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Martucci G, Schmidt M, Agerstrand C, Tabatabai A, Tuzzolino F, Giani M, Ramanan R, Grasselli G, Schellongowski P, Riera J, Hssain AA, Duburcq T, Gorjup V, De Pascale G, Buabbas S, Gannon WD, Jeon K, Trethowan B, Fanelli V, Chico JI, Balik M, Broman LM, Pesenti A, Combes A, Ranieri MV, Foti G, Buscher H, Tanaka K, Lorusso R, Arcadipane A, Brodie D, Arcadipane A, Pesenti A, Grasselli G, Brioni M, De Pascale G, Montini L, Giani M, Foti G, Bosa L, Curcio P, Fanelli V, Garofalo E, Martin-Villen L, Garcìa-Álvarez R, Lopez Sanchez M, Principe N, Chica Saez V, Chico JI, Gomez V, Colomina-Climent J, Riera J, Pacheco AF, Gorjup V, Goutay J, Thibault D, Szułdrzyński K, Eller P, Lobmeyr E, Schellongowski P, Schmidt M, Combes A, Lorusso R, Mariani S, Ranieri MV, Suk P, Maly M, Balik M, Forestier J, Broman LM, Rizzo M, Tuzzolino F, Tanaka K, Holsworth T, Trethowan B, Serra A, Agerstrand C, Brodie D, Cavayas YA, Tabatabai A, Menaker J, Galvagno S, Gannon WD, Rice TW, Grandin WE, Nunez J, Cheplic C, Ramanan R, Rivosecchi R, Cho YJ, Buabbas S, Jeon K, Kwan MC, Sallam H, Villanueva JA, Aliudin J, Ait Hssain A, Hoshino K, Hara Y, Ramanathan K, Maclaren G, Buscher H. Transfusion practice in patients receiving VV ECMO (PROTECMO): a prospective, multicentre, observational study. Lancet Respir Med 2023; 11:245-255. [PMID: 36240836 DOI: 10.1016/s2213-2600(22)00353-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 08/18/2022] [Accepted: 08/22/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND In patients receiving venovenous (VV) extracorporeal membrane oxygenation (ECMO) packed red blood cell (PRBC) transfusion thresholds are usually higher than in other patients who are critically ill. Available guidelines suggest a restrictive approach, but do not provide specific recommendations on the topic. The main aim of this study was, in a short timeframe, to describe the actual values of haemoglobin and the rate and the thresholds for transfusion of PRBC during VV ECMO. METHODS PROTECMO was a multicentre, prospective, cohort study done in 41 ECMO centres in Europe, North America, Asia, and Australia. Consecutive adult patients with acute respiratory distress syndrome (ARDS) who were receiving VV ECMO were eligible for inclusion. Patients younger than 18 years, those who were not able to provide informed consent when required, and patients with an ECMO stay of less than 24 h were excluded. Our main aim was to monitor the daily haemoglobin concentration and the value at the point of PRBC transfusion, as well as the rate of transfusions. The practice in different centres was stratified by continent location and case volume per year. Adjusted estimates were calculated using marginal structural models with inverse probability weighting, accounting for baseline and time varying confounding. FINDINGS Between Dec 1, 2018, and Feb 22, 2021, 604 patients were enrolled (431 [71%] men, 173 [29%] women; mean age 50 years [SD 13·6]; and mean haemoglobin concentration at cannulation 10·9 g/dL [2·4]). Over 7944 ECMO days, mean haemoglobin concentration was 9·1 g/dL (1·2), with lower concentrations in North America and high-volume centres. PRBC were transfused on 2432 (31%) of days on ECMO, and 504 (83%) patients received at least one PRBC unit. Overall, mean pretransfusion haemoglobin concentration was 8·1 g/dL (1·1), but varied according to the clinical rationale for transfusion. In a time-dependent Cox model, haemoglobin concentration of less than 7 g/dL was consistently associated with higher risk of death in the intensive care unit compared with other higher haemoglobin concentrations (hazard ratio [HR] 2·99 [95% CI 1·95-4·60]); PRBC transfusion was associated with lower risk of death only when transfused when haemoglobin concentration was less than 7 g/dL (HR 0·15 [0·03-0·74]), although no significant effect in reducing mortality was reported for transfusions for other haemoglobin classes (7·0-7·9 g/dL, 8·0-9·9 g/dL, or higher than 10 g/dL). INTERPRETATION During VV ECMO, there was no universally accepted threshold for transfusion, but PRBC transfusion was invariably associated with lower mortality only when done with haemoglobin concentration of less than 7 g/dL. FUNDING Extracorporeal Life Support Organization.
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Affiliation(s)
- Gennaro Martucci
- Department of Anesthesia and Intensive Care, Istituto Mediterraneo per i trapianti e Terapie ad alta specializzazione (IRCCS-ISMETT), Palermo, Italy.
| | - Matthieu Schmidt
- INSERM 1166, Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris France; Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Paris, France
| | - Cara Agerstrand
- Department of Medicine and Center for Acute Respiratory Failure, Irving Medical Center, Columbia University, New York, NY, USA
| | - Ali Tabatabai
- School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Fabio Tuzzolino
- Statistics and Data Management Services, Istituto Mediterraneo per i trapianti e Terapie ad alta specializzazione (IRCCS-ISMETT), Palermo, Italy
| | - Marco Giani
- Ospedale San Gerardo, Università degli Studi Di Milano-Bicocca, Monza, Italy
| | - Raj Ramanan
- Department of Critical Care, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Giacomo Grasselli
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Italy
| | - Peter Schellongowski
- Department of Medicine I, Intensive Care Unit 13i2, Center of Excellence in Medical Intensive Care, Medical University of Vienna, Vienna, Austria
| | - Jordi Riera
- Critical Care Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Shock Organ Dysfunction and Resuscitation, Vall d'Hebron Institut de Recerca, Barcelona, Spain; Centro de Investigacion en Red de Enfermedades Respiratorias Instituto de Salud Carlos III, Barcelona, Spain
| | | | - Thibault Duburcq
- Centre Hospitalier Regional Universitaire Lille, Hôpital Roger Salengro, Lille, France
| | | | - Gennaro De Pascale
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy; Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Sarah Buabbas
- Kuwait Extracorporeal Life Support Program, Jaber Al-Ahmad Alsabah Hospital, Kuwait City, Kuwait
| | - Whitney D Gannon
- Department of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kyeongman Jeon
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Brian Trethowan
- Meijer Heart Center Butterworth Hospital, Spectrum Health, Grand Rapids, MI, USA
| | - Vito Fanelli
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Juan I Chico
- Critical Care Department, Alvaro Cunqueiro University Hospital, Vigo, Spain
| | - Martin Balik
- Department of Anesthesiology and Intensive Care, 1st Medical Faculty, General University Hospital, Prague, Czech Republic
| | - Lars M Broman
- ECMO Centre Karolinska, Karolinska University Hospital, Stockholm, Sweden; Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Antonio Pesenti
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Italy
| | - Alain Combes
- INSERM 1166, Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris France; Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Paris, France
| | | | - Giuseppe Foti
- Ospedale San Gerardo, Università degli Studi Di Milano-Bicocca, Monza, Italy
| | - Hergen Buscher
- Department of Intensive Care Medicine, St Vincent's Hospital, Sydney, NSW, Australia
| | - Kenichi Tanaka
- The University of Oklahoma Health Sciences Center, University of Oklahoma, Oklahoma City, OK, USA
| | - Roberto Lorusso
- Cardiothoracic Surgery Department, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Antonio Arcadipane
- Department of Anesthesia and Intensive Care, Istituto Mediterraneo per i trapianti e Terapie ad alta specializzazione (IRCCS-ISMETT), Palermo, Italy
| | - Daniel Brodie
- Department of Medicine and Center for Acute Respiratory Failure, Irving Medical Center, Columbia University, New York, NY, USA
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