Platelet transfusion stated practices among neonatal and paediatric veno-arterial extracorporeal membrane oxygenation providers: A survey.

Abstract

Background and objectives: Extracorporeal membrane oxygenation (ECMO) provides cardiopulmonary support to over 4000 neonates and children annually worldwide. Although potentially lifesaving, ECMO carries bleeding and thromboembolic risks, often managed with platelet transfusions to maintain specific thresholds. Platelet transfusions themselves carry many risks. This survey aimed to describe stated prophylactic platelet transfusion practices among paediatric veno-arterial (VA)-ECMO providers and identify factors influencing transfusion decisions.

Materials and methods: This is a cross-sectional electronic survey of paediatric ECMO providers from 10 centres evaluating platelet transfusion thresholds based on six patient scenarios (non-bleeding, minimally bleeding and resolved bleeding in neonates and children). Descriptive statistics were used for analysis.

Results: The survey response rate was 56% (114 of 204). Paediatric intensivists comprised 66% of respondents. The median pre-transfusion platelet count varied across VA-ECMO scenarios, with a threshold of 50 × 10⁹/L (interquartile range [IQR] 45-75) for non-bleeding children and 70 × 10⁹/L (IQR 50-85) for non-bleeding neonates. The threshold for minimally bleeding children, minimally bleeding neonates and resolved bleeding in children was 75 × 10⁹/L (IQR 50-100). The threshold for resolved bleeding in neonates was 80 × 10⁹/L (IQR 50-100). There was significant heterogeneity between and within sites (p < 0.001). Uncertainty about the level of evidence was high (59%), with clinical judgement being the most influential factor in transfusion decisions (85%).

Conclusion: Prophylactic platelet transfusion practices in paediatric ECMO vary widely, highlighting uncertainty and the need for clinical trials to improve patient outcomes.