TrainECMO |
Introduction
Dear Colleague,
We would like to invite you to take part in this survey on your practice concerning transfusions of red blood cells during extracorporeal membrane oxygenation (ECMO).
Mortality associated with acute respiratory distress syndrome (ARDS) remains high despite continual improvement in mechanical ventilation and ECMO.
Technical simplifications, and its use during the 2009 H1N1 influenza pandemic prompted a sharp increase in the use of ECMO worldwide. Despite the lack of large randomized controlled trials, the survival rate in large volume centers has improved over recent years.
The optimal management of an anticoagulation target and transfusion practice in VV-ECMO patients is still under debate. [1] Traditionally, the threshold for transfusions of packed red blood cells (PRBC) in ECMO aims to keep hemoglobin values (Hb) in the normal range (12-14 g/dL).
More recently, this notion has been challenged by several case series that reported on lower transfusion thresholds and good outcomes. [2]
Even if strict triggers have been questioned by several experts because they appear to be too simplistic, a liberal transfusion strategy in critically ill patients seems to be associated with increased morbidity and mortality, as many randomized controlled studies have shown. [3]
There is also some evidence that a higher number of transfusions in ECMO patients is associated with worse outcomes, but such a relationship is difficult to assess.
Considering the conventionally accepted restrictive strategy on different populations of critically ill patients, as well as the increasing experience with ECMO management, and improvement in the equipment, the aim of reaching a normal physiologic range of Hb should be reconsidered also in ECMO.
We would like to invite you to take part in this survey on your practice concerning transfusions of red blood cells during extracorporeal membrane oxygenation (ECMO).
Mortality associated with acute respiratory distress syndrome (ARDS) remains high despite continual improvement in mechanical ventilation and ECMO.
Technical simplifications, and its use during the 2009 H1N1 influenza pandemic prompted a sharp increase in the use of ECMO worldwide. Despite the lack of large randomized controlled trials, the survival rate in large volume centers has improved over recent years.
The optimal management of an anticoagulation target and transfusion practice in VV-ECMO patients is still under debate. [1] Traditionally, the threshold for transfusions of packed red blood cells (PRBC) in ECMO aims to keep hemoglobin values (Hb) in the normal range (12-14 g/dL).
More recently, this notion has been challenged by several case series that reported on lower transfusion thresholds and good outcomes. [2]
Even if strict triggers have been questioned by several experts because they appear to be too simplistic, a liberal transfusion strategy in critically ill patients seems to be associated with increased morbidity and mortality, as many randomized controlled studies have shown. [3]
There is also some evidence that a higher number of transfusions in ECMO patients is associated with worse outcomes, but such a relationship is difficult to assess.
Considering the conventionally accepted restrictive strategy on different populations of critically ill patients, as well as the increasing experience with ECMO management, and improvement in the equipment, the aim of reaching a normal physiologic range of Hb should be reconsidered also in ECMO.
Survey Committee:
- A. Arcadipane, G. Panarello, G. Martucci: IRCCS-ISMETT: Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione
- K. Tanaka: Department of Anesthesiology, University of Maryland
- G. Bellani: Anestesia e rianimazione, Università di Milano Bicocca
- G. Grasselli: Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano
- A. Arcadipane, G. Panarello, G. Martucci: IRCCS-ISMETT: Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione
- K. Tanaka: Department of Anesthesiology, University of Maryland
- G. Bellani: Anestesia e rianimazione, Università di Milano Bicocca
- G. Grasselli: Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano
1. Fan E, Gattinoni L, Combes A, Schmidt M, Peek G, Brodie D, Muller T, Morelli A, Ranieri VM, Pesenti A, Brochard L, Hodgson C, Van Kiersbilck C, Roch A, Quintel M, Papazian L, (2016) Venovenous extracorporeal membrane oxygenation for acute respiratory failure : A clinical review from an international group of experts. Intensive care medicine 42: 712-724
2. Martucci G, Panarello G, Occhipinti G, (2017) Anticoagulation and Transfusions Management in Veno-Venous Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome: Assessment of Factors Associated With Transfusion Requirements and Mortality: 885066617706339
3. Vincent JL, (2016) Improved survival in critically ill patients: are large RCTs more useful than personalized medicine? No. Intensive care medicine 42: 1778-1780
2. Martucci G, Panarello G, Occhipinti G, (2017) Anticoagulation and Transfusions Management in Veno-Venous Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome: Assessment of Factors Associated With Transfusion Requirements and Mortality: 885066617706339
3. Vincent JL, (2016) Improved survival in critically ill patients: are large RCTs more useful than personalized medicine? No. Intensive care medicine 42: 1778-1780