A Program to Limit Donor Exposures to Neonates Undergoing Extracorporeal Membrane Oxygenation

Abstract

Objective. Extracorporeal membrane oxygenation (ECMO) has dramatically improved the survival of neonates with life-threatening respiratory and cardiac failure. However, ECMO requires numerous transfusions with significant risks. This study evaluated the effects of changing transfusion practices and blood component management on blood donor exposures in neonatal ECMO. Design. A 3-year retrospective chart review of all neonatal ECMO patients from December 1989 through November 1992 was undertaken. During this 3-year period, transfusion practices and blood product preparation were altered twice to reduce blood donor exposures. The use of apheresis platelets and fresh frozen plasma (FFP), and preserving the expiration date on packed red blood cells (PRBCs) through the use of a sterile connecting device, allowed multiple transfusions from individual donor components. In addition, education of the ECMO physicians was focused on standardizing and reducing transfused volumes. Sixty-four surviving neonatal patients (91.4%) were evaluated. Five patients had excessive bleeding and were excluded from analysis. The remaining 59 patients were divided into three protocols based upon the transfusion practice at the time of their ECMO course. Protocol 1 received PRBCs less than 5 days of age, volume-reduced platelet concentrates, and standard FFP units up to 24 hours after thawing. Changes in transfusion practice for protocol 2 included extended outdate for PRBCs to 10 days, and using single donor apheresis platelet aliquots. The third protocol entailed the use single donor apheresis FRP aliquots in addition to the protocol 2 changes. Results. Total PRBC transfusion volumes (721 ± 406 ml for protocol 1, 637 ± 172 ml for protocol 3) and associated blood donor exposures (5 ± 2.1 for protocol 1, 3.9 ± 0.9 for protocol 3) did not change substantially over the reviewed period. However, FFP transfusion volumes (478 ± 170 ml for protocol 1, 274 ± 63 ml for protocol 3), FFP-related donor exposures (4.5 ± 1.6 for protocol 1, 1.2 ± 0.4 for protocol 3) and platelet-related donor exposures (4.6 ± 3.6 for protocol 1, 2.5 ± 1.5 for protocol 3) were reduced progressively and significantly from protocol 1 to protocol 3 (P < .01, Tukey's B test adjusted for multiple comparisons). The total number of donor exposures per patient while on ECMO was decreased from 14.1 in protocol 1 to 10.0 in protocol 2 to 7.5 in protocol 3 (P < .01). Conclusions. We conclude that the changes in blood bank component selection and management as well as physician practice were effective in substantially reducing ECMO-related transfusion volumes and the resulting donor exposures.