Blood products other than packed red blood cells in extracorporeal membrane oxygenation: guidelines, local protocols, and outcomes-a narrative review

Background and Objective: Blood Product transfusion is often required during extracorporeal membrane oxygenation (ECMO) support for several reasons. Most of the available data and literature have assessed packed red blood cells (PRBCs) transfusion during extracorporeal support, however it is key to define the threshold for the variability of other blood products available for transfusion. This review aims to highlight published data supporting blood product transfusion, other than PRBCs, in patients on ECMO support, including guidelines, local protocols, and patient outcomes. Methods: PubMed and Google Scholar were primarily used to access the targeted literature published until December 2022. We have also used authoritative text, published guidelines, and expert consensus. The literature on platelets, fresh frozen plasma (FFP), cryoprecipitate, albumin, and activated recombinant factor VII (rFVIIa) was summarized separately. Key Content and Findings: Platelets, FFP, and cryoprecipitate, were discussed in detail with their guidelines and recommended dosage, while albumin and rFVIIa are discussed briefly, primarily due to lack of literature. The relevance of viscoelastic clotting tests to blood product transfusion were also reviewed. In emergency setting, ECMO circuits can be primed with crystalloid while cross -matching blood is being prepared. Albumin can be used as an additive to the primes as it increases the circuit life and prevents protein loss by adding oncotic pressure to the prime. The average platelet units transfused directly correlated with the type of ECMO. Platelet transfusion increases the platelet count by 30,000-100,000/mu L. If the international normalized ratio (INR) is greater than 1.5-2.0 or if there is significant bleeding, FFP can be given in aliquots of 10 mL/kg. Cryoprecipitate is given at a dose of 5 mL/kg of body weight if the fibrinogen level is less than 100-150 mg/dL and will increase the fibrinogen concentration by 50 mg/dL/10 kg of body weight. Thromboelastography (TEG), and thromboelastometry (TEM) reduce the requirement for blood product transfusion in bleeding patients. Conclusions: This review has highlighted the lack of data available regarding non-PRBC blood product transfusions and the appropriate therapy practices and preventive measures in ECMO patients. Further research is warranted to define and guide blood product transfusion thresholds, management practices, and limitations in ECMO patients.