Current Practice Optimization Suggestions and Future Perspectives on Transfusion in Patients Supported by Extracorporeal Membrane Oxygenation: a Narrative Review

Background and Objective: Patients on extracorporeal membrane oxygenation (ECMO) are transfused more than other critically ill patients. The risk of bleeding, anticoagulation, and restoration of oxygen carrying capacity are all reasons why practitioners decide to transfuse these patients. However, the cost/ benefit ratio of transfusion in this setting is unclear, especially when practiced liberally. The association between the volume of red blood transfused and morbidity and mortality is becoming increasingly clearer. Therefore, more effort should be made to find transfusion -sparing strategies. This review explores studies on the practice of blood transfusion among ECMO patients, and whether a hemoglobin trigger is considered when deciding to transfuse. Furthermore, we wanted to identify alternative strategies for blood transfusion to maintain adequate oxygen delivery, such as optimal fluid balance, anticoagulation protocols, and dynamic ECMO configurations. Methods: We used the PubMed database to identify articles on transfusion practice in ECMO patients and on possible strategies under development to improve patient blood management. All selected papers were written in English and published between 2003 and 2022. Key Content and Findings: In this review we emphasize the importance of combining hemoglobin values with physiological parameters of peripheral perfusion to assess the need for transfusion. Optimizing blood flow dynamically with patient fluid balance and improving in ECMO circuit efficiency may also be important for meeting a patient's metabolic needs and sparing transfusion. Conclusions: Clinical and research efforts should be made to optimize blood management of ECMO patients through a multidisciplinary approach.