Determinants of red blood cell transfusions in a pediatric critical care unit: A prospective, descriptive epidemiological study*

Patient blood management in critically ill children undergoing cardiac surgery: A cohort study

OBJECTIVE

The objective of this study was to audit current patient blood management practice in children throughout cardiac surgery and paediatric intensive care unit (PICU) admission.

DESIGN

This was a prospective observational cohort study.

SETTING

This was a single-centre study in the cardiac operating room (OR) and PICU in a major tertiary children's hospital in Australia.

PATIENTS

Children undergoing corrective cardiac surgery and requiring admission to PICU for postoperative recovery were included in the study.

MEASUREMENTS AND MAIN RESULTS

Fifty-six patients and 1779 blood sampling episodes were audited over a 7-month period. The median age was 9 months (interquartile range [IQR] = 1-102), with the majority (n = 30 [54%]) younger than 12 months. The median number of blood sampling episodes per patient per day was 6.6 (IQR = 5.8-8.0) in total, with a median of 5.0 (IQR = 4.0-7.5) episodes in the OR and 5.0 (IQR = 3.4-6.2) episodes per day throughout PICU admission. The most common reason for blood tests across both OR and PICU settings was arterial blood gas analysis (total median = 86%, IQR = 79-96). The overall median blood sampling volume per kg of bodyweight, patient, and day was 0.63 mL (IQR = 0.20-1.14) in total. Median blood loss for each patient was 3.5 mL/kg per patient per day (IQR = 1.7-5.6) with negligible amounts in the OR and a median of 3.6 mL/kg (IQR = 1.7-5.7) in the PICU. The median Cell Saver® transfusion volume was 9.9 mL/kg per patient per day (IQR = 4.0-19.1) in the OR. The overall median volume of other infusion products (albumin 4%, albumin 20%, packed red blood cells) received by each patient was 20.1 mL/kg (IQR = 10.7-36.4) per day. Sampling events and blood loss were positively associated with PICU stay.

CONCLUSIONS

Patient blood management practices observed in this study largely conform to National Blood Authority guidelines. Further implementation projects and research are needed to accelerate implementation of known effective blood conservation strategies within paediatric critical care environments.

7 Is the New 8: Improving Adherence to Restrictive PRBC Transfusions in the Pediatric ICU

Up to 30%-40% of children admitted to the pediatric intensive care unit (PICU) have anemia, and approximately 15% receive packed red blood cell (pRBC) transfusions. Current literature supports a pRBC transfusion threshold of hemoglobin less than or equal to seven for most PICU patients. Our objective was to determine pRBC transfusion rates, assess compliance with transfusion guidelines, understand patient-level variables that affect transfusion practices, and use cross-industry innovation to implement a practice strategy. This was a pre-post study of pediatric patients admitted to our PICU. We collected baseline data on pRBC transfusion practices. Next, we organized an innovation platform, which generated multi-industry ideas and produced an awareness campaign to effect pRBC ordering behavior. Innovative educational interventions were implemented, and postintervention transfusion practices were monitored. Statistical analysis was performed using linear mixed models. A p value < .05 was considered statistically significant. At baseline, 41% of pRBC transfusions met restrictive transfusion guidelines with a pretransfusion hemoglobin less than or equal to 7 g/dl. In the postintervention period, 53% of transfusions met restrictive transfusion guidelines (odds ratio 1.66, 95% confidence interval 1.21-2.28). Implementation of a behavioral campaign using multi-industry innovation led to improved adherence to pRBC transfusion guidelines in a tertiary care PICU.

Residual Negative Pressure in Vacuum Blood-Collection Tube and Hemolysis in Pediatric Blood Specimens

OBJECTIVE

To determine a method to reduce specimen hemolysis rates in pediatric blood specimens.

METHODS

A total of 290 blood specimens from pediatric patients were classified into the capped group or uncapped group. The hemolysis index and levels of lactate dehydrogenase (LDH) were measured using an automated biochemical analyzer. Also, we performed a paired test to measure the concentration of free hemoglobin in specimens from 25 randomly selected healthy adult volunteers, using a direct spectrophotometric technique.

RESULTS

The hemolytic rate of capped specimens was 2-fold higher than that of uncapped specimens. We found significant differences for LDH. Also, there was a significant difference in the concentration of free hemoglobin in the random-volunteers test.

CONCLUSIONS

Eliminating the residual negative pressure of vacuum blood-collection tubes was effective at reducing the macrohemolysis and/or microhemolysis rate.

Red cell transfusion practices after stage 1 palliation: a survey of practitioners from the Pediatric Cardiac Intensive Care Society

INTRODUCTION

Neonates may require increased red cell mass to optimise oxygen content after stage 1 palliation; however, data informing transfusion practices are limited. We hypothesise there is a patient-, provider-, and institution-based heterogeneity in red cell transfusion decision-making after stage 1 palliation.

METHODS

We conducted an online survey of Pediatric Cardiac Intensive Care Society practitioners in 2016. Respondents answered scenario-based questions that defined transfusion indications and identified haematocrit transfusion thresholds. Respondents were divided into restrictive and liberal groups based on a haematocrit score. Fisher's exact test was used to determine the associations between transfusion likelihood and patient, provider, and institutional characteristics. Bonferroni correction was applied to adjust the p-value to 0.004 for multiple comparisons.

RESULTS

There was a 21% response rate (116 responses). Most were male (58.6%), attending physicians (85.3%) with >5 year of intensive care experience (88.7%) and subspeciality training in critical care medicine (47.4%). The majority of institutions were academic (96.6%), with a separate cardiac ICU (86.2%), and performed >10 stage 1 palliation cases annually (68.1%). After Bonferroni correction, there were no significant patient, respondent, or institutional differences between the restrictive and liberal groups. No respondent or institutional characteristics influenced transfusion decision-making after stage 1 palliation.

CONCLUSIONS

Decision-making around red cell transfusion after stage 1 palliation is heterogeneous. We found no clear relationships between patient, respondent, or institutional characteristics and transfusion decision-making among surveyed respondents. Given the lack of existing data informing red cell transfusion after stage 1 palliation, further studies are necessary to inform evidence-based guidelines.

Patient Blood Management in Pediatric Cardiac Surgery: A Review

Efforts to reduce blood product transfusions and adopt blood conservation strategies for infants and children undergoing cardiac surgical procedures are ongoing. Children typically receive red blood cell and coagulant blood products perioperatively for many reasons, including developmental alterations of their hemostatic system, and hemodilution and hypothermia with cardiopulmonary bypass that incites inflammation and coagulopathy and requires systemic anticoagulation. The complexity of their surgical procedures, complex cardiopulmonary interactions, and risk for inadequate oxygen delivery and postoperative bleeding further contribute to blood product utilization in this vulnerable population. Despite these challenges, safe conservative blood management practices spanning the pre-, intra-, and postoperative periods are being developed and are associated with reduced blood product transfusions. This review summarizes the available evidence regarding anemia management and blood transfusion practices in the perioperative care of these critically ill children. The evidence suggests that adoption of a comprehensive blood management approach decreases blood transfusions, but the impact on clinical outcomes is less well studied and represents an area that deserves further investigation.

Standardized Implementation of Evidence-based Guidelines to Decrease Blood Transfusions in Pediatric Intensive Care Units

Introduction

Despite evidence that red blood cell (RBC) transfusions may be associated with more harm than benefit, current transfusion practices vary significantly. This multicenter, quality improvement study aimed to sustainably decrease the rate of RBC transfusions in pediatric intensive care units (PICUs).

Methods

This 16-month prospective study included 5 PICUs. We implemented a standardized project plan including education, bedside tools, real-time reminders, and email feedback. We collected data from consecutive transfusions during pre-implementation (Phase I), postimplementation (Phase II), and post-stabilization phases (Phase III).

Results

Of the 2,064 RBC transfusions, we excluded 35% (N = 729) from analysis in patients undergoing extracorporeal membrane oxygenation. Transfusion/1,000 admissions improved throughout the study periods from a baseline 209.6 -199.8 in Phase II and 195.8 in Phase III (P value < 0.05). There were fewer transfusions outside of the hemoglobin threshold guideline, decreasing from 81% of transfusions outside of guidelines in Phase I to 74% in Phases II and III, P < 0.05. Study phase, site, co-management status, service of requesting provider, admit reason, previous transfusion status, and age were associated with transfusion above guideline threshold.

Conclusions

Multicenter collaboration can successfully deploy a standardized plan that adheres to implementation science principles to sustainably decrease the rate of RBC transfusion outside of guideline thresholds. However, we did not decrease the total number of transfusions in our study. The complexity of multiple specialties co-managing patients is common in the contemporary PICU. Educational initiatives aimed at one specialty may have limited effectiveness in a multifaceted system of care.

Cyanotic heart disease is an independent predicting factor for fresh frozen plasma and platelet transfusion after cardiac surgery

OBJECTIVES

Cyanotic heart disease is associated with increased risk of bleeding in children undergoing cardiac surgery. We studied if the presence of a cyanotic heart disease was an independent predictive factor for fresh frozen plasma (FFP) and platelets transfusion in these patients. In children with ROTEM measurements, we also tried to characterize the coagulation profile between both groups.

DESIGN

Retrospective observational study.

SETTING

Tertiary university hospital; single center.

PARTICIPANTS

All consecutive children admitted for cardiac surgery with cardiopulmonary bypass (CPB) from January 2006 to December 2014. Patients who received FFP in the CPB priming were excluded. Multivariate logistic regression was used to determine the predictive factors for FFP and platelet transfusions.

INTERVENTION

none.

MEASUREMENTS AND MAIN RESULTS

From the 1846 patients included for analysis: 1063 were acyanotic and 783 were cyanotic. The presence of cyanotic heart disease was an independent predicting factor for both FFP (OR: 2.09; 95%CI: 1.44-3.02) and platelets (OR:3.98; 95%CI: 2.28-6.70) transfusion. Cyanotic children exhibited also higher perioperative blood losses [Intraoperative: 31.1 (17.6-50.4) versus 26.7 (14.8-44.7); P < 0.001 and Postoperative: 31.2 (19.1-51.9) versus 16.9 (10.4-26.9); P < 0.001]. Thromboelastometry assays after separation from CPB and heparin reversal revealed more complex coagulation disturbances in cyanotic than acyanotic children.

CONCLUSION

Children with a cyanotic heart disease are at higher risk of FFP and platelet transfusion after cardiac surgery. Intraoperative monitoring should be used to guide administration of blood and haemostatic product in this population at high risk of postoperative bleeding.

Red blood cell transfusion in infants and children - Current perspectives

Children routinely receive packed red blood transfusion when they are admitted in the intensive care unit or undergoing cardiac surgeries. These guidelines aim to summarize literature and provide transfusion triggers exclusively in infants and children.

Indications for red cell transfusions in pediatric patients

Red cell transfusions are amongst the most common therapeutic procedures in seriously ill children, particularly in the inpatient setting. This is despite the fact that there is no evidence base for most clinical settings, with the exception of patients with hemoglobinopathies, particularly thalassemia and sickle cell anemia. Obviously exsanguinating hemorrhage and life threatening anemia are urgent indications for which no other therapeutic approach is currently available. Most transfusions are, however, given prophylactically to prevent the complications of hypoxia or hemodynamic stability, based upon expert opinion and a faith in the oxygen carrying capacity and beneficial hemodynamic properties of transfused red cells. The question confronting current day pediatric practice is to what extent transfused red cells prevent adverse events, other than in thalassemia and sickle cell anemia, as opposed to causing them. Do transfusions of red cells prevent organ failure, stroke, etc. or not? There is epidemiologic evidence in the adult randomized trial literature that liberal red cell transfusion likely causes more such adverse events than it prevents. The relevance of such studies to children, particularly neonates, is uncertain. Randomized trials in critically ill neonates have yielded little to no evidence that liberal red cell transfusion is beneficial, but the data are not definitive. In critically ill older children the data suggest there is no benefit to liberal red cell transfusion, but the indications for red cell transfusion are uncertain. Most practitioners would agree that combining laboratory data such hemoglobin/hematocrit with clinical indications for transfusions (evidence of end organ hypoxia such as tachycardia, shortness of breath, etc.) is the only viable strategy at present, until more definitive randomized trial data are available.

Pediatric admissions that include intensive care: a population-based study

Background

Pediatric admissions to intensive care outside children’s hospitals are generally excluded from registry-based studies. This study compares pediatric admission to specialist pediatric intensive care units (PICU) with pediatric admissions to intensive care units (ICU) in general hospitals in an Australian population.

Methods

We undertook a population-based record linkage cohort study utilizing longitudinally-linked hospital and death data for pediatric hospitalization from New South Wales, Australia, 2010–2013. The study population included all new pediatric, post-neonatal hospital admissions that included time in ICU (excluding neonatal ICU).

Results

Of 498,466 pediatric hospitalizations, 7525 (1.5%) included time in an intensive care unit – 93.7% to PICU and 6.3% to ICU in a general (non-PICU) hospital. Non-PICU admissions were of older children, in rural areas, with shorter stays in ICU, more likely admitted for acute conditions such as asthma, injury or diabetes, and less likely to have chronic conditions, receive continuous ventilatory support, blood transfusion, parenteral nutrition or die.

Conclusions

A substantial proportion of children are admitted to ICUs in general hospitals. A comprehensive overview of pediatric ICU admissions includes these admissions and the context of the total hospitalization.

Comprehensive Analysis of Liberal and Restrictive Transfusion Strategies in Pediatric Intensive Care Unit

BACKGROUND

We prospectively compared restrictive and liberal transfusion strategies for critically ill children regarding hemodynamic and laboratory parameters.

METHODS

A total of 180 children requiring packed red blood cells (PRBCs) were randomized into two groups: the liberal transfusion strategy group (transfusion trigger < 10 g/dL, Group 1) and the restrictive transfusion strategy group (transfusion trigger ≤ 7 g/dL, Group 2). Basal variables including venous/arterial hemoglobin, hematocrit and lactate levels; stroke volume; and cardiac output were recorded at the beginning and end of the transfusion. Oxygen saturation, noninvasive total hemoglobin, noninvasive total oxygen content, perfusion index (PI), heart rate and systolic and diastolic blood pressures were assessed via the Radical-7 Pulse co-oximeter (Masimo, Irvine, CA, USA) with the Root monitor, initially and at 4 h.

RESULTS

In all, 160 children were eligible for final analysis. The baseline hemoglobin level for the PRBC transfusion was 7.38 ± 0.98 g/dL for all patients. At the end of the PRBC transfusion, cardiac output decreased by 9.9% in Group 1 and by 24% in Group 2 (p  < 0.001); PI increased by 10% in Group 1 and by 45% in Group 2 (p  < 0.001). Lactate decreased by 9.8% in Group 1 and by 31.68% in Group 2 (p < 0.001).

CONCLUSION

Restrictive blood transfusion strategy is better than liberal transfusion strategy with regard to the hemodynamic and laboratory values during the early period. PI also provides valuable information regarding the efficacy of PRBC transfusion in clinical practice.

Mechanisms of red blood cell transfusion-related immunomodulation

Red blood cell (RBC) transfusion is common in critically ill, postsurgical, and posttrauma patients in whom both systemic inflammation and immune suppression are associated with adverse outcomes. RBC products contain a multitude of immunomodulatory mediators that interact with and alter immune cell function. These interactions can lead to both proinflammatory and immunosuppressive effects. Defining clinical outcomes related to immunomodulatory effects of RBCs in transfused patients remains a challenge, likely due to complex interactions between individual blood product characteristics and patient-specific risk factors. Unpacking these complexities requires an in-depth understanding of the mechanisms of immunomodulatory effects of RBC products. In this review, we outline and classify potential mediators of RBC transfusion-related immunomodulation and provide suggestions for future research directions.

Controlling Phlebotomy Volume Diminishes PICU Transfusion: Implementation Processes and Impact

BACKGROUND AND OBJECTIVES

Phlebotomy excess contributes to anemia in PICU patients and increases the likelihood of red blood cell transfusion, which is associated with risk of adverse outcomes. Excessive phlebotomy reduction (EPR) strategies may reduce the need for transfusion, but have not been evaluated in a PICU population. We hypothesized that EPR strategies, facilitated by implementation science methods, would decrease excess blood drawn and reduce transfusion frequency.

METHODS

Quantitative and qualitative methods were used. Patient and blood draw data were collected with survey and focus group data to evaluate knowledge and attitudes before and after EPR intervention. The Consolidated Framework for Implementation Research was used to interpret qualitative data. Multivariate regression was employed to adjust for potential confounders for blood overdraw volume and transfusion incidence.

RESULTS

Populations were similar pre- and postintervention. EPR strategies decreased blood overdraw volumes 62% from 5.5 mL (interquartile range 1-23) preintervention to 2.1 mL (interquartile range 0-7.9 mL) postintervention (P < .001). Fewer patients received red blood cell transfusions postintervention (32.1% preintervention versus 20.7% postintervention, P = .04). Regression analyses showed that EPR strategies reduced blood overdraw volume (P < .001) and lowered transfusion frequency (P = .05). Postintervention surveys reflected a high degree of satisfaction (93%) with EPR strategies, and 97% agreed EPR was a priority postintervention.

CONCLUSIONS

Implementation science methods aided in the selection of EPR strategies and enhanced acceptance which, in this cohort, reduced excessive overdraw volumes and transfusion frequency. Larger trials are needed to determine if this approach can be applied in broader PICU populations.

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.

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.

Blood transfusion in acute and chronic pediatric settings: beliefs and practices

BACKGROUND

Blood has been imbued with powerful connotations through history and across cultures. Currently bestowed with scientific meaning, blood nevertheless carries symbolic resonance. This study examines these representations among practitioners and sheds light on the clinical and nonclinical factors that guide blood transfusion (BT) decision-making in Quebec, Canada.

STUDY DESIGN AND METHODS

With a qualitative exploratory study design, data were collected in the pediatric intensive care unit and the hematology-oncology unit of Sainte-Justine Hospital in 2009. A total of fifteen 1-hour-long semistructured interviews were conducted with physicians.

RESULTS

Physicians affirm that the symbolic connotations of blood found in the lay population do not influence their transfusion decisions. However, there are other "social" and "cultural' aspects that influence these practices. Also, BT strategies remain diverse across units. Practitioners perceive these situations as resulting from insufficient training and by the existence of an "oral tradition" and a professional culture that are resistant to change.

CONCLUSION

BT practices differ within and across units. Many dimensions intervene in the decision to transfuse, from individual clinical appreciation and local unit "culture" to formal and ad hoc training. Consistent change in BT can only occur with the implementation of norms and guidelines that are endorsed by key influential figures. An extensive multicentered study is necessary to better understand how social and cultural factors affect BT practices. This knowledge will sustain an enlightened clinical practice and lead to the recognition that peer practices are also embedded in professional cultures.

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.

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.

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.

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.

Blood component transfusion increases the risk of death in children with traumatic brain injury

BACKGROUND

Blood transfusion has been associated with worse outcomes in adult trauma patients with traumatic brain injury (TBI). However, the effects in injured children have not been evaluated. We hypothesize that blood transfusion is also associated with worse outcomes in children with TBI.

METHODS

A retrospective review of the trauma database at two Level I pediatric trauma centers was performed. We reviewed all patients 18 years and younger with TBI, who survived at least 24 hours, from 2002 to 2011. Exclusion criteria include those who underwent craniotomy, thoracotomy, exploratory laparotomy, and any orthopedic procedure.

RESULTS

A total of 1,607 children with TBI were included in the study population (mean age, 6.4 [5.7] years; 65% male), 178 of whom received a blood transfusion. Mean Injury Severity Score (ISS) was 16.5 (9.1). Patients who received a transfusion had a higher ISS than those who did not (26.7 vs. 15.3). After controlling for age, sex, ISS, Glasgow Coma Scale (GCS) score on presentation, and mechanism of injury, patients who received a blood transfusion were more likely to be admitted to the intensive care unit (p < 0.0001), less likely to survive to hospital discharge (p = 0.02), more likely to be discharged to a rehabilitation facility (p = 0.01) and be dependent on caretakers at follow-up (p < 0.0001), as well as more likely to develop urinary tract infection (p = 0.02) and bacteremia (p = 0.02) during their hospital stay. These differences in outcomes among those who did and did not receive a blood transfusion began to disappear in patients with a nadir hemoglobin of less than 8.0 g/dL.

CONCLUSION

Pediatric patients sustaining TBI who receive blood transfusion and do not require operative intervention have worse outcomes compared with patients who do not receive transfusion. This includes an increased risk of death. These data suggest that a transfusion trigger of hemoglobin level at 8.0 g/dL in injured children with TBI may be beneficial.

LEVEL OF EVIDENCE

Epidemiologic study, level III. Therapeutic study, level IV.

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.

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.

Safety and effects of two red blood cell transfusion strategies in pediatric cardiac surgery patients: a randomized controlled trial

OBJECTIVE

To investigate the safety and effects of a restrictive red blood cell (RBC) transfusion strategy in pediatric cardiac surgery patients.

DESIGN

Randomized controlled trial.

SETTING

Pediatric ICU in an academic tertiary care center, Leiden University Medical Center, Leiden, The Netherlands.

PATIENTS

One hundred seven patients with non-cyanotic congenital heart defects between 6 weeks and 6 years of age. One hundred three patients underwent corrective surgery on cardiopulmonary bypass.

INTERVENTIONS

Prior to surgery patients were randomly assigned to one of two groups with specific RBC transfusion thresholds: Hb 10.8 g/dl (6.8 mmol/l) and Hb 8.0 g/dl (5.0 mmol/l).

MEASUREMENTS

Length of stay in hospital (primary outcome), length of stay in PICU, duration of ventilation (secondary outcome), incidence of adverse events and complications related to randomization (intention to treat analysis).

RESULTS

In the restrictive transfusion group, mean volume of transfused RBC was 186 (±70) ml per patient and in the liberal transfusion group 258 (±87) ml per patient, (95% CI 40.6-104.6), p < 0.001. Length of hospital stay was shorter in patients with a restrictive RBC transfusion strategy: median 8 (IQR 7-11) vs. 9 (IQR 7-14) days, p = 0.047. All other outcome measures and incidence of adverse effects were equal in both RBC transfusion groups. Cost of blood products for the liberal transfusion group was 438.35 (±203.39) vs. 316.27 (±189.96) euros (95% CI 46.61-197.51) per patient in the restrictive transfusion group, p = 0.002.

CONCLUSIONS

For patients with a non-cyanotic congenital heart defect undergoing elective cardiac surgery, a restrictive RBC transfusion policy (threshold of Hb 8.0 g/dl) during the entire perioperative period is safe, leads to a shorter hospital stay and is less expensive.

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.

Anemia among Pediatric Critical Care Survivors: Prevalence and Resolution

To determine the incidence of anemia among pediatric critical care survivors and to determine whether it resolves within 6 months of discharge. Design. A prospective observational study. Patients with anemia upon discharge from the pediatric critical care unit (PCCU) underwent in hospital and post hospital discharge followup (4-6 months) for hemoglobin (Hb) levels. Setting. A medical-surgical PCCU in a tertiary care center. Patients. Patients aged 28 days to 18 years who were treated in the PCCU for over 24 hours. Measurements and Main Results. 94 (24%) out of 392 eligible patients were anemic at time of discharge. Patients with anemia were older, median 8.0 yrs [(IQR 1.0-14.4) versus 3.2 yrs (IQR 0.65-9.9) (P < 0.001)], and had higher PeLOD [median 11 (IQR 10-12) versus 1.5 (1-4) (P < 0.001)], and PRISM [median 5 (IQR 2-11) versus 3 (IQR 0-6) (P < 0.001)] scores. The Hb level normalized in 32% of patients before discharge from hospital. Of the 28 patients who completed followup, all had normalization of their Hb in the absence of medical intervention. Conclusions. Anemia is not common among patients discharged from the PCCU and recovers spontaneously within 4-6 months.

Transfusion-related biologic effects and free hemoglobin, heme, and iron

BACKGROUND

Red blood cell (RBC) transfusion is common in intensive care unit (ICU) patients and is associated with complications that appear related to the duration of blood storage. We hypothesize that hemolysis of stored RBCs results in increases in the availability of non-heme-bound iron, which inhibits macrophage activation.

STUDY DESIGN AND METHODS

RBCs were sampled at multiple time points to evaluate hemolysis and iron release. Activation of THP-1 monocytic cells was assessed in the presence of plasma from aged RBCs. Age of transfused blood in our pediatric intensive care unit (PICU) from 2001 to 2006 was analyzed to assess relevance to our patient population.

RESULTS

Hemolysis increased significantly during storage time as demonstrated by increases in free heme and hemoglobin. While there was a trend toward elevated levels of non-heme-bound iron, this was not significant (p = 0.07). THP-1 cell activation was inhibited by exposures to both plasma and a ferric compound; the effect of plasma on macrophage activation was not reversed by the iron chelator desferroxamine. Thirty-one percent of our PICU patients received blood older than 2 weeks.

CONCLUSION

Hemolysis products increased significantly over time in our stored RBCs. Ferric compounds and plasma from stored blood inhibit THP-1 cell activation. Plasma inhibition does not appear to be due primarily to increased iron. Further studies are needed to define the inhibitory effect of stored blood plasma on macrophage function. Complications related to blood storage are relevant to our PICU patients.

Red blood cell transfusion: decision making in pediatric intensive care units

The results of the Transfusion Requirements in Pediatric Intensive Care Unit study suggest that a red blood cell transfusion is not required in stable or stabilized pediatric intensive care unit children as long as their hemoglobin level is >7 g/dL. Subgroup analyses suggest that this recommendation is also adequate for stable critically ill children with a high severity of illness, respiratory dysfunction, acute lung injury, sepsis, neurological dysfunction, severe head trauma, or severe trauma, and during the postoperative period, for noncyanotic patients older than 28 days. A small randomized clinical trial suggests that a hemoglobin level of 9 g/dL is safe in the postoperative care of children with single-ventricle physiology undergoing cavopulmonary connection. Although there is consensus that blood is clearly indicated for the treatment of hemorrhagic shock, the clinical determinants that should prompt pediatric intensivists to prescribe a red blood cell transfusion to unstable PICU children are not well characterized.

[Evaluation of the concordance between guidelines and transfusion practices in neonatal intensive care units]

OBJECTIVE

To assess the concordance rate between the prescriptions of blood products and Afssaps guidelines for transfusion practices in neonatology.

STUDY DESIGN

Retrospective monocentric study.

PATIENTS AND METHODS

Children transfused in the neonatology intensive care units in the Universitary Hospital of Rouen were included. Concordance rates between transfusion prescriptions, delivered and transfused products and the Afssaps guidelines were assessed. Any additional costs resulting from a theoretical discordance was also assessed.

RESULTS

In 2006, 380 PSL were administered to 168 newborn children (NBC). Packed red blood cells (PRBC) represented the most often transfused products (n=290, 76%). Fifty packed platelets (PP) were transfused (13% of the blood products) and 41 fresh frozen plasmas (11%). Overall concordance rate between the Afssaps guidelines and the prescriptions was 64.9%. In 35.1% of cases, the prescription was excessive, compared to the recommendations. Excessive transfusion represented a total of 27,307 euros.

CONCLUSION

Global concordance's rate between the guidelines and the prescriptions is fairly well. PRBC are the most blood product transfused. Excessive transfusions related to this concordance rate are leading to important theoretical costs. New informations to the guidelines are warranted to improve transfusional practices in this institution.

Critically ill children: to transfuse or not to transfuse packed red blood cells, that is the question

OBJECTIVES

This article summarizes the current data on packed red blood cell transfusion in the pediatric intensive care unit setting to help providers make evidence-based decisions regarding packed red blood cell transfusions.

DATA SOURCES

Review of the literature, including PubMed, citations from relevant articles, and some articles that have been particularly relevant in adult critical care practice regarding packed red blood cell transfusion.

CONCLUSIONS

The use of packed red blood cell transfusions is common in the pediatric intensive care unit setting. However, until recently there have been little data to guide providers in this practice. Studies in adult intensive care units have shown less favorable outcomes in patients who received packed red blood cell transfusions. This has led to renewed questioning of the practice of packed red blood cell transfusion in critically ill pediatric patients. New data indicate that using a hemoglobin transfusion threshold of >7 g/dL does not yield improved outcomes. Furthermore, smaller studies have suggested that pediatric intensive care unit patients may be at an increased risk for morbidity and mortality when undergoing transfusion.

Transfusion of leukocyte-depleted red blood cells is not a risk factor for nosocomial infections in critically ill children

OBJECTIVES

Transfusion of red blood cells is increasingly linked with adverse outcomes in critically ill children. We tested the hypothesis that leukocyte-depleted red blood cell transfusions were independently associated with increased development of bloodstream infections, ventilator-associated pneumonias, or urinary tract infections.

DESIGN

Historical, descriptive cohort study.

SETTING

Single-center, mixed medical-surgical, closed nine-bed pediatric intensive care unit of a tertiary university hospital.

PATIENTS

All children <18 yrs of age consecutively admitted to the pediatric intensive care unit during a 3-yr period (January 1, 2005, to December 31, 2007).

INTERVENTIONS

None.

RESULTS

One thousand one hundred twenty-three patients were admitted, of whom 503 (44.8%) were admitted for >48 hrs. Sixty-five (12.9%) had a nosocomial infection (incidence 19.3 per 1,000 pediatric intensive care unit admissions per year). Patients with a nosocomial infection were significantly more often male (72.3% vs. 27.7%, p = .033), had a higher Pediatric Risk of Mortality II score (median 19.1 [range, 6-44] vs. 18.0 [range, 2-39], p = .023), were more often ventilated (95.4% vs. 80.1%, p = .003), and received more often red blood cell transfusions (55.4% vs. 40.2%, p = .021). Multivariate logistic regression analysis showed that male gender (odds ratio, 2.07; 95% confidence interval, 1.14-3.76), presence of an indwelling central venous catheter (odds ratio, 2.41; 95% confidence interval, 1.29-4.48), and simultaneous use of more than one type of antimicrobial drug were independently associated with the development of nosocomial infections. Red blood cell transfusion was discarded as a predictor.

CONCLUSIONS

Transfusion of leukocyte-depleted red blood cells was not independently associated with the development of nosocomial infections in a heterogeneous group of critically ill children.

Blood product transfusion: does location make a difference?

Early blood product administration during acute blood loss may improve outcomes, yet blood product transfusion for anemia of critical illness has been associated with increased mortality. After major burn injury, patients have two sources of anemia: massive acute blood loss during excision and insidious losses in the intensive care unit (ICU). The purpose of this study was to assess the relationship between the administration of fresh frozen plasma (FFP), platelets, and cryoprecipitate and outcomes in children with major burn injury. This was a retrospective review of children admitted with >20% TBSA burn from 2006 to 2009. Parameters measured included demographics, injury characteristics, operations, blood product transfusions, and outcomes. A total of 143 children received a mean of 3342 ± 283 ml blood. Nonsurvivors had larger burns (62.1 ± 4.6% vs 41.0 ± 1.5% TBSA, P < .001) and received similar amounts of packed red blood cells (PRBCs) during hospitalization (12.8 ± 2.4 units vs 10.9 ± 1.0 units, P = .5) than survivors. Nonsurvivors received more total units of FFP during hospitalization than survivors (8.0 ± 1.7 units vs 3.1 ± 0.4 units, P < .0001) because of the FFP units transfused in the ICU (5.5 ± 1.2 units vs 1.1 ± 0.2 units, P < .0001). The overall FFP:PRBC transfusion ratio in survivors was 1:4, whereas mean FFP:PRBC volume ratio in nonsurvivors was 3:4 (P < .0001). Nonsurvivors received more platelets (3.4 ± 1.0 units vs 0.50 ± 0.1 units, P < .001) and cryoprecipitate (1.9 ± 0.9 units vs 0.3 ± 0.1 units, P < .001) than survivors, both in the operating room and in the ICU. Blood product use in children with severe burns is associated with increased mortality. Appropriate use of blood products may need to be different in the operating room (massive acute hemorrhage) vs the ICU (ongoing red cell senescence).

Red blood cell transfusion practice in a Pediatric Intensive Care Unit

OBJECTIVES

To describe a population of children that received red blood cell transfusions.

METHODS

A retrospective observational study carried out at the Pediatric Intensive Care Unit of the Instituto da Criança of Hospital das Clínicas of Faculdade de Medicina of Universidade de São Paulo in 2004, with children that received red blood cell transfusions.

RESULTS

Transfusion of red blood cells was performed in 50% of the patients hospitalized. Median age was 18 months, and the primary motive for admission was respiratory insufficiency (35%). Underlying disease was present in 84% of the cases and multiple organ and system dysfunction in 46.2%. The median value of pretransfusion hemoglobin concentration was 7.8 g/dL. Transfused patients were undergoing some form of therapeutic procedure in 82% of the cases.

CONCLUSIONS

Red blood cell transfusions are performed at all ages. Hemoglobin concentration and hematocrit rate are the primary data used to indicate these transfusions. The values of arterial serum lactate and SvO2were seldom used. Most patients transfused were submitted to some form of therapeutic procedure, and in many cases, transfusions were carried out in patients with multiple organ and system dysfunctions.

Computerized physician order entry with decision support decreases blood transfusions in children

OBJECTIVE

Timely provision of evidence-based recommendations through computerized physician order entry with clinical decision support may improve use of red blood cell transfusions (RBCTs).

METHODS

We performed a cohort study with historical controls including inpatients admitted between February 1, 2008, and January 31, 2010. A clinical decision-support alert for RBCTs was constructed by using current evidence. RBCT orders resulted in assessment of the patient's medical record with prescriber notification if parameters were not within recommended ranges. Primary end points included the average pretransfusion hemoglobin level and the rate of RBCTs per patient-day.

RESULTS

In total, 3293 control discharges and 3492 study discharges were evaluated. The mean (SD) control pretransfusion hemoglobin level in the PICU was 9.83 (2.63) g/dL (95% confidence interval [CI]: 9.65-10.01) compared with the study value of 8.75 (2.05) g/dL (95% CI: 8.59-8.90) (P < .0001). The wards' control value was 7.56 (0.93) g/dL (95% CI: 7.47-7.65), the study value was 7.14 (1.01) g/dL (95% CI: 6.99-7.28) (P < .0001). The control PICU rate of RBCTs per patient-day was 0.20 (0.11) (95% CI: 0.13-0.27), the study rate was 0.14 (0.04) (95% CI: 0.11-0.17) (P = .12). The PICU's control rate was 0.033 (0.01) (95% CI: 0.02-0.04), and the study rate was 0.017 (0.007) (95% CI: 0.01-0.02) (P < .0001). There was no difference in mortality rates across all cohorts.

CONCLUSIONS

Implementation of clinical decision-support alerts was associated with a decrease in RBCTs, which suggests improved adoption of evidence-based recommendations. This strategy might be widely applied to promote timely adoption of scientific evidence.

Red blood cell transfusion in critically ill children: a narrative review

OBJECTIVE

To review the pathophysiology of anemia, as well as transfusion-related complications and indications for red blood cell (RBC) transfusion, in critically ill children. Although allogeneic blood has become increasingly safer from infectious agents, mounting evidence indicates that RBC transfusions are associated with complications and unfavorable outcomes. As a result, there has been growing interest and efforts to limit RBC transfusion, and indications are being revisited and revamped. Although a so-called restrictive RBC transfusion strategy has been shown to improve morbidity and mortality in critically ill adults, there have been relatively few studies on RBC transfusion performed in critically ill children.

DATA SOURCES

Published literature on transfusion medicine and outcomes of RBC transfusion. STUDY SELECTION, DATA EXTRACTION, AND SYNTHESIS: After a brief overview of physiology of oxygen transportation, anemia compensation, and current transfusion guidelines based on available literature, risks and outcomes of transfusion in general and in critically ill children are summarized in conjunction with studies investigating the safety of restrictive transfusion strategies in this patient population.

CONCLUSIONS

The available evidence does not support the extensive use of RBC transfusions in general or critically ill patients. Transfusions are still associated with risks, and although their benefits are established in limited situations, the associated negative outcomes in many more patients must be closely addressed. Given the frequency of anemia and its proven negative outcomes, transfusion decisions in the critically ill children should be based on individual patient's characteristics rather than generalized triggers, with consideration of potential risks and benefits, and available blood conservation strategies that can reduce transfusion needs.

Blood transfusion after pediatric cardiac surgery is associated with prolonged hospital stay

BACKGROUND

Red blood cell transfusion is associated with morbidity and mortality among adults undergoing cardiac surgery. We aimed to evaluate the association of transfusion with morbidity among pediatric cardiac surgical patients.

METHODS

Patients discharged after cardiac surgery in 2003 were retrospectively reviewed. The red blood cell volume administered during the first 48 postoperative hours was used to classify patients into nonexposure, low exposure (≤15 mL/kg), or high exposure (>15 mL/kg) groups. Cox proportional hazards modeling was used to evaluate the association of red blood cell exposure to length of hospital stay (LOS).

RESULTS

Of 802 discharges, 371 patients (46.2%) required blood transfusion. Demographic differences between the transfusion exposure groups included age, weight, prematurity, and noncardiac structural abnormalities (all p<0.001). Distribution of Risk Adjusted Classification for Congenital Heart Surgery, version 1 (RACHS-1) categories, intraoperative support times, and postoperative Pediatric Risk of Mortality Score, Version III (PRISM-III) scores varied among the exposure groups (p<0.001). Median duration of mechanical ventilation (34 hours [0 to 493] versus 27 hours [0 to 621] versus 16 hours [0 to 375]), incidence of infection (21 [14%] versus 29 [13%] versus 17 [4%]), and acute kidney injury (25 [17%] versus 29 [13%] versus 34 [8%]) were highest in the high transfusion exposure group when compared with the low or nontransfusion groups (all p<0.001). In a multivariable Cox proportional hazards model, both the low transfusion group (adjusted hazard ratio [HR] 0.80, 95% confidence interval [CI]: 0.66 to 0.97, p=0.02) and high transfusion group (adjusted HR 0.66, 95% CI: 0.53 to 0.82, p<0.001) were associated with increased LOS. In subgroup analyses, both low transfusion (adjusted HR 0.81, 95% CI: 0.65 to 1.00, p=0.05) and high transfusion (adjusted HR 0.65, 95% CI: 0.49 to 0.87, p=0.004) in the biventricular group but not in the single ventricle group was associated with increased LOS.

CONCLUSIONS

Blood transfusion is associated with prolonged hospitalization of children after cardiac surgery, with biventricular patients at highest risk for increased LOS. Future studies are necessary to explore this association and refine transfusion practices.

Children with single-ventricle physiology do not benefit from higher hemoglobin levels post cavopulmonary connection: results of a prospective, randomized, controlled trial of a restrictive versus liberal red-cell transfusion strategy

OBJECTIVE

To examine the impact of a restrictive vs. liberal transfusion strategy on arterial lactate and oxygen content differences in children with single-ventricle physiology post cavopulmonary connection. Children with single-ventricle physiology are routinely transfused postoperatively to increase systemic oxygen delivery, and transfusion thresholds in this population have not been studied.

DESIGN

Prospective, randomized, controlled, clinical trial.

SETTING

Pediatric cardiac intensive care unit in a teaching hospital.

PATIENTS

Infants and children (n = 60) with variations of single-ventricle physiology presenting for cavopulmonary connection.

INTERVENTIONS

Subjects were randomized to a restrictive (hemoglobin of < 9.0 g/dL), or liberal (hemoglobin of ≥ 13.0 g/dL) transfusion strategy for 48 hrs post operation. Primary outcome measures were mean and peak arterial lactate. Secondary end points were arteriovenous (C(a-v)o2) and arteriocerebral oxygen content (C(a-c)o2) differences and clinical outcomes.

MEASUREMENTS AND MAIN RESULTS

A total of 30 children were in each group. There were no significant preoperative differences. Mean hemoglobin in the restrictive and liberal groups were 11 ± 1.3 g/dL and 13.9 ± 0.5 g/dL, respectively (p < .01). No differences in mean (1.4 ± 0.5 mmol/L [Restrictive] vs. 1.4 ± 0.4 mmol/L [Liberal]) or peak (3.1 ± 1.5 mmol/L [Restrictive] vs. 3.2 ± 1.3 mmol/L [Liberal]) lactate between groups were found. Mean number of red blood cell transfusions were 0.43 ± 0.6 and 2.1 ± 1.2 (p < .01), and donor exposure was 1.2 ± 0.7 and 2.4 ± 1.1 to (p < .01), for each group, respectively. No differences were found in C(a-v)o2, C(a-c)o2, or clinical outcome measures.

CONCLUSION

Children with single-ventricle physiology do not benefit from a liberal transfusion strategy after cavopulmonary connection. A restrictive red blood cell transfusion strategy decreases the number of transfusions, donor exposures, and potential risks in these children. Larger studies with clinical outcome measures are needed to determine the transfusion threshold for children post cardiac repair or palliation for congenital heart disease.

Association between length of storage of transfused red blood cells and multiple organ dysfunction syndrome in pediatric intensive care patients

BACKGROUND

The objective was to determine if there is an association between red blood cell (RBC) storage time and development of new or progressive multiple organ dysfunction syndrome (MODS) in critically ill children.

STUDY DESIGN AND METHODS

This was an analytic cohort analysis of patients enrolled in a randomized controlled trial, TRIPICU (Transfusion Requirements in Pediatric Intensive Care Units; ISRCTN37246456), in which stable critically ill children were randomly assigned to a restrictive or liberal strategy. Transfused patients were analyzed using three different sliding time cutoffs (7, 14, and 21 days). Storage time for multiply transfused patients was defined according to the oldest unit transfused.

RESULTS

A total of 455 patients were retained (liberal, 310; restrictive, 145). Multivariate logistic regression was performed to determine independent associations. In the restrictive group, a maximum RBC storage time of more than 21 days was independently associated with new or progressive MODS (adjusted odds ratio [OR], 3.29; 95% confidence interval [CI], 1.21-9.04). The same association was found in the liberal group for a storage time of more than 14 days (adjusted OR, 2.50; 95% CI, 1.12-5.58). When the two groups were combined in a meta-analysis, a storage time of more than 14 days was independently associated with increased MODS (adjusted OR, 2.23; 95% CI, 1.20-4.15) and more than 21 days was associated with increased Pediatric Logistic Organ Dysfunction (PELOD) scores (adjusted mean difference, 4.26; 95% CI, 1.99-6.53) and higher mortality (9.2% vs. 3.8%).

CONCLUSION

Stable critically ill children who receive RBC units with storage times longer than 2 to 3 weeks may be at greater risk of developing new or progressive MODS.

Transfusion of blood and components in critically ill children

The physicians prescribing transfusions must have a thorough understanding of the various blood products, their indications and contraindications, and requirements for modification of the blood products to prevent probable adverse effects. Decision to give an RBC transfusion should not be based solely on Hb concentration, it should take in account high severity of illness; active bleeding; emergency surgery; etc. Using restrictive transfusion strategy of transfusion RBCs can decrease transfusion requirements without increasing adverse outcomes. In most circumstances, platelets should be maintained greater than 10×10(9)/L. Platelet counts greater than 20×10(9)/L are indicated for invasive procedures and greater than 50×10(9)/L for major surgeries or invasive procedures with risk of bleeding. Whenever possible, ABO-compatible platelets should be administered. Fresh frozen plasma should be transfused in multiple coagulation factor deficiencies, DIC with bleeding, replacement of rare single congenital factor deficiencies when specific concentrates are not available (e.g., protein C or factor II, V, X, XI, or XIII deficiency). During transfusion child should be monitored carefully.

Are red blood cell transfusions associated with nosocomial infections in pediatric intensive care units?

OBJECTIVES

To determine whether red blood cell transfusion is similarly associated with nosocomial infections in pediatric intensive care unit patients and whether reduced lymphocyte numbers is a possible mechanism. In adult studies, red blood cell transfusions are associated with nosocomial infections.

DESIGN

Historical cohort study.

SETTING

Single-center, mixed medical-surgical, closed pediatric intensive care unit of a tertiary university-affiliated children's hospital.

PATIENTS

All patients < or = 18 yrs old admitted to the pediatric intensive care unit during a 6-month period from January 1 to July 3, 2005.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Nosocomial infections (respiratory, urinary tract, and bloodstream infections) were the primary outcome measure and were defined as post transfusion if occurring within 14 days after red blood cell transfusion. Of the 209 subjects enrolled, 32 (15%) acquired nosocomial infections and 45 (22%) received red blood cell transfusions. Patients with versus without nosocomial infections had received red blood cell transfusions significantly more often (odds ratio, 18.0; 95% confidence interval, 7.6-45.9; p < .001). In a dose-dependence analysis, we found that patients receiving > or = 3 red blood cell transfusions had a similar prevalence of nosocomial infections compared with those receiving one to two red blood cell transfusions (61% vs. 44%, p = .365), but greater mortality (22% vs. 0%, p = .04). In a multiple logistic regression analysis controlling for gender, age, pediatric intensive care unit length of stay, presence of an invasive catheter, mechanical ventilation, and surgery, red blood cell transfusion remained independently associated with risk of nosocomial infection (odds ratio, 3.73; 95% confidence interval, 1.19-11.85, p = .023). Transfused subjects had lower absolute lymphocyte counts compared with nontransfused subjects (1605 vs. 2054/microL, p = .041), but similar total white blood cell counts (10.4 vs. 11.4 x 10/microL, p = .52).

CONCLUSION

Red blood cell transfusion in pediatric intensive care unit patients is associated with an increased risk of nosocomial infections.

The effect of blood transfusion on brain oxygenation in children with severe traumatic brain injury

OBJECTIVE

The indications for blood transfusion in traumatic brain injury are controversial. In particular, little is known about the effect of blood transfusion in childhood traumatic brain injury. This study aimed to examine the influence of blood transfusion on brain tissue oxygen tension in children with severe traumatic brain injury.

DESIGN

A retrospective analysis of a prospective observational database of children with severe traumatic brain injury who received brain tissue oxygen tension monitoring and a blood transfusion.

SETTING

University-affiliated pediatric hospital.

PATIENTS

Children with severe traumatic brain injury and blood transfusion.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Brain tissue oxygen tension was measured in normal-appearing white matter with a commercially available polarographic Clarke-type electrode. Brain tissue oxygen tension values after blood transfusion were compared with pre-transfusion values in hemodynamically stable patients. Limited interventions were allowed during the studied period. Brain tissue oxygen tension values were examined for early (1-4 hrs) and late (24 hrs) changes after blood transfusion, controlling for multiple clinical and physiologic variables with regression techniques. Further comparison was made with matched non-transfused controls to examine the influence of time after injury. Nineteen blood transfusions in 17 patients were evaluated. Brain tissue oxygen tension increased significantly in the early period after blood transfusion (p = .0018; 79% increased, 21% decreased) in comparison with baseline values and matched controls, but the overall changes were small and, in part, influenced by accompanying cerebral perfusion pressure changes. Also, this effect was limited to the early period after blood transfusion and was not significant after 24 hrs. In general, the brain tissue oxygen tension increase was larger in patients with higher baseline brain tissue oxygen tension and lower initial hemoglobin; however, no factors associated with the magnitude of the brain tissue oxygen tension change were significant in multivariate analysis. Increased age of blood did not appear to impair brain tissue oxygen tension changes, but most blood transfusion were <14 days old.

CONCLUSIONS

Brain tissue oxygen tension increased transiently in 79% of blood transfusion in pediatric traumatic brain injury patients, and decreased transiently in 21%. Brain tissue oxygen tension returned to baseline within 24 hrs. Reliable predictors of this brain tissue oxygen tension response to blood transfusion, however, remain elusive.

Red blood cell transfusion threshold in postsurgical pediatric intensive care patients: a randomized clinical trial

BACKGROUND

The optimal transfusion threshold after surgery in children is unknown. We analyzed the general surgery subgroup of the TRIPICU (Transfusion Requirements in Pediatric Intensive Care Units) study to determine the impact of a restrictive versus a liberal transfusion strategy on new or progressive multiple organ dysfunction syndrome (MODS).

METHODS

The TRIPICU study, a prospective randomized controlled trial conducted in 17 centers, enrolled a total of 648 critically ill children with a hemoglobin equal to or below 9.5 g/dL within 7 days of pediatric intensive care unit (PICU) admission to receive prestorage leukocyte-reduced red-cell transfusion if their hemoglobin dropped below either 7.0 g/dL (restrictive) or 9.5 g/dL (liberal). A subgroup of 124 postoperative patients (60 randomized to restrictive and 64 to the liberal group) were analyzed. This study was registered at http://www.controlled-trials.com and carries the following ID ISRCTN37246456.

RESULTS

Participants in the restrictive and liberal groups were similar at randomization in age (restrictive vs. liberal: 53.5 +/- 51.8 vs. 73.7 +/- 61.8 months), severity of illness (pediatric risk of mortality [PRISM] score: 3.5 +/- 4.0 vs. 4.4 +/- 4.0), MODS (35% vs. 29%), need for mechanical ventilation (77% vs. 74%), and hemoglobin level (7.7 +/- 1.1 vs. 7.9 +/- 1.0 g/dL). The mean hemoglobin level remained 2.3 g/dL lower in the restrictive group after randomization. No significant differences were found for new or progressive MODS (8% vs. 9%; P = 0.83) or for 28-day mortality (2% vs. 2%; P = 0.96) in the restrictive versus liberal group. However, there was a statistically significant difference between groups for PICU length of stay (7.7 +/- 6.6 days for the restrictive group vs. 11.6 +/- 10.2 days for the liberal group; P = 0.03).

CONCLUSIONS

In this subgroup analysis of pediatric general surgery patients, we found no conclusive evidence that a restrictive red-cell transfusion strategy, as compared with a liberal one, increased the rate of new or progressive MODS or mortality.