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1. The interaction of thrombocytopenia, hemorrhage, and platelet transfusion in venoarterial extracorporeal membrane oxygenation: a multicenter observational study

Author

Senta Jorinde Raasveld, Claudia van den Oord, Jimmy Schenk, Walter M. van den Bergh, Annemieke Oude Lansink - Hartgring, Franciska van der Velde, Jacinta J. Maas, Pablo van de Berg, Roberto Lorusso, Thijs S. R. Delnoij, Dinis Dos Reis Miranda, Erik Scholten, Fabio Silvio Taccone, Dieter F. Dauwe, Erwin De Troy, Greet Hermans, Federico Pappalardo, Evgeny Fominskiy, Višnja Ivancan, Robert Bojčić, Jesse de Metz, Bas van den Bogaard, Dirk W. Donker, Christiaan L. Meuwese, Martin De Bakker, Benjamin Reddi, José P. S. Henriques, Lars Mikael Broman, Dave A. Dongelmans, and Alexander P. J. Vlaar

Subjects
Thrombocytopenia, Platelet transfusion, Hemorrhage, Venoarterial extracorporeal membrane oxygenation, Medical emergencies. Critical care. Intensive care. First aid, RC86-88.9
Abstract

Abstract Background Thrombocytopenia, hemorrhage and platelet transfusion are common in patients supported with venoarterial extracorporeal membrane oxygenation (VA ECMO). However, current literature is limited to small single-center experiences with high degrees of heterogeneity. Therefore, we aimed to ascertain in a multicenter study the course and occurrence rate of thrombocytopenia, and to assess the association between thrombocytopenia, hemorrhage and platelet transfusion during VA ECMO. Methods This was a sub-study of a multicenter (N = 16) study on transfusion practices in patients on VA ECMO, in which a retrospective cohort (Jan-2018–Jul-2019) focusing on platelets was selected. The primary outcome was thrombocytopenia during VA ECMO, defined as mild (100–150·109/L), moderate (50–100·109/L) and severe (

Published
2023
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2. Plasma Transfusion and Procoagulant Product Administration in Extracorporeal Membrane Oxygenation: A Secondary Analysis of an International Observational Study on Current Practices

Author

Maite M.T. van Haeren, MD, Senta Jorinde Raasveld, MD, Mina Karami, MD, PhD, Dinis Dos Reis Miranda, MD, PhD, Loes Mandigers, MD, Dieter F. Dauwe, MD, PhD, Erwin De Troy, MD, Federico Pappalardo, MD, PhD, Evgeny Fominskiy, MD, PhD, Walter M. van den Bergh, MD, PhD, Annemieke Oude Lansink-Hartgring, MD, PhD, Franciska van der Velde, MD, Jacinta J. Maas, MD, PhD, Pablo van de Berg, MD, PhD, Maarten de Haan, ECCP, Dirk W. Donker, MD, PhD, Christiaan L. Meuwese, MD, PhD, Fabio Silvio Taccone, MD, PhD, Lorenzo Peluso, MD, Roberto Lorusso, MD, PhD, Thijs S.R. Delnoij, MD, Erik Scholten, MD, Martijn Overmars, MD, Višnja Ivancan, MD, PhD, Robert Bojčić, MD, Jesse de Metz, MD, PhD, Bas van den Bogaard, MD, PhD, Martin de Bakker, MB, BCh, BAO, Benjamin Reddi, MBChB, PhD, Greet Hermans, MD, PhD, Lars Mikael Broman, MD, PhD, José P.S. Henriques, MD, PhD, Jimmy Schenk, PhD, Alexander P.J. Vlaar, MD, PhD, and Marcella C.A. Müller, MD, PhD

Subjects
Medical emergencies. Critical care. Intensive care. First aid, RC86-88.9
Abstract

OBJECTIVES:. To 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. DESIGN:. A 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. SETTING:. Sixteen international ICUs. PATIENTS:. Adult patients on VA-ECMO or VV-ECMO. INTERVENTIONS:. None. MEASUREMENTS AND MAIN RESULTS:. Of 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). CONCLUSIONS:. The 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.

Published
2023
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3. RBC Transfusion in Venovenous Extracorporeal Membrane Oxygenation: A Multicenter Cohort Study

Author

Senta Jorinde Raasveld, Mina Karami, Walter M. van den Bergh, Annemieke Oude Lansink-Hartgring, Franciska van der Velde, Jacinta J. Maas, Pablo van de Berg, Maarten de Haan, Roberto Lorusso, Thijs S. R. Delnoij, Dinis Dos Reis Miranda, Loes Mandigers, Erik Scholten, Martijn Overmars, Fabio Silvio Taccone, Alexandre Brasseur, Dieter F. Dauwe, Erwin De Troy, Greet Hermans, Philippe Meersseman, Federico Pappalardo, Evgeny Fominskiy, Višnja Ivancan, Robert Bojčić, Jesse de Metz, Bas van den Bogaard, Dirk W. Donker, Christiaan L. Meuwese, Martin de Bakker, Benjamin Reddi, Sanne de Bruin, Wim K. Lagrand, José P. S. Henriques, Lars M. Broman, Alexander P. J. Vlaar, Intensive Care, Graduate School, Intensive Care Medicine, Cardiology, ACS - Atherosclerosis & ischemic syndromes, ACS - Pulmonary hypertension & thrombosis, AII - Inflammatory diseases, ANS - Neuroinfection & -inflammation, ACS - Microcirculation, CTC, MUMC+: MA Med Staf Spec CTC (9), RS: Carim - V04 Surgical intervention, MUMC+: MA Medische Staf IC (9), MUMC+: MA Med Staf Spec Cardiologie (9), Critical care, Anesthesiology, Peri-operative and Emergency medicine (CAPE), Cardiovascular and Respiratory Physiology, and TechMed Centre

Subjects
Adult, Male, Croatia, RESPIRATORY-FAILURE, LIFE-SUPPORT, Critical Care and Intensive Care Medicine, Cohort Studies, Belgium, threshold, Humans, Netherlands, Retrospective Studies, transfusion, Sweden, 22/3 OA procedure, Australia, ADULTS, Middle Aged, extracorporeal membrane oxygenation, mortality, Intensive Care Units, Treatment Outcome, Italy, Female, Erythrocyte Transfusion, REQUIREMENTS, red blood cells
Abstract

OBJECTIVES: In the general critical care patient population, restrictive transfusion regimen of RBCs has been shown to be safe and is yet implemented worldwide. However, in patients on venovenous extracorporeal membrane oxygenation, guidelines suggest liberal thresholds, and a clear overview of RBC transfusion practice is lacking. This study aims to create an overview of RBC transfusion in venovenous extracorporeal membrane oxygenation. DESIGN: Mixed method approach combining multicenter retrospective study and survey. SETTING: Sixteen ICUs worldwide. PATIENTS: Patients receiving venovenous extracorporeal membrane oxygenation between January 2018 and July 2019. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the proportion receiving RBC, the amount of RBC units given daily and in total. Furthermore, the course of hemoglobin over time during extracorporeal membrane oxygenation was assessed. Demographics, extracorporeal membrane oxygenation characteristics, and patient outcome were collected. Two-hundred eight patients received venovenous extracorporeal membrane oxygenation, 63% male, with an age of 55 years (45-62 yr), mainly for acute respiratory distress syndrome. Extracorporeal membrane oxygenation duration was 9 days (5-14 d). Prior to extracorporeal membrane oxygenation, hemoglobin was 10.8 g/dL (8.9-13.0 g/dL), decreasing to 8.7 g/dL (7.7-9.8 g/dL) during extracorporeal membrane oxygenation. Nadir hemoglobin was lower on days when a transfusion was administered (8.1 g/dL [7.4-9.3 g/dL]). A vast majority of 88% patients received greater than or equal to 1 RBC transfusion, consisting of 1.6 U (1.3-2.3 U) on transfusion days. This high transfusion occurrence rate was also found in nonbleeding patients (81%). Patients with a liberal transfusion threshold (hemoglobin > 9 g/dL) received more RBC in total per transfusion day and extracorporeal membrane oxygenation day. No differences in survival, hemorrhagic and thrombotic complication rates were found between different transfusion thresholds. Also, 28-day mortality was equal in transfused and nontransfused patients. CONCLUSIONS: Transfusion of RBC has a high occurrence rate in patients on venovenous extracorporeal membrane oxygenation, even in nonbleeding patients. There is a need for future studies to find optimal transfusion thresholds and triggers in patients on extracorporeal membrane oxygenation.

Published
2022

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