Anemia, blood loss, and blood transfusions in North American children in the intensive care unit

Blood conservation pediatric cardiac surgery in all ages and complexity levels

AIM

To demonstrate the feasibility of blood conservation methods and practice across all ages and risk categories in congenital cardiac surgery.

METHODS

We retrospectively analyzed a collected database of 356 patients who underwent cardiac surgery using cardiopulmonary bypass (CPB) from 2010-2015. The patients were grouped into blood conservation (n = 138) and non-conservation (n = 218) groups and sub-grouped based on their ages and procedural complexity scores.

RESULTS

There were no statistical differences in gender, weight, pre-operative and pre-CPB hematocrit levels in both groups. Despite equivalent hematocrit levels during and after CPB for both groups, there was significantly less operative homologous blood utilized in blood conservation group across all ages and complexity levels.

CONCLUSION

Blood conservation surgery can be performed in congenital patients needing cardiac surgery in all age groups and complexity categories. The above findings in addition to attendant risks and side effects of blood transfusion and the rising cost of safer blood products justify blood conservation in congenital cardiac surgery.

Noninvasive hemoglobin monitoring in critically ill pediatric patients at risk of bleeding

OBJECTIVE

To determine the accuracy and usefulness of noninvasive continuous hemoglobin (Hb) monitoring in critically ill patients at risk of bleeding.

DESIGN

An observational prospective study was made, comparing core laboratory Hb measurement (LabHb) as the gold standard versus transcutaneous hemoglobin monitoring (SpHb).

SETTING

Pediatric Intensive Care Unit of a tertiary University Hospital.

PATIENTS

Patients weighing >3kg at risk of bleeding.

INTERVENTIONS

SpHb was measured using the Radical7 pulse co-oximeter (Masimo Corp., Irvine, CA, USA) each time a blood sample was drawn for core laboratory analysis (Siemens ADVIA 2120i).

VARIABLES

Sociodemographic characteristics, perfusion index (PI), pleth variability index, heart rate, SaO₂, rectal temperature, low signal quality and other events that can interfere with measurement.

RESULTS

A total of 284 measurements were made (80 patients). Mean LabHb was 11.7±2.05g/dl. Mean SpHb was 12.32±2g/dl (Pearson 0.72, R² 0.52). The intra-class correlation coefficient was 0.69 (95%CI 0.55-0.78)(p<0.001). Bland-Altman analysis showed a mean difference of 0.07 ±1.46g/dl. A lower PI and higher temperature independently increased the risk of low signal quality (OR 0.531 [95%CI 0.32-0.88] and 0.529 [95%CI 0.33-0.85], respectively).

CONCLUSIONS

SpHb shows a good overall correlation to LabHb, though with wide limits of agreement. Its main advantage is continuous monitoring of patients at risk of bleeding. The reliability of the method is limited in cases with poor peripheral perfusion.

Hematocrit Levels, Blood Testing, and Blood Transfusion in Infants After Heart Surgery

OBJECTIVE

To determine whether judicious blood testing impacts timing or amount of packed RBC transfusions in infants after heart surgery.

DESIGN

A retrospective study comparing before and after initiation of a quality improvement process.

SETTING

A university-affiliated cardiac ICU at a tertiary care children's hospital.

PATIENTS

Infants less than 1 year old with Risk Adjustment for Congenital Heart Surgery category 4, 5, 6, or d-transposition of great arteries (Risk Adjustment for Congenital Heart Surgery 3) consecutively treated during 2010 through 2013.

INTERVENTION

A quality improvement process implemented in 2011 to decrease routine laboratory testing after surgery.

MEASUREMENTS AND MAIN RESULTS

Fifty-two infants preintervention and 214 postintervention had similar age, weight, proportion of cyanotic lesions, and surgical complexity. Infants with single versus biventricular physiology were compared separately. The number of laboratory tests per patient adjusted for cardiac ICU length of stay (laboratory tests/patient/day) was significantly lower in postintervention populations for single and biventricular groups (9 vs 15 and 10 vs 15, respectively; p < 0.001). The proportion of single ventricle patients transfused post- and preintervention was not statistically different (72% vs 90%; p = 0.130). Transfusion in the biventricular groups was the same over time (65% vs 65%). Time to first transfusion was significantly longer in the postintervention single ventricle group (4 vs 1 d; p < 0.001), and was not statistically different in the biventricular patients (4 vs 7 d; p = 0.058). The median hematocrit level at first transfusion was significantly lower (37% vs 40%; p = 0.004) postintervention in the cyanotic population, but did not differ in the biventricular group (31% vs 31%; p = 0.840).

CONCLUSION

In infants after heart surgery, blood testing targeted to individual needs significantly decreased the number of blood tests, but did not significantly decrease postoperative blood transfusion.

Prediction of Catheter-Associated Thrombosis in Critically Ill Children

OBJECTIVE

We determined whether in critically ill children with an untunneled central venous catheter, the risk of catheter-associated deep venous thrombosis can be predicted within 24 hours after insertion of the catheter.

DESIGN

Secondary analysis of two multicenter prospective cohort studies.

SETTING

PICUs in Northeastern United States.

PATIENTS

A total of 175 children admitted to the PICU within 24 hours after insertion of an untunneled central venous catheter who did not receive anticoagulation were included. Of these, 53 (30.3%) developed catheter-associated thrombosis detected with active surveillance with ultrasonography.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We used logistic regression (models 1 and 2) and recursive partitioning (models 3 and 4) methods to develop risk prediction models with predictors present at any time while catheterized (models 1 and 3), or within 24 hours after insertion of the catheter (models 2 and 4). Age, recent surgery, catheter in the subclavian vein, and blood product transfusion were included in models 1 and 2. Areas under the receiver operating characteristic curves were similar for these models (model 1: 0.80 vs model 2: 0.80; p = 0.44). Except for recent surgery, predictors in model 1 were identified as partitioning variables for model 3. In addition to the predictors in model 2, severity of illness was used in partitioning for model 4. The area under the curve of model 3 appeared smaller than that of model 4 (0.75 vs 0.80; p = 0.08). Groups of children at low, intermediate, and high risks of catheter-associated thrombosis were identified using model 4.

CONCLUSIONS

Critically ill children at high risk of catheter-associated thrombosis can be identified within 24 hours after insertion of an untunneled central venous catheter.

Determinants of red blood cell transfusion in pediatric trauma patients admitted to the intensive care unit

BACKGROUND

There are no well-designed prospective studies evaluating transfusion practices in pediatric trauma. We sought to describe red blood cell (RBC) transfusion practices in trauma patients who were admitted to a pediatric intensive care unit (PICU).

STUDY DESIGN AND METHODS

This study is a post-hoc analysis of a prospective, 6-month observational study in 30 PICUs. We studied a total of 580 patients aged less than 18 years who had been admitted to a PICU for more than 48 hours, including 95 who were trauma patients.

RESULTS

Trauma patients more frequently received transfusion before PICU admission (p < 0.001), were older (p < 0.0001), and more frequently were mechanically ventilated (p = 0.05). In the PICU, trauma patients received more transfusions (55% vs. 37%; p < 0.001), although admission hemoglobin levels were similar in both groups (p = 0.86). The mean (± standard deviation) pretransfusion hemoglobin level in the PICU was 9.0 ± 2.4 g/dL for trauma patients compared with 8.3 ± 2.4 g/dL for nontrauma patients (p = 0.09). Among the trauma patients, transfusion was associated with younger age, higher Pediatric Logistic Organ Regression scores, mechanical ventilation, bleeding, and transfusion before PICU admission. Multivariate regression demonstrated that receiving an RBC transfusion before admission was strongly associated with receiving a blood transfusion in the PICU (p = 0.008).

CONCLUSION

Trauma patients are at high risk for receiving an RBC transfusion both before and during their PICU stay, despite a similar transfusion threshold compared with nontrauma patients. Transfusion before PICU admission is a strong determinant, suggesting ongoing bleeding that will require re-transfusion. Further studies are needed to evaluate whether a restrictive transfusion strategy can safely be considered in these patients.

Transfusion-related immunomodulation: review of the literature and implications for pediatric critical illness

Transfusion-related immunomodulation (TRIM) in the intensive care unit (ICU) is difficult to define and likely represents a complicated set of physiologic responses to transfusion, including both proinflammatory and immunosuppressive effects. Similarly, the immunologic response to critical illness in both adults and children is highly complex and is characterized by both acute inflammation and acquired immune suppression. How transfusion may contribute to or perpetuate these phenotypes in the ICU is poorly understood, despite the fact that transfusion is common in critically ill patients. Both hyperinflammation and severe immune suppression are associated with poor outcomes from critical illness, underscoring the need to understand potential immunologic consequences of blood product transfusion. In this review we outline the dynamic immunologic response to critical illness, provide clinical evidence in support of immunomodulatory effects of blood product transfusion, review preclinical and translational studies to date of TRIM, and provide insight into future research directions.

[Hospital-acquired anemia: Facts, consequences and prevention]

Hospital-acquired anemia is common, especially in the most critically ill patients. It may be associated with poor patient outcomes. It may result from increased blood loss, impaired red cell production or reduced red cell life span. Multiple associated factors may contribute simultaneously or sequentially to the decrease in hemoglobin level. Some of them are related to the underlying disease and others are iatrogenic. Clinicians should be aware of the importance and consequences of iatrogenic anemia caused by diagnostic blood sampling. Strategies and measures to minimize iatrogenic blood loss should be prioritized. They may reduce the risk of developing anemia and then red blood cells transfusion requirement.

Pediatric Patient Blood Management Programs: Not Just Transfusing Little Adults

Red blood cell transfusions are a common life-saving intervention for neonates and children with anemia, but transfusion decisions, indications, and doses in neonates and children are different from those of adults. Patient blood management (PBM) programs are designed to assist clinicians with appropriately transfusing patients. Although PBM programs are well recognized and appreciated in the adult setting, they are quite far from standard of care in the pediatric patient population. Adult PBM standards cannot be uniformly applied to children, and there currently is significant variation in transfusion practices. Because transfusing unnecessarily can expose children to increased risk without benefit, it is important to design PBM programs to standardize transfusion decisions. This article assesses the key elements necessary for a successful pediatric PBM program, systematically explores various possible pediatric specific blood conservation strategies and the current available literature supporting them, and outlines the gaps in the evidence suggesting need for further/improved research. Pediatric PBM programs are critically important initiatives that not only involve a cooperative effort between pediatric surgery, anesthesia, perfusion, critical care, and transfusion medicine services but also need operational support from administration, clinical leadership, finance, and the hospital information technology personnel. These programs also expand the scope for high-quality collaborative research. A key component of pediatric PBM programs is monitoring pediatric blood utilization and assessing adherence to transfusion guidelines. Data suggest that restrictive transfusion strategies should be used for neonates and children similar to adults, but further research is needed to assess the best oxygenation requirements, hemoglobin threshold, and transfusion strategy for patients with active bleeding, hemodynamic instability, unstable cardiac disease, and cyanotic cardiac disease. Perioperative blood management strategies include minimizing blood draws, restricting transfusions, intraoperative cell salvage, acute normovolemic hemodilution, antifibrinolytic agents, and using point-of-care tests to guide transfusion decisions. However, further research is needed for the use of intravenous iron, erythropoiesis-stimulating agents, and possible use of whole blood and pathogen inactivation. There are numerous areas where newly formed collaborations could be used to investigate pediatric transfusion, and these studies would provide critical data to support vital pediatric PBM programs to optimize neonatal and pediatric care.

Past, present and forecast of transfusion medicine: What has changed and what is expected to change?

Blood transfusion is the second most used medical procedures in health care systems worldwide. Over the last few decades, significant changes have been evolved in transfusion medicine practices. These changes were mainly needed to increase safety, efficacy, and availability of blood products as well as reduce recipients' unnecessary exposure to allogeneic blood. Blood products collection, processing, and storage as well as transfusion practices throughout all patient populations were the main stream of these changes. Health care systems across the world have adopted some or most of these changes to reduce transfusion risks, to improve overall patients' outcome, and to reduce health care costs. In this article, we are going to present and discuss some of these recent modifications and their impact on patients' safety.

Hemoglobin Threshold for Blood Transfusion in a Pediatric Intensive Care Unit

OBJECTIVE

To evaluate the hemoglobin threshold for red cell transfusion in children admitted to a pediatric intensive care unit (PICU).

METHODS

Retrospective chart review study. Tertiary care PICU. Critically ill pediatric patients requiring blood transfusion. No intervention.

RESULTS

We analyzed the charts of all children between 1 month and 21 years of age who received packed red blood cell (PRBC) transfusions during a 2-year period. The target patients were identified from our blood bank database. For analysis, the patients were subdivided into four groups: acute blood loss (postsurgically, trauma, or acute gastrointestinal bleeding from other causes), hematologic (hematologic malignancies, bone marrow suppression, hemolytic anemia, or sickle cell disease), unstable (FiO₂ > 0.6 and/or on inotropic support), and stable groups. We also compared the pre-transfusion hemoglobin threshold in all unstable patients with that of all stable patients. A total of 571 transfusion episodes in 284 patients were analyzed. 28% (n = 160) of transfusions were administered to patients in the acute blood loss group, 36% (n = 206) to hematologic patients, 17% (n = 99) to unstable patients, and 18% (n = 106) to stable patients. The mean pre-transfusion hemoglobin (± SD) in all children as well as in the acute blood loss, hematologic, unstable and stable groups was 7.3 ± 1.20, 7.83 ± 1.32, 6.97 ± 1.31, 7.96 ± 1.37, 7.31 ± 1.09 g/dl, respectively. The transfusion threshold for acute blood loss and unstable groups was higher compared to hematologic and stable groups (p < 0.001; ANOVA with multiple comparisons). The mean pre-transfusion hemoglobin threshold for stable and unstable patients among all groups was 7.3 ± 1.3 and 7.9 ± 1.3 (p < 0.0001), respectively. The observed mortality rate was higher among children who received transfusion compared to other children admitted to PICU.

CONCLUSION

The hemoglobin threshold for transfusion varied according to clinical conditions. Overall, the hemoglobin threshold for transfusion was 7.3 ± 1.20 g/dl.

Exploring the Role of Polycythemia in Patients With Cyanosis After Palliative Congenital Heart Surgery

OBJECTIVES

To understand the relationship between polycythemia and clinical outcome in patients with hypoplastic left heart syndrome following the Norwood operation.

DESIGN

A retrospective, single-center cohort study.

SETTING

Pediatric cardiovascular ICU, university-affiliated children's hospital.

PATIENTS

Infants with hypoplastic left heart syndrome admitted to our medical center from September 2009 to December 2012 undergoing stage 1/Norwood operation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Baseline demographic and clinical information including first recorded postoperative hematocrit and subsequent mean, median, and nadir hematocrits during the first 72 hours postoperatively were recorded. The primary outcomes were in-hospital mortality and length of hospitalization. Thirty-two patients were included in the analysis. Patients did not differ by operative factors (cardiopulmonary bypass time and cross-clamp time) or traditional markers of severity of illness (vasoactive inotrope score, lactate, saturation, and PaO2/FIO2 ratio). Early polycythemia (hematocrit value > 49%) was associated with longer cardiovascular ICU stay (51.0 [± 38.6] vs 21.4 [± 16.2] d; p < 0.01) and total hospital length of stay (65.0 [± 46.5] vs 36.1 [± 20.0] d; p = 0.03). In a multivariable analysis, polycythemia remained independently associated with the length of hospitalization after controlling for the amount of RBC transfusion (weight, 4.36 [95% CI, 1.35-7.37]; p < 0.01). No difference in in-hospital mortality rates was detected between the two groups (17.6% vs 20%).

CONCLUSIONS

Early polycythemia following the Norwood operation is associated with longer length of hospitalization even after controlling for blood cell transfusion practices. We hypothesize that polycythemia may be caused by hemoconcentration and used as an early marker of capillary leak syndrome.

Red blood cell transfusion is associated with increased hemolysis and an acute phase response in a subset of critically ill children

In healthy adults, transfusion of older stored red blood cells (RBCs) produces extravascular hemolysis and circulating non-transferrin-bound iron. In a prospective, observational study of critically ill children, we examined the effect of RBC storage duration on the extent of hemolysis by comparing laboratory measurements obtained before, and 4 hr after, RBC transfusion (N = 100) or saline/albumin infusion (N = 20). Transfusion of RBCs stored for longer than 4 weeks significantly increased plasma free hemoglobin (P < 0.05), indirect bilirubin (P < 0.05), serum iron (P < 0.001), and non-transferrin-bound iron (P < 0.01). However, days of storage duration poorly correlated (R(2) <0.10) with all measured indicators of hemolysis and inflammation. These results suggest that, in critically ill children, most effects of RBC storage duration on post-transfusion hemolysis are overwhelmed by recipient and/or donor factors. Nonetheless, we identified a subset of patients (N = 21) with evidence of considerable extravascular hemolysis (i.e., increased indirect bilirubin ≥0.4 mg/dL). In these patients, transfusion-associated hemolysis was accompanied by increases in circulating non-transferrin-bound iron and free hemoglobin and by an acute phase response, as assessed by an increase in median C-reactive protein levels of 21.2 mg/L (P < 0.05). In summary, RBC transfusions were associated with an acute phase response and both extravascular and intravascular hemolysis, which were independent of RBC storage duration. The 21% of transfusions that were associated with substantial hemolysis conferred an increased risk of inducing an acute phase response.

Association of Hematocrit and Red Blood Cell Transfusion with Outcomes in Infants Undergoing Norwood Operation

The objective of this study was to investigate the association between red blood cell (RBC) transfusion and hematocrit values with outcomes in infants undergoing Norwood operation. This study included infants ≤2 months of age who underwent Norwood operation with either a modified Blalock-Taussig shunt or a right ventricle-pulmonary artery shunt. Demographics, preoperative, operative, daily laboratory data, and postoperative variables were collected. The primary outcome measures evaluated included mortality, ICU length of stay, length of mechanical ventilation, and days to chest closure. The secondary outcome measures evaluated included lactate levels, estimated glomerular filtration rate, and inotrope score in the first 14 days after heart operation. Cox proportional hazard models were fitted to study the probability of study outcomes as a function of hematocrit values and RBC transfusions after operation. Eighty-nine patients qualified for inclusion. With a median hematocrit of 46 (IQR 44, 49), and a median RBC transfusion of 92 ml/kg (IQR 31, 384) in the first 14 days after operation, 81 (91 %) patients received RBC transfusions. A multivariable analysis adjusted for risk factors, including the age, weight, prematurity, cardiopulmonary bypass and cross-clamp time, and postoperative need for nitric oxide and dialysis, demonstrated no association between hematocrit and RBC transfusion with majority of study outcomes. This single-center study found that higher hematocrit values and increasing RBC transfusions are not associated with improved outcomes in infants undergoing Norwood operation.

Blood Transfusions After Pediatric Cardiac Operations: A North American Multicenter Prospective Study

BACKGROUND

Red blood cell transfusion is an important supportive measure after pediatric cardiac operations. However, no clear hemoglobin threshold has been established. This study characterized anemia development and red blood cell transfusions in the pediatric intensive care unit (PICU) after cardiac operations.

METHODS

A prospective, multicenter, 6-month cohort study on the management of anemia in critically ill pediatric patients was conducted in 30 North American PICUs. This observational study enrolled 977 consecutive children (aged <18 years) who stayed in the PICU for 48 hours or more. We analyzed a subgroup of postcardiac surgical patients from this study.

RESULTS

Included were 175 cardiac patients, 56% of whom had cyanotic heart disease. The mean Pediatric Risk of Mortality (PRISM III) score was 6.4 ± 5.4. Fifty-four percent of children were anemic in the PICU (20% on admission, 34% during PICU stay). Most patients (79%) received at least one red blood cell transfusion in the PICU. Patients who received a transfusion had a significantly longer PICU stay (9.3 ± 6.3 vs 6.1 ± 5.4 days, p = 0.01). Pretransfusion hemoglobin was different in acyanotic and cyanotic patients (mean ± standard deviation: 11.1 ± 2.2 g/dL and 11.8 ± 2.1 g/dL, respectively). According to the attending physician, a low hemoglobin level was the primary indication for transfusion in only 17% of cases.

CONCLUSIONS

Pediatric cardiac surgical patients are at high risk of receiving red blood cell transfusions. This study, which showed great variability in transfusion practices across North American PICUs, highlights the need for clearer transfusion guidelines in this specific population.

Clinical Outcomes Associated With RBC Transfusions in Critically Ill Children: A 1-Year Prospective Study

OBJECTIVE

To identify the potential complications associated with RBC transfusions.

DESIGN

Prospective observational study.

SETTING

PICU in a tertiary children's hospital.

PATIENTS

All children consecutively admitted to our PICU during a 1-year period.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Data were abstracted from medical charts prospectively. Outcomes possibly attributable to RBC transfusions were looked for daily. In transfused cases, it was considered that an outcome was associated with a transfusion only if it was observed after the first RBC transfusion. During the 1-year study period, 913 consecutive admissions were documented, 842 of which were included. Among them, 144 (17%) were transfused at least once. When comparing transfused cases with nontransfused cases, the odds ratio for new or progressive multiple organ dysfunction syndrome was 5.14 (95% CI, 3.28-8.06; p < 0.001). This association remained statistically significant in the multivariable analysis (odds ratio, 3.85; 95% CI, 2.38-6.24; p < 0.001). Transfused cases were ventilated longer than nontransfused cases (14.1 ± 32.6 vs 4.3 ± 9.6 d, p < 0.001), even after adjustment in a Cox model. The PICU length of stay was significantly increased for transfused cases (12.4 ± 26.2 vs 4.9 ± 10.2 d, p < 0.001), even after controlling for potential confounders. The paired analysis for comparison of pretransfusion and posttransfusion values showed that the arterial partial pressure in oxygen was significantly reduced within the 6 hours after the first RBC transfusion (mean difference, 25.6 torr, 95% CI, 5.7-45.4; p = 0.029). The paired analysis also showed an increased proportion of renal replacement therapy.

CONCLUSIONS

RBC transfusions in critically ill children were associated with prolonged mechanical ventilation and prolonged PICU stay. The risk of new or progressive multiple organ dysfunction syndrome was also increased in some transfused children. Furthermore, our study questions the ability of stored RBCs to improve oxygenation in critically ill children. Practitioners should take into account these data when prescribing an RBC transfusion to PICU patients.

The influence of the storage lesion(s) on pediatric red cell transfusion

PURPOSE OF REVIEW

This article will analyze and evaluate the current evidence regarding the use of older, longer-stored red blood cells (RBCs) for transfusion in pediatric patients and will examine some of the postulated mechanisms of injury related to prolonged refrigerated storage of RBCs and studies reporting clinical outcomes.

RECENT FINDINGS

Three randomized controlled trials and seven observational studies have been conducted entirely in pediatric patients. The outcomes, mortality and morbidity in critically ill patients and children undergoing cardiac surgery, and necrotizing enterocolitis in premature infants, have been inconsistent. However, many of these studies have been confounded by study design, mixed patient populations, red cell preparation, and other factors.

SUMMARY

Further exploration into the possible deleterious effects of older, longer-stored RBC transfusions on mortality and morbidity in different pediatric populations is merited. Understanding the potential mechanisms of injury should help explain the clinical findings.

Red blood cell transfusion decision making in critically ill children

PURPOSE OF REVIEW

To discuss the tradeoff between permissive anemia and administering red blood cell transfusion to children in pediatric ICUs.

RECENT FINDINGS

Postsurgical mortality in adults increases abruptly if their nadir hemoglobin level falls below 5 g/dl. Patients with sepsis, even those in septic shock, and patients with upper gastrointestinal bleeding do not require red blood cell (RBC) transfusion if their hemoglobin level is above 7 g/dl.

SUMMARY

Anemia is common in critically ill children and is well tolerated most of the time. RBC transfusion is required in cases of hemorrhagic shock and in children with a hemoglobin level below 5 g/dl. Children with sepsis, including septic shock, those with a severe upper gastrointestinal bleeding and all stable critically ill children, including noncyanotic cardiac children older than 28 days, do not require an RBC transfusion if their hemoglobin level is above 7 g/dl. Transfusion threshold in children with univentricular physiology and in critically ill children with a hemoglobin level between 5 and 7 g/dl remains to be determined.

Nonpulmonary treatments for pediatric acute respiratory distress syndrome: proceedings from the Pediatric Acute Lung Injury Consensus Conference

OBJECTIVE

To describe the recommendations from the Pediatric Acute Lung Injury Consensus Conference on nonpulmonary treatments in pediatric acute respiratory distress syndrome.

DESIGN

Consensus conference of experts in pediatric acute lung injury.

METHODS

A panel of 27 experts met over the course of 2 years to develop a taxonomy to define pediatric acute respiratory distress syndrome and to make recommendations regarding treatment and research priorities. The nonpulmonary subgroup comprised three experts. When published data were lacking, a modified Delphi approach emphasizing strong professional agreement was utilized.

RESULTS

The Pediatric Acute Lung Injury Consensus Conference experts developed and voted on a total of 151 recommendations addressing the topics related to pediatric acute respiratory distress syndrome, 30 of which related to nonpulmonary treatment. All 30 recommendations had strong agreement. Patients with pediatric acute respiratory distress syndrome should receive 1) minimal yet effective targeted sedation to facilitate mechanical ventilation; 2) neuromuscular blockade, if sedation alone is inadequate to achieve effective mechanical ventilation; 3) a nutrition plan to facilitate their recovery, maintain their growth, and meet their metabolic needs; 4) goal-directed fluid management to maintain adequate intravascular volume, end-organ perfusion, and optimal delivery of oxygen; and 5) goal-directed RBC transfusion to maintain adequate oxygen delivery. Future clinical trials in pediatric acute respiratory distress syndrome should report sedation, neuromuscular blockade, nutrition, fluid management, and transfusion exposures to allow comparison across studies.

CONCLUSIONS

The Consensus Conference developed pediatric-specific definitions for pediatric acute respiratory distress syndrome and recommendations regarding treatment and future research priorities. These recommendations for nonpulmonary treatment in pediatric acute respiratory distress syndrome are intended to promote optimization and consistency of care for patients with pediatric acute respiratory distress syndrome and identify areas of uncertainty requiring further investigation.

Higher fibrinogen concentrations for reduction of transfusion requirements during major paediatric surgery: A prospective randomised controlled trial

BACKGROUND

Hypofibrinogenaemia is one of the main reasons for development of perioperative coagulopathy during major paediatric surgery. The aim of this study was to assess whether prophylactic maintenance of higher fibrinogen concentrations through administration of fibrinogen concentrate would decrease the volume of transfused red blood cell (RBCs).

METHODS

In this prospective, randomised, clinical trial, patients aged 6 months to 17 yr undergoing craniosynostosis and scoliosis surgery received fibrinogen concentrate (30 mg kg(-1)) at two predefined intraoperative fibrinogen concentrations [ROTEM(®) FIBTEM maximum clot firmness (MCF) of <8 mm (conventional) or <13 mm (early substitution)]. Total volume of transfused RBCs was recorded over 24 h after start of surgery.

RESULTS

Thirty children who underwent craniosynostosis surgery and 19 children who underwent scoliosis surgery were treated per protocol. During craniosynostosis surgery, children in the early substitution group received significantly less RBCs (median, 28 ml kg(-1); IQR, 21 to 50 ml kg(-1)) compared with the conventional fibrinogen trigger of <8 mm (median, 56 ml kg(-1); IQR, 28 to 62 ml kg(-1)) (P=0.03). Calculated blood loss as per cent of estimated total blood volume decreased from a median of 160% (IQR, 110-190%) to a median of 90% (IQR, 78-110%) (P=0.017). No significant changes were observed in the scoliosis surgery population. No bleeding events requiring surgical intervention, postoperative transfusions of RBCs, or treatment-related adverse events were observed.

CONCLUSIONS

Intraoperative administration of fibrinogen concentrate using a FIBTEM MCF trigger level of <13 mm can be successfully used to significantly decrease bleeding, and transfusion requirements in the setting of craniosynostosis surgery, but not scoliosis.

CLINICAL TRIAL REGISTRY NUMBER

ClinicalTrials.gov NCT01487837.

Respiratory Dysfunction Associated With RBC Transfusion in Critically Ill Children: A Prospective Cohort Study

OBJECTIVE

Respiratory complications associated with RBC transfusions may be underestimated in PICUs because current definitions exclude patients with preexisting respiratory dysfunction. This study aims to determine the prevalence and characterize the risk factors and outcomes of new or progressive respiratory dysfunction observed after RBC transfusion in critically ill children.

DESIGN

Prospective cohort study of all children admitted over a 1-year period.

SETTING

A multidisciplinary PICU in a tertiary pediatric university hospital.

PATIENTS

Patients who received a RBC transfusion while in PICU.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Two independent adjudicators established the diagnosis of respiratory dysfunction. A respiratory dysfunction associated with transfusion was considered new if it appeared after the first RBC transfusion in PICU. A progressive respiratory dysfunction associated with transfusion was diagnosed if the respiratory dysfunction was present before the transfusion and the PaO2/FIO2 or the SpO2/FIO2 ratio dropped by at least 20% thereafter. Among 842 children admitted into the PICU, 136 received at least one RBC transfusion and were analyzed. Fifty-eight cases of respiratory dysfunction associated with transfusion (43% of transfused patients) were detected, including nine new respiratory dysfunction associated with transfusion (7%) and 49 progressive respiratory dysfunction associated with transfusion (36%). Higher severity of illness, multiple organ dysfunction syndrome prior to transfusion, and volume (mL/kg) of RBC transfusion were independently associated with respiratory dysfunction associated with transfusion. A dose-response relationship was observed between transfusion volume (mL/kg) and the prevalence of respiratory dysfunction associated with transfusion. Patients with respiratory dysfunction associated with transfusion had more progressive multiple organ dysfunction and less ventilation-free and PICU-free days at day 28.

CONCLUSIONS

Development of respiratory dysfunction associated with transfusion is frequent in PICU and occurs mainly in patients with prior respiratory dysfunction, who would not be identified using current definitions for transfusion-associated complications. A cause-effect relationship cannot be confirmed. However, the high prevalence and the serious adverse outcomes associated with respiratory dysfunction associated with transfusion suggest that this complication should be further studied.

Association of haematocrit and red blood cell transfusion with outcomes in infants with shunt-dependent pulmonary blood flow and univentricular physiology

BACKGROUND

The aim of this study was to investigate the association between red blood cell (RBC) transfusion and haematocrit values with outcomes in infants with univentricular physiology undergoing surgery for a modified Blalock-Taussig shunt.

MATERIAL AND METHODS

This study included infants ≤ 2 months of age who underwent modified Blalock-Taussig shunt surgery at the Arkansas Children's Hospital (2006-2012). Infants undergoing a Norwood operation or Damus-Kaye-Stansel operation with modified Blalock-Taussig shunt were excluded. Demographics, pre-operative, operative, daily laboratory data, and post-operative variables were collected. We studied the association between haematocrit and blood transfusion with a composite clinical outcome. Multivariable logistic regression models were fitted to study the probability of study outcomes as a function of haematocrit values and RBC transfusions after operation.

RESULTS

Seventy-three patients qualified for inclusion. All study patients received blood transfusion within the first 48 hours after heart surgery. The median haematocrit was 44.3 (interquartile range [IQR] 42.5-46.2), and the median volume of RBC transfused was 28 mL/kg (IQR, 10-125) in the first 14 days after surgery. The overall in-hospital mortality rate was 13.6% (10 patients). A multivariable analysis adjusted for risk factors, including weight, prematurity, cardiopulmonary bypass and postoperative need for nitric oxide and dialysis, revealed no association between haematocrit values and RBC transfusion with the composite clinical outcome.

DISCUSSION

We did not find an association between higher haematocrit values and increasing RBC transfusions with improved outcomes in infants with shunt-dependent pulmonary blood flow and univentricular physiology. The power of our study was small, which prevents any strong statement on this lack of association. Future multi-centre, randomised controlled trials are needed to investigate this topic in further detail.

One size will never fit all: the future of research in pediatric transfusion medicine

There is concern at the National Heart, Lung, and Blood Institute (NHLBI) and among transfusion medicine specialists regarding the small number of investigators and studies in the field of pediatric transfusion medicine (PTM). Accordingly, the objective of this article is to provide a snapshot of the clinical and translational PTM research considered to be of high priority by pediatricians, neonatologists, and transfusion medicine specialists. Included is a targeted review of three research areas of importance: (i) transfusion strategies, (ii) short- and long-term clinical consequences, and (iii) transfusion-transmitted infectious diseases. The recommendations by PTM and transfusion medicine specialists represent opportunities and innovative strategies to execute translational research, observational studies, and clinical trials of high relevance to PTM. With the explosion of new biomedical knowledge and increasingly sophisticated methodologies over the past decade, this is an exciting time to consider transfusion medicine as a paradigm for addressing questions related to fields such as cell biology, immunology, neurodevelopment, outcomes research, and many others. Increased awareness of PTM as an important, fertile field and the promotion of accompanying opportunities will help establish PTM as a viable career option and advance basic and clinical investigation to improve the health and wellbeing of children.

RBC transfusion in pediatric patients supported with extracorporeal membrane oxygenation: is there an impact on tissue oxygenation?

OBJECTIVE

To examine first the RBC transfusion practice in pediatric patients supported with extracorporeal membrane oxygenation and second the relationship between transfusion of RBCs and changes in mixed venous saturation (SvO2) and cerebral regional tissue oxygenation, as measured by near-infrared spectroscopy in patients supported with extracorporeal membrane oxygenation.

DESIGN

Retrospective observational study.

SETTING

Pediatric, cardiovascular, and neonatal ICUs of a tertiary care children's hospital.

PATIENTS

All pediatric patients supported with extracorporeal membrane oxygenation between January 1, 2010, and December 31, 2010.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

There were 45 patients supported with extracorporeal membrane oxygenation. The median (interquartile range) phlebotomy during extracorporeal membrane oxygenation was 75 mL/kg (33, 149 mL/kg). A total of 617 transfusions were administered (median, 9 per patient; range = 1-57). RBC volumes transfused during extracorporeal membrane oxygenation support were 254 mL/kg (136, 557) and 267 mL/kg (187, 393; p = 0.82) for cardiac and noncardiac patients, respectively. Subtracting the volume of RBCs used for extracorporeal membrane oxygenation circuit priming, median RBC transfusion volumes were 131 and 80 mL/kg for cardiac and noncardiac patients, respectively (p = 0.26). The cardiac surgical patients received the most RBCs (529 vs 74 mL/kg for nonsurgical cardiac patients). The median hematocrit maintained during extracorporeal membrane oxygenation support was 37%, with no difference between cardiac and noncardiac patients. Patients supported with extracorporeal membrane oxygenation were exposed to a median of 10.9 (range, 3-43) individual donor RBC units. Most transfusions resulted in no significant change in either SvO2 or cerebral near-infrared spectroscopy. Only 5% of transfusions administered (31/617) resulted in an increase in SvO2 of more than 5%, whereas an increase in cerebral near-infrared spectroscopy of more than 5 was only observed in 9% of transfusions (53/617). Most transfusions (73%) were administered at a time when the pretransfusion SvO2 was more than 70%.

CONCLUSIONS

Patients supported with extracorporeal membrane oxygenation were exposed to large RBC transfusion volumes for treatment of mild anemia resulting from blood loss, particularly phlebotomy. In the majority of events, RBC transfusion did not significantly alter global tissue oxygenation, as assessed by changes in SvO2 and cerebral near-infrared spectroscopy. Most transfusions were administered at a time at which the patient did not appear to be oxygen delivery dependent according to global measures of tissue oxygenation.

Reducing blood testing in pediatric patients after heart surgery: a quality improvement project

OBJECTIVES

To safely optimize blood testing and costs for pediatric cardiac surgical patients without adversely impacting patient outcomes.

DESIGN

This is a quality improvement cohort project with pre- and postintervention groups.

SETTING

University-affiliated pediatric cardiac ICU in a tertiary care children's hospital.

PATIENTS

All patients were surgical patients for whom Risk Adjustment for Congenital Heart Surgery categories allowed for stratification by complexity. The preintervention group was treated in 2010 and the postintervention group in 2011.

INTERVENTIONS

Laboratory ordering processes were analyzed, and practice changed to limit standing blood test orders and requires individualized ordering.

MEASUREMENTS AND MAIN RESULTS

Three hundred nineteen patients were studied in 2010 and 345 in 2011. Groups were similar in median age, weight, length of stay (ICU length of stay), and Risk Adjustment for Congenital Heart Surgery category. There was a reduction in the total blood tests per patient (24 vs 38; p < 0.0001) and length of stay adjusted tests per patient-day (10.4 vs 14.4; p = 0.0001) in the postintervention group. The largest test reductions were blood gases and single electrolytes. Adverse outcomes, such as extubation failure (6.4% vs 5.6%), central catheter-associated bloodstream infection (2.2 vs 1.5), and hospital mortality (0.6% vs 0.6%), were not significantly different between the groups. Cost analysis demonstrated an overall laboratory cost savings of 32%. In addition, the volume of packed RBC transfusions was also significantly decreased in the postintervention group among the most complex patients (Risk Adjustment for Congenital Heart Surgery, 6).

CONCLUSIONS

Blood testing rates were safely decreased in postoperative pediatric cardiac patients by changing laboratory ordering practices. In addition, packed RBC transfusion was decreased among the most complex patients.

The impact of leukoreduced red blood cell transfusion on mortality of neonates undergoing extracorporeal membrane oxygenation

BACKGROUND

Blood products containing leukocytes have been associated with negative immunomodulatory and infectious effects. Transfusion-related acute lung injury is partially explained by leucocyte agglutination. The Food and Drug Administration has therefore recommended leukoreduction strategies for blood product transfusion. Our institution has been using leukocyte-reduced blood via filtration for neonates on Extracorporeal Membrane Oxygenation (ECMO). We hypothesized that the use of leukocyte-reduced blood would decrease mortality and morbidity of neonatal ECMO patients.

METHODS

Retrospective review of noncardiac ECMO in neonates from 1984-2011, stratified into year groups I and II (≤1996 and ≥1997). Demographics, duration and type of ECMO, complications, and outcome data were collected. Blood product use data was collected. Univariate, bivariate, and multivariate analyses determined predictors of risk-adjusted mortality by year group.

RESULTS

Patients (827) underwent ECMO with 65.3% (540) in group I. Overall median blood product use in mL/kg/d was 36.2 packed red blood cells (pRBC), 8.1 platelets, and 0 cyroprecipitate and/or fresh-frozen plasma. Overall mortality was 16.4%. Median pRBC used or transfused was 42.1 mL/kg/d in group I versus 19.1 mL/kg/d group II (P <0.001). On bivariate analysis, there was no difference in crude mortality between the 2 year groups (17.2% versus 16.0%, P = 0.66). However, on multivariate analysis adjusting for demographics, diagnosis, complications, and blood product use other than pRBCs, each additional transfusion of 10 mL/kg/d of pRBC was associated with a 33% increase in mortality in group I (P <0.05). Group II also showed an increase in mortality with each additional transfusion (21%) but this was not statistically significant (P = 0.07). Days on ECMO were not associated with pRBC transfusion in group I but increased in group II (additional 3 d for each 10 mL/kg/d transfused). There was no difference in infectious complications between groups I and II.

CONCLUSIONS

Blood transfusion requirement has diminished in newborns undergoing ECMO at our institution. Transfusion of non leukocyte-reduced blood is associated with an increase in mortality whereas transfusion of leukocyte-reduced blood provided no benefit with a trend toward increased mortality. Further research is recommended to understand these trends.

Anemia and red blood cell transfusion in critically ill cardiac patients

Anemia and red blood cell (RBC) transfusion occur frequently in hospitalized patients with cardiac disease. In this narrative review, we report the epidemiology of anemia and RBC transfusion in hospitalized adults and children (excluding premature neonates) with cardiac disease, and on the outcome of anemic and transfused cardiac patients. Both anemia and RBC transfusion are common in cardiac patients, and both are associated with mortality. RBC transfusion is the only way to rapidly treat severe anemia, but is not completely safe. In addition to hemoglobin (Hb) concentration, the determinant(s) that should drive a practitioner to prescribe a RBC transfusion to cardiac patients are currently unclear. In stable acyanotic cardiac patients, Hb level above 70 g/L in children and above 70 to 80 g/L in adults appears safe. In cyanotic children, Hb level above 90 g/L appears safe. The appropriate threshold Hb level for unstable cardiac patients and for children younger than 28 days is unknown. The optimal transfusion strategy in cardiac patients is not well characterized. The threshold at which the risk of anemia outweighs the risk of transfusion is not known. More studies are needed to determine when RBC transfusion is indicated in hospitalized patients with cardiac disease.

Survey on stated transfusion practices in PICUs*

OBJECTIVES

To analyze the RBC transfusion practice patterns among pediatric intensivists in light of the new evidence advocating for a restrictive transfusion strategy.

DESIGN

Self-administered questionnaire.

SETTING

PICUs.

SUBJECTS

Intensivists and fellows in pediatric critical care medicine.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Scenario-based survey carried out among North American and European intensivists, working in tertiary-care PICUs. Respondents were asked to report their decisions with regard to RBC transfusion in stable critically ill children with bronchiolitis, septic shock, trauma, or tetralogy of Fallot repair scenarios. Answers were compared with those of a similar scenario-based survey administered to pediatric intensivists in 1997. Ninety-seven respondents were retained for the study, the majority from the United States, Canada, and France. In 2010, respondents reported that the mean (± SD) transfusion threshold was a hemoglobin level of 7.7 ± 1.0 g/dL for bronchiolitis, 8.1 ± 1.2 g/dL for trauma, 9.1 ± 1.2 g/dL for a tetralogy of Fallot repair, and 9.2 ± 1.0 g/dL for septic shock. For all clinical scenarios, there was a trend toward a more restrictive transfusion approach (a threshold ≤ 7 g/dL) in 2010 compared with 1997: a restrictive strategy was adopted by 55.7% of respondents in 2010 versus 37.0% in 1997 (p = 0.01) with the scenario of bronchiolitis, 8.3% versus 3.4% (p = 0.16) with septic shock, 38.1% versus 9.0% (p < 0.001) with trauma, and 16.0% versus 7.9% (p = 0.10) with tetralogy of Fallot repair.

CONCLUSIONS

Stated transfusion practice patterns of pediatric intensivists appear to be evolving toward a more restrictive approach two and a half years after the publication of the Transfusion Requirement in PICU trial. Incomplete implementation of new knowledge with regard to the safety of a restrictive transfusion approach in stable PICU patients is perplexing and requires further studies.

Association between anemia and packed cell transfusion and outcomes of ventricular septal defect and atrioventricular canal repair in children

Data on the prevalence and impact of anemia and packed red blood cell (PRBC) transfusions in children with congenital heart disease are limited. Our objectives were to determine the prevalence of anemia and its impact and the impact of PRBC transfusion in the initial 5 days after surgical repair on postoperative outcomes in infants with ventricular septal defect (VSD) and atrioventricular (AV) canal. Retrospective chart review of infants (1 year old) (n = 195) with AV canal or VSD who underwent surgical repair at Children's Hospital of Michigan during a 10-year period. Statistical analyses (SPSS 17.0) included Chi square and Student t test as well as regression analysis with significance set at p = 0.05. Preoperative anemia was diagnosed in 45 of 195 (23%) children. Anemic infants had VSD more frequently (80%), significantly shorter bypass and cross-clamp durations, and higher red cell distribution widths. Postoperative outcomes and PRBC transfusions were similar in the groups. On regression analysis, AV canal was associated with a significantly lower (odds ratio 0.21; 95% confidence interval 0.07-0.68, p = 0.009) risk of anemia. Infants who received a PRBC transfusion (n = 42) had significantly lower birth weights as well as weights at surgery and longer postoperative durations of pressor use, ventilation, oxygen supplementation, and length of stay than those who did not (n = 153) receive transfusions. PRBC transfusion was independently associated with longer postoperative length of stay, oxygen, pressor use, and ventilator duration. Approximately 23% of infants with AV canal or VSD are anemic. PRBC transfusions in the initial 5 postoperative days, but not anemia, are independently associated with adverse postoperative outcomes. Further studies to evaluate conservative transfusion strategies in this population are needed.

[Pediatric intermediate care unit in general hospital: recent survey in French Polynesia]

In 2006, decrees relating to pediatric critical care defined the main rules of pediatric intermediate care units (PIMU). These units ensure continuous monitoring of children at risk of critical deterioration without requiring invasive support. In French Polynesia, a PIMU has been integrated into the general pediatric ward since the new hospital opened in November 2010. We conducted a prospective observational study of patients admitted to the PIMU depending on whether they were surgical patients or were secondarily transferred to the ICU or were transferred via long-distance medical air transport for specialized care. For the very first operational year, 199 children (median age, 3 years old) were admitted to the PIMU: for the most part respiratory (31.7%) and neurologic (23.6%) failures were involved. Surgical patients more often required a prosthesis or treatments associated with serious adverse effects than nonsurgical patients (respectively, 46% vs. 16%, P<0.01; 29% vs. 7%, P<0.01) and the length of the hospital stay was longer (5 days vs. 2, P<0.01). Patients who were secondarily transferred to the ICU had a higher admission Pediatric RISk of Mortality (PRISM) score (6 vs. 4, P<0.01) and required more treatments associated with serious adverse effects (50% vs. 20%, P<0.01) than nontransferred patients. The length of the hospital stay was longer (6days) for patients who underwent long-distance medical transport. In addition to PIMU defining criteria, the use of treatments associated with serious adverse effects should be considered risk factors of impaired prognosis in local practical procedures. Assessment of PIMU activity should take into account that intensive surgical care and geographical isolation are closely related to increased length of hospital stay.

Assessment of hemoglobin threshold for packed RBC transfusion in a medical-surgical PICU

OBJECTIVE

Results of a large multicenter randomized clinical trial published in 2007 demonstrated no benefit in using a liberal versus conservative RBC transfusion threshold in stable critically ill children. Using the conservative threshold decreased the number of RBC transfusions without increasing adverse outcomes. We aimed to determine if wide dissemination of this evidence altered the hemoglobin threshold used for RBC transfusions in our pediatric medical-surgical ICU.

DESIGN

Before-after retrospective cohort study using multiple administrative databases and chart review.

SETTING

PICU serving medical and surgical patients.

PATIENTS

All potentially stable children receiving a RBC transfusion in the PICU in 2006 (prepublication) and in 2009-2010 (postpublication). Children were considered unstable and excluded if they were severely hypoxic, receiving renal replacement therapy, hemodynamically unstable, or bleeding.

INTERVENTIONS

Physician education on evidence supporting hemoglobin transfusion thresholds in teaching conferences, staff meetings, and via e-mail.

MEASUREMENTS AND MAIN RESULTS

In 2006, 14.6% of patients (n = 285/1,940) received a RBC transfusion. In 2009-2010, 12.1% of patients (n = 551/4,542) received a RBC transfusion. We evaluated patients transfused when they were potentially clinically stable, including 145 children in 2006 (191 transfusion days) and 266 children in 2009-2010 (369 transfusion days). We found no significant differences in age, sex, race, diagnoses, postoperative status, illness severity scores, mortality, or length of stay between these two groups. The median hemoglobin transfusion threshold decreased significantly from 8.0 g/dL (interquartile range 7.3, 8.6 g/dL) in 2006 to 7.5 g/dL (interquartile range 6.9, 8.1 g/dL) in 2009-2010 (p = 0.001). The percentage of transfusion days using a hemoglobin threshold more than 7 g/dL decreased from 81% (n = 154) in 2006 to 71% (n = 261) in 2009-2010.

CONCLUSION

Although transfusion thresholds in potentially stable critically ill children in our PICU significantly decreased after dissemination of best available evidence, 71% of patients were transfused at a hemoglobin threshold more than 7 g/dL.

Plasma transfusion strategies for critically ill patients

BACKGROUND

Although plasma transfusions are frequently prescribed for critically ill patients, most clinical uses of plasma are not supported by evidence. Plasma transfusions do not seem to correct mild coagulation abnormalities based on international normalised ratio (INR) testing, but they seem to be independently associated with worse clinical outcomes in non-massively bleeding patients. Current recommendations on plasma transfusion strategies advocate limiting plasma transfusions to patients who are actively bleeding or who are at risk of bleeding and concomitantly have moderately abnormal coagulation tests.

OBJECTIVES

To determine whether use of a restrictive versus a liberal plasma transfusion threshold affects mortality or morbidity in critically ill patients, and to assess the clinical effects of different plasma transfusion thresholds in critically ill patients.

SEARCH METHODS

A search for studies was run on 15 August 2013. We searched the Cochrane Injuries Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE(R) Ovid, MEDLINE(R) Ovid In-Process & Other Non-Indexed Citations, MEDLINE(R) Ovid Daily and OLDMEDLINE(R) Ovid, EMBASE Classic + EMBASE (Ovid SP), reference lists, related websites and trial registries and checked lists of references.

SELECTION CRITERIA

Randomised clinical trials that assessed the effects of two plasma transfusion strategies, using a restrictive and a liberal threshold of at least one coagulation test, in critically ill participants.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed trial quality using the standard methods of the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

Of 843 references identified by our search, none of the trials satisfied our predefined inclusion criteria. No studies are included in this review.

AUTHORS' CONCLUSIONS

This review highlights the lack of evidence that is available to guide plasma transfusions in critically ill patients. Randomised controlled trials are needed to determine the appropriate plasma transfusion strategy in critically ill patients.

Changes in transfusion practice over time in the PICU

OBJECTIVES

Recent randomized clinical trials have shown the efficacy of a restrictive transfusion strategy in critically ill children. The impact of these trials on pediatric transfusion practice is unknown. Additionally, long-term trends in pediatric transfusion practice in the ICU have not been described. We assessed transfusion practice over time, including the effect of clinical trial publication.

DESIGN

Single-center, retrospective observational study.

SETTING

A 10-bed PICU in an urban academic medical center.

PATIENTS

Critically ill, nonbleeding children between the ages of 3 days and 14 years old, admitted to the University of Maryland Medical Center PICU between January 1, 1998, and December 31, 2009, excluding those with congenital heart disease, hemolytic anemia, and hemoglobinopathies.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

During the time period studied, 5,327 patients met inclusion criteria. Of these, 335 received at least one RBC transfusion while in the PICU. The overall proportion transfused declined from 10.5% in 1998 to 6.8% in 2009 (p = 0.007). Adjusted for acuity, the likelihood of transfusion decreased by calendar year of admission. In transfused patients, the pretransfusion hemoglobin level declined, from 10.5 g/dL to 9.3 g/dL, though these changes failed to meet statistical significance (p = 0.09). Neonatal age, respiratory failure, shock, multiple organ dysfunction syndrome, and acidosis were associated with an increased likelihood of transfusion in both univariate and multivariable models.

CONCLUSIONS

The overall proportion of patients transfused between 1998 and 2009 decreased significantly. The magnitude of the decrease varied over time, and no additional change in transfusion practice occurred after the publication of a major pediatric clinical trial in 2007. Greater illness acuity and younger patient age were associated with an increased likelihood of transfusion.

Posterior reversible encephalopathy syndrome: incidence and associated factors in a pediatric critical care population

BACKGROUND

Posterior reversible encephalopathy syndrome may occur frequently and be underrecognized in children and young adults admitted to a pediatric critical care unit.

METHODS

Patients <21 years of age with the diagnosis of posterior reversible encephalopathy syndrome were reviewed in this retrospective cohort study conducted over a 30-month period.

RESULTS

There were 2588 admissions to pediatric critical care unit, 226 neurology service consultations, and 10 patients diagnosed with posterior reversible encephalopathy syndrome (incidence of 1 in 259 pediatric critical care unit admissions, 0.4%). The majority of posterior reversible encephalopathy syndrome patients (9/10) presented with generalized tonic and or clonic seizures. Apart from hypertension and cytotoxic medication use, anemia, a previously unreported risk factor, was found in all 10 (100%) patients with posterior reversible encephalopathy syndrome. One-year follow up available in eight patients showed no residual neurological deficits attributable to posterior reversible encephalopathy syndrome with significant resolution of white matter signal abnormalities on neuroimaging.

CONCLUSION

Our case cohort includes an estimation of incidence of posterior reversible encephalopathy syndrome in children and young adults with 1-year follow-up and anemia as a potential previously unreported risk factor.

Cardiac critical care: what really makes a difference

PURPOSE OF REVIEW

The sustained decline in mortality following congenital heart surgery, while important, also has resulted in an emerging focus upon the use of processes and technological developments to reduce early postoperative morbidity. We summarize here recent efforts within the field of pediatric cardiac intensive care to optimize outcomes associated with the perioperative management of the child with congenital heart disease.

RECENT FINDINGS

Goal-directed and protocol-driven therapy targeting optimization of oxygen delivery improves outcomes in the management of many populations of critically ill patients, and is now increasingly used following congenital heart surgery with a low associated incidence of organ failure and favorable early survival. Restrictive blood product transfusion practices following congenital heart surgery are showing promise in reducing donor exposures and transfusion-associated morbidities without a resulting increase in end organ dysfunction. Technological developments are affording noninvasive opportunities for earlier recognition and intervention in the deteriorating child, while also providing means for support of the failing myocardium, both in an acute setting during cardiopulmonary resuscitation, and among patients with end-stage heart failure requiring longer-term mechanical circulatory support.

SUMMARY

Multi-institutional, prospective evaluation of perioperative management practices, along with patient-specific, integrated electronic health information, provides unique opportunities for investigators to identify and test both processes and technological tools in confronting the most challenging aspects of early postoperative management following congenital heart surgery.

PELOD-2: an update of the PEdiatric logistic organ dysfunction score

OBJECTIVE

Multiple organ dysfunction syndrome is the main cause of death in adult ICUs and in PICUs. The PEdiatric Logistic Organ Dysfunction score developed in 1999 was primarily designed to describe the severity of organ dysfunction. This study was undertaken to update and improve the PEdiatric Logistic Organ Dysfunction score, using a larger and more recent dataset.

DESIGN

Prospective multicenter cohort study.

SETTING

Nine multidisciplinary, tertiary-care PICUs of university-affiliated hospitals in France and Belgium.

PATIENTS

All consecutive children admitted to these PICUs (June 2006-October 2007).

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

We collected data on variables considered for the PEdiatric Logistic Organ Dysfunction-2 score during PICU stay up to eight time points: days 1, 2, 5, 8, 12, 16, and 18, plus PICU discharge. For each variable considered for the PEdiatric Logistic Organ Dysfunction-2 score, the most abnormal value observed during time points was collected. The outcome was vital status at PICU discharge. Identification of the best variable cutoffs was performed using bivariate analyses. The PEdiatric Logistic Organ Dysfunction-2 score was developed by multivariable logistic regressions and bootstrap process. We used areas under the receiver-operating characteristic curve to evaluate discrimination and Hosmer-Lemeshow goodness-of-fit tests to evaluate calibration. We enrolled 3,671 consecutive patients (median age, 15.5 mo; interquartile range, 2.2-70.7). Mortality rate was 6.0% (222 deaths). The PEdiatric Logistic Organ Dysfunction-2 score includes ten variables corresponding to five organ dysfunctions. Discrimination (areas under the receiver-operating characteristic curve = 0.934) and calibration (chi-square test for goodness-of-fit = 9.31, p = 0.317) of the PEdiatric Logistic Organ Dysfunction-2 score were good.

CONCLUSION

We developed and validated the PEdiatric Logistic Organ Dysfunction-2 score, which allows assessment of the severity of cases of multiple organ dysfunction syndrome in the PICU with a continuous scale. The PEdiatric Logistic Organ Dysfunction-2 score now includes mean arterial pressure and lactatemia in the cardiovascular dysfunction and does not include hepatic dysfunction. The score will be in the public domain, which means that it can be freely used in clinical trials.

Transfusion in critically ill children: an ongoing dilemma

Transfusion of blood products is a cornerstone in managing many critically ill children. Major improvements in blood product safety have not diminished the need for caution in transfusion practice. In this review, we aim to discuss the interplay between benefits and potential adverse effects of transfusion in critically ill children by including 65 papers, which were evaluated based on previously agreed selection criteria. Current practice on transfusing critically ill children is mainly founded on the basis of adult studies, common practices with cut-off values, and expert opinions, rather than evidence-based medicine. Paediatric patients have explicit physiological challenges and requirements to be addressed. Critically ill children often suffer from anaemia, have substantial iatrogenic blood loss with subsequent transfusions, and are at a higher risk of complications, often due to human errors. Transfusion in children is associated with increased morbidity. A restrictive transfusion strategy is not associated with increased morbidity. Thus, transfusion in paediatrics should be considered a high-risk treatment and requires individual clinical assessment. Current level of evidence support the notion that in most stable cases, despite high severity of illness (cyanotic children and neonates excluded), a restrictive haemoglobin threshold of 70 g/l (4.3 mmol/l) is no more harmful than to transfuse at a liberal trigger, e.g. haemoglobin 95 g/l (5.9 mmol/l). Thus, balanced against potential benefits and often its necessity, a restrictive approach may be appropriate due to the associated risks of transfusion.

Red blood cell transfusion in critically ill children (CME)

BACKGROUND

Red blood cell (RBC) transfusions are common in the pediatric intensive care unit (PICU). However, there are no recent data on transfusion practices in the PICU. Our objective was to determine transfusion practice in the PICU, to compare this practice with that observed 10 years earlier, and to estimate the compliance to the recommendation of a large randomized clinical trial, the Transfusion Requirements in Pediatric Intensive Care Unit (TRIPICU) study.

STUDY DESIGN AND METHODS

This was a single-center prospective observational study over a 1-year period. Information was abstracted from medical charts. Determinants of transfusion were searched for daily until the first transfusion in transfused cases or until PICU discharge in nontransfused cases. The justifications for transfusions were assessed using a questionnaire.

RESULTS

Of 913 consecutive admissions, 842 were included. At least one RBC transfusion was given in 144 patients (17.1%). The mean hemoglobin (Hb) level before the first transfusion was 77.3 ± 27.2 g/L. The determinants of a first transfusion event retained in the multivariate analysis were young age (<12 months), congenital cardiopathy, lowest Hb level of not more than 70 g/L, severity of illness, and some organ dysfunctions. The three most frequently quoted justifications for RBC transfusion were a low Hb level, intent to improve oxygen delivery, and hemodynamic instability. The main recommendation of the TRIPICU study was applied in 96.4% of the first transfusion events.

CONCLUSIONS

RBC transfusions are frequent in the PICU. Young age, congenital heart disease, low Hb level, severity of illness, and some organ dysfunctions are significant determinants of RBC transfusions in the PICU. Most first transfusion events were prescribed according to recent recommendations.