Decreasing the post surgical ooze: Utilizing a perioperative guideline to decrease transfusion needs following congenital diaphragmatic hernia repair on ECMO.

Abstract

Purpose: To evaluate changes in post-operative transfusion requirements of infants undergoing congenital diaphragmatic hernia (CDH) repair on ECMO following implementation of a perioperative guideline.

Methods: In 2021, a multidisciplinary team created a guideline for perioperative management of CDH repair on ECMO, including guidance on pre-operative lab values, antifibrinolytic dosing, transfusion recommendations, and anticoagulation titration. CDH repairs on ECMO from 2010 to 2024 were divided into Pre- and Post- Guideline groups. A retrospective cohort study comparing Pre- and Post- Guideline outcomes was performed utilizing descriptive statistics for analysis.

Results: Twenty-seven infants underwent CDH repair on ECMO within the study period: 16 Pre and 11 Post guideline implementation. Gestational age, weight, and day of life at cannulation did not differ. The Post group had higher Vasoactive-Inotropic Scores (Pre:10.5 versus Post:17.5, p = 0.01) and underwent repair sooner after ECMO cannulation (Pre:3 (1,8) versus Post:1 (1,2) days, p = 0.02). At 24-h post-operatively, pRBC transfusions were lower in the Post group (Pre:121 (51,210) versus Post:60 (31, 90) mL, p = 0.03) and platelet transfusions (Pre:93 (60,133) versus Post:50 (30,81) mL, p = 0.004). Re-operation for re-bleeding occurred in 19% of infants Pre versus 9% of infants Post, p = 0.62. Rate of intraventricular hemorrhages trended lower in the Post group (Pre:44% versus Post:9%, p = 0.09). ECMO cannula clotting rates were similar. 13% of infants Pre and 55% of infants Post survived to hospital discharge, p = 0.03.

Conclusion: Implementation of a perioperative guideline for procedures on ECMO was associated with reduced transfusion requirement and improved survival of these high-risk patients.

Level of evidence: Level 3 evidence.