Multicenter Analysis of Platelet Transfusion Usage Among Neonates on Extracorporeal Membrane Oxygenation

Abstract

ABSTRACT. Objective. Multiple platelet transfusions are invariably given to neonates on extracorporeal membrane oxygenation (ECMO), and no alternative to repeated transfusions exists. Before any alternatives, such as administration of thrombopoietic stimulators, could be contemplated, data regarding the number of platelet transfusions received by neonatal ECMO patients is needed, and the mechanisms that cause the thrombocytopenia of these patients must be better defined. As a step toward determining this, we analyzed the use of platelet transfusions in this group of neonates. We conducted a historic cohort study of neonates who were treated with ECMO to determine the number of platelet units received as a function of 1) days on ECMO, 2) medical diagnosis for which ECMO Results. Of the 234 ECMO patients, 81 were placed on VV, 138 were placed on VA, and 15 were converted from VV to VA. The average number of platelet transfusions received per day was 1.3 and varied by diagnosis and by type of ECMO. Neonates with meconium aspiration and sepsis required more platelet transfusions per day than neonates with other conditions. Infants who were converted from VV to VA required more transfusions per day (mean: 1.57) than did patients on VA (1.47) or VV (1.06).Conclusions. Platelet transfusions among neonates on ECMO are dependent of their medical diagnosis; they average 1.3 transfusions per day and are higher on VA than VV ECMO. Pediatrics 2002;109(6). URL: http://www. pediatrics.org/cgi/content/full/109/6/e89; neonates, extracorporeal membrane oxygenation, platelet transfusions.ABBREVIATIONS. ECMO, extracorporeal membrane oxygenation; PPHN, persistent pulmonary hypertension; CDH, congenital diaphragmatic hernia; MAS, meconium aspiration syndrome; RDS, respiratory distress syndrome; VV, venovenous; VA, venoarterial. E xtracorporeal membrane oxygenation (ECMO) is a mainstay therapy of modern neonatology. In fact, certain neonatal patients survive only because of ECMO. 1,2 ECMO is used to treat a variety of conditions in neonatal patients, including respiratory and cardiac failure as a result of persistent pulmonary hypertension (PPHN), congenital diaphragmatic hernia (CDH), meconium aspiration syndrome (MAS), respiratory distress syndrome (RDS), pneumonia, severe air-leak syndromes, and sepsis.The platelet count falls immediately after a neonate is placed on ECMO. The rapidity of this fall suggests that the predominant mechanism that causes thrombocytopenia is accelerated platelet destruction. 3 Presumably, this occurs by activation and adherence of platelets to the circuit tubing or the membrane oxygenator. 4 When accelerated platelet destruction occurs among adult patients, platelet production rapidly increases in an attempt to compensate. 5 The compensatory mechanisms include increasing the size, ploidy, and number of megakaryocytes. By deploying these mechanisms, platelet production can increase by 3-to 5-fold, and such compensation is successful unless the rate of platelet destruction exceeds the rate of maximum pla...

Hemolytic and thrombocytopathic characteristics of extracorporeal membrane oxygenation systems at simulated flow rate for neonates*

“…Previous literature proposed that platelet levels were important in predicting intracranial hemorrhage when platelet counts were <200,000/mm 3 (31), when platelet counts were difficult to maintain (32), or with increasing platelet transfusion requirements (33). Further research found a significant correlation between the total number of platelet transfusions and the length of the ECMO run (34), attributing the large need for platelet transfusions during ECMO because of impairment of platelet function (35-37). Although the mechanisms of platelet dysfunction are not completely understood, several researchers believe it is the result of deficiency of platelet agonists.…”

Adherence to NICU transfusion guidelines: data from a multihospital healthcare system

“…12,18,19 Future randomized trials, using different transfusion 'trigger levels' would be helpful in assessing this issue. Similarly, we are aware of little evidence to support giving erythrocyte transfusions to non-bleeding, non-mechanically ventilated NICU patients with a hemoglobin >9 g per 100 ml.…”

Massive RBC fragmentation masks severe thrombocytopenia in both impedance and optical platelet count measurements – a case report of a neonate on ECMO support

“…These include persistent pulmonary hypertension, congenital diaphragmatic hernia, meconium aspiration syndrome, respiratory distress syndrome, pneumonia, severe air-leak syndromes, sepsis and septic shock. (1,2) Even though lifesaving, ECMO introduces a high risk of complications including intravascular haemolysis, bleeding or clot formation, inflammation and sepsis. (3,4) Thrombocytopenia in neonates is a major problem in neonatal intensive care units (NICU), as studies have shown the association of thrombocytopenia with increased mortality, length of hospital stay as well as some major comorbidities such as intraventricular haemorrhage, disseminated intravascular coagulopathy and necrotising enterocolitis.…”

“…Therefore, the impedance method allows for the differentiation of different cell lineages, such as platelets and red blood cells (RBCs), based on the cell size. (1,5) This is sufficient when platelet and RBC size are normal. However, in cases of abnormal platelet (large platelets) or RBC (microcytes, shizocytes) size, cell fragments, and less commonly, bacteraemia and cryoglobulins, impedance platelet counting is subjected to interferences because of overlap between RBCs and platelets and is therefore inadequate as a method for counting platelets.…”