(P-TS-51) Evaluation of Transfusion Volumes and Donor Exposure in a Complex Pediatric ECMO Population

Background/Case Studies: Extracorporeal membrane oxygenation (ECMO) can be a life-saving modality but is associated with bleeding and thrombosis complications. Transfusions occur frequently during pediatric ECMO, with recent literature reporting a mean of almost 30 ml/kg/day of transfused red blood cells (RBC) and 12 ml/kg/day of platelets, with >50% reported as prophylactic transfusions. While there are no prospective studies published to date evaluating optimal transfusion thresholds on pediatric ECMO, there is evidence that patients who receive higher volume transfusions may have increased mortality. With increased transfusion volume, donor exposure would be expected to increase as well, although there remains a paucity of literature on this aspect of transfusion during pediatric ECMO.

Study

Design/Methods: We conducted a retrospective review of pediatric ECMO cases from January 1 to December 31, 2024 at a tertiary care children’s hospital. All transfusions administered during ECMO were analyzed with review of blood bank records and manual chart review.

Results/Findings: There were 36 ECMO runs for 32 unique patients, with a mean age of 4.7 years (range: 0 days to 61 years). Mean ECMO duration was 403 hours. Congenital heart disease was the most common diagnosis (24/32, 75%), with 63% of patients requiring cardiac surgery within 1 week prior to or during their ECMO run. Mean volume of products transfused (ml/kg/day) during ECMO was: RBC 10.3, plasma 3.5, platelets 2.3 and cryoprecipitate 1.0. Most common hemoglobin threshold for transfusion was < 8 gm/dL and platelet threshold < 30,000/microliter, guided by institutional ECMO recommendations, with 33% (12/36) of ECMO runs in this cohort with no platelet transfusion. Regarding product modification, 25% received washed RBCs at least once, with indications including: pump prime in neonates and infants, patients in renal failure, and for potential heart transplant patients based on guideline development with blood bank and heart failure team leadership. Median donor exposure was 10 (range: 2-137), with increased donor exposure with use of plasmapheresis and renal replacement therapy on ECMO and for ECMO pump prime. Survival to ECMO decannulation was 75% for the overall cohort. However, in patients requiring > 18 ml/kg/day of RBCs, survival was 17% (1/6) and of 8 ECMO runs in 7 patients with >20 donor exposures, survival was 37%.

Conclusions: Volume of transfused products may be decreased by use of transfusion guidelines for pediatric patients on ECMO using clinical assessments of oxygen delivery and functional assessments of coagulation and platelet function, even in a complex pediatric cardiac population. Future study should evaluate the potential association of donor exposures and product modifications on antibody development, particularly for patients who may ultimately require heart transplant.