Dynamic platelets transfusion thresholds in pediatric ECMO - giving less and gaining more (?)

Most pediatric ECMO patients need anticoagulation and suffer from severe thrombocytopenia which increases their tendency to bleed. Hence, most centers adhere to current guidelines that recommend platelet transfusion when the count<100,000 cells/mm3. Our practice is to set the platelet transfusion goal during the morning rounds according to the patient status and bleeding tendency. In the non-bleeding, stable patient, the platelets transfusion threshold is decreased daily from 100,000 to ~20,000 cells/mm3
When bleeding occurs, the patient is transfused with blood products and/or hemostatic medications as needed.

This is a retrospective, single-center, chart review, study of all ECMO supported patients between 05/2010-05/2020 looking at bleeding complications and use of blood products. Included were 229 patients, most with VA ECMO support, with a median age of 21 days.

We showed that platelet transfusions were used in fewer ECMO days and in smaller doses than in the literature. Bleeding complications were similar to previously published rates with fewer bleeding days and PRBC use. Intracranial hemorrhage was not more common in our cohort than in the literature.

We estimated that a cost of ~2,000,000 US$ was saved by practicing our restrictive policy.

In conclusion, we may be giving less platelets and no more blood than other centers with comparable hemorrhagic complications. A cautious gradual decrease in platelets transfusion thresholds is safe in pediatric ECMO patients, but reevaluation is required once the patient bleeds or becomes unstable.