The purpose of these guidelines is to provide a framework to support the Extracorporeal Life Support (ECLS) team in the safe management of blood and blood products.
Background
This guideline should be read in conjunction with the Great Ormond Street Hospital (GOSH) blood handling policy (2009) (Rationale 1). E-learning and practical assessment should be undertaken by all staff involved in the transfusion process.
Note: While this guideline refers to the ‘child’ throughout, all activities are applicable to young people.
The multiprofessional team involved in the care of the ECLS patient should have an understanding of the physiology of ECLS, familiarity with the ECLS circuit and have reached a recognised level of competence in managing the ECLS patient and prepared to deal with any trouble shooting that may be required.
Please inform blood bank as soon as possible that a child is being admitted for ECLS support (Rationale 2).
Please ensure all children are wearing an accurate name band with any known allergies plus separate red allergy band if applicable (Rationale 3).
Blood does not need to be brought from the referring hospital. There is standby emergency blood in blood bank of five days old or less available 24 hours/day.
All blood samples which could be contaminated by a large blood transfusion should be taken prior to Extra Corporeal Membrance Oxygenation (ECMO) support eg cardiomyopathy investigations.
- Fresh frozen plasma (FFP), cryoprecipitate, platelets and packed red cells must be cross matched/compatibility tested and issued by the GOSH Blood Bank for a specific patient.
- All blood sample tubes must be clearly labelled with the patients’ full name, date of birth and hospital number. These details must be hand-written and signed for on blue crossmatch specimen bottles, at the bedside. Printed labels are not acceptable. Minimum sample size: 2ml (Rationale 4).
- It is essential that the patient identity is verified by examining the patients name band and checking that it coincides with blood bottle labelling, before any sample is dispatched to the laboratory.
- Repeat cross match must be done during an ECLS run in line with the national policy.
- < 4/12 months: once per week
- > 4/12 months: every other day ie 48 hourly
- If the child is bleeding over 10 ml/kg/hour, a daily cross match may be required. Discuss with blood bank.
Blood must only be stored in the blood bank refrigerator at the entrance to cardiac theatre or the refrigerator in the hospital blood bank.
Platelets should
not be refrigerated and used as soon as possible. They should only be issued by blood bank when they are required for use, kept at room temperature and agitated until transfusion. Platelets should be transfused within four hours.
Fresh frozen plasma and cryoprecipitate must be issued by the Blood Bank ready thawed (15 minutes) and used immediately. Do not refrigerate or refreeze fresh frozen plasma, cryoprecipitate. These products should be used within four hours.
Two large units of emergency O negative, irradiated blood are held in the cardiac blood fridge theatres, Level 3 cardiac theatres, and in the emergency blood fridge in VCB theatres. If this blood is used please ensure that blood bank is informed and the labels completed and returned with the blood bags to blood bank, as soon as possible to allow prompt replacement of units (
Rationale 5).
ECLS patients
Two emergency large units of O negative blood, non-irradiated, less than five days old, are held in blood bank and changed weekly. This can be used if there is an emergency or a child needs to go onto ECMO before a blood cross match can be undertaken, to prime the ECMO circuit. Children over 10kg can be supported with an initial clear prime.
Inform the Blood Bank of an anticipated ECMO referral as soon as possible. Please give them details of the child and where they are coming from. They can then double check with the referring hospital the blood group and age of the patient (and mother’s details if neonatal patient), though a hospital blood cross match will still be required on the child’s arrival.
An estimate of the blood product requirement for the first 24 hours of support should be given (see
appendix (PDF)). Please stress that it is for an ECMO patient and that the products will be required urgently on the child’s arrival (
Rationale 6).
Immediately on admission send an adequate sample of blood to Blood Bank for cross matching. If a maternal blood sample has been provided (not essential), this should accompany the cross match in neonates to check for antibodies. You should also let them know if the baby has had any previous blood transfusions.
The
appendix (PDF) to this guideline gives the suggested blood product requirements for different groups of patients.
Anticipated blood and blood product usage for the ensuing 24-hour period should be reviewed each day at 09:00 hours. This is especially important for plates - short shelf life and limited availability. The Blood Bank should then be contacted with the days 'order' – this must be done in time to coincide with the routine deliveries to GOSH by the blood transfusion service (see below) otherwise a charge is incurred (
Rationale 7).
Platelet ordering time
| Approximate delivery time
|
| 12:00 | 15:00 - 16:00
|
| 17:30 | 20:00 - 20:30
|
Platelet ordering times and approximate delivery times
Blood product usage for the weekend should be assessed on Fridays to try to cover until 10:00 hours on Monday. If more than one child is on ECMO support please call with the blood requirements of all ECMO candidates to minimise calls to blood bank.
Use Paedi-pak units of blood and FFP for top-up transfusions in infants and neonates. If large units ordered for priming or procedures and not used please return to Blood bank as soon as possible for re-issue.
Infuse blood, FFP, platelet and cryoprecipitate through the standard blood giving set (see hospital guidelines). This should be labelled with when the infusion was put up and changed four-hourly whether single or multiple transfusions are given. The patient should be monitored throughout the transfusion (
Rationale 8) and vital signs recorded every 15 mins according to hospital policy (
Rationale 9).
Blood requirements
All ECMO patients should receive cytomegalovirus (CMV) negative blood. This should be <7 days old for all ECMO patients.
Patients with Di George syndrome or immunosupression (heart transplantation) should receive irradiated blood. This should be documented on the pink blood and blood product prescription sheet (
Rationale 10).
Blood should only be irradiated up to five days post collection to avoid hyperkalaemia. Blood is then suitable for use for up to four days post irradiation except for adult units of blood used for patients <4 months of age which must be used within 24 hours of irradiation
Transfuse into patient IV line if available.
Red cells can be transfused into any available pigtail within the ECMO circuit. FFP, platelets, cryoprecipitate and other clotting products can only be given by a post membrane pigtail or directly into a patient venous line.
Very close control of the activated clotting time (ACT) is required when clotting factors, including platelets, FFP and cryoprecipitate, are administered to the circuit or patient (
Rationale 11). The ACT should be in the high-normal range prior to administration of these products, and should be measured every 15 minutes during administration. Platelets and FFP should be administered within the four-hour rule via the patient venous line or post oxygenator pigtail. A small heparin bolus or an increase in the heparin infusion rate is frequently required during platelet and clotting factor administration. The amount required will be individual to that patient.
Platelets levels
Platelets should be ordered for the first 24 hours (see
appendix (PDF)).
Respiratory ECMO (neonatal and paediatric), closed cardiac
After 24 hours (and first head ultrasound in neonates), platelets levels can be reduced to 80,000 and no standby platelets are required. Platelets at this time will be pulled from the two units of "Pan Trust Spare standby platelets Group A negative", or ordered on an individual need basis. These will be topped up by blood bank as used, and are held in blood bank.
If the clinical state of the child changes (eg bleeding/sepsis) and regular platelet transfusions are required, you may have to ask for the patient specific ECMO standby platelets to be reinstated for that patient.
Please reassess this requirement daily in order to minimise wastage and discuss with ECMO coordinator if unsure.
- First 24 hours: Maintain platelets at >100,000 (or as prescribed) by the administration of 10 ml/kg slow infusion of platelets for the first 24 hours.
- After 24 hours: If the child is not actively bleeding or septic, this can be reduced to 80,000. This should be discussed after the first head ultrasound at 24 hours in neonates.
Bleeding cardiac ECMO
Standby platelets should be ordered as normal for the individual patient.
Occasionally platelet levels will be taken up to 150,000 in the bleeding cardiac patient (see cardiac guidelines).
Expiry dates – please check daily the expiry dates on platelets and when ordering ask for a longer expiry date. Greater than 24 hours if possible. Blood bank can then order in bags with a longer expiry date when possible. The platelets not used prior to midnight can then be put back into the hospital pool (
Rationale 12).
The red cell mass should be maintained within the prescribed limits (35–40 %) by the administration of 10ml/kg packed red cells as required but in veno-venous ECMO they should be maintained at 40%.
FFP or cryoprecipitate may be required in patients with documented coagulopathies:
- going on to ECMO
- where active bleeding is occurring (clotting factors cannot be expected to control ‘surgical’ bleeding and should not be given until surgical control is established)
- sepsis
The use of components should be discussed with the ECMO physician if ACT or Prothrombin Time (PT) or Thrombin Time (TT) are persistently prolonged, or if the Fibrinogen concentration is <1.5 G/L in a bleeding patient. Otherwise aim to keep fibrinogen > 1.0 g/l with cryoprecipitate. On discussion with the multidisciplinary team, this level may be increased to 1.5g/l or 2.0g/l.
FFP and cryoprecipitate should not normally be given for ‘volume’ (blood/gelofusin should be used according to the haematocrit and unit policy).
A thromboelastrogram (TEG) may be useful in assessing whether there is clotting deficiency or a surgical bleed.
Always inform the ECMO physician:
- If the platelet count remains low despite platelet transfusion.
- If the haematocrit remains low despite transfusion of red cells.
- If there is any bleeding - see cardiac ECMO protocol for acceptable limits in cardiac ECMO.
At the completion of an ECMO run, please inform the blood bank that the baby/child is off ECMO support as soon as possible post decannulation, so that they can reduce their blood ordering requirements, return unused units to the blood bank and assist us at times of greatest need. Please complete the discharge pages from the ECMO pathway.
Back-up blood (available from transfusion)
If patient is bleeding significantly, blood bank need to be informed to allow adequate stock to be maintained. Bleeding cardiac patients – review daily needs at 10:00 hours, may need extra units available depending on bleeding status of patient.
Neonates will have one paedi-pack kept on hold in Blood Bank. All other patients will only be cross matched as needed unless bleeding.
Rationale 1: To ensure safe practice.
Rationale 2: Allow time for consultation with the referring hospital, for preparation of blood and blood products.
Rationale 3: Maintaining good clinical practice, checking the patients wrist band for accuracy.
Rationale 4: In accordance with hospital guidelines, reduce error and the risk of mislabelling the sample.
Rationale 5: Allow for re-stocking of emergency supplies.
Rationale 6: Providing the ability for the child to receive ECMO support as soon as possible.
Rationale 7: Efficiency of service in providing good communication with the blood transfusion department.
Rationale 8: Severe reaction can occur in the early stages of the transfusion process.
Rationale 9: Good record keeping is the mark of a skilled and safe practitioner.
Rationale 10: Engraftment of viable lymphocytes transfused with blood products can cause fatal GvHD. Patients with Di Geroge syndrome are at risk of transfused associated GvHD.
Rationale 11: To maintain safety of the circuit.
Rationale 12: Effective practice and reduce wastage.
Reference 1:
Van Meurs K, Hintz SR, Sheehan AH (2005)
ECMO for neonatal respiratory failure in Van Meurs K, Lally KP, Peek G, Zwischenberger JB (Editors) ECMO Extracorporeal cardiopulmonary support in critical care. Ann Arbor Michigan, ELSO.
Reference 2:
Van Meurs K, Lally KP, Peek G, Zwischenberger JB (2005)
ECMO Extracorporeal cardiopulmonary support in critical care. Ann Arbor Michigan, ELSO
Document control information
Lead authorMaura O'Callaghan, ECMO Co-ordinator, ECMO
Additional authorLiz Smith, Lead Nurse ANP, Cardiac ANP
Document owner
Maura O'Callaghan, ECMO Co-ordinator, ECMO
Approved byClinical Practice Committee
First introduced: 20 July 1999
Date approved: 17 May 2012
Review schedule: Two years
Next review: 17 May 2014
Document version: 6.0
Replaces version: 5.0
