortality and transfusion requirements in venoarterial extracorporeal membrane oxygenation patients. Lab Med 2024; 55:347-354. [PMID: 37706544 DOI: 10.1093/labmed/lmad089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023] Open
Abstract
OBJECTIVE The aim of this study was to evaluate the prognostic impact of variables, including thrombocytopenia and the amount of platelet transfusion, for predicting survival in venoarterial extracorporeal membrane oxygenation (ECMO) recipients. Additionally, we aimed to identify the predictors of increased transfusion requirement during venoarterial ECMO support. METHODS All patients who received venoarterial ECMO between December 2008 and March 2020 were retrospectively analyzed. Univariate and multivariate Cox regressions were used to evaluate in-hospital mortality according to variables including thrombocytopenia and daily average of platelet concentrate transfusion. Stepwise multiple linear regression analysis was used to identify independent predictors for transfusion requirements. RESULTS Analysis of 218 patients demonstrated severe thrombocytopenia as an independent predictor of in-hospital mortality (hazard ratio = 2.840, 95% CI: 1.593-5.063, P < .001), along with age, pre-ECMO cardiac arrest, and pH. In contrast, the amount of platelet transfusion was not associated with in-hospital mortality. Multiple variables, including the type of indication for ECMO were associated with transfusion requirements. CONCLUSION Our findings identified severe thrombocytopenia as an independent prognostic factor of in-hospital mortality. However, daily average platelet transfusion was not associated with survival outcomes. Additionally, our study identified predictive variables of increased transfusion requirements.
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Affiliation(s)
- Jongmin Kim
- Department of Laboratory Medicine, Pusan National University Hospital, Busan, Korea
| | - Hye Ju Yeo
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Korea
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Woo Hyun Cho
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Korea
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Hyun-Ji Lee
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
- Department of Laboratory Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
- Department of Laboratory Medicine, Pusan National University School of Medicine, Yangsan, Korea
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Luo Z, Qin L, Xu S, Yang X, Peng Z, Huang C. Impact of fresh frozen plasma transfusion on mortality in extracorporeal membrane oxygenation. Perfusion 2024; 39:294-303. [PMID: 36305199 DOI: 10.1177/02676591221137034] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
BACKGROUND Patients who receive extracorporeal membrane oxygenation (ECMO) support require substantial transfusions. Red blood cell (RBC) and platelet (PLT) transfusions have been reported to be associated with adverse outcomes in ECMO patients. However, little is known about whether the transfusion of fresh frozen plasma (FFP) is associated with mortality and morbidity among patients receiving ECMO. The aim of this study was to examine the relationship between FFP transfusion and mortality in ECMO patients and assess risk factors for the transfusion of FFP. METHODS The clinical parameters of 116 ECMO patients were collected. The machine learning approach of the Boruta algorithm was employed to select the variables associated with ECMO patients' in-hospital mortality. Univariate and multivariate logistic regression analyses were applied to identify the association between the selected variables and in-hospital mortality. Spearman correlation and backwards stepwise multiple linear regression analyses were used to examine parameters contributing to FFP transfusion. RESULTS Among the 116 patients who received ECMO support, the in-hospital mortality was 32.8%. The median FFP (mL/kg/d) transfusion was higher in dead patients (5.07, IQR 1.78-8.90) when compared to alive patients (2.16, IQR 0.79-4.66) (p = 0.007). After adjustment for confounders, FFP transfusion (mL/kg/d) was associated with in-hospital mortality (OR 1.09, 95% CI, 1.01-1.18; p = 0.035). Further analysis found that higher activated partial thromboplastin time (APTT), higher levels of uric acid (UA) and lower PLT counts were significant risk factors for FFP transfusion, with estimated values of 0.06 (95% CI, 0.02-0.11; p = 0.009), 0.01 (95% CI, 0.00-0.02; p = 0.003) and -0.03 (95% CI, -0.05--0.01; p = 0.007), respectively. CONCLUSION FFP transfusion is markedly associated with in-hospital mortality among patients receiving ECMO, and higher APTT, higher levels of UA and lower PLT counts are risk factors for FFP transfusion. This suggests that better management of patients' coagulation system and kidney function may reduce the utilization of FFP, thus improving ECMO patient outcomes.
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Affiliation(s)
- Zhenglian Luo
- Department of Transfusion Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Li Qin
- Department of Transfusion Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Shilan Xu
- Department of Transfusion Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Xinxin Yang
- Department of Transfusion Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Zhuoyue Peng
- Department of Transfusion Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Chunyan Huang
- Department of Transfusion Medicine, West China Hospital, Sichuan University, Chengdu, China
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Braaten JA, Dillon BS, Wothe JK, Olson CP, Lusczek ER, Sather KJ, Beilman GJ, Brunsvold ME. Extracorporeal Membrane Oxygenation Patient Outcomes Following Restrictive Blood Transfusion Protocol. Crit Care Explor 2023; 5:e1020. [PMID: 38107536 PMCID: PMC10723844 DOI: 10.1097/cce.0000000000001020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023] Open
Abstract
OBJECTIVES To investigate the effect of a restrictive blood product utilization protocol on blood product utilization and clinical outcomes. DESIGN We retrospectively reviewed all adult extracorporeal membrane oxygenation (ECMO) patients from January 2019 to December 2021. The restrictive protocol, implemented in March 2020, was defined as transfusion of blood products for a hemoglobin level less than 7, platelet levels less than 50, and/or fibrinogen levels less than 100. Subgroup analysis was performed based on the mode of ECMO received: venoarterial ECMO, venovenous ECMO, and ECMO support following extracorporeal cardiopulmonary resuscitation (ECPR). SETTING M Health Fairview University of Minnesota Medical Center. PATIENTS The study included 507 patients. INTERVENTIONS One hundred fifty-one patients (29.9%) were placed on venoarterial ECMO, 70 (13.8%) on venovenous ECMO, and 286 (56.4%) on ECPR. MEASUREMENTS AND MAIN RESULTS For patients on venoarterial ECMO (48 [71.6%] vs. 52 [63.4%]; p = 0.374), venovenous ECMO (23 [63.9%] vs. 15 [45.5%]; p = 0.195), and ECPR (54 [50.0%] vs. 69 [39.2%]; p = 0.097), there were no significant differences in survival on ECMO. The last recorded mean hemoglobin value was also significantly decreased for venoarterial ECMO (8.10 [7.80-8.50] vs. 7.50 [7.15-8.25]; p = 0.001) and ECPR (8.20 [7.90-8.60] vs. 7.55 [7.10-8.88]; p < 0.001) following implementation of the restrictive transfusion protocol. CONCLUSIONS These data suggest that a restrictive transfusion protocol is noninferior to ECMO patient survival. Additional, prospective randomized trials are required for further investigation of the safety of a restrictive transfusion protocol.
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Muche Y, Gelaw Y, Atnaf A, Getaneh Z. Blood Transfusion Complications and Associated Factors Among Blood-Transfused Adult Patients at Debre Markos Comprehensive Specialized Hospital, Ethiopia: A Cross Sectional Study. J Blood Med 2023; 14:389-398. [PMID: 37313438 PMCID: PMC10259606 DOI: 10.2147/jbm.s412002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 05/26/2023] [Indexed: 06/15/2023] Open
Abstract
Background Blood transfusion is the infusion of whole blood or its components into the veins of the patient to improve tissue oxygenation and maintain hemostasis. Besides its clinical use, it can pose a risk of transfusion complications with different factors. Purpose The aim of this study was to assess blood transfusion complications, and associated factors among transfused adult patients at Debre Markos Comprehensive Specialized Hospital, North West Ethiopia, 2022. Materials and Methods An institution-based cross-sectional study design was conducted on a total of 182 patients from March 20 to June 15, 2022. Patients were enrolled in the study using consecutive sampling method. The socio-demographic and clinical data were collected using a structured questionnaire and data extraction sheet, respectively. About 3 ml of anti-coagulated blood and 30 ml of urine samples were collected to assess transfusion complications. CBC and Coombs test were performed from blood and urinalysis from urine, respectively. Chi-square, Fisher's exact test, and binary logistic regression were done using SPSS version 25. P-values less than 0.05 are declared as statistically significant. Results An acute transfusion reaction (ATR) was encountered in 12 (6.6%) patients. It was 4.13, 7.78 and 3.96 times more likely to occur among patients with a previous history of transfusion, abortion, and transfused blood stored for more than 20 days compared to their counterparts, respectively. In addition, the odds of developing ATR increase by 2.07 as the number of transfused blood units increases by 1 unit. Conclusion The incidence of acute transfusion reactions was high. During transfusion, clinicians should closely monitor patients who had history of transfusion, abortion, transfused old blood and more than 1 unit.
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Affiliation(s)
- Yalew Muche
- Department of Medical Laboratory Sciences, College of Medicine and Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | - Yemataw Gelaw
- Department of Hematology & Immunohematology, School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Aytenew Atnaf
- Department of Medical Laboratory Sciences, College of Medicine and Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | - Zegeye Getaneh
- Department of Hematology & Immunohematology, School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Tang W, Zhang WT, Zhang J, Jiang KH, Ge YW, Zheng AB, Wang QW, Xue P, Chen HL. Prevalence of hematologic complications on extracorporeal membranous oxygenation in critically ill pediatric patients: A systematic review and meta-analysis. Thromb Res 2023; 222:75-84. [PMID: 36603406 DOI: 10.1016/j.thromres.2022.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 12/13/2022] [Accepted: 12/20/2022] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Despite advances in Extracorporeal Membranous Oxygenation (ECMO) equipment, hematologic complications remain significant in critically ill children. The aim of this study is to summarize prevalence of hematologic complications for children and neonates. METHODS MEDLINE, PubMed and Scopus databases were searched focusing on the period from January 01, 2017 to October 01, 2022. The population included critically ill children and neonates with hematologic complications. The review included all aspects of related complications including hemorrhage, thrombosis, and hemolysis. We performed random effects meta-analyses. The primary outcome measure was overall hematologic complications. Secondary outcomes are changes in the prevalence of hemorrhagic complications. Risk of bias of included studies was assessed using the Joanna Briggs Institute checklist. RESULTS The systematic search identified 37 studies totaling 10,659 critically ill pediatric patients receiving ECMO. The pooled prevalence of hemorrhagic complications, thrombotic complications and hemolysis among pediatric patients requiring ECMO was 43.7 % (95 % CI: 28.6 % to 58.9 %, P < 0.001), 27.6 % (95 % CI: 20.4 % to 34.8 %, P < 0.001), 34.3 % (95 % CI: 22.9 % to 45.7 %, P < 0.001). The prevalence of hemorrhagic complications was represented in descending order: surgical site (21.6 %, 95 % CI: 10.3 % to 32.9 %); cannulation site (20.6 %, 95 % CI: 11.8 % to 29.3 %); intracranial (12.2 %, 95 % CI: 9.5 % to 15.0 %); pulmonary (7.7 %, 95 % CI: 5.9 % to 9.6 %); gastrointestinal (6.0 %, 3.7 % to 8.4 %). For the assessment of thrombotic complications, thrombosis in cannulation site had a higher prevalence (28.5 %, 95 % CI: 22.1 % to 34.9 %), followed by DIC (13.5 %, 95 % CI: 8.7 % to 18.3 %) and intracranial thrombosis (4.5 %, 95 % CI: 1.4 % to 7.6 %). Predictors of increased prevalence of hemorrhagic complications included age (P = 0.017) and VV-ECMO support mode (P = 0.029). CONCLUSIONS Among critically ill pediatric patients, there was a series of hematologic complications can occur during ECMO support. Physicians should pay special attention to the management and establish appropriate treatment programs to reduce the occurrence of hematologic complications.
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Affiliation(s)
- Wen Tang
- Medical School, Nantong University, Nantong, China
| | - Wen-Ting Zhang
- Affiliated Changzhou Children's Hospital of Nantong University, Changzhou Children's Hospital, Changzhou, China
| | - Jun Zhang
- Affiliated Changzhou Children's Hospital of Nantong University, Changzhou Children's Hospital, Changzhou, China
| | - Kai-Hua Jiang
- Affiliated Changzhou Children's Hospital of Nantong University, Changzhou Children's Hospital, Changzhou, China
| | - Ya-Wen Ge
- Affiliated Changzhou Children's Hospital of Nantong University, Changzhou Children's Hospital, Changzhou, China
| | - Ai-Bing Zheng
- Affiliated Changzhou Children's Hospital of Nantong University, Changzhou Children's Hospital, Changzhou, China
| | - Qiu-Wei Wang
- Affiliated Changzhou Children's Hospital of Nantong University, Changzhou Children's Hospital, Changzhou, China
| | - Peng Xue
- Affiliated Changzhou Children's Hospital of Nantong University, Changzhou Children's Hospital, Changzhou, China.
| | - Hong-Lin Chen
- School of Public Health, Nantong University, Nantong, China.
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Platelet Transfusion and In-Hospital Mortality in Veno-Arterial Extracorporeal Membrane Oxygenation Patients. ASAIO J 2022; 68:1249-1255. [PMID: 34967786 DOI: 10.1097/mat.0000000000001643] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Thrombocytopenia is common during extracorporeal membrane oxygenation (ECMO), and platelets are sometimes transfused to meet arbitrary goals. We performed a retrospective cohort study of veno-arterial (VA) ECMO patients from a single academic medical center and explored the relationship between platelet transfusion and in-hospital mortality using multivariable logistic regression. One hundred eighty-eight VA ECMO patients were included in the study. Ninety-one patients (48.4%) were transfused platelets during ECMO. Patients who received platelet transfusion had more coronary artery disease, lower platelet counts at cannulation, higher predicted mortality, lower nadir platelet counts, more ECMO days, and more red blood cell (RBC) and plasma transfusion. Mortality was 19.6% for patients who received no platelets, 40.8% for patients who received 1-3 platelets, and 78.6% for patients who received 4 or more platelets ( P < 0.001). After controlling for confounding variables including baseline severity of illness, central cannulation, postcardiotomy status, RBC and plasma transfusion, major bleeding, and total ECMO days, transfusion of 4 or more platelets remained associated with in-hospital mortality; OR = 4.68 (95% CI = 1.18-27.28), P = 0.03. Our findings highlight the need for randomized controlled trials that compare different platelet transfusion triggers, so that providers can better understand when platelet transfusion is indicated in VA ECMO patients.
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Mazzeffi MA, Rao VK, Dodd-O J, Del Rio JM, Hernandez A, Chung M, Bardia A, Bauer RM, Meltzer JS, Satyapriya S, Rector R, Ramsay JG, Gutsche J. Intraoperative Management of Adult Patients on Extracorporeal Membrane Oxygenation: An Expert Consensus Statement From the Society of Cardiovascular Anesthesiologists-Part II, Intraoperative Management and Troubleshooting. Anesth Analg 2021; 133:1478-1493. [PMID: 34559091 DOI: 10.1213/ane.0000000000005733] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In the second part of the Society of Cardiovascular Anesthesiologists Extracorporeal Membrane Oxygenation (ECMO) working group expert consensus statement, venoarterial (VA) and venovenous (VV) ECMO management and troubleshooting in the operating room are discussed. Expert consensus statements are provided about intraoperative monitoring, anesthetic drug dosing, and management of intraoperative problems in VA and VV ECMO patients.
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Affiliation(s)
- Michael A Mazzeffi
- From the Department of Anesthesiology and Critical Care Medicine, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Vidya K Rao
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alton, California
| | - Jeffrey Dodd-O
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jose Mauricio Del Rio
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - Antonio Hernandez
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Mabel Chung
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard University School of Medicine, Boston, Massachusetts
| | - Amit Bardia
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut
| | - Rebecca M Bauer
- Department of Anesthesiology, University of Massachusetts School of Medicine, Worcester, Massachusetts
| | - Joseph S Meltzer
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles School of Medicine, Los Angeles, California
| | - Sree Satyapriya
- Department of Anesthesiology, Ohio State University School of Medicine, Columbus, Ohio
| | - Raymond Rector
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - James G Ramsay
- Department of Anesthesia and Perioperative Care, University of California San Francisco School of Medicine, San Francisco, California
| | - Jacob Gutsche
- Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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Mazzeffi MA, Rao VK, Dodd-O J, Del Rio JM, Hernandez A, Chung M, Bardia A, Bauer RM, Meltzer JS, Satyapriya S, Rector R, Ramsay JG, Gutsche J. Intraoperative Management of Adult Patients on Extracorporeal Membrane Oxygenation: an Expert Consensus Statement From the Society of Cardiovascular Anesthesiologists- Part II, Intraoperative Management and Troubleshooting. J Cardiothorac Vasc Anesth 2021; 35:3513-3527. [PMID: 34774253 DOI: 10.1053/j.jvca.2021.07.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Michael A Mazzeffi
- Department of Anesthesiology and Critical Care Medicine, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia.
| | - Vidya K Rao
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alton, California
| | - Jeffrey Dodd-O
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jose Mauricio Del Rio
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - Antonio Hernandez
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Mabel Chung
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard University School of Medicine, Boston, Massachusetts
| | - Amit Bardia
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut
| | - Rebecca M Bauer
- Department of Anesthesiology, University of Massachusetts School of Medicine, Worcester, Massachusetts
| | - Joseph S Meltzer
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles School of Medicine, Los Angeles, California
| | - Sree Satyapriya
- Department of Anesthesiology, Ohio State University School of Medicine, Columbus, Ohio
| | - Raymond Rector
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - James G Ramsay
- Department of Anesthesia and Perioperative Care, University of California San Francisco School of Medicine, San Francisco, California
| | - Jacob Gutsche
- Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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11
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Karam O, Nellis ME. Transfusion management for children supported by extracorporeal membrane oxygenation. Transfusion 2021; 61:660-664. [PMID: 33491189 DOI: 10.1111/trf.16272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 01/03/2021] [Accepted: 01/04/2021] [Indexed: 11/30/2022]
Abstract
Due to the patients' underlying illness, in combination with circuit-induced coagulopathy, as well as PLT dysfunction, children supported by ECMO are a risk of receiving large volumes of blood components. Given the increasing use of modified blood products and newer biologics, it is unknown whether these products have equal efficacy and safety, in ECMO. The majority of guidance for transfusion therapy is based on expert opinion alone, and research on indications for RBC, plasma, and PLT transfusions for children on ECMO should be a priority.
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Affiliation(s)
- Oliver Karam
- Division of Pediatric Critical Care Medicine, Children's Hospital of Richmond at VCU, Richmond, Virginia
| | - Marianne E Nellis
- Pediatric Critical Care Medicine, NY Presbyterian Hospital - Weill Cornell Medicine, New York, New York
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12
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Mazzeffi M, Bathula A, Tabatabai A, Menaker J, Kaczorowski D, Madathil R, Galvagno S, Pasrija C, Rector R, Tanaka K, Herr D. Von Willebrand Factor Concentrate Administration for Acquired Von Willebrand Syndrome- Related Bleeding During Adult Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2020; 35:882-887. [PMID: 32758410 DOI: 10.1053/j.jvca.2020.06.083] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 06/26/2020] [Accepted: 06/27/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To review the use of Von Willebrand Factor (VWF) concentrate for treatment of acquired Von Willebrand syndrome (VWS)-related bleeding in adult extracorporeal membrane oxygenation (ECMO) patients and determine if it was associated with improved VWF laboratory parameters. DESIGN Retrospective observational cohort study. SETTING Tertiary care academic medical center. PARTICIPANTS Adult ECMO patients who received VWF concentrate for treatment of acquired VWS- related bleeding. INTERVENTIONS None, observational study. MEASUREMENTS AND MAIN RESULTS Ten adult ECMO patients received VWF concentrate for treatment of bleeding with evidence of acquired VWS over a 15-month period. Six patients were on veno-arterial ECMO and 4 were on veno-venous ECMO. The most common site of bleeding was airway or tracheal bleeding. The mean dose of VWF concentrate was 41 IU/kg. Mean VWF antigen was 263 ± 93 IU/dL before treatment and 394 ± 54 after treatment. Mean ristocetin cofactor activity was 127 ± 47 IU/dL before treatment and 240 ± 33 after treatment. The mean VWF ristocetin cofactor activity antigen ratio increased from 0.52 ± 0.14 before treatment to 0.62 ± 0.04 after treatment. Four of 10 patients had complete resolution of their bleeding within 24 hours, and 6 of 10 had complete resolution of their bleeding within 2- to- 4 days. There were 3 patients who had thrombotic events potentially related to VWF concentrate administration. No patient had an arterial thrombosis, stroke, or myocardial infarction. CONCLUSIONS VWF concentrate administration increases VWF function in adult ECMO patients, but also may be associated with increased thrombotic risk. Larger studies are needed to determine VWF concentrate's safety, efficacy, and optimal dosing in adult ECMO patients.
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Affiliation(s)
- Michael Mazzeffi
- University of Maryland School of Medicine, Department of Anesthesiology, Baltimore, MD.
| | - Allison Bathula
- University of Maryland Medical Center, Department of Pharmacy, Baltimore, MD
| | - Ali Tabatabai
- University of Maryland School of Medicine, Department of Medicine, Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD
| | - Jay Menaker
- University of Maryland School of Medicine, Department of Surgery, Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD
| | - David Kaczorowski
- University of Maryland School of Medicine, Department of Surgery, Division of Cardiothoracic Surgery, Baltimore, MD
| | - Ronson Madathil
- University of Maryland School of Medicine, Department of Surgery, Division of Cardiothoracic Surgery, Baltimore, MD
| | - Samuel Galvagno
- University of Maryland School of Medicine, Department of Anesthesiology, Baltimore, MD
| | - Chetan Pasrija
- University of Maryland School of Medicine, Department of Surgery, Division of Cardiothoracic Surgery, Baltimore, MD
| | - Raymond Rector
- University of Maryland School of Medicine, Department of Surgery, Division of Cardiothoracic Surgery, Baltimore, MD
| | - Kenichi Tanaka
- University of Maryland School of Medicine, Department of Anesthesiology, Baltimore, MD
| | - Daniel Herr
- University of Maryland School of Medicine, Department of Medicine, Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD
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