Hemoglobin trigger and approach to red blood cell transfusions during veno-venous extracorporeal membrane oxygenation: the international TRAIN-ECMO survey

Abstract

Introduction:

Optimal red blood cell transfusion practice during veno-venous extracorporeal membrane oxygenation (VV ECMO) is still under debate. This survey aimed to assess the Hb trigger (also comparing with other critically ill patients) and major physiologic determinants considered for transfusions during veno-venous extracorporeal membrane oxygenation.

Methods:

Voluntary Web-based survey, endorsed by the European Society of Intensive Care Medicine, conducted among VV ECMO pratictioners worldwide.

Results:

A total of 447 respondents worldwide answered the questionnaire: 277 (61.9%) from Europe, 99 (22.1%) from North America, 36 (8.2%) from Asia and Oceania, and 35 (7.8%) from Central and South America. Among the respondents, 59.2% managed less than 12 venous extracorporeal membrane oxygenation runs/year, 19.4% between 12 and 24 runs/year, and 21.4% more than 24 runs/year. Of the respondents, 54.4% do not use a predefined Hb trigger in veno-venous extracorporeal membrane oxygenation, and, while the rate of adoption of a defined trigger varied worldwide, the effective value of Hb did not differ significantly among macro-regions. In patients on veno-venous extracorporeal membrane oxygenation, the Hb trigger to initiate red blood cell transfusion, was higher than in other critically ill patients: 9.1 ± 1.8 g/dL versus 8.3 ± 1.7 g/dL, p < 0.01. The Hb trigger was lower in centers with more than 24 venous extracorporeal membrane oxygenation runs/year (8.4 mg/dL (95% CI: 7.7-8.9)); (8.9 mg/dL (95% CI: 8.2-9.7)) in centers with between 12 and 24 venous extracorporeal membrane oxygenation runs/year; and (9.6 mg/dL (95% CI: 9.1-10.0)) in centers with fewer than 12 venous extracorporeal membrane oxygenation runs/year (p < 0.01). Several and variable adjunctive parameters are considered in cases of uncertainty for transfusion: the principal are hemodynamic status, SvO2, lactates, and fluid balance.

Conclusion:

Although the use of a predefined Hb trigger is still under-adopted among centers with low or median extracorporeal membrane oxygenation case volume, the majority of respondents use a higher Hb trigger for veno-venous extracorporeal membrane oxygenation patients compared with other critically ill patients. Higher volume centers tolerate lower Hb levels.

Keywords

Extracorporeal membrane oxygenation acute respiratory distress syndrome outcome critically ill patients hemoglobin hematocrit transfusion iron threshold

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References

Bellani

Laffey

Pham

et al . Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries. JAMA 2016; 315: 788–800.

Rozencwajg

Pilcher

Combes

et al . Outcomes and survival prediction models for severe adult acute respiratory distress syndrome treated with extracorporeal membrane oxygenation. Crit Care 2016; 20: 392.

Combes

Pesenti

Ranieri

. Fifty years of research in ARDS. Is extracorporeal circulation the future of acute respiratory distress syndrome management? Am J Respir Crit Care Med 2017; 195: 1161–1170.

Abrams

Brodie

. Extracorporeal membrane oxygenation for adult respiratory failure: 2017 update. Chest 2017; 152: 639–649.

Combes

Brodie

Bartlett

et al . Position paper for the organization of extracorporeal membrane oxygenation programs for acute respiratory failure in adult patients. Am J Respir Crit Care Med 2014; 190: 488–496.

Combes

Hajage

Capellier

et al . Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome. N Engl J Med 2018; 378: 1965–1975.

Zangrillo

Biondi-Zoccai

Landoni

et al . Extracorporeal membrane oxygenation (ECMO) in patients with H1N1 influenza infection: a systematic review and meta-analysis including 8 studies and 266 patients receiving ECMO. Crit Care 2013; 17: R30.

Fan

Gattinoni

Combes

et al . Venovenous extracorporeal membrane oxygenation for acute respiratory failure: a clinical review from an international group of experts. Intensive Care Med 2016; 42: 712–724.

Winkler

. Transfusion management during extracorporeal support. In: Brogan

Lequier

Lorusso

et al (eds) Extracorporeal life support: the ELSO red book. 5th ed. Ann Arbor, MI: ELSO—Extracorporeal Life Support Organization, 2018, pp. 105–116.

10.

Hebert

Wells

Blajchman

et al . A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med 1999; 340: 409–417.

11.

Agerstrand

Burkart

Abrams

et al . Blood conservation in extracorporeal membrane oxygenation for acute respiratory distress syndrome. Ann Thorac Surg 2015; 99: 590–595.

12.

Martucci

Panarello

Occhipinti

et al . Anticoagulation and transfusions management in veno-venous extracorporeal membrane oxygenation for acute respiratory distress syndrome: assessment of factors associated with transfusion requirements and mortality. J Intensive Care Med. Epub ahead of print 1 January 2017. DOI: 10.1177/0885066617706339.

13.

Smith

Hardison

Bridges

et al . Red blood cell transfusion volume and mortality among patients receiving extracorporeal membrane oxygenation. Perfusion 2013; 28: 54–60.

14.

Swol

Marschall

Strauch

et al . Hematocrit and impact of transfusion in patients receiving extracorporeal life support. Perfusion 2018; 33: 546–552.

15.

Vincent

Sakr

Sprung

et al . Are blood transfusions associated with greater mortality rates? Results of the Sepsis Occurrence in Acutely Ill Patients study. Anesthesiology 2008; 108: 31–39.

16.

Vincent

. Indications for blood transfusions: too complex to base on a single number. Ann Intern Med 2012; 157: 71–72.

17.

Millar

Fanning

McDonald

et al . The inflammatory response to extracorporeal membrane oxygenation (ECMO): a review of the pathophysiology. Crit Care 2016; 20: 387.

18.

Chant

Wilson

Friedrich

. Anemia, transfusion, and phlebotomy practices in critically ill patients with prolonged ICU length of stay: a cohort study. Crit Care 2006; 10: R140.

19.

Vincent

Sakr

Lelubre

. The future of observational research and randomized controlled trials in red blood cell transfusion medicine. Shock 2014; 41(Suppl. 1): 98–101.

20.

Esper

Welsby

Subramaniam

et al . Adult extracorporeal membrane oxygenation: an international survey of transfusion and anticoagulation techniques. Vox Sang 2017; 112: 443–452.

21.

Bembea

Annich

Rycus

et al . Variability in anticoagulation management of patients on extracorporeal membrane oxygenation: an international survey. Pediatr Crit Care Med 2013; 14: e77–e84.

22.

Eysenbach

. Improving the quality of Web surveys: the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). J Med Internet Res 2004; 6: e34.

23.

Jones

Story

Clavisi

et al . An introductory guide to survey research in anaesthesia. Anaesth Intensive Care 2006; 34: 245–253.

24.

Kelley

Clark

Brown

et al . Good practice in the conduct and reporting of survey research. Int J Qual Health Care 2003; 15: 261–266.

25.

Laffey

Madotto

Bellani

et al . Geo-economic variations in epidemiology, patterns of care, and outcomes in patients with acute respiratory distress syndrome: insights from the LUNG SAFE prospective cohort study. Lancet Respir Med 2017; 5: 627–638.

26.

Laffey

Pham

Bellani

. Continued under-recognition of acute respiratory distress syndrome after the Berlin definition: what is the solution. Curr Opin Crit Care 2017; 23: 10–17.

27.

Vaquer

deHaro

Peruga

et al . Systematic review and meta-analysis of complications and mortality of veno-venous extracorporeal membrane oxygenation for refractory acute respiratory distress syndrome. Ann Intensive Care 2017; 7: 51.

28.

Vincent

Van Der Linden

. Restrictive versus more liberal blood transfusions? The answer is in your heart. Minerva Anestesiol 2016; 82: 511–513.

29.

Buscher

Vukomanovic

Benzimra

et al . Blood and anticoagulation management in extracorporeal membrane oxygenation for surgical and nonsurgical patients: a single-center retrospective review. J Cardiothorac Vasc Anesth 2017; 31: 869–875.

30.

Holst

Haase

Wetterslev

et al . Lower versus higher hemoglobin threshold for transfusion in septic shock. N Engl J Med 2014; 371: 1381–1391.

31.

Tobian

Heddle

Wiegmann

et al . Red blood cell transfusion: 2016 clinical practice guidelines from AABB. Transfusion 2016; 56: 2627–2630.

32.

Peek

Mugford

Tiruvoipati

et al . Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet 2009; 374(: 1351–1363.

33.

Pavenski

Stanworth

Fung

et al . Quality of evidence-based guidelines for transfusion of red blood cells and plasma: a systematic review. Transfus Med Rev 2018; 32: 135–143.

34.

American Society of Anesthesiologists Task Force on Perioperative Blood Management. Practice guidelines for perioperative blood management: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Management. Anesthesiology 2015; 122: 241–275.

35.

Grasselli

Scaravilli

Di Bella

et al . Nosocomial infections during extracorporeal membrane oxygenation: incidence, etiology, and impact on patients’ outcome. Crit Care Med 2017; 45: 1726–1733.

36.

Tulman

Stawicki

Whitson

et al . Veno-venous ECMO: a synopsis of nine key potential challenges, considerations, and controversies. BMC Anesthesiol 2014; 14: 65.

37.

Addison

Buck

Fang

et al . Decreased blood product usage during extracorporeal life support with reduced circuit volumes. Transfusion 2017; 57: 1391–1395.

38.

Karagiannidis

Brodie

Strassmann

et al . Extracorporeal membrane oxygenation: evolving epidemiology and mortality. Intensive Care Med 2016; 42: 889–896.

39.

Aubron

Cheng

Pilcher

et al . Factors associated with outcomes of patients on extracorporeal membrane oxygenation support: a 5-year cohort study. Crit Care 2013; 17: R73.

40.

Lo Pinto

Allyn

Persichini

et al . Predictors of red blood cell transfusion and its association with prognosis in patients undergoing extracorporeal membrane oxygenation. Int J Artif Organs 2018; 41: 644–652.

41.

Cavarocchi

Wallace

Hong

et al . A cost-reducing extracorporeal membrane oxygenation (ECMO) program model: a single institution experience. Perfusion 2015; 30: 148–153.

42.

Ejaz

Frank

Spolverato

et al . Potential economic impact of using a restrictive transfusion trigger among patients undergoing major abdominal surgery. JAMA Surg 2015; 150: 625–630.

43.

Roncon-Albuquerque

Jr Almeida

Lopes

et al . Cost analysis of miniaturized ECMO in H1N1-related ARDS managed by a single caregiver. Intensive Care Med 2014; 40: 910–911.

44.

Blum

Lynch

Coopersmith

. Clinical and billing review of extracorporeal membrane oxygenation. Chest 2015; 147: 1697–1703.