Reduction in blood product transfusion requirements with early on-ECMO repair of congenital diaphragmatic hernia

Abstract Background For infants with severe congenital diaphragmatic hernia (CDH) stabilized with extracorporeal membrane oxygenation (ECMO), early repair on ECMO improves outcome; however when compared to operative repair after ECMO, repair on ECMO is associated with increase bleeding risk and need for blood product transfusions. Methods A retrospective review of 54 patients with CDH placed on ECMO prior to CDH repair was performed. For the subset of patients repaired on ECMO, analysis comparing those repaired early (within 48 h of cannulation) and late (beyond 48 h) on ECMO was performed. Outcomes of interest included survival to discharge, days on ECMO, and postoperative blood product utilization. Results When compared to those patients repaired prior to 48 h of ECMO initiation, 57.7% of patients survived versus 40.9% of late repair patients. For those repaired early, blood product utilization was significantly less. Early repair patients received a median of 72 mL/kg packed red blood cells (PRBC) and 75 mL/kg platelets compared to 151.9 mL/kg and 98.7 mL/kg, respectively (p < 0.05 respectively). There was no difference in median days on ECMO (p = 0.38). Conclusion Our data supports prior reports of improved outcome with repair with 48 h of ECMO initiation and suggests early repair on ECMO is associated with less bleeding and decreased blood product requirement in the postoperative period.

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UK Helicopter Emergency Medical Services’ use of circulatory access devices, blood product transfusion and fluid warmers – a cross-sectional survey

Trauma ◽

10.1177/1460408618819642 ◽

2018 ◽

Vol 22 (1) ◽

pp. 45-50

Author(s):

Jonathan Morris ◽

Simon Hughes

Keyword(s):

Red Blood Cells ◽

Blood Cells ◽

Blood Product ◽

Central Venous Access ◽

Venous Access ◽

Blood Product Transfusion ◽

Blood Products ◽

Central Venous ◽

Packed Red Blood Cells ◽

Warming Devices

Introduction The pre-hospital environment provides significant challenges to clinicians who wish to rapidly administer warmed blood products and fluids to patients with haemorrhagic shock. Large-bore circulatory access is required with the use of devices that will successfully warm cold blood with minimal impact on flow rates. Until now, no information has been available that defines UK Helicopter Emergency Medical Services’ (HEMS) use of circulatory access and fluid warming devices, nor the recent adoption of pre-hospital blood product transfusion. Methods A survey was sent to all 22 UK HEMS asking which circulatory access devices crews have available, whether blood products are being transfused and if fluid warming devices are used as part of their resuscitations. Results All services responded. All UK HEMS use peripheral intravenous cannulae and intraosseous access. In addition, seven use central venous catheters and three use large-bore peripheral access (the Arrow Rapid Infusion Catheter®). Three services use landmark technique alone to gain central venous access, whereas four use a combination of landmark and ultrasound-guided techniques. Different sites for central venous access are used: subclavian (seven services), internal jugular (four) and femoral (four). Fourteen services carry pre-hospital blood products of which six transfuse packed red blood cells; four transfuse packed red blood cells and fresh frozen plasma; four transfuse packed red blood cells and lyophilised plasma. Eight services carry no pre-hospital blood products. Seventeen HEMS use fluid warmers; 13 use the Belmont® buddy lite™ and four use the QinFlow Warrior. Conclusion The use of a variety of policies and range of equipment has evolved across UK HEMS, demonstrating a lack of consensus on best practice. This is the first study to record a complete picture of current UK HEMS practice with regard to the use of circulatory access devices, fluid warmers and blood product administration.

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Desmopressin Reduces Transfusion Needs after Surgery

Anesthesiology ◽

10.1097/aln.0b013e31818db18b ◽

2008 ◽

Vol 109 (6) ◽

pp. 1063-1076 ◽

Cited By ~ 97

Author(s):

Giuseppe Crescenzi ◽

Giovanni Landoni ◽

Giuseppe Biondi-Zoccai ◽

Federico Pappalardo ◽

Massimiliano Nuzzi ◽

...

Keyword(s):

Blood Loss ◽

Excess Mortality ◽

Blood Product ◽

Meta Analysis ◽

Blood Product Transfusion ◽

Blood Products ◽

Hemostatic Agents ◽

Randomized Controlled ◽

Randomized Controlled Studies ◽

Transfusion Requirements

Background Perioperative pathologic microvascular bleeding is associated with increased morbidity and mortality and could be reduced by hemostatic drugs. At the same time, safety concerns regarding existing hemostatic agents include excess mortality. Numerous trials investigating desmopressin have lacked power to detect a beneficial effect on transfusion of blood products. The authors performed a meta-analysis of 38 randomized, placebo-controlled trials (2,488 patients) investigating desmopressin in surgery and indicating at least perioperative blood loss or transfusion of blood products. Methods Pertinent studies were searched in BioMed Central, CENTRAL, and PubMed (updated May 1, 2008). Further hand or computerized searches involved recent (2003-2008) conference proceedings. Results In most of the included studies, 0.3 microg/kg desmopressin was used prophylactically over a 15- to 30-min period. In comparison with placebo, desmopressin was associated with reduced requirements of blood product transfusion (standardized mean difference = -0.29 [-0.52 to -0.06] units per patient; P = 0.01), which were more pronounced in the subgroup of noncardiac surgery and were without a statistically significant increase in thromboembolic adverse events (57/1,002 = 5.7% in the desmopressin group vs. 45/979 = 4.6% in the placebo group; P = 0.3). Conclusions Desmopressin slightly reduced blood loss (almost 80 ml per patient) and transfusion requirements (almost 0.3 units per patient) in surgical patients, without reduction in the proportion of patients who received transfusions. This meta-analysis suggests the importance of further large, randomized controlled studies using desmopressin in patients with or at risk of perioperative pathologic microvascular bleeding.

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Estimating the ratio of multivariate recurrent event rates with application to a blood transfusion study

Statistical Methods in Medical Research ◽

10.1177/0962280215593974 ◽

2015 ◽

Vol 26 (4) ◽

pp. 1969-1981 ◽

Cited By ~ 7

Author(s):

Jing Ning ◽

Mohammad H Rahbar ◽

Sangbum Choi ◽

Jin Piao ◽

Chuan Hong ◽

...

Keyword(s):

Blood Cells ◽

Latent Variables ◽

Recurrent Events ◽

Blood Product ◽

Massive Transfusion ◽

Informative Censoring ◽

Recurrent Event ◽

Dependence Structure ◽

Blood Product Transfusion ◽

Finite Sample

In comparative effectiveness studies of multicomponent, sequential interventions like blood product transfusion (plasma, platelets, red blood cells) for trauma and critical care patients, the timing and dynamics of treatment relative to the fragility of a patient’s condition is often overlooked and underappreciated. While many hospitals have established massive transfusion protocols to ensure that physiologically optimal combinations of blood products are rapidly available, the period of time required to achieve a specified massive transfusion standard (e.g. a 1:1 or 1:2 ratio of plasma or platelets:red blood cells) has been ignored. To account for the time-varying characteristics of transfusions, we use semiparametric rate models for multivariate recurrent events to estimate blood product ratios. We use latent variables to account for multiple sources of informative censoring (early surgical or endovascular hemorrhage control procedures or death). The major advantage is that the distributions of latent variables and the dependence structure between the multivariate recurrent events and informative censoring need not be specified. Thus, our approach is robust to complex model assumptions. We establish asymptotic properties and evaluate finite sample performance through simulations, and apply the method to data from the PRospective Observational Multicenter Major Trauma Transfusion study.

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Blood Utilization at Regional Hospitals

American Journal of Clinical Pathology ◽

10.1093/ajcp/aqz131.000 ◽

2019 ◽

Vol 152 (Supplement_1) ◽

pp. S151-S151

Author(s):

Ryan Demkowicz ◽

Josephine Dermawan ◽

Sindu Shetty ◽

Richard Scarborough ◽

Haiyan Lu ◽

...

Keyword(s):

Decision Process ◽

Blood Cells ◽

Chart Review ◽

Blood Product ◽

Transfusion Medicine ◽

Screening Criteria ◽

Packed Red Blood Cells ◽

Blood Utilization ◽

Regional Hospitals ◽

Multiple Units

Abstract Introduction Transfusion medicine is unique to lab medicine. While it still involves testing and reporting of results, it is one of the few areas where the laboratory is providing treatment. The risk of providing a blood product must be weighed against the benefit before the decision is made to transfuse a patient. Our study looked at blood utilization at our regional hospitals to assess if there were areas where we need to improve this decision process. Methods Chart reviews were performed for patients who received packed red blood cells (RBCs) in the regional hospitals over a 2-month period. Using the AABB and Choosing Wisely recommendations, we created two screening criteria: hemoglobin (Hb) >8 g/dL or greater than 1 unit RBC ordered when Hb is >6 g/dL to screen for outliers among RBC orders. A more in-depth chart review including information on clinical diagnosis, indications, bleeding status, and blood loss during surgery was performed on cases that met these criteria. Using this information, a decision was made on the appropriateness of the transfusion. Results In total, 1,592 RBC units were screened at eight regional hospitals. Sixty-eight (4%) were flagged as inappropriate, 57 (83.8%) due to multiple units, and 11 (16.2%) for an Hb >8 g/dL. The percentage of inappropriate transfusions at a hospital ranged from 5.2% to 13.6%. However, all hospitals except one were under 5.5%. Discussion In general, regional physicians are transfusing RBCs appropriately. When a unit is ordered inappropriately, it is most likely due to ordering multiple units upfront. To further improve blood utilization, these data were presented to hospital administration and a new alert in the EMR was created. A repeat study will be performed to see if the alerts and awareness of these data has had an effect on blood utilization.

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Reply: Effect of low central venous pressure and phlebotomy on blood product transfusion requirements during liver transplantations

Liver Transplantation ◽

10.1002/lt.20855 ◽

2006 ◽

Vol 12 (8) ◽

pp. 1303-1304

Author(s):

Luc Massicotte ◽

Serge Lénis ◽

Lynda Thibeault ◽

André Roy

Keyword(s):

Central Venous Pressure ◽

Blood Product ◽

Venous Pressure ◽

Blood Product Transfusion ◽

Central Venous ◽

Transfusion Requirements ◽

Liver Transplantations ◽

Low Central Venous Pressure

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Effect of low central venous pressure and phlebotomy on blood product transfusion requirements during liver transplantations

Liver Transplantation ◽

10.1002/lt.20559 ◽

2005 ◽

Vol 12 (1) ◽

pp. 117-123 ◽

Cited By ~ 189

Author(s):

Luc Massicotte ◽

Serge Lenis ◽

Lynda Thibeault ◽

Marie-Pascale Sassine ◽

Robert F. Seal ◽

...

Keyword(s):

Central Venous Pressure ◽

Blood Product ◽

Venous Pressure ◽

Blood Product Transfusion ◽

Central Venous ◽

Transfusion Requirements ◽

Liver Transplantations ◽

Low Central Venous Pressure

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Congenital diaphragmatic hernia repair in patients requiring extracorporeal membrane oxygenation: are outcomes better with repair on ECMO or after decannulation?

Interactive Cardiovascular and Thoracic Surgery ◽

10.1093/icvts/ivaa303 ◽

2020 ◽

Author(s):

Zhao Kai Low ◽

Amelia Su May Tan ◽

Masakazu Nakao ◽

Kok Hooi Yap

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Hernia Repair ◽

Congenital Diaphragmatic Hernia ◽

Diaphragmatic Hernia ◽

Bleeding Risk ◽

Aminocaproic Acid ◽

Bleeding Complications ◽

Membrane Oxygenation ◽

Study Type ◽

Diaphragmatic Hernia Repair

Summary A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether congenital diaphragmatic hernia repair outcomes are better before or after decannulation in infants requiring extracorporeal membrane oxygenation (ECMO). A total of 884 papers were found using the reported search, of which 9 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that infants with congenital diaphragmatic hernia requiring ECMO should undergo a trial of weaning and aim for post-decannulation repair, as this has been associated with improved survival, shorter ECMO duration and fewer bleeding complications. However, if weaning of ECMO is unsuccessful, the patient should ideally undergo early on-ECMO repair (within 72 h of cannulation), which has been associated with improved survival, less bleeding, shorter ECMO duration and fewer circuit changes compared to late on-ECMO repair. Anticoagulation protocols including perioperative administration of aminocaproic acid or tranexamic acid, as well as close perioperative monitoring of coagulation parameters have been associated with reduced bleeding risk with on-ECMO repairs.

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Thrombocytopenia Associated with Perceval Sutureless Aortic Valve Replacement in Elderly Patients: A Word of Caution

The Heart Surgery Forum ◽

10.1532/hsf.1324 ◽

2015 ◽

Vol 18 (3) ◽

pp. 093 ◽

Cited By ~ 9

Author(s):

Turki B. Albacker

Keyword(s):

Aortic Valve ◽

Elderly Patients ◽

Blood Cells ◽

Slow Recovery ◽

Aortic Valves ◽

Significant Drop ◽

Extreme Caution ◽

Packed Red Blood Cells ◽

Transfusion Requirements ◽

First Time

Objective: The aim of this study was to report for the first time the phenomenon of thrombocytopenia associated with the use of sutureless aortic valve replacements (AVR), and try to find an explanation for its occurrence.Methods: The data was collected retrospectively for all patients who had sutureless AVR (7 patients) and was compared to patients who underwent sutured AVR (22 patients) by the same surgeon between February 2012 and November 2013. Results: Cardiopulmonary bypass and cross-clamp durations were shorter in the sutureless group (96.4 min, 70.6 min) compared to the sutured group (128.3 min, 97.3 min), (P = .04, P = .003) respectively. Mean transvalvular gradients were lower in the sutureless group (mean = 9.6 mmHg) compared to the sutured group (mean = 17.3 mmHg). Platelet levels were significantly lower in the Perceval patients compared to the Enable patients and sutured valves. Platelet transfusion was higher for sutureless valves (6.5 units versus 5.4 units for the sutured group, P = .63), especially the Perceval valve (7.6 units versus 5.3 for the Enable valve, P = .35), but was not statistically significant. Packed red blood cells (PRBCs) transfusion was significantly higher in the sutureless group (6 units versus 3.1 for the sutured group, P = .002). Conclusion: The implantation of sutureless aortic valves, especially the Perceval valve, was associated with a significant drop in platelet count postoperatively with slow recovery and higher PRBCs transfusion requirements. Extreme caution should be taken before the routine use of these valves in elderly patients who are already at risk of thrombocytopenia postoperatively.

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Hepatopulmonary fusion associated with right-sided congenital diaphragmatic hernia: management of this rare anomaly and a review of the literature

Journal of International Medical Research ◽

10.1177/0300060518759892 ◽

2018 ◽

Vol 46 (12) ◽

pp. 5278-5284 ◽

Cited By ~ 1

Author(s):

Hamdi H. Almaramhy

Keyword(s):

Respiratory Distress ◽

Congenital Diaphragmatic Hernia ◽

Diaphragmatic Hernia ◽

Search Engines ◽

English Literature ◽

Relevant Literature ◽

Review Of The Literature ◽

Operative Repair ◽

Rare Anomaly ◽

Rare Malformation

Hepatopulmonary fusion is a rare malformation that is often discovered during operative repair of right-sided congenital diaphragmatic defects. Based on a search using medical search engines, we only found 22 cases of hepatopulmonary fusion in the English literature worldwide to date. We describe herein a case of hepatopulmonary fusion with right-sided congenital diaphragmatic hernia in a female neonate who presented with respiratory distress. We discuss management of this case and review the relevant literature.

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Prognostic impact of blood product transfusion in VA and VV ECMO

Perfusion ◽

10.1177/0267659118814690 ◽

2018 ◽

Vol 34 (3) ◽

pp. 246-253 ◽

Cited By ~ 4

Author(s):

Guillaume Guimbretière ◽

Amedeo Anselmi ◽

Antoine Roisne ◽

Bernard Lelong ◽

Hervé Corbineau ◽

...

Keyword(s):

Fresh Frozen Plasma ◽

Blood Product Transfusion ◽

Prognostic Impact ◽

Post Transplantation ◽

Reliable Technique ◽

Packed Red Blood Cells ◽

Transfusion Requirements ◽

Va Ecmo ◽

Vv Ecmo

Background: Extracorporeal membrane oxygenation (ECMO) is an accepted and reliable technique to provide temporary circulatory and/or respiratory support. Our objective was to describe the transfusion requirements in ECMO recipients. Secondarily, we addressed the effect of indications for ECMO on transfusion requirements and the baseline factors associated with worse survival. Methods: We reviewed the prospectively collected data of 509 patients receiving venoarterial (VA) or venovenous (VV) ECMO therapy (2005-2016). Follow-up was prospectively conducted. Data were prospectively entered in the Rennes ECMO database. Results: VA ECMO was employed in 81% of cases; indications were post-cardiotomy myocardial failure in 28% of cases, post-heart transplantation (early graft failure) in 13.2% and cardiogenic shock in 149 (36.4%). VV ECMO was employed in the remaining patients. Average follow-up was 80.25 ± 85.13 days and was 100% complete. In the VA and VV groups, survival at the 30th post-implantation day was 58.3% and 71.1%, respectively, and survival at 6 months was 40.5% and 50.5%, respectively. Platelets and prothrombin time (PT) levels were significantly lower in the VA ECMO group at implantation (p<0.001). VA ECMO patients had a higher rate of thrombotic/haemorrhagic complications (p<0.001) and received both fresh frozen plasma (FFP) (60.5% vs. 31.8% p<0.001) and platelet units (Plt) (61.7% vs. 34.1% p<0.001) more frequently than VV ECMO patients. Post-cardiotomy and post-transplantation patients had significantly higher rates of transfusion of packed red blood cells (pRBC), FFP and Plt than other VA ECMO cases (p<0.001, all). Mortality was equal or greater than 80% among patient subgroups who received more than 19 pRBC, 5 Plt and/or 12 FFP. Conclusions: An ECMO program is associated with important consumption of blood products. VA ECMO patients have a greater transfusion burden than VV ECMO patients. Mortality is greater in the case of extreme transfusion requirements.

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