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Kazamer A, Ilinca R, Stanescu-Spinu II, Lutescu DA, Greabu M, Miricescu D, Coricovac AM, Ionescu D. Perceptions of the Conditions and Barriers in Implementing the Patient Blood Management Standard by Anesthesiologists and Surgeons. Healthcare (Basel) 2024; 12:760. [PMID: 38610182 PMCID: PMC11011949 DOI: 10.3390/healthcare12070760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 03/15/2024] [Accepted: 03/29/2024] [Indexed: 04/14/2024] Open
Abstract
Patient Blood Management (PBM) as a multidisciplinary practice and a standard of care for the anemic surgical patient is playing an increasingly important role in reducing transfusions and optimizing both clinical outcomes and costs. The success of PBM implementation depends on staff awareness and involvement in this approach. The main objective of our study was to explore physicians' perceptions of the conditions for implementing PBM in hospitals and the main obstacles they face in detecting and treating anemic patients undergoing elective surgery. This cross-sectional descriptive study includes 113 Romanian health units, representing 23% of health units with surgical wards nationwide. A 12-item questionnaire was distributed to the participants in electronic format. A total of 413 questionnaires representing the perceptions of 347 surgeons and 66 anesthesia and intensive-care specialists were analyzed. Although a lack of human resources was indicated by 23.70% of respondents as the main reason for not adhering the guidelines, the receptiveness of medical staff to implementing the PBM standard was almost 90%. In order to increase adherence to the standard, additional involvement of anesthesia and intensive-care physicians would be necessary from the perception of 35.70% of the responders: 23.60% of surgeons and 18.40% of hematologists.
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Affiliation(s)
- Andrea Kazamer
- Department of Anaesthesia and Intensive Care I, Iuliu Hatieganu University of Medicine and Pharmacy, 8 Victor Babes Street, 400347 Cluj-Napoca, Romania;
- CREST Association, 48 Alexandru Odobescu Street, 440069 Satu Mare, Romania
| | - Radu Ilinca
- Discipline of Medical Informatics and Biostatistics, Faculty of Dentistry, Carol Davila University of Medicine and Pharmacy, 4–6 Eforie Street, 020021 Bucharest, Romania;
| | - Iulia-Ioana Stanescu-Spinu
- Discipline of Physiology, Faculty of Dentistry, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania;
| | - Dan Adrian Lutescu
- Discipline of Medical Informatics and Biostatistics, Faculty of Dentistry, Carol Davila University of Medicine and Pharmacy, 4–6 Eforie Street, 020021 Bucharest, Romania;
| | - Maria Greabu
- Discipline of Biochemistry, Faculty of Dentistry, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania; (M.G.); (D.M.)
| | - Daniela Miricescu
- Discipline of Biochemistry, Faculty of Dentistry, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania; (M.G.); (D.M.)
| | - Anca Magdalena Coricovac
- Discipline of Embryology, Faculty of Dentistry, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania;
| | - Daniela Ionescu
- Department of Anaesthesia and Intensive Care I, Iuliu Hatieganu University of Medicine and Pharmacy, 8 Victor Babes Street, 400347 Cluj-Napoca, Romania;
- Outcome Research Consortium, Cleveland, OH 44195, USA
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Hammon DE, Chidambaran V, Templeton TW, Pestieau SR. Error traps and preventative strategies for adolescent idiopathic scoliosis spinal surgery. Paediatr Anaesth 2023; 33:894-904. [PMID: 37528658 DOI: 10.1111/pan.14735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/26/2023] [Accepted: 07/10/2023] [Indexed: 08/03/2023]
Abstract
Anesthesia for posterior spinal fusion for adolescent idiopathic scoliosis remains one of the most common surgeries performed in adolescents. These procedures have the potential for significant intraprocedural and postoperative complications. The potential for pressure injuries related to prone positioning must be understood and addressed. Additionally, neuromonitoring remains a mainstay for patient care in order to adequately assess patient neurologic integrity and alert the providers to a reversible action. As such, causes of neuromonitoring signal loss must be well understood, and the provider should have a systematic approach to signal loss. Further, anesthetic design must facilitate intraoperative wake-up to allow for a definitive assessment of neurologic function. Perioperative bleeding risk is high in posterior spinal fusion due to the extensive surgical exposure and potentially lengthy operative time, so the provider should undertake strategies to reduce blood loss and avoid coagulopathy. Pain management for adolescents undergoing spinal fusion is also challenging, and inadequate analgesia can delay recovery, impede patient/family satisfaction, increase the risk of chronic postsurgical pain/disability, and lead to prolonged opioid use. Many of the significant complications associated with this procedure, however, can be avoided with intentional and evidence-based approaches covered in this review.
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Affiliation(s)
- Dudley E Hammon
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Vidya Chidambaran
- Department of Anesthesiology, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Thomas W Templeton
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Sophie R Pestieau
- Department of Anesthesiology, Washington National, Washington, DC, USA
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Govender K, Kemp E, Motshabi Chakane P. Intraoperative transfusion practice and associated outcomes following neonatal surgery in a middle-income country: A 5-year single center retrospective review. Paediatr Anaesth 2023; 33:720-727. [PMID: 37368461 DOI: 10.1111/pan.14715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 06/13/2023] [Accepted: 06/16/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUND Neonates undergoing surgery are at greater risk of requiring packed red blood cell transfusion. Pediatric transfusion practices vary widely between countries and institutions, especially in the management of neonates. AIMS The aim of this study was to describe the use of intraoperative blood product transfusion during neonatal surgery in current clinical practice at our institution. METHODS A retrospective contextual, descriptive, and comparative study was conducted at Chris Hani Baragwanath Academic Hospital. A total of 1078 anesthetic records of neonates who underwent surgery from January 1, 2015 to December 31, 2019 were reviewed. Descriptive and inferential statistics were used to analyze the data. RESULTS Blood products were transfused during 374 (34.7%) neonatal surgeries. Packed red blood cells, platelet concentrate, and fresh frozen plasma were administered during 327 (30.3%), 133 (12.3%), and 85 (7.9%) of the total 1078 surgeries, respectively. The median (interquartile range) volume of packed red blood cells, fresh frozen plasma, platelets, and clear fluid administered was 15 (10-21.8) mL/kg, 12.3 (10-23.5) mL/kg, 13.6 (10-20.5) mL/kg, and 19 (9.1-28.8) mL/kg, respectively. Very low weight, low preoperative hemoglobin, long total anesthetic time, emergency surgery, and major surgery were independently associated with blood product transfusion. Gestational age at birth, blood product transfusion, emergency surgery, and major surgery were independently associated with the composite adverse outcomes. The median preoperative hemoglobin was 11.8 g/dL. CONCLUSIONS Intraoperative blood product transfusion occurred at a much higher rate with a high median pre-transfusion hemoglobin compared to other studies.
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Affiliation(s)
- Kushal Govender
- Department of Anesthesiology, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Anesthesiology, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
| | - Ellen Kemp
- Department of Anesthesiology, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Anesthesiology, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
| | - Palesa Motshabi Chakane
- Department of Anesthesiology, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Anesthesiology, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
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Kazamer A, Ilinca R, Vesa S, Lorenzovici L, Stanescu-Spinu II, Ganea I, Greabu M, Miricescu D, Biczo A, Ionescu D. A Potential Indicator for Assessing Patient Blood Management Standard Implementation. Healthcare (Basel) 2023; 11:2233. [PMID: 37628431 PMCID: PMC10454481 DOI: 10.3390/healthcare11162233] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 07/13/2023] [Accepted: 08/05/2023] [Indexed: 08/27/2023] Open
Abstract
(1) Background: Patient blood management (PBM) program as a multidisciplinary practice and a standard of care for the anemic surgical patient has an increasingly important role in reducing transfusions and optimizing both clinical outcomes and costs. Documented success of PBM implementation is not sufficient for implementation of recommendations and correct use at hospital level. The primary objective of our study was to define a composite patient blood management process safety index-Safety Index in PBM (SIPBM)-that measures the impact of screening and treating anemic patients on the efficiency and effectiveness of the patient care process undergoing elective surgery. (2) Methods: We conducted a retrospective comparative study in a tertiary hospital by collecting data and analyzing the Safety Index in PBM (SIPBM) in patients undergoing major elective surgical procedures. (3) Results: The percentage of patients from the total of 354 patients (178 in 2019 and 176 in 2022) included in the study who benefited from preoperative iron treatment increased in 2022 compared to 2019 from 27.40% to 36.71%. The median value of the SIPBM was 1.00 in both periods analyzed, although there is a significant difference between the two periods (p < 0.005), in favor of 2022. (4) Conclusions: Measuring the effectiveness of PBM implementation and providing ongoing feedback through the Safety Index in PBM (SIPBM) increases the degree to which opportunities to improve the PBM process are identified. The study represents a first step for future actions and baselines to develop tools to measure the safety and impact of the patient blood management process in the surgical field.
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Affiliation(s)
- Andrea Kazamer
- CREST Association, 48 Alexandru Odobescu Street, 440069 Satu Mare, Romania
- Department of Anaesthesia and Intensive Care I, Faculty of Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 8 Victor Babes Street, 400012 Cluj-Napoca, Romania; (S.V.); (D.I.)
| | - Radu Ilinca
- Discipline of Medical Informatics and Biostatistics, Faculty of Dentistry, Carol Davila University of Medicine and Pharmacy, 4-6 Eforie Street, 050037 Bucharest, Romania
| | - Stefan Vesa
- Department of Anaesthesia and Intensive Care I, Faculty of Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 8 Victor Babes Street, 400012 Cluj-Napoca, Romania; (S.V.); (D.I.)
| | - Laszlo Lorenzovici
- Faculty of Technical and Human Sciences, Sapientia Hungarian University of Transylvania, 4 Matei Corvin Street, 400112 Cluj-Napoca, Romania;
| | - Iulia-Ioana Stanescu-Spinu
- Discipline of Biochemistry, Faculty of Dentistry, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Street, 050474 Bucharest, Romania; (I.-I.S.-S.); (M.G.); (D.M.)
| | - Ionela Ganea
- Department of Modern Languages, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Street, 050474 Bucharest, Romania;
| | - Maria Greabu
- Discipline of Biochemistry, Faculty of Dentistry, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Street, 050474 Bucharest, Romania; (I.-I.S.-S.); (M.G.); (D.M.)
| | - Daniela Miricescu
- Discipline of Biochemistry, Faculty of Dentistry, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Street, 050474 Bucharest, Romania; (I.-I.S.-S.); (M.G.); (D.M.)
| | - Andras Biczo
- Department Hamm 2 Manufacturing and Production Technology, Hamm-Lippstadt University of Applied Sciences, Allee 76-78, D-59063 Hamm, Germany;
| | - Daniela Ionescu
- Department of Anaesthesia and Intensive Care I, Faculty of Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 8 Victor Babes Street, 400012 Cluj-Napoca, Romania; (S.V.); (D.I.)
- Outcome Research Consortium, Cleveland, OH 44195, USA
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Del Fante C, Mortellaro C, Recupero S, Giorgiani G, Agostini A, Panigari A, Perotti C, Zecca M. Patient Blood Management after Hematopoietic Stem Cell Transplantation in a Pediatric Setting: Starting Low and Going Lower. Diagnostics (Basel) 2023; 13:2257. [PMID: 37443651 DOI: 10.3390/diagnostics13132257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 06/28/2023] [Accepted: 07/01/2023] [Indexed: 07/15/2023] Open
Abstract
Despite the substantial transfusion requirements, there are few studies on the optimal transfusion strategy in pediatric patients undergoing hematopoietic stem cell transplantation (HSCT). Our study aimed to retrospectively analyze red blood cell (RBC) and platelet (PLT) transfusion practices during the first 100 days after HSCT at the pediatric hematology/oncology unit of our hospital between 2016 and 2019, due to a more restrictive approach adopted after 2016. We also evaluated the impact on patient outcomes. A total of 146 consecutive HSCT patients were analyzed. In patients without hemorrhagic complications, the Hb threshold for RBC transfusions decreased significantly from 2016 to 2017 (from 7.8 g/dL to 7.3 g/dL; p = 0.010), whereas it remained the same in 2017, 2018, and 2019 (7.3, 7.2, and 7.2 g/dL, respectively). Similarly, the PLT threshold decreased significantly from 2016 to 2017 (from 18,000 to 16,000/μL; p = 0.026) and further decreased in 2019 (15,000/μL). In patients without severe hemorrhagic complications, the number of RBC and PLT transfusions remained very low over time. No increase in 100-day and 180-day non-relapse mortality or adverse events was observed during the study period. No patient died due to hemorrhagic complications. Our preliminary observations support robust studies enrolling HSCT patients in patient blood management programs.
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Affiliation(s)
- Claudia Del Fante
- Immunohaematology and Transfusion Service, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Cristina Mortellaro
- Immunohaematology and Transfusion Service, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Santina Recupero
- Pediatric Hematology/Oncology, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Giovanna Giorgiani
- Pediatric Hematology/Oncology, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Annalisa Agostini
- Pediatric Hematology/Oncology, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Arianna Panigari
- Pediatric Hematology/Oncology, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Cesare Perotti
- Immunohaematology and Transfusion Service, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Marco Zecca
- Pediatric Hematology/Oncology, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
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Wang JT, Seshadri SC, Butler CG, Staffa SJ, Kordun AS, Lukovits KE, Goobie SM. Tranexamic Acid Use in Pediatric Craniotomies at a Large Tertiary Care Pediatric Hospital: A Five Year Retrospective Study. J Clin Med 2023; 12:4403. [PMID: 37445437 DOI: 10.3390/jcm12134403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/30/2023] [Accepted: 06/27/2023] [Indexed: 07/15/2023] Open
Abstract
Tranexamic acid (TXA), a synthetic antifibrinolytic drug, has proven efficacy and is recommended for major pediatric surgery to decrease perioperative blood loss. Accumulating evidence suggests that TXA reduces bleeding and transfusion in a variety of adult neurosurgical settings. However, there is a paucity of research regarding TXA indications for pediatric neurosurgery and thus, there are currently no recommendations for its use with this specific population. The objective of this study is to evaluate the existing practice of TXA administration for pediatric neurosurgery at a U.S. tertiary care pediatric hospital over a five-year period. The authors conclude that TXA administration is feasible and should be considered for pediatric neurosurgical cases where potential blood loss is a concern.
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Affiliation(s)
- Jue T Wang
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Samir C Seshadri
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Carolyn G Butler
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Anna S Kordun
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Karina E Lukovits
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Susan M Goobie
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA
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Wittenmeier E, Komorek Y, Engelhard K. Current hemoglobin thresholds in pediatric anesthesia - guidelines and studies. Curr Opin Anaesthesiol 2023; 36:301-310. [PMID: 36794871 DOI: 10.1097/aco.0000000000001253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
PURPOSE OF REVIEW The use of restrictive transfusion triggers to avoid unnecessary transfusions is one important pillar of Patient Blood Management (PBM). For the safe application of this principle in pediatric patients, anesthesiologists need evidence-based guidelines for hemoglobin (Hb) transfusions thresholds in this specially vulnerable age-group. RECENT FINDINGS This review outlines recent prospective and observational studies examining transfusion thresholds in pediatrics. Recommendations to use transfusion triggers in the perioperative or intensive care setting are summarized. SUMMARY Two high-quality studies confirmed that the use of restrictive transfusion triggers in preterm infants in the intensive care unit (ICU) is reasonable and feasible. Unfortunately, no recent prospective study could be found investigating intraoperative transfusion triggers. Some observational studies showed wide variability in Hb levels before transfusion, a tendency toward restrictive transfusion practices in preterm infants, and liberal transfusion practices in older infants. Although there are comprehensive and useful guidelines for clinical practice in pediatric transfusion, most of them do not cover the intraoperative period in particular because of a lack of high-quality studies. This lack of prospective randomized trials focusing on intraoperative transfusion management remains a major problem for the application of pediatric PBM.
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Affiliation(s)
- Eva Wittenmeier
- Department of Anesthesiology, University Medical Centre of the Johannes Gutenberg University Mainz, Germany
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Tan GM, Murto K, Downey LA, Wilder MS, Goobie SM. Error traps in Pediatric Patient Blood Management in the Perioperative Period. Paediatr Anaesth 2023. [PMID: 37144721 DOI: 10.1111/pan.14683] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 04/04/2023] [Accepted: 04/12/2023] [Indexed: 05/06/2023]
Abstract
Patient blood management is a patient-centered evidence-based approach to improve patient outcomes by harnessing the patient's own hematopoietic system to optimize blood health while promoting patient safety and empowerment. Perioperative patient blood management is a standard of care in adult medicine, yet it is not commonly accepted in pediatrics. Raising awareness may be the first step in improving perioperative care for the anemic and/or bleeding child. This article highlights five preventable perioperative blood conservation error traps for children. The goal is to provide practical clinical guidance to improve preoperative diagnosis and treatment of anemia, facilitate recognition and treatment of massive hemorrhage, reduce unnecessary allogeneic blood transfusions, and decrease associated complications of anemia and blood component transfusions utilizing a patient/family-centered informed consent and shared decision-making approach.
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Affiliation(s)
- Gee Mei Tan
- Pediatric Anesthesiology Division, Children's Hospital Colorado, University of Colorado, School of Medicine, Aurora, Colorado, USA
| | - Kimmo Murto
- Department of Anesthesiology & Pain Medicine, Children's Hospital of Eastern Ontario Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Laura A Downey
- Department of Anesthesiology, Emory University Medical School, Atlanta, Georgia, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Matthew S Wilder
- Pediatric Anesthesiology Division, Children's Hospital Colorado, University of Colorado, School of Medicine, Aurora, Colorado, USA
| | - Susan M Goobie
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Piekarski F, Noone S, Engelhardt T, Hellmich M, Wittenmeier E, Quintao V, Arnold P, Goobie SM, Zacharowski K, Kaufmann J. Evaluation of a Pre-Filled Table and a Flowchart-Based Algorithm as Cognitive Aids to Reduce Deviations in Dose Calculation for Intraoperative Red Blood Cell Transfusions in Children-An International Web-Based Simulation. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10050815. [PMID: 37238363 DOI: 10.3390/children10050815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 04/14/2023] [Accepted: 04/27/2023] [Indexed: 05/28/2023]
Abstract
BACKGROUND Transfusion of red blood cell concentrate can be life-saving, but requires accurate dose calculations in children. AIMS We tested the hypothesis that cognitive aids would improve identification of the correct recommended volumes and products, according to the German National Transfusion guidelines, in pediatric transfusion scenarios. METHODS Four online questionnaire-based scenarios, two with hemodynamically stable and two with hemodynamically unstable children, were sent to German and international pediatric anesthetists for completion. In the two stable scenarios, participants were given pre-filled tables that contained all required information. For the two emergency scenarios, existing algorithms were used and required calculation by the user. The results were classified into three categories of deviations from the recommended values (DRV): DRV120 (<80% or >120%), as the acceptable variation; DRV 300 (<33% or >300%), the deviation of concern for potential harm; and DRV 1000 (<10% or >1000%), the excessive deviation with a high probability of harm. RESULTS A total of 1.458 pediatric anesthetists accessed this simulation questionnaire, and 402 completed questionnaires were available for analysis. A pre-filled tabular aid, avoiding calculations, led to a reduction in deviation rates in the category of DRV120 by 60% for each and of DRV300 by 17% and 20%, respectively. The use of algorithms as aids for unstable emergencies led to a reduction in the deviation rate only for DRV120 (20% and 15% respectively). In contrast, the deviation rates for DRV300 and DRV1000 rose by 37% and 16%, respectively. Participants used higher transfusion thresholds for the emergency case of a 2-year-old compromised child than for the stable case with a patient of the same age (on average, 8.6 g/dL, 95% CI 8.5-8.8 versus 7.1 g/dL, 95% CI 7.0-7.2, p < 0.001) if not supported by our aids. Participants also used a higher transfusion threshold for unstable children aged 3 months than for stable children of the same age (on average, 8.9 g/dL, 95% CI 8.7-9.0 versus 7.9 g/dL, 95% CI 7.7-8.0, p < 0.001). CONCLUSIONS The use of cognitive aids with precalculated transfusion volumes for determining transfusion doses in children may lead to improved adherence to published recommendations, and could potentially reduce dosing deviations outside those recommended by the German national transfusion guidelines.
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Affiliation(s)
- Florian Piekarski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, 60590 Frankfurt, Germany
| | - Stephanie Noone
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, 60590 Frankfurt, Germany
| | - Thomas Engelhardt
- Department for Anesthesia, Montreal Children's Hospital, Montreal, QC 1001, Canada
| | - Martin Hellmich
- Institute for Medical Statistics, Informatics, and Epidemiology (IMSIE), University Hospital Cologne, University of Cologne, 50923 Cologne, Germany
| | - Eva Wittenmeier
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University, 55131 Mainz, Germany
| | - Vinicius Quintao
- Discipline of Anesthesiology, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo 05403-010, Brazil
| | - Philip Arnold
- The Jackson Rees Department of Anaesthesia, Alder Hey Children's Hospital, Liverpool L12 2AP, UK
| | - Susan M Goobie
- Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston Children's Hospital, Boston, MA 02115, USA
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, 60590 Frankfurt, Germany
| | - Jost Kaufmann
- Department for Paediatric Anaesthesia, Children's Hospital Cologne, 50735 Cologne, Germany
- Faculty for Health, University of Witten/Herdecke, 58455 Witten, Germany
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Kietaibl S, Ahmed A, Afshari A, Albaladejo P, Aldecoa C, Barauskas G, De Robertis E, Faraoni D, Filipescu DC, Fries D, Godier A, Haas T, Jacob M, Lancé MD, Llau JV, Meier J, Molnar Z, Mora L, Rahe-Meyer N, Samama CM, Scarlatescu E, Schlimp C, Wikkelsø AJ, Zacharowski K. Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022. Eur J Anaesthesiol 2023; 40:226-304. [PMID: 36855941 DOI: 10.1097/eja.0000000000001803] [Citation(s) in RCA: 49] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management. DESIGN A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline. RESULTS These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%. DISCUSSION Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality. CONCLUSION All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.
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Affiliation(s)
- Sibylle Kietaibl
- From the Department of Anaesthesiology & Intensive Care, Evangelical Hospital Vienna and Sigmund Freud Private University Vienna, Austria (SK), Department of Anaesthesia and Critical Care, University Hospitals of Leicester NHS Trust (AAh), Department of Cardiovascular Sciences, University of Leicester, UK (AAh), Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (AAf), Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark (AAf), Department of Anaesthesiology & Critical Care, CNRS/TIMC-IMAG UMR 5525/Themas, Grenoble-Alpes University Hospital, Grenoble, France (PA), Department of Anaesthesiology & Intensive Care, Hospital Universitario Rio Hortega, Valladolid, Spain (CA), Department of Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania (GB), Division of Anaesthesia, Analgesia, and Intensive Care - Department of Medicine and Surgery, University of Perugia, Italy (EDR), Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA (DFa), University of Medicine and Pharmacy Carol Davila, Department of Anaesthesiology & Intensive Care, Emergency Institute for Cardiovascular Disease, Bucharest, Romania (DCF), Department of Anaesthesia and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria (DFr), Department of Anaesthesiology & Critical Care, APHP, Université Paris Cité, Paris, France (AG), Department of Anesthesiology, University of Florida, College of Medicine, Gainesville, Florida, USA (TH), Department of Anaesthesiology, Intensive Care and Pain Medicine, St.-Elisabeth-Hospital Straubing, Straubing, Germany (MJ), Department of Anaesthesiology, Medical College East Africa, The Aga Khan University, Nairobi, Kenya (MDL), Department of Anaesthesiology & Post-Surgical Intensive Care, University Hospital Doctor Peset, Valencia, Spain (JVL), Department of Anaesthesiology & Intensive Care, Johannes Kepler University, Linz, Austria (JM), Department of Anesthesiology & Intensive Care, Semmelweis University, Budapest, Hungary (ZM), Department of Anaesthesiology & Post-Surgical Intensive Care, University Trauma Hospital Vall d'Hebron, Barcelona, Spain (LM), Department of Anaesthesiology & Intensive Care, Franziskus Hospital, Bielefeld, Germany (NRM), Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP. Centre - Université Paris Cité - Cochin Hospital, Paris, France (CMS), Department of Anaesthesiology and Intensive Care, Fundeni Clinical Institute, Bucharest and University of Medicine and Pharmacy Carol Davila, Bucharest, Romania (ES), Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Linz and Ludwig Boltzmann-Institute for Traumatology, The Research Centre in Co-operation with AUVA, Vienna, Austria (CS), Department of Anaesthesia and Intensive Care Medicine, Zealand University Hospital, Roskilde, Denmark (AW) and Department of Anaesthesiology, Intensive Care Medicine & Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany (KZ)
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11
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Al-Mozain N, Arora S, Goel R, Pavenski K, So-Osman C. Patient Blood Management in adults and children: what have we achieved, and what still needs to be addressed? Transfus Clin Biol 2023:S1246-7820(23)00041-1. [PMID: 36965848 DOI: 10.1016/j.tracli.2023.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2023]
Abstract
An overview of Patient Blood Management (PBM), with its main scope to preserve the patient's own blood to improve the patient's outcome, is presented here, including the research gaps that needs to be addressed, particularly in the pediatric age group. Next, novel techniques to analyse PBM data and the challenges and strategies of PBM implementation will also be discussed.
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Affiliation(s)
- Nour Al-Mozain
- Department of Pathology & Laboratory Medicine, King Faisal Specialist Hospital, Riyadh, Saudi Arabia.
| | - Satyam Arora
- Department of Transfusion Medicine. Post Graduate Institute of Child Health, Noida, UP, India.
| | - Ruchika Goel
- Department of Pathology, Div. of Transfusion Medicine, Johns Hopkins University, Baltimore, MD, Department of Internal Medicine and Pediatrics, Div. of Hematology/Oncology, Simmons Cancer Institute at SIU School of Medicine, USA.
| | - Katerina Pavenski
- Departments of Laboratory Medicine and Medicine, St. Michael's Hospital - Unity Health Toronto, Toronto, Canada, Departments of Laboratory Medicine & Pathobiology and Medicine, University of Toronto, Toronto, Canada.
| | - Cynthia So-Osman
- Department of Transfusion medicine, Sanquin Blood Supply, Amsterdam and Department of Haematology, Erasmus Medical Centre, Rotterdam, The Netherlands.
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12
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Longacre MM, Seshadri SC, Adil E, Baird LC, Goobie SM. Perioperative management of pediatric patients undergoing juvenile angiofibroma resection. A case series and educational review highlighting patient blood management. Paediatr Anaesth 2023. [PMID: 36869694 DOI: 10.1111/pan.14655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 02/25/2023] [Accepted: 02/28/2023] [Indexed: 03/05/2023]
Abstract
BACKGROUND Juvenile nasopharyngeal angiofibromas are one of the most enigmatic, bloody tumors encountered by otorhinolarygnologists, head and neck surgeons, neurosurgeons, and anesthesiologists. Juvenile nasopharyngeal angiofibromas are rare, benign, highly vascular tumors with a propensity towards aggressive local invasion. Surgery, open or endoscopic, to remove the growth is the primary treatment of choice for Juvenile nasopharyngeal angiofibromas. Historically, surgical resection was associated with massive, rapid blood loss, traditionally managed by blood product transfusion and deliberate hypotension. Preventative management employing multimodal blood conservation strategies should be an essential standard of perioperative care for patients with Juvenile nasopharyngeal angiofibromas. METHODS We describe a contemporary and comprehensive approach in the management of patients with high grade Juvenile nasopharyngeal angiofibromas. This includes surgical strategies such as preemptive external carotid artery embolization, endoscopic surgical approach, and staged operations, as well as anesthetic strategies including antifibrinolytic therapy and acute normovolemic hemodilution. These surgeries, once synonymous with massive transfusion, may potentially be performed without allogeneic blood transfusion, or deliberate hypotension. AIMS Using a case series, the authors introduce a contemporary approach to multimodal, multidisciplinary blood conservation strategies for Juvenile nasopharyngeal angiofibromas surgery. RESULTS Here in the authors report on an updated contemporary perioperative clinical approach to patients with Juvenile nasopharyngeal angiofibromas. From an anesthetic perspective, we describe the successful use of normal hemodynamic goals, restrictive transfusion strategy, antifibrinolytic therapy, autologous normovolemic hemodilution, and early extubation in the care of three adolescent males with highly invasive tumors. We demonstrate that new surgical and anesthetic strategies have yielded a significant decrease in intraoperative blood loss and eliminated the need for transfusion of autologous red blood cells, which enable improved outcomes. CONCLUSIONS The perioperative approach to elective surgery for Juvenile nasopharyngeal angiofibromas management is presented from a multidisciplinary patient blood management perspective.
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Affiliation(s)
- M M Longacre
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - S C Seshadri
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - E Adil
- Department of Otolaryngology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - L C Baird
- Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - S M Goobie
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
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13
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The Incidence and Risk Factors for Allogeneic Blood Transfusions in Pediatric Spine Surgery: National Data. Healthcare (Basel) 2023; 11:healthcare11040533. [PMID: 36833065 PMCID: PMC9956304 DOI: 10.3390/healthcare11040533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 01/29/2023] [Accepted: 02/08/2023] [Indexed: 02/15/2023] Open
Abstract
(1) Background: Pediatric spinal surgery is a blood-intensive procedure. In order to introduce a rational blood management program, identifying the risk factors for transfusions is mandatory. (2) Methods: Data from the national database covering the period from January 2015 to July 2017 were analyzed. The available data included the demographics, characteristics of the surgeries performed, length of stay, and in-house mortality. (3) Results: The total number of patients used for the analysis was 2302. The primary diagnosis was a spinal deformity (88.75%). Most fusions were long, with four levels or more (89.57%). A total of 938 patients received a transfusion; thus, the transfusion rate was 40.75%. The present study identified several risk factors; the most significant was a number of levels fused greater than 4 (RR 5.51; CI95% 3.72-8.15; p < 0.0001), followed by the deformity as the main diagnosis (RR 2.69; CI95% 1.98-3.65; p < 0.0001). These were the two most significant factors increasing the odds of a transfusion. Other factors associated with an increased risk of transfusion were elective surgery, the female sex, and an anterior approach. The mean length of stay in days was 11.42 (SD 9.93); this was greater in the transfused group (14.20 vs. 9.50; p < 0.0001). (4) Conclusions: The rate of transfusions in pediatric spinal surgery remains high. A new patient blood management program is necessary to improve this situation.
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14
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Determination of reference ranges for the ClotPro® thromboelastometry device in paediatric patients. Br J Anaesth 2023; 130:183-190. [PMID: 36376099 DOI: 10.1016/j.bja.2022.09.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 09/09/2022] [Accepted: 09/24/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND A new thromboelastometry analyser (ClotPro®) was developed with advanced diagnostics. The reference ranges of ClotPro® in children ages 0-16 yr have not been reported. METHODS In this prospective study, venous blood samples from 321 patients were obtained from children undergoing elective surgery after induction of anaesthesia. Reference ranges were defined by calculating the 2.5% and 97.5% percentiles for each age group (0-3 months, 4-12 months, 13-24 months, 2-5 yr, 6-10 yr, and 11-16 yr). RESULTS Reference ranges of the ClotPro® analyser in all age groups demonstrated significant differences in some parameters between age groups. In the first 3 months of life, a significant shortening of the clotting time (CT) in the extrinsically activated test (EX-test) was observed in children aged 0-3 months compared with children of all older age groups (P<0.001), whereas there were no overall differences in the intrinsically activated test (IN-test). In both assays, the clot amplitude 5 and 10 min after CT (A5, A10 value) was significantly higher in the first year of life compared with children older than 1 yr (EX-test and IN-test A5 and A10, respectively; P<0.001). The strength of fibrin polymerisation (FIB-test) was significantly higher in the first 3 months of life (A5 and A10, P<0.003). CONCLUSIONS ClotPro® reference ranges were determined for six paediatric age groups, and show age-dependent differences in specific parameters. These values will be helpful in monitoring haemostasis in paediatric patients and for developing tailored bleeding management protocols. CLINICAL TRIAL REGISTRATION NCT04190615.
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15
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Ozawa S, Ozawa-Morriello J, Perelman S, Thorpe E, Rock R, Pearse BL. Improving Patient Blood Management Programs: An Implementation Science Approach. Anesth Analg 2023; 136:397-407. [PMID: 36638516 DOI: 10.1213/ane.0000000000006273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Organized patient blood management (PBM) programs function in numerous hospitals and health systems around the world contributing to improved patient outcomes as well as increased patient engagement, decreased resource use, and reductions in health care costs. PBM "programming" ranges from the implementation of single strategies/initiatives to comprehensive programs led by dedicated clinicians and PBM committees, employing the use of multiple PBM strategies. Frontline health care professionals play an important role in leading, implementing, operationalizing, measuring, and sustaining successful PBM programs. In this article, we provide practical implementation guidance to support key clinical, administrative, leadership, and structural elements required for the safe and comprehensive delivery of care in PBM programs at the local level.
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Affiliation(s)
- Sherri Ozawa
- From Department of Clinical Optimization, Accumen Incorporated, Phoenix, Arizona.,Department of Bloodless Medicine and Surgery and Patient Blood Management, Englewood Health, Englewood, New Jersey.,Society for the Advancement of Patient Blood Management, Mt Royal, New Jersey
| | - Joshua Ozawa-Morriello
- Department of Bloodless Medicine and Surgery, Hackensack University Medical Center, Hackensack, New Jersey
| | - Seth Perelman
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Langone Health, NYU School of Medicine, New York, New York
| | - Elora Thorpe
- From Department of Clinical Optimization, Accumen Incorporated, Phoenix, Arizona
| | - Rebecca Rock
- Department of Patient Blood Management, Alberta Health Services, Calgary, Alberta, Canada
| | - Bronwyn L Pearse
- Department of Surgery and Critical Care, The Prince Charles Hospital, Brisbane, Queensland, Australia.,Department of Nursing and Midwifery, Griffith University, Brisbane, Queensland, Australia
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16
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King MR, Staffa SJ, Stricker PA, Pérez-Pradilla C, Nelson O, Benzon HA, Goobie SM. Safety of antifibrinolytics in 6583 pediatric patients having craniosynostosis surgery: A decade of data reported from the multicenter Pediatric Craniofacial Collaborative Group. Paediatr Anaesth 2022; 32:1339-1346. [PMID: 35925835 DOI: 10.1111/pan.14540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 07/17/2022] [Accepted: 07/21/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Antifibrinolytics such as tranexamic acid and epsilon-aminocaproic acid are effective at reducing blood loss and transfusion in pediatric patients having craniofacial surgery. The Pediatric Craniofacial Collaborative Group has previously reported low rates of seizures and thromboembolic events (equal to no antifibrinolytic given) in open craniofacial surgery. AIMS To query the Pediatric Craniofacial Collaborative Group database to provide an updated antifibrinolytic safety profile in children given that antifibrinolytics have become recommended standard of care in this surgical population. Additionally, we include the population of younger infants having minimally invasive procedures. METHODS Patients in the Pediatric Craniofacial Collaborative Group registry between June 2012 and March 2021 having open craniofacial surgery (fronto-orbital advancement, mid and posterior vault, total cranial vault remodeling, intracranial LeFort III monobloc), endoscopic cranial suture release, and spring mediated cranioplasty were included. The primary outcome is the rate of postoperative complications possibly attributable to antifibrinolytic use (seizures, seizure-like activity, and thromboembolic events) in infants and children undergoing craniosynostosis surgery who did or did not receive antifibrinolytics. RESULTS Forty-five institutions reporting 6583 patients were included. The overall seizure rate was 0.24% (95% CI: 0.14, 0.39%), with 0.20% in the no Antifibrinolytic group and 0.26% in the combined Antifibrinolytic group, with no statistically reported difference. Comparing seizure rates between tranexamic acid (0.22%) and epsilon-aminocaproic acid (0.44%), there was no statistically significant difference (odds ratio = 2.0; 95% CI: 0.6, 6.7; p = .257). Seizure rate was higher in patients greater than 6 months (0.30% vs. 0.18%; p = .327), patients undergoing open procedures (0.30% vs. 0.06%; p = .141), and syndromic patients (0.70% vs. 0.19%; p = .009). CONCLUSIONS This multicenter international experience of pediatric craniofacial surgery reports no increase in seizures or thromboembolic events in those that received antifibrinolytics (tranexamic acid and epsilon-aminocaproic acid) versus those that did not. This report provides further evidence of antifibrinolytic safety. We recommend following pharmacokinetic-based dosing guidelines for administration.
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Affiliation(s)
- Michael R King
- Department of Pediatric Anesthesiology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Paul A Stricker
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Carolina Pérez-Pradilla
- Department of Anesthesia, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Olivia Nelson
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hubert A Benzon
- Department of Pediatric Anesthesiology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Susan M Goobie
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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17
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Adler AC, Hensch LAH, Bryant BE, Chandrakantan A, Nguyen HY, Nathanson BH, Rosenfeld SB. Factors affecting need for blood transfusion in paediatric patients undergoing open surgery for hip dysplasia. Vox Sang 2022; 117:1384-1390. [PMID: 36300858 PMCID: PMC9772120 DOI: 10.1111/vox.13372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 09/27/2022] [Accepted: 10/08/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND OBJECTIVES The management of intraoperative blood loss in the surgical treatment of paediatric hip dysplasia is resource intensive. There are numerous clinical factors that impact the need for intraoperative transfusion. Identification of patient and surgical factors associated with increased blood loss may reduce the unnecessary use of resources. This study aimed to identify factors predictive of intraoperative transfusion in children undergoing hip dysplasia surgery. MATERIALS AND METHODS This is a single-centre retrospective review of patients undergoing surgery for hip dysplasia from 1 January 2012 to 15 April 2021. Patient demographic factors, anaesthetic, surgical and transfusion histories were reviewed. Multivariable logistic regression analysis was performed to identify factors predictive of allogeneic red blood cell transfusion requirements during the intraoperative period. RESULTS This study includes 595 patients who underwent open surgery for hip dysplasia, including 297 (52.6%) classified as developmental dysplasia (DD) and 268 (47.3%) as neuromuscular (NM) with a mean age of 9.1 years (interquartile range 3-14). Intraoperative allogeneic transfusion was identified in 26/297 (8.8%) DD and 73/268 (27.2%) NM patients. Adjusted factors associated with increased odds of intraoperative transfusion were NM (odds ratio [OR] = 2.96, 95% confidence interval [CI] [1.76, 5.00]) and the number of osteotomies performed (OR = 1.82/osteotomy, 95% CI [1.40, 2.35]). Adjusted factors that reduced the odds of transfusion were the use of antifibrinolytics (OR = 0.35, 95% CI [0.17, 0.71]) and regional anaesthesia (OR = 0.52, 95% CI [0.29, 0.94]). CONCLUSION For children undergoing surgery for hip dysplasia, the number of osteotomies performed is predictive of the need for allogeneic blood transfusion. Antifibrinolytics and regional anaesthesia are associated with reduced risk for allogeneic blood transfusion. Blood management initiatives, such a preoperative optimization of haemoglobin and the use of antifibrinolytics, could target patients at increased risk of intraoperative bleeding and transfusion.
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Affiliation(s)
- Adam C. Adler
- Department of Anesthesiology, Perioperative and Pain Medicine; Texas Children’s Hospital; Houston TX, USA
- Baylor College of Medicine; Houston, TX, USA
| | - Lisa A. H. Hensch
- Department of Pathology & Immunology, Texas Children’s Hospital, Houston, Texas
- Baylor College of Medicine; Houston, TX, USA
| | - Brittany E. Bryant
- Department of Pathology & Immunology, Texas Children’s Hospital, Houston, Texas
- Baylor College of Medicine; Houston, TX, USA
| | - Arvind Chandrakantan
- Department of Anesthesiology, Perioperative and Pain Medicine; Texas Children’s Hospital; Houston TX, USA
- Baylor College of Medicine; Houston, TX, USA
| | - Hai-Yen Nguyen
- Department of Surgery, Baylor College of Medicine; Houston, TX, USA
| | | | - Scott B. Rosenfeld
- Baylor College of Medicine; Houston, TX, USA
- Department of Orthopaedic Surgery; Texas Children’s Hospital; Baylor College of Medicine; Houston, TX, USA
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18
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Perioperative Pediatric Erythrocyte Transfusions: Incorporating Hemoglobin Thresholds and Physiologic Parameters in Decision-making. Anesthesiology 2022; 137:604-619. [PMID: 36264089 DOI: 10.1097/aln.0000000000004357] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This article presents current literature and scientific evidence on hemoglobin thresholds and physiologic parameters to guide decisions regarding perioperative erythrocyte transfusions in pediatric patients based on the most up-to-date studies and expert consensus recommendations.
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19
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Gammon RR, Al-Mozain N, Auron M, Bocquet C, Clem S, Gupta GK, Hensch L, Klein N, Lea NC, Mandal S, Pelletier P, Resheidat A, Yossi Schwartz J. Transfusion therapy of neonatal and paediatric patients: They are not just little adults. Transfus Med 2022; 32:448-459. [PMID: 36207985 DOI: 10.1111/tme.12921] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 08/01/2022] [Accepted: 09/11/2022] [Indexed: 11/28/2022]
Abstract
Patient blood management (PBM) strategies are needed in the neonate and paediatric population, given that haemoglobin thresholds used are often higher than recommended by evidence, with exposure of children to potential complications without meaningful benefit. A literature review was performed on the following topics: evidence-based transfusions of blood components and pharmaceutical agents. Other topics reviewed included perioperative coagulation assessment and perioperative PBM. The Transfusion and Anaemia Expertise Initiative (TAXI) consortium published a consensus statement addressing haemoglobin (Hb) transfusion threshold in multiple subsets of patients. A multicentre trial (PlaNeT-2) reported a higher risk of bleeding and death or serious new bleeding among infants who received platelet transfusion at a higher (50 000/μl) compared to a lower (25 000/μl) threshold. Recent data support the use of a restrictive transfusion threshold of 25 000/μl for prophylactic platelet transfusions in preterm neonates. The TAXI-CAB consortium mentioned that in critically ill paediatric patients undergoing invasive procedures outside of the operating room, platelet transfusion might be considered when the platelet count is less than or equal to 20 000/μl and there is no benefit of platelet transfusion when the platelet count is more than 50 000/μl. There are limited controlled studies in paediatric and neonatal population regarding plasma transfusion. Blood conservation strategies to minimise allogenic blood exposure are essential to positive patient outcomes neonatal and paediatric transfusion practices have changed significantly in recent years since randomised controlled trials were published to guide practice. Additional studies are needed in order to provide practice change recommendations.
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Affiliation(s)
| | - Nour Al-Mozain
- King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia.,Whittington Health NHS Trust, London, UK
| | | | - Christopher Bocquet
- Association for the Advancement of Blood and Biotherapies, Bethesda, Maryland, USA
| | - Sam Clem
- American Red Cross, Fort Wayne, Indiana, USA
| | - Gaurav K Gupta
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Lisa Hensch
- Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Norma Klein
- University of California, Davis, California, USA
| | | | | | | | - Ashraf Resheidat
- Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
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20
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Judd L, Hof L, Beladdale L, Friederich P, Thoma J, Wittmann M, Zacharowski K, Meybohm P, Choorapoikayil S. Prevalence of pre‐operative anaemia in surgical patients: a retrospective, observational, multicentre study in Germany. Anaesthesia 2022; 77:1209-1218. [DOI: 10.1111/anae.15847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2022] [Indexed: 12/01/2022]
Affiliation(s)
- L. Judd
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy University Hospital Frankfurt, Goethe University Frankfurt Frankfurt Germany
| | - L. Hof
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy University Hospital Frankfurt, Goethe University Frankfurt Frankfurt Germany
| | - L. Beladdale
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy University Hospital Frankfurt, Goethe University Frankfurt Frankfurt Germany
| | - P. Friederich
- Department of Anaesthesiology, Surgical Intensive Care Medicine and Pain Therapy Munich Clinic Bogenhausen Munich Germany
| | - J. Thoma
- Department of Anaesthesiology and Intensive Care Medicine Ortenau Clinic Offenburg‐Kehl Germany
| | - M. Wittmann
- Department of Anaesthesiology and Intensive Care Medicine University Hospital Bonn Germany
| | - K. Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy University Hospital Frankfurt, Goethe University Frankfurt Frankfurt Germany
| | - P. Meybohm
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine University Hospital Wuerzburg Germany
| | - S. Choorapoikayil
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy University Hospital Frankfurt, Goethe University Frankfurt Frankfurt Germany
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21
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Valentine SL, Cholette JM, Goobie SM. Transfusion Strategies for Hemostatic Blood Products in Critically Ill Children: A Narrative Review and Update on Expert Consensus Guidelines. Anesth Analg 2022; 135:545-557. [PMID: 35977364 DOI: 10.1213/ane.0000000000006149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Critically ill children commonly receive coagulant products (plasma and/or platelet transfusions) to prevent or treat hemorrhage or correct coagulopathy. Unique aspects of pediatric developmental physiology, and the complex pathophysiology of critical illness must be considered and balanced against known transfusion risks. Transfusion practices vary greatly within and across institutions, and high-quality evidence is needed to support transfusion decision-making. We present recent recommendations and expert consensus statements to direct clinicians in the decision to transfuse or not to transfuse hemostatic blood products, including plasma, platelets, cryoprecipitate, and recombinant products to critically ill children.
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Affiliation(s)
- Stacey L Valentine
- From the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jill M Cholette
- Department of Pediatrics, Divisions of Critical Care Medicine and Cardiology, University of Rochester Golisano Children's Hospital, Rochester, New York
| | - Susan M Goobie
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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22
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Patel PA, Wyrobek JA, Butwick AJ, Pivalizza EG, Hare GMT, Mazer CD, Goobie SM. Update on Applications and Limitations of Perioperative Tranexamic Acid. Anesth Analg 2022; 135:460-473. [PMID: 35977357 DOI: 10.1213/ane.0000000000006039] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Tranexamic acid (TXA) is a potent antifibrinolytic with documented efficacy in reducing blood loss and allogeneic red blood cell transfusion in several clinical settings. With a growing emphasis on patient blood management, TXA has become an integral aspect of perioperative blood conservation strategies. While clinical applications of TXA in the perioperative period are expanding, routine use in select clinical scenarios should be supported by evidence for efficacy. Furthermore, questions regarding optimal dosing without increased risk of adverse events such as thrombosis or seizures should be answered. Therefore, ongoing investigations into TXA utilization in cardiac surgery, obstetrics, acute trauma, orthopedic surgery, neurosurgery, pediatric surgery, and other perioperative settings continue. The aim of this review is to provide an update on the current applications and limitations of TXA use in the perioperative period.
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Affiliation(s)
- Prakash A Patel
- From the Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut
| | - Julie A Wyrobek
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Alexander J Butwick
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Evan G Pivalizza
- Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center, Houston, Texas
| | - Gregory M T Hare
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - C David Mazer
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Susan M Goobie
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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Zhang T, Feng H, Xiao W, Li J, Liu Q, Feng X, Qi D, Fan X, Shan Y, Yu T, Zhao G, Wang T. Prophylactic administration of tranexamic acid combined with thromboelastography-guided hemostatic algorithm reduces allogeneic transfusion requirements during pediatric resective epilepsy surgery: A randomized controlled trial. Front Pharmacol 2022; 13:916017. [PMID: 36059956 PMCID: PMC9428586 DOI: 10.3389/fphar.2022.916017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 07/27/2022] [Indexed: 11/25/2022] Open
Abstract
Background: Intraoperative bleeding and allogeneic transfusion remain common problems in pediatric resective epilepsy surgery. Tranexamic acid (TXA) is a widely recommended antifibrinolytic drug that reduces blood loss and transfusion requirements for bleeding patients. Thromboelastography (TEG)-guided hemostatic algorithm is commonly used in bleeding management. This trial was designed to validate the efficacy of a multimodal coagulation therapy involving continuous TXA infusion with TEG-guided hemostatic algorithm in reducing allogeneic exposure risk in pediatric resective epilepsy surgery. Methods: Eighty-three children undergoing resective epilepsy surgery were randomized into a treatment group (Group T; n = 42) and a control group (Group C; n = 41). Group T received prophylactic TXA (10 mg/kg followed by 5 mg/kg/h) with TEG-guided hemostatic algorithm, whereas Group C received conventional coagulation management. The primary outcome was allogeneic transfusion rate during surgery, and the secondary outcomes were intraoperative blood loss, incidence of postoperative seizures, and thromboembolic events during hospitalization. Results: The incidence of intraoperative allogeneic transfusion reduced by 34.7% with the use of a multimodal coagulation therapy (19.0% in Group T vs. 53.7% in Group C; RR 0.355, 95% CI 0.179–0.704; p = 0.001). This was mainly triggered by a significant reduction (44.1%) in intraoperative plasma transfusion (7.1% in Group T vs. 51.2% in Group C; RR 0.139, 95% CI 0.045–0.432; p = 0.000). The risk of intraoperative RBC transfusion was lower in Group T than in Group C, but the difference was not statistically significant (14.3% in Group T vs. 29.3% in Group C; RR 0.488, 95% CI 0.202–1.177; p = 0.098). No platelets were transfused in both groups. Further, 19 (45.2%) patients in Group T received fibrinogen concentrates guided by TEG data, whereas 1 (2.4%) patient in Group C received fibrinogen concentrates empirically. There were no significant differences in estimated blood loss and postoperative seizures between the two groups, and no thromboembolic events were observed after surgery. Conclusion: Prophylactic administration of TXA combined with TEG-guided hemostatic algorithm can be an effective multimodal coagulation strategy for reducing allogeneic transfusion requirements during pediatric resective epilepsy surgery. Clinical Trial Registration:www.chictr.org.cn/index.aspx, identifier ChiCTR1800016188.
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Affiliation(s)
- Ting Zhang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hua Feng
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wei Xiao
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jingsheng Li
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Qinghai Liu
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xuexin Feng
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Dezhou Qi
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiaotong Fan
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yongzhi Shan
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tao Yu
- Department of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Guoguang Zhao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tianlong Wang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
- *Correspondence: Tianlong Wang,
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Otsuka Y, Naraine N, Switzer T, Faraoni D. Preoperative Iron Supplementation in Pediatric Cardiac Surgical Patients: A Preliminary Single-Center Experience. J Cardiothorac Vasc Anesth 2022; 36:1565-1570. [PMID: 35283042 DOI: 10.1053/j.jvca.2021.12.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 12/01/2021] [Accepted: 12/16/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To assess preoperative hemoglobin and perioperative red blood cell transfusion in children undergoing cardiac surgery after the implementation of a preoperative patient blood management (PBM) clinic with oral iron supplementation. DESIGN A retrospective analysis. SETTING A single tertiary hospital. PARTICIPANTS Patients who underwent cardiac surgery with cardiopulmonary bypass at the Hospital for Sick Children (Toronto, Canada) during a 12-month period before and following the implementation of a preoperative PBM clinic. Patients younger than 3 months of age, or who were admitted to the cardiac intensive care unit preoperatively, were excluded because they were not systematically assessed by the PBM clinic. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 296 patients were included in the authors' analysis. After adjustment for confounding factors (age at surgery, preoperative oxygen saturation, type of congenital heart disease, surgery type), they found that preoperative hemoglobin levels were significantly higher in children treated with iron supplementation (n = 201) compared to historic controls (n = 95) (13.9 [12.8-15.1] g/dL v 12.9 [11.7-15.0] g/dL, adjusted p = 0.001). The exposure rate to red blood cell transfusion (50% v 61%, adjusted p = 0.930) was not significantly different between groups. However, the volumes of allogeneic red blood cells (1.4 (0.0-14.0) mL/kg v 12.5 (0.0-23.0) mL/kg, adjusted p = 0.004) and autologous blood (11.0 (6.8-17.0) v 17.0 (11.0-31.0), adjusted p < 0.001) transfused were significantly reduced in children treated with iron supplementation. CONCLUSIONS Preoperative iron supplementation led to an increase in preoperative hemoglobin levels. The exact prevalence of iron deficiency and the effect of iron supplementation on perioperative allogeneic blood transfusion and long-term outcomes should be studied in a prospective randomized study.
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Affiliation(s)
- Yoji Otsuka
- Division of Cardiac Anesthesia, Department of Anesthesiology and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Nadia Naraine
- Transfusion Medicine, Department of Pediatric Laboratory Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Timothy Switzer
- Division of Cardiac Anesthesia, Department of Anesthesiology and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - David Faraoni
- Arthur S. Keats Division of Pediatric Cardiovascular Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX.
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25
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Pavithran P, Sekhar B, Sudarshan P. Patient blood management in a paediatric patient – A success story. Indian J Anaesth 2022; 66:673-674. [DOI: 10.4103/ija.ija_514_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 07/24/2022] [Accepted: 09/01/2022] [Indexed: 11/04/2022] Open
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Eisler L, Chihuri S, Lenke LG, Sun LS, Faraoni D, Li G. Development of a preoperative risk score predicting allogeneic red blood cell transfusion in children undergoing spinal fusion. Transfusion 2022; 62:100-115. [PMID: 34761400 PMCID: PMC8758528 DOI: 10.1111/trf.16722] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 10/06/2021] [Accepted: 10/07/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Children undergoing spinal fusion often receive blood products. The goal of this study was to develop a preoperative score to help physicians identify those who are at risk of allogeneic red blood cell (RBC) transfusion. STUDY DESIGN AND METHODS This retrospective study of children undergoing spinal fusion in the ACS-NSQIP Pediatric database (2016-2019) aimed at identifying risk factors associated with allogeneic RBC transfusion. Univariable logistic regression and multivariable logistic regression were performed using preoperative patient characteristics and aided in the creation of a simplified scoring system. RESULTS Out of 13,929 total patients, 2990 (21.5%) were transfused. We created a risk score based on 10 independent predictors of transfusion: age, sex, race, weight < 3rd percentile, American Society of Anesthesiologists physical status classification, cardiac risk factors, hematologic disease, preoperative anemia, deformity type, and number of spinal levels to be fused. Patients in both the training and testing cohorts were assigned a score ranging from 0 (lowest risk) to 21 (highest risk). The developed transfusion risk score showed 77% accuracy in distinguishing patients who did not receive a transfusion during or soon after surgery (AUROC 0.7736 [95% CI, 0.7619-0.7852]) in the training cohort and 77% accuracy (AUROC 0.7732 [95% CI, 0.7554-0.7910]) in the testing cohort. DISCUSSION Our score, based on routinely available preoperative data, accurately estimates the risk of allogeneic RBC transfusion in pediatric patients undergoing spinal fusion. Future studies will inform whether patient blood management interventions targeted to high-risk patients can help reduce the need for transfusion and improve outcomes.
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Affiliation(s)
- Lisa Eisler
- Anesthesiology, Columbia University College of Physicians and Surgeons, New York, NY
| | - Stanford Chihuri
- Anesthesiology, Columbia University College of Physicians and Surgeons, New York, NY
| | - Lawrence G. Lenke
- Orthopedic Surgery, Columbia University College of Physicians and Surgeons, New York, NY
| | - Lena S. Sun
- Anesthesiology and Pediatrics, Columbia University College of Physicians and Surgeons, New York, NY
| | - David Faraoni
- Anesthesiology, Perioperative and Pain Medicine, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas
| | - Guohua Li
- Anesthesiology and Epidemiology, Columbia University College of Physicians and Surgeons, New York, NY
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Chegini A. Evaluating the Importance of Patient Blood Management During COVID-19 Pandemic. Anesth Pain Med 2022; 11:e112910. [PMID: 35291403 PMCID: PMC8909534 DOI: 10.5812/aapm.112910] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 11/29/2021] [Accepted: 12/07/2021] [Indexed: 01/28/2023] Open
Abstract
Due to the COVID-19 pandemic, the demand for blood products may decrease as the health care system shifts toward treating the increased number of patients afflicted with COVID-19 and delaying selective surgeries and emergency procedures. One of the most important problems for blood transfusion services during COVID-19 pandemic is the reduction in the number of donors and a decrease in blood stocks. This happens due to the limitations of attendance of donors in blood centers, lack of awareness, misinformation, fear of being infected while donating blood, and restricting the freedom of blood collection teams to attend public places. Blood transfusion services should be prepared and well-responded in a timely manner. In this regard, appropriate use of blood, diminishing unnecessary transfusions, and implementation of patient blood management (PBM) principles are considered as significant measurements. PBM can help maintain blood supply throughout the crisis and reduce the pressure on blood demand. As a result, blood products can be saved for patients who need it urgently. PBM focuses on the patient, as well as the conditions that make patients transfuse blood, such as blood loss, coagulopathy, platelet dysfunction, and anemia. Thus, the majority of health systems in different countries have made recommendations to the PBM in hospitals.
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Affiliation(s)
- Azita Chegini
- Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran
- Corresponding Author: Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran.
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Blood transfusion trends in the United States: national inpatient sample, 2015 to 2018. Blood Adv 2021; 5:4179-4184. [PMID: 34551093 PMCID: PMC8945622 DOI: 10.1182/bloodadvances.2021005361] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 07/19/2021] [Indexed: 01/28/2023] Open
Abstract
There is significant decline in RBC and plasma transfusions nationally among hospitalized patients in the United States through 2018. Increased cryoprecipitate use suggests wider adoption of hypofibrinogenemia management and hemostasis testing for coagulopathic patients.
Blood transfusions are among the most common therapeutic procedures performed in hospitalized patients. This study evaluates contemporary national trends in red blood cell (RBC), plasma, platelet, and cryoprecipitate transfusions. National Inpatient Sample, the largest all-payer inpatient database representing 94% to 97% of the US population, was evaluated from the fourth quarter (Q4) of 2015 through 2018. Quarterly trends for the percentage of hospitalizations with a transfusion procedure were separately examined for each blood product using log binomial regression and reported as quarterly percent change (QPC). The percentage of hospitalizations with an RBC transfusion decreased from 4.22% (2015Q4) to 3.79% (2018Q4) (QPC = −0.72; 95% confidence interval [CI], −1.26 to −0.19; Ptrend = .008). Although plasma transfusions also decreased, QPC = −1.33 (95% CI, −2.00 to −0.65; Ptrend < .001), platelet transfusions remained stable QPC = −0.13 (95% CI, −0.99 to 0.73; Ptrend = .766). In contrast, hospitalizations with cryoprecipitate utilization significantly increased QPC = 2.01 (95% CI, 0.57 to 3.44; Ptrend = .006). Significant quarterly reductions in RBC transfusions were also seen among many, but not all, strata of sex, race/ethnicity, patient risk severity, and admission type (elective vs nonelective). Despite significant declines in RBC transfusions among older adults, there were no significant changes among pediatric age-group (<18 years) and those 18 to 49 years. The decline in RBC and plasma transfusions suggests steady incorporation of robust evidence base showing safety of restrictive transfusions. Increased cryoprecipitate use may be reflective of wider adoption of hypofibrinogenemia management and hemostasis testing for coagulopathic patients.
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29
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Evenepoel A, Herroelen P, Lanckmans K, van der Werff Ten Bosch J, Martin M, Weets I, van Dalem A. Asparaginase-induced pseudohyponatremia, a case-driven working strategy in pediatric patients. Acta Clin Belg 2021; 77:832-836. [PMID: 34666631 DOI: 10.1080/17843286.2021.1992583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES When using indirect ion-selective electrode (ISE) methods, hypertriglyceridemia leads to pseudohyponatremia due to water displacement artifacts. Multiple strategies exist to minimize this interference. Our objective was to create a patient-friendly one-tube-fits-all testing setup without compromising the method robustness. METHODS Four strategies were evaluated in a single patient with hypertriglyceridemia. Additionally, the interchangeability between the Cobas 8000 and ABL Flex was evaluated on samples (n = 2274) with different total protein (TP) concentrations. Finally, a proof-of-concept (n = 40) was performed by re-measuring the routine sample with the ABL90 Flex. RESULTS ABL90 flex results and calculated sodium did not suffer from the presence of high triglyceride levels. We did not observe any significant differences between the three groups (P > 0.05) of sample types (arterial vs. venous plasma vs. venous whole blood after mixing up) nor for the analysers (Roche vs. ABL90 Flex). Passing-Bablok and Bland-Altman tests revealed interchangeability. CONCLUSION In future cases of hypertriglyceridemia, 1500 mg/dL will be used as a preliminary threshold for reliable sodium determination. Routine Li-heparin samples can be used for accurate sodium determination without any need for extra arterial or venous blood gas tubes, offering a patient-friendly test setup for similar cases.
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Affiliation(s)
- A. Evenepoel
- Department of Clinical Biology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - P. Herroelen
- Department of Clinical Biology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - K. Lanckmans
- Department of Clinical Biology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - J. van der Werff Ten Bosch
- Department of Pediatric Hemato-oncology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - M. Martin
- Department of Clinical Biology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - I. Weets
- Department of Clinical Biology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - A. van Dalem
- Department of Clinical Biology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
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30
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Gozubuyuk E, Aygun E, Basaran I, Canbolat N, Cavdaroglu B, Akgul T, Buget MI. Effects of Changes in Body Temperature on Perioperative Bleeding in Adolescent Idiopathic Scoliosis Surgery. Ther Hypothermia Temp Manag 2021; 12:146-154. [PMID: 34665055 DOI: 10.1089/ther.2021.0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Perioperative bleeding is a critical challenge in adolescent idiopathic scoliosis (AIS) surgery. Preventing hypothermia is associated with decreased development of coagulopathy, blood transfusion rate in various surgery groups. We hypothesized that blood loss would be reduced in patients who were kept normothermic by implementation of aggressive warming methods in AIS. This randomized-controlled study included patients aged 12-18 years who were scheduled to undergo elective scoliosis deformity correction surgery. The patients were divided into two groups: the study group (Group S) was heated aggressively with three different heaters including compressed-air blower heater, intravenous fluid heating, and a heating bed, while the control group (Group C) received only heating with a standard compressed-air blower heater. Tympanic, esophageal, and axillary body temperatures were measured, and hemoglobin and arterial blood gas analyses were repeated during the anesthesia period. Daily bleeding-coagulation parameters were recorded on postoperative days 0, 1, and 2. Forty-eight patients were randomized, and 39 patients were included into the final analysis. The total amount of intraoperative bleeding (p = 0.027) was significantly lower, and duration of surgery (p = 0.025) and length of hospital stay (p = 0.002) were significantly shorter in Group S. Significant linear relationships were found between the core body temperature and the amount of bleeding (β = 0.0001; p = 0.009), operation time (β = 0.003; p = 0.015), and length of hospital stay (β = 0.027; p = 0.044) with linear logistic regression analysis. We reported that normothermia was preserved in the multiheated group, which diminished blood loss, operation time, and the length of hospital stay. Consequently, we suggested that active heating should be applied in AIS surgeries. ClinicalTrials.gov (NCT04686214).
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Affiliation(s)
- Ezgi Gozubuyuk
- Department of Anesthesiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Elif Aygun
- Department of Anesthesiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Irem Basaran
- Department of Anesthesiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Nur Canbolat
- Department of Anesthesiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Binnur Cavdaroglu
- Department of Anesthesiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Turgut Akgul
- Department of Orthopedics and Traumatology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Mehmet I Buget
- Department of Anesthesiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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Patient Blood Management in Pediatric Anesthesiology. CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-021-00481-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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32
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Haas T, Faraoni D. Viscoelastic testing in pediatric patients. Transfusion 2021; 60 Suppl 6:S75-S85. [PMID: 33089938 DOI: 10.1111/trf.16076] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/04/2020] [Accepted: 06/14/2020] [Indexed: 12/18/2022]
Abstract
A tailored transfusion algorithm based on viscoelastic testing in the perioperative period or in trauma patients is recommended by guidelines for bleeding management. Bleeding management strategies in neonates and children are mostly extrapolated from the adult experience, as published evidence in the youngest age group is scarce. This manuscript is intended to give a structured overview of what has been published on the use of viscoelastic testing to guide bleeding management in neonates and children. Several devices that use either the traditional viscoelastic method or resonance viscoelastography technology are on the market. Reference ranges for children have been evaluated in only some of them. As most of the hemostasis maturation processes can be observed during the first year of life, adult reference ranges for viscoelastic testing could be applied over the age of 1 year. The majority of the published trials in children are based on retrospective analyses describing the correlation between viscoelastic testing and standard laboratory testing or focusing on the prediction of bleeding. Clinically more relevant studies in pediatric patients undergoing cardiac surgery have demonstrated that the implementation of a transfusion algorithm based on viscoelastic testing has significantly reduced transfusion requirements and that this approach has enabled a rapid detection of coagulation disorders in the presence of excessive bleeding. Although further studies are urgently needed, experts have reviewed the use of a transfusion algorithm based on viscoelastic testing in children as a feasible approach, as it has been shown to improve bleeding management and rationalize blood product transfusion.
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Affiliation(s)
- Thorsten Haas
- Department of Pediatric Anesthesia, Zurich University Children's Hospital, Zurich, Switzerland
| | - David Faraoni
- Division of Cardiac Anesthesia, Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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33
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Takae S, Furuta S, Keino D, Shiraishi E, Iwahata Y, Oyama K, Iwahata H, Nishiya Y, Kawaguchi K, Obayashi J, Tanaka K, Sawada S, Suzuki Y, Sugishita Y, Deura I, Horage Y, Nagae H, Kondo H, Sakamoto M, Mori T, Kitagawa H, Suzuki N. Surgical management of unilateral oophorectomy for ovarian tissue cryopreservation in high-risk children and adolescents with varied backgrounds. Pediatr Surg Int 2021; 37:1021-1029. [PMID: 33855613 DOI: 10.1007/s00383-021-04900-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/28/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE Fertility preservation (FP) for children is still challenging due to an information gap. In particular, there is little information about the surgical aspects of ovarian tissue cryopreservation (OTC) for children. In the present study, the appropriateness of preoperative management and the criteria of our cases were investigated with the aim of establishing a safe OTC procedure. METHODS A total of 25 girls who underwent OTC from November 2015 through May 2020 were retrospectively analyzed with IRB approval. RESULTS The median age of the patients was 13 (1-17) years. The medical indications were varied (e.g., leukemia, lymphoma, brain tumor), and included rare diseases. Seventeen cases (68%) underwent OTC during chemotherapy or radiotherapy, and 21 (84%) had comorbidities. All cases underwent ovarian tissue retrieval (OTR) with laparoscopy, and the median operating time was 64 (36-97) min, with little bleeding. Although two had complications, all patients started treatment on schedule. The median WBC and CRP increases a day after OTR were 0 (- 4400 to + 5200)/µl and 0.21 (- 0.2 to 0.87) mg/dl, respectively, with no complications. CONCLUSION As long as the preoperative criteria are met, OTC could be possible even for children with a severe blood condition. In such cases, the degrees of the WBC and CRP elevations are useful to assess surgical infection.
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Affiliation(s)
- Seido Takae
- Department of Obstetrics and Gynecology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Shigeyuki Furuta
- Department of Pediatric Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Dai Keino
- Kanagawa Children's Medical Center, 2-138-4 Mutsukawa, Minami-ku, Yokohama, Kanagawa, 232-8555, Japan.,Department of Pediatrics, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 232-8555, Japan
| | - Eriko Shiraishi
- Department of Obstetrics and Gynecology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Yuriko Iwahata
- Department of Obstetrics and Gynecology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Kei Oyama
- Department of Pediatric Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Hideyuki Iwahata
- Department of Obstetrics and Gynecology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Yuri Nishiya
- Department of Pediatric Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Kohei Kawaguchi
- Department of Pediatric Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Juma Obayashi
- Department of Pediatric Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Kunihide Tanaka
- Department of Pediatric Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Shino Sawada
- Department of Obstetrics and Gynecology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Yuki Suzuki
- Department of Obstetrics and Gynecology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Yodo Sugishita
- Department of Obstetrics and Gynecology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Imari Deura
- Department of Obstetrics and Gynecology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Yuki Horage
- Department of Obstetrics and Gynecology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Hideki Nagae
- Department of Pediatric Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Haruhiro Kondo
- Department of Obstetrics and Gynecology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Miki Sakamoto
- Department of Anesthesiology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Tetsuya Mori
- Department of Pediatrics, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 232-8555, Japan
| | - Hiroaki Kitagawa
- Department of Pediatric Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Nao Suzuki
- Department of Obstetrics and Gynecology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan.
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Independent Risk Factors for RBC Transfusion in Children Undergoing Surgery. Analysis of 14,248 Cases at a German University Hospital. CHILDREN-BASEL 2021; 8:children8080634. [PMID: 34438525 PMCID: PMC8394932 DOI: 10.3390/children8080634] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 07/22/2021] [Accepted: 07/22/2021] [Indexed: 11/17/2022]
Abstract
Background: paediatric patients are vulnerable to blood loss and even a small loss of blood can be associated with severe shock. In emergency situations, a red blood cell (RBC) transfusion may become unavoidable, although it is associated with various risks. The aim of this trial was to identify independent risk factors for perioperative RBC transfusion in children undergoing surgery. Methods: to identify independent risk factors for perioperative RBC transfusion in children undergoing surgery and to access RBC transfusion rates and in-hospital outcomes (e.g., length of stay, mortality, and typical postoperative complication rates), a monocentric, retrospective, and observational study was conducted. Descriptive, univariate, and multivariate analyses were performed. Results: between 1 January 2010 and 31 December 2019, data from n = 14,248 cases were identified at the centre. Analysis revealed an RBC transfusion rate of 10.1% (n = 1439) in the entire cohort. The independent predictors of RBC transfusion were the presence of preoperative anaemia (p < 0.001; OR = 15.10 with preoperative anaemia and OR = 2.40 without preoperative anaemia), younger age (p < 0.001; ORs between 0.14 and 0.28 for children older than 0 years), female gender (p = 0.036; OR = 1.19 compared to male gender), certain types of surgery (e.g., neuro surgery (p < 0.001; OR = 10.14), vascular surgery (p < 0.001; OR = 9.93), cardiac surgery (p < 0.001; OR = 4.79), gynaecology (p = 0.014; OR = 3.64), visceral surgery (p < 0.001; OR = 2.48), and the presence of postoperative complications (e.g., sepsis (p < 0.001; OR = 10.16), respiratory dysfunction (p < 0.001; OR = 7.56), cardiovascular dysfunction (p < 0.001; OR = 4.68), neurological dysfunction (p = 0.029; OR = 1.77), and renal dysfunction (p < 0.001; OR = 16.17)). Conclusion: preoperative anaemia, younger age, female gender, certain types of surgery, and postoperative complications are independent predictors for RBC transfusion in children undergoing surgery. Future prospective studies are urgently required to identify, in detail, the potential risk factors and impact of RBC transfusion in children.
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Hofmann A, Spahn DR, Holtorf AP. Making patient blood management the new norm(al) as experienced by implementors in diverse countries. BMC Health Serv Res 2021; 21:634. [PMID: 34215251 PMCID: PMC8249439 DOI: 10.1186/s12913-021-06484-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 05/06/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Patient blood management (PBM) describes a set of evidence-based practices to optimize medical and surgical patient outcomes by clinically managing and preserving a patient's own blood. This concepts aims to detect and treat anemia, minimize the risk for blood loss and the need for blood replacement for each patient through a coordinated multidisciplinary care process. In combination with blood loss, anemia is the main driver for transfusion and all three are independent risk factors for adverse outcomes including morbidity and mortality. Evidence demonstrates that PBM significantly improves outcomes and safety while reducing cost by macroeconomic magnitudes. Despite its huge potential to improve healthcare systems, PBM is not yet adopted broadly. The aim of this study is to analyze the collective experiences of a diverse group of PBM implementors across countries reflecting different healthcare contexts and to use these experiences to develop a guidance for initiating and orchestrating PBM implementation for stakeholders from diverse professional backgrounds. METHODS Semi-structured interviews were conducted with 1-4 PBM implementors from 12 countries in Asia, Latin America, Australia, Central and Eastern Europe, the Middle East, and Africa. Responses reflecting the drivers, barriers, measures, and stakeholders regarding the implementation of PBM were summarized per country and underwent qualitative content analysis. Clustering the resulting implementation measures by levels of intervention for PBM implementation informed a PBM implementation framework. RESULTS A set of PBM implementation measures were extracted from the interviews with the implementors. Most of these measures relate to one of six levels of implementation including government, healthcare providers, funding, research, training/education, and patients/public. Essential cross-level measures are multi-stakeholder communication and collaboration. CONCLUSION The implementation matrix resulting from this research helps to decompose the complexity of PBM implementation into concrete measures on each implementation level. It provides guidance for diverse stakeholders to design, initiate and develop strategies and plans to make PBM a national standard of care, thus closing current practice gaps and matching this unmet public health need.
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Affiliation(s)
- Axel Hofmann
- Institute of Anesthesiology, University and University Hospital of Zurich, Zurich, Switzerland
- University of Western Australia Faculty of Health and Medical Sciences, Perth, Australia
| | - Donat R. Spahn
- Institute of Anesthesiology, University and University Hospital of Zurich, Zurich, Switzerland
| | - Anke-Peggy Holtorf
- Health Outcomes Strategies GmbH, Colmarerstrasse 58, CH4055 Basel, Switzerland
- Faculty of the College of Pharmacy, University of Utah, Salt Lake City, UT USA
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Crighton GL, Huisman EJ. Pediatric Fibrinogen PART II-Overview of Indications for Fibrinogen Use in Critically Ill Children. Front Pediatr 2021; 9:647680. [PMID: 33968851 PMCID: PMC8097134 DOI: 10.3389/fped.2021.647680] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 03/09/2021] [Indexed: 01/16/2023] Open
Abstract
Bleeding is frequently seen in critically ill children and is associated with increased morbidity and mortality. Fibrinogen is an essential coagulation factor for hemostasis and hypofibrinogenemia is an important risk factor for bleeding in pediatric and adult settings. Cryoprecipitate and fibrinogen concentrate are often given to critically ill children to prevent bleeding and improve fibrinogen levels, especially in the setting of surgery, trauma, leukemia, disseminated intravascular coagulopathy, and liver failure. The theoretical benefit of fibrinogen supplementation to treat hypofibrinogenemia appears obvious, yet the evidence to support fibrinogen supplementation in children is sparce and clinical indications are poorly defined. In addition, it is unknown what the optimal fibrinogen replacement product is in children and neonates or what the targets of treatment should be. As a result, there is considerable variability in practice. In this article we will review the current pediatric and applicable adult literature with regard to the use of fibrinogen replacement in different pediatric critical care contexts. We will discuss the clinical indications for fibrinogen supplementation in critically ill children and the evidence to support their use. We summarize by highlighting current knowledge gaps and areas for future research.
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Affiliation(s)
| | - Elise J. Huisman
- Department of Hematology, Erasmus MC–Sophia Children's Hospital, Rotterdam, Netherlands
- Department of Clinical Chemistry and Blood Transfusion, Erasmus MC, Rotterdam, Netherlands
- Department of Transfusion Medicine, Sanquin Blood Supply, Amsterdam, Netherlands
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Wittenmeier E, Katharina A, Schmidtmann I, Griemert EV, Kriege M, König T, Nina P. Intraoperative transfusion practice in burned children in a university hospital over four years: a retrospective analysis. BMC Anesthesiol 2021; 21:118. [PMID: 33858338 PMCID: PMC8048155 DOI: 10.1186/s12871-021-01336-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 04/09/2021] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Patient blood management programs should be applied to the pediatric population, but little is known about the current transfusion practice of pediatric burn injury patients. This retrospective study was performed to evaluate the practice of red blood cell (RBC) transfusion in children with burn injury, their predictive factors, and adherence to the German transfusion guideline. METHODS We reviewed the RBC transfusion practice of all children younger than 8 years with burn injury who were operated during a four-year period in a German university medical center. We analyzed the data associated with transfusion and guideline conformity of transfusion triggers for RBCs from the beginning to the end of hospital stay using logistic regression. RESULTS During the four-year period, 138 children (median age 21 months, minimum-maximum 9-101 months) with burn injury needed surgery, 31 children were transfused with RBCs. During their hospital stay, the median hemoglobin concentrations (Hb) of transfused and non-transfused children were 8 g/dL (6.3-11.3 g/dL) and 10.7 (7-13.8 g/dL), respectively. Total body surface area burned (TBSA) (OR = 1.17 per % TBSA, 95% CI = [1.05; 1.30], p = 0.0056), length of surgery (OR = 1.016 per minute, 95% CI = [1.003; 1.028], p = 0.0150), and Hb (OR = 0.48 per 1 g/dl in Hb, 95% CI = [0.24; 0.95], p = 0.0343) were associated with transfusion while other factors (age, gender, ASA, and catecholamines) did not show notable association. Length of stay was mainly influenced by TSBA (+ 1.38 days per %, p < 0.0001), age (+ 0.21 days per month, p = 0.0206), and administering of catecholamines (+ 14.3 days, p = 0.0118), but not by RBC transfusion. The decision to transfuse was in 23% too restrictive and in 74% too liberal according to the German guidelines. CONCLUSIONS Amount of TBSA, length of surgery, and Hb influenced the RBC transfusion rate in burned children. However, age and length of stay were not affected by transfusion of RBCs. In clinical practice of burned children, physicians follow a more liberal transfusion strategy than the proposed in guidelines.
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Affiliation(s)
- Eva Wittenmeier
- Department of Anesthesiology, University Medical Centre of Johannes Gutenberg University, Langenbeckstraße 1, 55131, Mainz, Germany.
| | - Astor Katharina
- Department of Anesthesiology and Intensive Care, Catholic Clinical Centre, Mainz, Germany
| | - Irene Schmidtmann
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Centre of Johannes Gutenberg University, Mainz, Germany
| | - Eva-Verena Griemert
- Department of Anesthesiology, University Medical Centre of Johannes Gutenberg University, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Marc Kriege
- Department of Anesthesiology, University Medical Centre of Johannes Gutenberg University, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Tatjana König
- Department of Pediatric Surgery, University Medical Centre of Johannes Gutenberg University, Mainz, Germany
| | - Pirlich Nina
- Department of Anesthesiology, University Medical Centre of Johannes Gutenberg University, Langenbeckstraße 1, 55131, Mainz, Germany
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Disma N, Veyckemans F, Virag K, Hansen TG, Becke K, Harlet P, Vutskits L, Walker SM, de Graaff JC, Zielinska M, Simic D, Engelhardt T, Habre W. Morbidity and mortality after anaesthesia in early life: results of the European prospective multicentre observational study, neonate and children audit of anaesthesia practice in Europe (NECTARINE). Br J Anaesth 2021; 126:1157-1172. [PMID: 33812668 DOI: 10.1016/j.bja.2021.02.016] [Citation(s) in RCA: 74] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 02/15/2021] [Accepted: 02/21/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Neonates and infants requiring anaesthesia are at risk of physiological instability and complications, but triggers for peri-anaesthetic interventions and associations with subsequent outcome are unknown. METHODS This prospective, observational study recruited patients up to 60 weeks' postmenstrual age undergoing anaesthesia for surgical or diagnostic procedures from 165 centres in 31 European countries between March 2016 and January 2017. The primary aim was to identify thresholds of pre-determined physiological variables that triggered a medical intervention. The secondary aims were to evaluate morbidities, mortality at 30 and 90 days, or both, and associations with critical events. RESULTS Infants (n=5609) born at mean (standard deviation [sd]) 36.2 (4.4) weeks postmenstrual age (35.7% preterm) underwent 6542 procedures within 63 (48) days of birth. Critical event(s) requiring intervention occurred in 35.2% of cases, mainly hypotension (>30% decrease in blood pressure) or reduced oxygenation (SpO2 <85%). Postmenstrual age influenced the incidence and thresholds for intervention. Risk of critical events was increased by prior neonatal medical conditions, congenital anomalies, or both (relative risk [RR]=1.16; 95% confidence interval [CI], 1.04-1.28) and in those requiring preoperative intensive support (RR=1.27; 95% CI, 1.15-1.41). Additional complications occurred in 16.3% of patients by 30 days, and overall 90-day mortality was 3.2% (95% CI, 2.7-3.7%). Co-occurrence of intraoperative hypotension, hypoxaemia, and anaemia was associated with increased risk of morbidity (RR=3.56; 95% CI, 1.64-7.71) and mortality (RR=19.80; 95% CI, 5.87-66.7). CONCLUSIONS Variability in physiological thresholds that triggered an intervention, and the impact of poor tissue oxygenation on patient's outcome, highlight the need for more standardised perioperative management guidelines for neonates and infants. CLINICAL TRIAL REGISTRATION NCT02350348.
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Affiliation(s)
- Nicola Disma
- Department of Anaesthesia, Unit for Research & Innovation, Istituto Giannina Gaslini, Genova, Italy.
| | - Francis Veyckemans
- Département d'Anaesthésie-Réanimation pédiatrique, Hôpital Jeanne de Flandre, CHRU de Lille, Lille, France
| | - Katalin Virag
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | - Tom G Hansen
- Department of Anaesthesia and Intensive Care -Paediatrics, Odense University Hospital, Odense, Denmark; Department of Clinical Research - Anaesthesiology, University of Southern Denmark, Odense, Denmark
| | - Karin Becke
- Department of Anaesthesia and Intensive Care, Cnopf Children's Hospital/Hospital Hallerwiese, Nürnberg, Germany
| | - Pierre Harlet
- Research Department, European Society of Anaesthesiology, Brussels, Belgium
| | - Laszlo Vutskits
- Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospitals of Geneva, Geneva, Switzerland; University of Geneva, Geneva, Switzerland
| | - Suellen M Walker
- Department of Anaesthesia and Pain Management, Great Ormond Street Hospital NHS Foundation Trust, London, United Kingdom
| | - Jurgen C de Graaff
- Department of Anesthesia, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Marzena Zielinska
- Department of Paediatric Anaesthesiology and Intensive Care, Wroclaw Medical University, Wroclaw, Poland
| | - Dusica Simic
- Department of Pediatric Anesthesia and Intensive Care, University Children's Hospital, Medical Faculty University of Belgrade, Belgrade, Serbia
| | - Thomas Engelhardt
- Department of Anaesthesia, Montreal Children's Hospital, Montreal, QC, Canada
| | - Walid Habre
- Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospitals of Geneva, Geneva, Switzerland; University of Geneva, Geneva, Switzerland
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Huisman EJ, Crighton GL. Pediatric Fibrinogen PART I-Pitfalls in Fibrinogen Evaluation and Use of Fibrinogen Replacement Products in Children. Front Pediatr 2021; 9:617500. [PMID: 33968842 PMCID: PMC8097151 DOI: 10.3389/fped.2021.617500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 02/26/2021] [Indexed: 11/13/2022] Open
Abstract
Fibrinogen is a key coagulation protein, playing a critical role in hemostasis. It is the first factor to decrease to critical levels during bleeding. Hypofibrinogenemia is an important risk factor for bleeding in clinical settings, including pediatric surgery. Yet, the optimal measurement of fibrinogen levels is subject to debate, as is the critical threshold for intervention. Fibrinogen replacement may be provided by cryoprecipitate and fibrinogen concentrate. Whilst both products contain fibrinogen, they are not equivalent, each has its own advantages and disadvantages, especially for pediatric use. Unfortunately, medical literature to support fibrinogen replacement in children is limited. In this article we review the current diagnostic tools to measure fibrinogen, with respect to their use in the pediatric critical care setting. Secondly, we evaluate the different fibrinogen replacement therapies, focusing on cryoprecipitate and fibrinogen concentrate and examine their individual product characteristics, associated risks and benefits, different dosing strategies and specific pitfalls for use in children. We summarize by highlighting current knowledge gaps and areas for future research.
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Affiliation(s)
- Elise J Huisman
- Department of Hematology, Erasmus Medical Center (MC)-Sophia Children's Hospital, Rotterdam, Netherlands.,Department of Clinical Chemistry and Blood Transfusion, Erasmus Medical Center (MC), Rotterdam, Netherlands.,Department of Transfusion Medicine, Sanquin Blood Supply, Amsterdam, Netherlands
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Chang T, Yan X, Zhao C, Zhang Y, Wang B, Gao L. Risk Factors and Neurologic Outcomes in Patients with Traumatic Brain Injury and Coagulopathy Within 72 h After Surgery. Neuropsychiatr Dis Treat 2021; 17:2905-2913. [PMID: 34531657 PMCID: PMC8439966 DOI: 10.2147/ndt.s323897] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 08/06/2021] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE The purpose of this study was to explore the effect of coagulopathy in patients with traumatic brain injury (TBI) during the early postoperative period. METHODS The baseline characteristics, intraoperative management, and follow-up data of 462 patients with TBI between January 2015 and June 2019 were collected and retrospectively analyzed by multivariate logistic regression. Coagulopathy was defined as activated partial thromboplastin time > 40 s, international normalized ratio > 1.4, or platelet counts < 100×109/L. RESULTS Multivariate logistic regression analysis revealed that the Glasgow Coma Scale (GCS) on admission, Injury Severity Score (ISS) on admission, pupil mydriasis, duration of surgery, intraoperative blood loss, and intraoperative crystalloid resuscitation were independent risk factors for patients who developed coagulopathy after surgery. There were statistical differences in mortality (p = 0.049), the Glasgow Outcome Scale-Extended (GCS-E; p = 0.024), and the modified Rankin Scale (p = 0.043) between the patients with and without coagulopathy 1 week after surgery. Coagulopathy within 72 h after surgery revealed the higher mortality at 1 week (66.7%), 3 months (71.4%), and 6 months (76.2%). Coagulopathy within 72 h after surgery in patients with a TBI predicted worse disease progression and unfavorable neurologic outcomes. CONCLUSION Taking practical and reasonable measures to manage these risk factors may protect patients with TBI from postoperative coagulopathy.
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Affiliation(s)
- Tao Chang
- Department of Emergency, The Second Affiliated Hospital of Air Force Medical University, Xi'an, 710038, Shaanxi Province, People's Republic of China
| | - Xigang Yan
- Department of Anesthesiology, The Second Affiliated Hospital of Air Force Medical University, Xi'an, 710038, Shaanxi Province, People's Republic of China
| | - Chao Zhao
- Department of Neurology, The Second Affiliated Hospital of Air Force Medical University, Xi'an, 710038, Shaanxi Province, People's Republic of China
| | - Yufu Zhang
- Department of Neurosurgery, The Second Affiliated Hospital of Air Force Medical University, Xi'an, 710038, Shaanxi Province, People's Republic of China
| | - Bao Wang
- Department of Neurosurgery, The Second Affiliated Hospital of Air Force Medical University, Xi'an, 710038, Shaanxi Province, People's Republic of China
| | - Li Gao
- Department of Neurosurgery, The Second Affiliated Hospital of Air Force Medical University, Xi'an, 710038, Shaanxi Province, People's Republic of China
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Flores CJ, Lakkundi A, McIntosh J, Freeman P, Thomson A, Saxon B, Parsons J, Spigiel T, Milton S, Ross B. Embedding best transfusion practice and blood management in neonatal intensive care. BMJ Open Qual 2020; 9:bmjoq-2019-000694. [PMID: 31986114 PMCID: PMC7011898 DOI: 10.1136/bmjoq-2019-000694] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 12/02/2019] [Accepted: 12/05/2019] [Indexed: 11/04/2022] Open
Abstract
Background Transfusion is a common procedure for neonates receiving intensive care management. Recognising a paucity of patient blood management (PBM) programmes in neonates, we aimed to embed blood management and best transfusion principles in the neonatal intensive care unit (NICU) by aligning local policies, providing targeted education and partnering with parents. Methods Practice-based evidence for clinical practice improvement (PBE-CPI) methodology was used. Previous hospital accreditation audits were reviewed and a neonate-specific transfusion audit was developed. Audit was performed at baseline and repeated following the intervention period. NICU clinicians received targeted education in obtaining informed consent, prescription and safe administration of blood components during a ‘Blood Month’ awareness period. A neonate-specific parent handout about transfusion was developed in partnership with parents. A pilot video demonstrating a shared consent discussion was also developed to assist in the consent process. Parents’ knowledge, concerns and feedback regarding transfusion practice was sought at baseline (survey) and on project completion (experience trackers). Results Neonate-specific baseline transfusion audit showed inconsistent consent, monitoring and documentation processes in neonatal transfusions. Post-targeted education audit showed improvement in these parameters. The targeted PBM and transfusion-related education delivered during ‘Blood Month’ was well-received by staff. Parents’ feedback about the NICU transfusion consenting process was consistently positive. NICU medical and nursing clinicians (n=25) surveyed agreed that the parent handout was well set out, easy to understand and recommended that it be used to complement practice. Conclusion PBE-CPI tools aligned with Australian PBM guidelines for clinicians and parents were well-accepted by clinical stakeholders and were associated with practice improvement in PBM awareness and transfusion consent processes. This PBE-CPI project developed NICU-specific consent information, not previously available, by partnering with parents to ensure quality of care in transfusion practice. Adoption of this also helps to meet accreditation for Australian Blood Management Standards. These strategies and tools translate readily into other NICUs to embed and support best PBM and transfusion practice.
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Affiliation(s)
- Cindy J Flores
- Clinical Services and Research Division-Transfusion Policy and Education, Australian Red Cross Lifeblood, Adelaide, South Australia, Australia
| | - Anil Lakkundi
- Neonatal Intensive Care Unit, John Hunter Children's Hospital, Newcastle, New South Wales, Australia
| | - Joanne McIntosh
- Neonatal Intensive Care Unit, John Hunter Children's Hospital, Newcastle, New South Wales, Australia
| | - Peter Freeman
- Hunter New England Local Health District, New Lambton, New South Wales, Australia
| | - Amanda Thomson
- Clinical Services and Research Division-Transfusion Policy and Education, Australian Red Cross Lifeblood, Adelaide, South Australia, Australia
| | - Ben Saxon
- Clinical Services and Research Division-Transfusion Policy and Education, Australian Red Cross Lifeblood, Adelaide, South Australia, Australia.,Women's and Children's Hospital Adelaide, North Adelaide, South Australia, Australia
| | - Justine Parsons
- Neonatal Intensive Care Unit, John Hunter Children's Hospital, Newcastle, New South Wales, Australia
| | - Tracey Spigiel
- Clinical Services and Research Division-Transfusion Policy and Education, Australian Red Cross Lifeblood, Adelaide, South Australia, Australia
| | - Sarah Milton
- The Royal Children's Hospital, Melbourne, Parkville, Victoria, Australia
| | - Bryony Ross
- Oncology and Haematology, John Hunter Children's Hospital, Newcastle, New South Wales, Australia.,Calvary Mater Hospital, Newcastle, New South Wales, Australia
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Piekarski F, Steinbicker A, Zacharowski K, Meybohm P. Changes in Transfusion Practice in Children and Adolescents over Time. Transfus Med Hemother 2020; 47:379-384. [PMID: 33173456 DOI: 10.1159/000511231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 08/31/2020] [Indexed: 01/09/2023] Open
Abstract
Introduction In recent years, resource-saving handling of allogeneic blood products and a reduction of transfusion rates in adults has been observed. However, comparable published national data for transfusion practices in pediatric patients are currently not available. In this study, the transfusion rates for children and adolescents were analyzed based on data from the Federal Statistical Office of Germany during the past 2 decades. Methods Data were queried via the database of the Federal Statistical Office (Destasis). The period covered was from 2005 to 2018, and those in the sample group were children and adolescents aged 0-17 years receiving inpatient care. Operation and procedure codes (OPS) for transfusions, procedures, or interventions with increased transfusion risk were queried and evaluated in detail. Results In Germany, 0.9% of the children and adolescents treated in hospital received a transfusion in 2018. A reduction in transfusion rates from 1.02% (2005) to 0.9% (2018) was observed for the total collective of children and adolescents receiving inpatient care. Increases in transfusion rates were recorded for 1- to 4- (1.41-1.45%) and 5- to 10-year-olds (1.24-1.33%). Children under 1 year of age were most frequently transfused (in 2018, 40.2% of the children were cared for in hospital). Transfusion-associated procedures such as chemotherapy or machine ventilation and respiratory support for newborns and infants are on the rise. Conclusion Transfusion rates are declining in children and adolescents, but the reasons for increases in transfusion rates in other groups are unclear. Prospective studies to evaluate transfusion rates and triggers in children are urgently needed.
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Affiliation(s)
- Florian Piekarski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Andrea Steinbicker
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, University of Münster, Münster, Germany
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Patrick Meybohm
- Department of Anaesthesia and Critical Care, University Hospitals of Würzburg, University of Würzburg, Würzburg, Germany
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The Road to Transfusion-free Craniosynostosis Repair in Children Less Than 24 Months Old: A Quality Improvement Initiative. Pediatr Qual Saf 2020; 5:e331. [PMID: 32766502 PMCID: PMC7365706 DOI: 10.1097/pq9.0000000000000331] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 06/18/2020] [Indexed: 12/25/2022] Open
Abstract
Introduction: Pediatric craniofacial reconstruction has historically resulted in extensive blood loss necessitating transfusion. This single-center quality improvement initiative evaluates the impact of perioperative practice changes on the allogeneic transfusion rate for children 24 months and younger of age undergoing craniofacial reconstruction. Methods: At project initiation, an appointed core group of anesthesiologists provided all intraoperative anesthetic care for patients undergoing craniofacial reconstruction. Standardized anesthetic guidelines established consistency between providers. Using the Plan-do-check-act methodology, practice changes had been implemented and studied over a 5-year period. Improvement initiatives included developing a temperature-management protocol, using a postoperative transfusion protocol, administering intraoperative tranexamic acid, and a preincisional injection of 0.25% lidocaine with epinephrine. For each year of the project, we acquired data for intraoperative and postoperative allogeneic transfusion rates. Results: A cohort of 119 pediatric patients, ages 4–24 months, underwent anterior or posterior vault reconstruction for craniosynostosis at a tertiary children’s hospital between March 2013 and November 2018. Intraoperative and postoperative transfusion of allogeneic blood products in this cohort decreased from 100% preintervention to 22.7% postintervention. Conclusions: Interdepartmental collaboration and practice modifications using sequential Plan-do-check-act cycles resulted in a bundle of care that leads to a sustainable decrease in the rate of intraoperative and postoperative allogeneic blood transfusions in patients less than 24 months of age undergoing craniosynostosis repair. This bundle decreases the risk of transfusion-related morbidity for these patients. Other institutions looking to achieve similar outcomes can implement this project.
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Eisler LD, Lenke LG, Sun LS, Li G, Kim M. Do Antifibrinolytic Agents Reduce the Risk of Blood Transfusion in Children Undergoing Spinal Fusion?: A Propensity Score-matched Comparison Using a National Database. Spine (Phila Pa 1976) 2020; 45:1055-1061. [PMID: 32675611 PMCID: PMC8120993 DOI: 10.1097/brs.0000000000003455] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort. OBJECTIVE To evaluate the effectiveness and safety of antifibrinolytic (AF) agents in reducing perioperative blood transfusion in pediatric patients undergoing spinal fusion. SUMMARY OF BACKGROUND DATA The potential for AF to decrease bleeding and reduce exposure to allogenic transfusions has led to widespread off-label use in a number of major pediatric surgical procedures. Recent reviews call for improving the body of evidence for their effectiveness and safety in pediatric spinal fusion. METHODS Children undergoing spinal fusion were identified in the American College of Surgeons National Surgical Quality Improvement Program Pediatric (NSQIP-P) 2016 and 2017 databases. Univariate analyses of patient and perioperative characteristics informed the creation of a propensity score model predicting treatment with AF, followed by 1:1 matching to allow comparison of allogenic red blood cell transfusion rates and secondary outcomes between treated and untreated patients. RESULTS Of 6626 total patients, 5434 (81%) received AF and 1533 (23%) received a blood transfusion. Analysis of data for 1192 propensity score-matched pairs revealed that treatment with AF was associated with a statistically nonsignificant 16% reduction in perioperative transfusion (OR 0.84, 95% confidence interval 0.68-1.05, P = 0.119) and a statistically significant 43% reduction in postoperative transfusion (OR 0.57, 95% confidence interval 0.39-0.81, P = 0.002). No differences in the incidences of postoperative seizure or thrombosis were observed, with overall rates of 7.5 and 22.5 events per 10,000 patients, respectively. CONCLUSION AF agents appear to reduce postoperative allogenic transfusion in children undergoing spinal fusion surgery. Adverse drug effects such as thromboembolic complications and seizure were extremely rare and warrant continued monitoring, though this is the largest study to date providing evidence for the safety profile of these drugs. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Lisa D. Eisler
- Anesthesiology, Columbia University Medical Center, New York, NY, USA
| | | | - Lena S. Sun
- Anesthesiology, Columbia University Medical Center, New York, NY, USA
- Pediatrics, Columbia University Medical Center, New York, NY, USA
| | - Guohua Li
- Anesthesiology, Columbia University Medical Center, New York, NY, USA
- Epidemiology, Mailman School of Public Health, Columbia University Medical Center, New York, NY, USA
| | - Minjae Kim
- Anesthesiology, Columbia University Medical Center, New York, NY, USA
- Epidemiology, Mailman School of Public Health, Columbia University Medical Center, New York, NY, USA
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45
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Cohn CS, Pagano MB, Allen ES, Frey KP, Gniadek T, Lokhandwala PM, Murphy CH, Raval JS, Dunbar NM. How do I manage long-term blood component shortages in a hospital transfusion service? Transfusion 2020; 60:1897-1904. [PMID: 32643156 DOI: 10.1111/trf.15857] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 04/27/2020] [Accepted: 04/28/2020] [Indexed: 01/09/2023]
Affiliation(s)
- Claudia S Cohn
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Monica B Pagano
- Department of Laboratory Medicine, University of Washington, Seattle, Washington, USA
| | - Elizabeth S Allen
- Department of Pathology, University of California San Diego, La Jolla, California, USA
| | - Kathrine P Frey
- Department of Pathology, Fairview Southdale Hospital, Minneapolis, Minnesota, USA
| | - Thomas Gniadek
- Department of Pathology and Laboratory Medicine, North Shore University Health System, Evanston, Illinois, USA
| | - Parvez M Lokhandwala
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Colin H Murphy
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jay S Raval
- Department of Pathology, University of New Mexico, Albuquerque, New Mexico, USA
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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46
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Switzer T, Faraoni D. Blood Conservation in Pediatric Surgical Patients. CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00399-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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47
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High-dose versus low-dose tranexamic acid for paediatric craniosynostosis surgery: a double-blind randomised controlled non-inferiority trial. Br J Anaesth 2020; 125:336-345. [PMID: 32620262 DOI: 10.1016/j.bja.2020.05.054] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/19/2020] [Accepted: 05/20/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Tranexamic acid (TXA) reduces blood loss and transfusion in paediatric craniosynostosis surgery. The hypothesis is that low-dose TXA, determined by pharmacokinetic modelling, is non-inferior to high-dose TXA in decreasing blood loss and transfusion in children. METHODS Children undergoing craniosynostosis surgery were enrolled in a two-centre, prospective, double-blind, randomised, non-inferiority controlled trial to receive high TXA (50 mg kg-1 followed by 5 mg kg-1 h-1) or low TXA (10 mg kg-1 followed by 5 mg kg-1 h-1). Primary outcome was blood loss. Low dose was determined to be non-inferior to high dose if the 95% confidence interval (CI) for the mean difference in blood loss was above the non-inferiority margin of -20 ml kg-1. Secondary outcomes were transfusion, TXA plasma concentrations, and biological markers of fibrinolysis and inflammation. RESULTS Sixty-eight children were included. Values were non-inferior regarding blood loss (39.4 [4.4] vs 40.3 [6.2] ml kg-1 [difference=0.9; 95% CI: -14.2, 15.9]) and blood transfusion (21.3 [1.6] vs 23.6 [1.5] ml kg-1 [difference=2.3; 95% CI: -2.1, 6.7]) between high-dose (n=32) and low-dose (n=34) groups, respectively. The TXA plasma concentrations during surgery averaged 50.2 (8.0) and 29.6 (7.6) μg ml-1. There was no difference in fibrinolytic and inflammatory biological marker concentrations. No adverse events were observed. CONCLUSIONS Tranexamic acid 10 mg kg-1 followed by 5 mg kg-1 h-1 is not less effective than a higher dose of 50 mg kg-1 and 5 mg kg-1 h-1 in reducing blood loss and transfusion in paediatric craniosynostosis surgery. CLINICAL TRIAL REGISTRATION NCT02188576.
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48
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Piekarski F, Kaufmann J, Engelhardt T, Raimann FJ, Lustenberger T, Marzi I, Lefering R, Zacharowski K, Meybohm P. Changes in transfusion and fluid therapy practices in severely injured children: an analysis of 5118 children from the TraumaRegister DGU®. Eur J Trauma Emerg Surg 2020; 48:373-381. [PMID: 32601717 PMCID: PMC8825567 DOI: 10.1007/s00068-020-01423-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 06/19/2020] [Indexed: 11/23/2022]
Abstract
Purpose Trauma is the leading cause of death in children. In adults, blood transfusion and fluid resuscitation protocols changed resulting in a decrease of morbidity and mortality over the past 2 decades. Here, transfusion and fluid resuscitation practices were analysed in severe injured children in Germany. Methods Severely injured children (maximum Abbreviated Injury Scale (AIS) ≥ 3) admitted to a certified trauma-centre (TraumaZentrum DGU®) between 2002 and 2017 and registered at the TraumaRegister DGU® were included and assessed regarding blood transfusion rates and fluid therapy. Results 5,118 children (aged 1–15 years) with a mean ISS 22 were analysed. Blood transfusion rates administered until ICU admission decreased from 18% (2002–2005) to 7% (2014–2017). Children who are transfused are increasingly seriously injured. ISS has increased for transfused children aged 1–15 years (2002–2005: mean 27.7–34.4 in 2014–2017). ISS in non-transfused children has decreased in children aged 1–15 years (2002–2005: mean 19.6 to mean 17.6 in 2014–2017). Mean prehospital fluid administration decreased from 980 to 549 ml without affecting hemodynamic instability. Conclusion Blood transfusion rates and amount of fluid resuscitation decreased in severe injured children over a 16-year period in Germany. Restrictive blood transfusion and fluid management has become common practice in severe injured children. A prehospital restrictive fluid management strategy in severely injured children is not associated with a worsened hemodynamic state, abnormal coagulation or base excess but leads to higher hemoglobin levels.
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Affiliation(s)
- Florian Piekarski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt, Germany.
| | - Jost Kaufmann
- Department for Paediatric Anaesthesia, Children's Hospital Cologne, Cologne, Germany.,Faculty of Health, University of Witten/Herdecke, Witten, Germany
| | - Thomas Engelhardt
- Department for Anesthesia, Montreal Children's Hospital, Montreal, Canada
| | - Florian J Raimann
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Thomas Lustenberger
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - Rolf Lefering
- Faculty of Health, University of Witten/Herdecke, Witten, Germany.,IFOM, Institute for Research in Operative Medicine, Faculty of Health, University Witten/Herdecke, Cologne, Germany
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Patrick Meybohm
- Department of Anaesthesia and Critical Care, University Hospital Würzburg, Würzburg, Germany
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49
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Shander A, Goobie SM, Warner MA, Aapro M, Bisbe E, Perez-Calatayud AA, Callum J, Cushing MM, Dyer WB, Erhard J, Faraoni D, Farmer S, Fedorova T, Frank SM, Froessler B, Gombotz H, Gross I, Guinn NR, Haas T, Hamdorf J, Isbister JP, Javidroozi M, Ji H, Kim YW, Kor DJ, Kurz J, Lasocki S, Leahy MF, Lee CK, Lee JJ, Louw V, Meier J, Mezzacasa A, Munoz M, Ozawa S, Pavesi M, Shander N, Spahn DR, Spiess BD, Thomson J, Trentino K, Zenger C, Hofmann A. Essential Role of Patient Blood Management in a Pandemic: A Call for Action. Anesth Analg 2020; 131:74-85. [PMID: 32243296 PMCID: PMC7173035 DOI: 10.1213/ane.0000000000004844] [Citation(s) in RCA: 103] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The World Health Organization (WHO) has declared coronavirus disease 2019 (COVID-19), the disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a pandemic. Global health care now faces unprecedented challenges with widespread and rapid human-to-human transmission of SARS-CoV-2 and high morbidity and mortality with COVID-19 worldwide. Across the world, medical care is hampered by a critical shortage of not only hand sanitizers, personal protective equipment, ventilators, and hospital beds, but also impediments to the blood supply. Blood donation centers in many areas around the globe have mostly closed. Donors, practicing social distancing, some either with illness or undergoing self-quarantine, are quickly diminishing. Drastic public health initiatives have focused on containment and "flattening the curve" while invaluable resources are being depleted. In some countries, the point has been reached at which the demand for such resources, including donor blood, outstrips the supply. Questions as to the safety of blood persist. Although it does not appear very likely that the virus can be transmitted through allogeneic blood transfusion, this still remains to be fully determined. As options dwindle, we must enact regional and national shortage plans worldwide and more vitally disseminate the knowledge of and immediately implement patient blood management (PBM). PBM is an evidence-based bundle of care to optimize medical and surgical patient outcomes by clinically managing and preserving a patient's own blood. This multinational and diverse group of authors issue this "Call to Action" underscoring "The Essential Role of Patient Blood Management in the Management of Pandemics" and urging all stakeholders and providers to implement the practical and commonsense principles of PBM and its multiprofessional and multimodality approaches.
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Affiliation(s)
- Aryeh Shander
- From the Department of Anesthesiology, Critical Care and Hyperbaric Medicine, Englewood Health, Englewood, New Jersey
| | - Susan M Goobie
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Matthew A Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Matti Aapro
- Cancer Center Clinique Genolier, Genolier, Switzerland
| | - Elvira Bisbe
- Department of Anesthesiology, Perioperative Medicine Research Group, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Angel A Perez-Calatayud
- Department of Critical Care, Hospital General de Mexico Dr Eduardo Liceaga, Mexico City, Mexico
| | - Jeannie Callum
- Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Melissa M Cushing
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, New York
| | - Wayne B Dyer
- Australian Red Cross Lifeblood and Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Jochen Erhard
- Department of Surgery, Evangelisches Klinikum Niederrhein, Duisburg, Germany
| | - David Faraoni
- Department of Anesthesiology and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Shannon Farmer
- Medical School, Division of Surgery, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Western Australia, Australia.,School of Health Sciences and Graduate Studies, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
| | - Tatyana Fedorova
- Institute of Anesthesiology, Resuscitation and Transfusiology of the National Medical Research Center of Obstetrics, Gynecology and Perinatology named after Acad. V. I. Kulakov, Ministry of Health of the Russian Federation, Moscow, Russia
| | - Steven M Frank
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Bernd Froessler
- Department of Anesthesia, Lyell McEwin Hospital, Elizabeth Vale, South Australia, Australia.,Discipline of Acute Care Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Hans Gombotz
- Department of Anesthesiology and Intensive Care, General Hospital Linz, Linz, Austria
| | - Irwin Gross
- Northern Light Health, Brewer, Maine.,Accumen, Inc, San Diego, California
| | - Nicole R Guinn
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Thorsten Haas
- Department of Anesthesiology, University Children's Hospital Zurich, Zurich, Switzerland
| | - Jeffrey Hamdorf
- Medical School, The University of Western Australia, Western Australia Patient Blood Management Group, Perth, Western Australia, Australia
| | - James P Isbister
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Mazyar Javidroozi
- From the Department of Anesthesiology, Critical Care and Hyperbaric Medicine, Englewood Health, Englewood, New Jersey
| | - Hongwen Ji
- Department of Anesthesiology and Transfusion Medicine, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Young-Woo Kim
- Department of Cancer Control and Population Health, National Cancer Center Graduate School of Cancer Science and Policy and Center for Gastric Cancer, National Cancer Center, Ilsandong-gu, Goyang, Korea
| | - Daryl J Kor
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Johann Kurz
- Austrian Federal Ministry of Health, Vienna, Austria.,Department Applied Sciences, University of Applied Sciences, Vienna, Austria
| | - Sigismond Lasocki
- Département Anesthésie-Réanimation, Anesthésie Samu Urgences Réanimation, CHU Angers, Angers, France
| | - Michael F Leahy
- Department of Haematology, PathWest Laboratory Medicine, University of Western Australia, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Cheuk-Kwong Lee
- Hong Kong Red Cross Blood Transfusion Service, Hong Kong Special Administrative Region, China
| | - Jeong Jae Lee
- Department of Obstetrics and Gynecology, Soonchunhyang University Hospital, Seoul, Korea
| | - Vernon Louw
- Division Clinical Haematology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Jens Meier
- Clinic of Anesthesiology and Intensive Care Medicine, Johannes Kepler University Linz, Linz, Austria
| | | | - Manuel Munoz
- Department of Surgical Sciences, Biochemistry and Immunology, School of Medicine, University of Málaga, Málaga, Spain
| | - Sherri Ozawa
- Patient Blood Management, Englewood Health, Englewood, New Jersey
| | - Marco Pavesi
- Department of Anesthesiology and Intensive Care, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Nina Shander
- Jerry M. Wallace School of Osteopathic Medicine, Campbell University, Buies Creek, North Carolina
| | - Donat R Spahn
- Institute of Anesthesiology, University of Zurich, University Hospital of Zurich, Zurich, Switzerland
| | - Bruce D Spiess
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
| | - Jackie Thomson
- South African National Blood Service, Johannesburg, South Africa
| | - Kevin Trentino
- Medical School, The University of Western Australia, Perth, Western Australia, Australia.,Data and Digital Innovation, East Metropolitan Health Service, Perth, Western Australia, Australia
| | - Christoph Zenger
- Center for Health Law and Management, University of Bern, Bern, Switzerland
| | - Axel Hofmann
- Institute of Anesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland.,Medical School, The University of Western Australia, Crawley, Western Australia, Australia.,School of Health Sciences and Graduate Studies, Curtin University, Perth, Western Australia, Australia
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50
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Demaret P, Karam O, Labreuche Bst J, Chiusolo F, Mayordomo Colunga J, Erickson S, Nellis ME, Perez MH, Ray S, Tucci M, Willems A, Duhamel A, Lebrun F, Loeckx I, Mulder A, Leteurtre S. How 217 Pediatric Intensivists Manage Anemia at PICU Discharge: Online Responses to an International Survey. Pediatr Crit Care Med 2020; 21:e342-e353. [PMID: 32217901 DOI: 10.1097/pcc.0000000000002307] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To describe the management of anemia at PICU discharge by pediatric intensivists. DESIGN Self-administered, online, scenario-based survey. SETTING PICUs in Australia/New Zealand, Europe, and North America. SUBJECTS Pediatric intensivists. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Respondents were asked to report their decisions regarding RBC transfusions, iron, and erythropoietin prescription to children ready to be discharged from PICU, who had been admitted for hemorrhagic shock, cardiac surgery, craniofacial surgery, and polytrauma. Clinical and biological variables were altered separately in order to assess their effect on the management of anemia. Two-hundred seventeen responses were analyzed. They reported that the mean (± SEM) transfusion threshold was a hemoglobin level of 6.9 ± 0.09 g/dL after hemorrhagic shock, 7.6 ± 0.10 g/dL after cardiac surgery, 7.0 ± 0.10 g/dL after craniofacial surgery, and 7.0 ± 0.10 g/dL after polytrauma (p < 0.001). The most important increase in transfusion threshold was observed in the presence of a cyanotic heart disease (mean increase ranging from 1.80 to 2.30 g/dL when compared with baseline scenario) or left ventricular dysfunction (mean increase, 1.41-2.15 g/dL). One third of respondents stated that they would not prescribe iron at PICU discharge, regardless of the hemoglobin level or the baseline scenario. Most respondents (69.4-75.0%, depending on the scenario) did not prescribe erythropoietin. CONCLUSIONS Pediatric intensivists state that they use restrictive transfusion strategies at PICU discharge similar to those they use during the acute phase of critical illness. Supplemental iron is less frequently prescribed than RBCs, and prescription of erythropoietin is uncommon. Optimal management of post-PICU anemia is currently unknown. Further studies are required to highlight the consequences of this anemia and to determine appropriate management.
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Affiliation(s)
- Pierre Demaret
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHC, Liège, Belgium.,Univ. Lille, EA 2694 - Santé Publique: épidémiologie et qualité des soins, F-59000 Lille, France
| | - Oliver Karam
- Division of Pediatric Critical Care Medicine, Children's Hospital of Richmond at VCU, Richmond, VA
| | - Julien Labreuche Bst
- Univ. Lille, CHU Lille, EA 2694 - Santé publique: épidémiologie et qualité des soins, F-59000 Lille, France
| | - Fabrizio Chiusolo
- Anesthesia and Critical Care, Bambino Gesù Children's Hospital, Rome, Italy
| | - Juan Mayordomo Colunga
- Sección de Cuidados Intensivos Pediátricos, Área de Gestión Clínica de Pediatría, Hospital Universitario Central de Asturias, Oviedo, Spain.,CIBER-Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.,Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
| | - Simon Erickson
- Division of Pediatric Critical Care, Princess Margaret Hospital, Perth, WA, Australia
| | - Marianne E Nellis
- Pediatric Critical Care Medicine, Department of Pediatrics, NY Presbyterian Hospital - Weill Cornell Medicine, New York, NY
| | - Marie-Hélène Perez
- Pediatric Intensive Care Unit, Department of Pediatrics, University Hospital of Lausanne, Lausanne, Switzerland
| | - Samiran Ray
- Pediatric Intensive Care Unit, Great Ormond Street Hospital NHS Foundation Trust, London, United Kingdom
| | - Marisa Tucci
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Sainte-Justine Hospital and Université de Montréal, Montreal, QC, Canada
| | - Ariane Willems
- Pediatric Intensive Care Unit, Department of Intensive Care, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
| | - Alain Duhamel
- Univ. Lille, CHU Lille, EA 2694 - Santé publique: épidémiologie et qualité des soins, F-59000 Lille, France
| | - Frédéric Lebrun
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHC, Liège, Belgium
| | - Isabelle Loeckx
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHC, Liège, Belgium
| | - André Mulder
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHC, Liège, Belgium
| | - Stéphane Leteurtre
- Univ. Lille, EA 2694 - Santé Publique: épidémiologie et qualité des soins, F-59000 Lille, France.,CHU Lille, Pediatric Intensive Care Unit, CHU Lille, F-59000 Lille, France
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