Pediatric Plasma and Platelet Transfusions on Extracorporeal Membrane Oxygenation: A Subgroup Analysis of Two Large International Point-Prevalence Studies and the Role of Local Guidelines

Abstract

Objectives: To describe the indications and thresholds for plasma and platelet transfusions for pediatric extracorporeal membrane oxygenation, to compare responses to these transfusions and to describe institutional protocols directing their administration.

Design: Subgroup analysis of two prospective, observational studies paired with survey of sites who enrolled subjects into this cohort.

Setting: Fifty-one PICUs in 13 countries.

Patients: Children (3 d to 16 yr old) were enrolled if they received a plasma or platelet transfusion while on extracorporeal membrane oxygenation during one of the predefined screening weeks.

Interventions: None.

Measurements and main results: Forty-eight children on extracorporeal membrane oxygenation received plasma transfusions and 90 received platelet transfusions. Sixty percent of plasma transfusions (29/48) and 79% of the platelet transfusions (71/90) were given for prophylaxis of bleeding. The median (interquartile range) international normalized ratio prior to transfusion, known in 75% of the patients (36/48), was 1.45 (1.20-1.85). The median (interquartile range) total platelet count prior to transfusion, known in all of the patients, was 70 × 10/L (52-90 × 10/L). The international normalized ratio and total platelet count values prior to transfusion did not vary based on bleeding versus nonbleeding indications. The median (interquartile range) reduction in international normalized ratio for mild coagulopathies (international normalized ratio ≤ 2.0) was 0.1 (0.4-0), median (interquartile range) increase in fibrinogen was 0.2 g/L (0.1-0.4 g/L) and median increase in total platelet count was 34 × 10/L (10-74 × 10/L). Through the course of their admission, children supported by extracorporeal membrane oxygenation received a total median (interquartile range) dose of 75 mL/kg (36-159 mL/kg) of plasma transfusions and 92 mL/kg (42-239 mL/kg) of platelet transfusions. Institutional protocols varied but provided guidance for platelet transfusions more commonly.

Conclusions: Children supported by extracorporeal membrane oxygenation receive large volumes of plasma and platelet transfusions with some institutional guidance in the form of protocols, but significant variation in practice. Interventional studies are necessary to provide evidence to direct the transfusion of hemostatic products in children supported by extracorporeal membrane oxygenation.

Figure 1.

Comparison of pre and post INR values in bleeding versus non-bleeding indications for plasma. Mild outliers (<1.5 IQR) and extreme outliers (>1.5 IQR) are marked with circles and asterisks, respectively.

Figure 2.

Comparison of pre and post fibrinogen values in bleeding versus non-bleeding indications for plasma

Figure 3.

Comparison of pre and post TPC values in bleeding versus non-bleeding indications for platelets

Figure 4A:

Boxplot of stated plasma transfusion thresholds based on INR, according to the bleeding status based on the survey (n=9).

Figure 4B:

Boxplot of stated platelet transfusion thresholds based on platelet count (10⁶ cells), according to the bleeding status based on the survey (n=23).