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Sigurdsson TS, Øberg E, Roshauw J, Snorradottir B, Holst LB. A survey on perioperative red blood cell transfusion trigger strategies for pediatric patients in the Nordic countries. Acta Anaesthesiol Scand 2024; 68:764-771. [PMID: 38549369 DOI: 10.1111/aas.14416] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 02/25/2024] [Accepted: 03/18/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Transfusion of red blood cells (RBC) to rapidly increase hemoglobin levels have been associated with increased risks and worse outcomes in critically ill children. The international TAXI consensus from 2018 (pediatric critical care transfusion and anemia expertise initiative) recommended restrictive RBC transfusion strategies in pediatric patients. OBJECTIVE To elucidate physicians perioperative RBC transfusion trigger strategies for pediatric patients in the Nordic countries and to investigate what factors influence the decision to transfuse this group of patients. METHODS An electronic web-based survey designed by the TransfUsion triggers in Pediatric perioperAtive Care (TUPAC) initiative including six different clinical scenarios was sent to anesthesiologist treating pediatric patients at university hospitals in the Nordic countries on February 1, 2023 and closed May 1, 2023. RESULTS The study had a response rate of 67.7% (180 responders out of 266 contacted). Median hemoglobin thresholds triggering RBC transfusions were 7.0 [IQR, 7.0-7.3] g/dL in a stable young child (1-year-old), 7.0 [IQR, 7.0-7.0] g/dL in the stable older child (5-year-old), 8.5 [IQR, 8.0-9.0] g/dL in the older child with cardiac disease, 9.0 [IQR, 8.0-10.0] g/dL the older child with traumatic brain injury, 8.0 [IQR, 7.3-9.0] g/dL in stabilized older child with septic shock and 8.0 [IQR, 7.0-9.0] g/dL in the older child with active but non-life-threatening bleeding. Apart from specific hemoglobin level, RBC transfusions were mostly triggered by high lactate level (74.2%), increasing heart rate (68.0%), prolonged capillary refill time (48.3%), and lowered blood pressure (47.8%). No statistical difference was found between the Nordic countries, work experience, or enrollment in a pediatric anesthesia fellowship program regarding RBC transfusion strategies. CONCLUSIONS Anesthesiologists in the Nordic countries report restrictive perioperative RBC transfusion strategies for children that are mostly in agreement with the international TAXI recommendations. However, RBC transfusions strategies were modified to be guided by more liberal trigger levels when pediatric patients presented with severe comorbidity such as severe sepsis, septic shock, and non-life-threatening bleeding.
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Affiliation(s)
- Theodor S Sigurdsson
- Department of Anesthesiology and Intensive Care Medicine, Landspitali University Hospital, Reykjavik, Iceland
- Faculty of Medicine, University of Iceland, Reykjavík, Iceland
| | - Emilie Øberg
- Department of Pediatric and Obstetric Anesthesia, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Janne Roshauw
- Department of Anesthesiology and Intensive Care Medicine, Ullevål University Hospital, Oslo, Norway
| | - Bryndis Snorradottir
- Department of Anesthesiology and Intensive Care Medicine, Landspitali University Hospital, Reykjavik, Iceland
| | - Lars Broksø Holst
- Department of Pediatric and Obstetric Anesthesia, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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2
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Wilhelm M, Torgeson J, Cook C, Erdmann A, Boriosi J, Lamers L. Reducing Adverse Events Associated with Pediatric Cardiac Catheterization: A Quality Improvement Project Focusing on Decreasing Catheterization-Associated Blood Transfusions. Pediatr Cardiol 2024:10.1007/s00246-024-03553-2. [PMID: 38916668 DOI: 10.1007/s00246-024-03553-2] [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: 04/22/2024] [Accepted: 06/14/2024] [Indexed: 06/26/2024]
Abstract
The objective of this study is to describe interventions and outcomes of a quality improvement (QI) project to reduce red blood cell transfusion (RBCT) within 72 h of pediatric cardiac catheterization. Using Plan-Do-Study-Act (PDSA) methodology, we applied interventions including (1). Intraprocedural-to reduce hemodilution, blood loss, and excessive anticoagulation, (2). Standardization of institutional transfusion criteria, and (3). "Hard stop" requiring QI team consultation prior to elective post-catheterization RBCT. Primary outcome measures were frequency of RBCT from IMPACT quarterly reports and cases between transfusions (CBT). Length of stay (LOS) was the primary countermeasure. Characteristics of patients who did and did not receive RBCT were compared. 698 pediatric cardiac catheterizations occurred between 4/2017 and 8/2023. Intraprocedural interventions did not alter frequency of RBCT or CBT. Standardized transfusion guidelines followed by the "hard stop" decreased RBCT frequency from 10 to 1.9% and increased CBT without increasing LOS. Patients requiring RBCT were younger (medians 0.31 vs 2.4 years), smaller (5.2 vs 11.8 kg), and had longer procedures (2.24 vs 1.57 h) all p < 0.001. Single ventricle patients were more likely to have RBCT than simple biventricular patients (14.1% vs 3.1%; RR = 4.57, 95% CI 2.29-10.4; p < 0.001). Procedure type (diagnostic vs. intervention) and starting hemoglobin concentration were comparable between groups. Programmatic adherence to standardized peri-procedural transfusion guidelines successfully decreased RBCT without compromising patient care or increasing LOS. Younger age, lower weight, procedure length, and single ventricle physiology were all associated with RBCT risk.
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Affiliation(s)
- Michael Wilhelm
- Division of Pediatric Critical Care, Department of Pediatrics, University of Wisconsin-Madison, Madison, USA
| | - Jenna Torgeson
- Division of Cardiology, Department of Pediatrics, University of Wisconsin-Madison, Madison, USA
| | - Connor Cook
- Department of Pediatrics, University of Wisconsin-Madison, Madison, USA
| | - Alexandra Erdmann
- Division of Cardiology, Department of Pediatrics, University of Wisconsin-Madison, Madison, USA
| | - Juan Boriosi
- Division of Pediatric Critical Care, Department of Pediatrics, University of Wisconsin-Madison, Madison, USA
| | - Luke Lamers
- Division of Cardiology, Department of Pediatrics, University of Wisconsin-Madison, Madison, USA.
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3
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Kayoum AA, Rivera Flores E, Reyes M, Almasarweh SI, Ojito J, Burke RP, Sasaki J. Safety of bloodless open-heart surgery on cardiopulmonary bypass in selected children: A single center experience with minimal invasive extracorporeal circulation. Perfusion 2024; 39:391-398. [PMID: 36482703 DOI: 10.1177/02676591221145623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
INTRODUCTION Bloodless cardiac surgery refers to open-heart surgery without blood or blood products. The cardiopulmonary bypass (CPB) circuits are primed with crystalloid solely, and there is no intraoperative blood transfusion. METHODS Our program considers bloodless congenital cardiac surgery with a minimal invasive extracorporeal circulation (MiECC) system for patients above 10 kg of weight. We performed a single-center retrospective cohort study of all consecutive patients undergoing bloodless cardiac surgery for congenital heart defects between January 2016 and December 2018. RESULTS A total of 164 patients were reviewed (86 male and 78 female) at a median age of 9.6 years (interquartile range (IQR), 4.5-15), a weight of 32 kg (IQR, 16-55), preoperative hemoglobin 13.7 g/dl (IQR, 12.6-14.9), and preoperative hematocrit of 40.4% (IQR, 37.2-44.3). Median CPB time was 81.5 min (IQR, 58-125), and median hematocrit coming off CPB was 26% (IQR, 23-29.7). The congenital heart surgery risk (STAT) category was distributed in STAT 1 for 70, STAT 2 for 80, STAT 3 for 9, and STAT 4 for 5 patients. Most patients (95%) were extubated in the operating room with a low complication rate during the hospital stay (14.6%). Only 6 (4%) patients needed a blood transfusion during the postoperative period, with a higher incidence of complications during the hospital course (p < 0.001). CONCLUSIONS Bloodless congenital heart surgery with MiECC system is safe in low-surgical-risk patients. Our patients had a low rate of complications and short hospital stays.
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Affiliation(s)
- Anas Abdul Kayoum
- Division of Cardiology, Department of Pediatrics, Duke University Hospital, Durham, NC, USA
| | | | - Marcelle Reyes
- Department of Cardiology, Nicklaus Children's Hospital, Miami, FL, USA
| | - Saleem I Almasarweh
- Division of Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Jorge Ojito
- Department of Cardiology, Nicklaus Children's Hospital, Miami, FL, USA
| | - Redmond P Burke
- Department of Cardiology, Nicklaus Children's Hospital, Miami, FL, USA
| | - Jun Sasaki
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
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4
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Wittenmeier E, Piekarski F, Steinbicker AU. Blood Product Transfusions for Children in the Perioperative Period and for Critically Ill Children. DEUTSCHES ARZTEBLATT INTERNATIONAL 2024; 121:58-65. [PMID: 38051160 PMCID: PMC10979439 DOI: 10.3238/arztebl.m2023.0243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 11/08/2023] [Accepted: 11/08/2023] [Indexed: 12/07/2023]
Abstract
BACKGROUND Approximately 1% to 2% of all hospitalized children receive a transfusion of blood products, in Germany as in other countries. High-quality scientific evidence on transfusions in children is scarce. The available evidence is discussed in this review. METHODS This review is based on publications on blood product transfusions in children that were retrieved by a literature search, including clinical studies, international guideline recommendations, the recommendations of the German cross-sectional guideline, and results of other recent, relevant publications. RESULTS A restrictive transfusion strategy is recommended for all children, including those who are critically ill. Randomized controlled trials have shown that a restrictive strategy for erythrocyte concentrate transfusion in the intensive care unit is safe for children, including neonates. No robust data are available to enable the definition of a suitable threshold for the intraoperative administration of red blood cell concentrates in children undergoing extracardiac surgery. On the basis of studies from pediatric intensive care units, transfusions for hemodynamically stable children with a hemoglobin concentration of more than 7 g/dL are recommended only in exceptional cases. Therapeutic plasma is not recommended as volume replacement, except in massive transfusion. Platelet concentrate transfusions are indicated in case of active hemorrhage, and only rarely for prophylaxis. CONCLUSION There is a broad lack of evidence from randomized controlled trials concerning the indications for transfusions in children. A restrictive transfusion strategy, which has been found safe in the intensive-care setting, is favored by the guidelines in the perioperative setting as well. Further studies are needed to evaluate transfusion triggers and indications for all types of blood products, especially therapeutic plasma. Until more evidence is available, physicians should be aware of what the current evidence supports, and blood products should be given restrictively, and not prophylactically.
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Affiliation(s)
- Eva Wittenmeier
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg University Mainz, Germany
- German Working Group on Paediatric Anesthesia (WAKKA)
| | - Florian Piekarski
- Goethe University Frankfurt, University Hospital, Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Frankfurt, Germany
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Andrea U. Steinbicker
- Goethe University Frankfurt, University Hospital, Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Frankfurt, Germany
- German Working Group on Paediatric Anesthesia (WAKKA)
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5
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Garcia Guerra A, Ryerson L, Garros D, Nahirniak S, Granoski D, Calisin O, Sheppard C, Lequier L, Garcia Guerra G. Standard Versus Restrictive Transfusion Strategy for Pediatric Cardiac ECLS Patients: Single Center Retrospective Cohort Study. ASAIO J 2023; 69:681-686. [PMID: 37084290 DOI: 10.1097/mat.0000000000001917] [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: 04/23/2023] Open
Abstract
This retrospective cohort study aimed to compare blood component transfusion before and after the implementation of a restrictive transfusion strategy (RTS) in pediatric cardiac Extracorporeal Life Support (ECLS) patients. The study included children admitted to the pediatric cardiac intensive care unit (PCICU) at the Stollery Children's Hospital who received ECLS between 2012 and 2020. Children on ECLS between 2012 and 2016 were treated with standard transfusion strategy (STS), while those on ECLS between 2016 and 2020 were treated with RTS. During the study, 203 children received ECLS. Daily median (interquartile range [IQR]) packed red blood cell (PRBC) transfusion volume was significantly lower in the RTS group; 26.0 (14.4-41.5) vs. 41.5 (26.6-64.4) ml/kg/day, p value <0.001. The implementation of a RTS led to a median reduction of PRBC transfusion of 14.5 (95% CI: 6.70-21.0) ml/kg/day. Similarly, the RTS group received less platelets: median (IQR) 8.4 (4.50-15.0) vs. 17.5 (9.40-29.0) ml/kg/day, p value <0.001. The implementation of a RTS resulted in a median reduction of platelet transfusion of 9.2 (95% CI: 5.45-13.1) ml/kg/day. The RTS resulted in less median (IQR) fluid accumulation in the first 48 hours: 56.7 (2.30-121.0) vs. 140.4 (33.8-346.2) ml/kg, p value = 0.001. There were no significant differences in mechanical ventilation days, PCICU/hospital days, or survival. The use of RTS resulted in lower blood transfusion volumes, with similar clinical outcomes.
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Affiliation(s)
| | - Lindsay Ryerson
- Stollery Children's Hospital, Edmonton, Alberta, Canada
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Daniel Garros
- Stollery Children's Hospital, Edmonton, Alberta, Canada
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Susan Nahirniak
- Department of Pediatrics, University of Calgary, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Don Granoski
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Olivia Calisin
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Cathy Sheppard
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Laurance Lequier
- Stollery Children's Hospital, Edmonton, Alberta, Canada
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Gonzalo Garcia Guerra
- Department of Pediatrics, University of Calgary, Alberta Children's Hospital, Calgary, Alberta, Canada
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
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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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7
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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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8
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Jutras C, Sauthier M, Tucci M, Trottier H, Lacroix J, Robitaille N, Ducharme-Crevier L, Du Pont-Thibodeau G. Prevalence and determinants of anemia at discharge in pediatric intensive care survivors. Transfusion 2023; 63:973-981. [PMID: 36907652 DOI: 10.1111/trf.17309] [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: 04/20/2022] [Revised: 12/06/2022] [Accepted: 01/11/2023] [Indexed: 03/13/2023]
Abstract
BACKGROUND Restrictive transfusion practices are increasingly being followed in pediatric intensive care units (PICU); consequently, more patients are discharged anemic from PICU. Given the possible impact of anemia on long-term neurodevelopmental outcomes, we aim to describe the epidemiology of anemia at PICU discharge in a mixed (pediatric and cardiac) cohort of PICU survivors and to characterize risk factors for anemia. STUDY DESIGN AND METHODS We performed a retrospective cohort study in the PICU of a multidisciplinary tertiary-care university-affiliated center. All consecutive PICU survivors for whom a hemoglobin level was available at PICU discharge were included. Baseline characteristics and hemoglobin levels were extracted from an electronic medical records database. RESULTS From January 2013 to January 2018, 4750 patients were admitted to the PICU (97.1% survival); discharge hemoglobin levels were available for 4124 patients. Overall, 50.9% (n = 2100) were anemic at PICU discharge. Anemia at PICU discharge was also common in the cardiac surgery population (53.3%), mainly in acyanotic patients; only 24.6% of cyanotic patients were anemic according to standard definitions of anemia. Cardiac surgery patients were transfused more often and at higher hemoglobin levels than medical and non-cardiac surgery patients. Anemia at admission was the strongest predictor of anemia at discharge (odds ratios (OR): 6.51, 95% confidence interval (CI:5.40;7.85)). DISCUSSION Half of PICU survivors are anemic at discharge. Further studies are required to determine the course of anemia after discharge and to ascertain whether anemia is associated with adverse long-term outcomes.
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Affiliation(s)
- Camille Jutras
- Department of Pediatrics, CHU Sainte-Justine, Montréal, Québec, Canada
| | - Michaël Sauthier
- Department of Pediatrics, CHU Sainte-Justine, Montréal, Québec, Canada
| | - Marisa Tucci
- Department of Pediatrics, CHU Sainte-Justine, Montréal, Québec, Canada
| | - Helen Trottier
- Public Health School, Université de Montréal and Research Center, CHU Sainte-Justine, Montréal, Québec, Canada
| | - Jacques Lacroix
- Department of Pediatrics, CHU Sainte-Justine, Montréal, Québec, Canada
| | - Nancy Robitaille
- Department of Pediatrics, CHU Sainte-Justine, Montréal, Québec, Canada.,Public Health School, Université de Montréal and Research Center, CHU Sainte-Justine, Montréal, Québec, Canada.,Héma-Québec, Montréal, Québec, Canada
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9
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The Impact of Restrictive Transfusion Practices on Hemodynamically Stable Critically Ill Children Without Heart Disease: A Secondary Analysis of the Age of Blood in Children in the PICU Trial. Pediatr Crit Care Med 2023; 24:84-92. [PMID: 36661416 DOI: 10.1097/pcc.0000000000003128] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES Guidelines recommend against RBC transfusion in hemodynamically stable (HDS) children without cardiac disease, if hemoglobin is greater than or equal to 7 g/dL. We sought to assess the clinical and economic impact of compliance with RBC transfusion guidelines. DESIGN A nonprespecified secondary analysis of noncardiac, HDS patients in the randomized trial Age of Blood in Children (NCT01977547) in PICUs. Costs analyzed included ICU stay and physician fees. Stabilized inverse propensity for treatment weighting was used to create a cohort balanced with respect to potential confounding variables. Weighted regression models were fit to evaluate outcomes based on guideline compliance. SETTING Fifty international tertiary care centers. PATIENTS Critically ill children 3 days to 16 years old transfused RBCs at less than or equal to 7 days of ICU admission. Six-hundred eighty-seven subjects who met eligibility criteria were included in the analysis. INTERVENTIONS Initial RBC transfusions administered when hemoglobin was less than 7 g/dL were considered "compliant" or "non-compliant" if hemoglobin was greater than or equal to 7 g/dL. MEASUREMENTS AND MAIN RESULTS Frequency of new or progressive multiple organ system dysfunction (NPMODS), ICU survival, and associated costs. The hypothesis was formulated after data collection but exposure groups were masked until completion of planned analyses. Forty-nine percent of patients (338/687) received a noncompliant initial transfusion. Weighted cohorts were balanced with respect to confounding variables (absolute standardized differences < 0.1). No differences were noted in NPMODS frequency (relative risk, 0.86; 95% CI, 0.61-1.22; p = 0.4). Patients receiving compliant transfusions had more ICU-free days (mean difference, 1.73; 95% CI, 0.57-2.88; p = 0.003). Compliance reduced mean costs in ICU by $38,845 U.S. dollars per patient (95% CI, $65,048-$12,641). CONCLUSIONS Deferring transfusion until hemoglobin is less than 7 g/dL is not associated with increased organ dysfunction in this population but is independently associated with increased likelihood of live ICU discharge and lower ICU costs.
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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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11
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Karimi M. A Surgeon's Perspective on Blood Conservation Practice in Pediatric Cardiac Surgery. World J Pediatr Congenit Heart Surg 2022; 13:782-787. [DOI: 10.1177/21501351221114846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Blood conservation practice in pediatric cardiac surgery has not been consistently adopted as quality improvement in many centers despite known risks associated with allogeneic blood products, shortage of donors, and costs. There are many blood conservation strategies available which collectively minimize exposure to allogeneic transfusion by maximizing the use of autologous red cells. These strategies are safe, reproducible, and have been implemented in clinical practice collectively with great efficacy for all patient ages and complexity levels. Institutional commitment to a set guideline will improve their blood conservation practice and quality outcome. The purpose of this article is to provide early career and practicing congenital cardiac surgeons with practical information concerning blood conservation strategies which can be considered for implementation in any pediatric cardiac surgery program, and which may be of particular value in resource-limited programs.
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Affiliation(s)
- Mohsen Karimi
- Department of Cardiothoracic Surgery, Stead Family Children’s Hospital, University of Iowa Healthcare, Iowa City, IA, USA
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12
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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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Hanson SJ, Karam O, Birch R, Goel R, Patel RM, Sola-Visner M, Sachais BS, Hauser RG, Luban NLC, Gottschall J, Josephson CD, Hendrickson JE, Karafin MS, Nellis ME. Transfusion Practices in Pediatric Cardiac Surgery Requiring Cardiopulmonary Bypass: A Secondary Analysis of a Clinical Database. Pediatr Crit Care Med 2021; 22:978-987. [PMID: 34261944 PMCID: PMC8570986 DOI: 10.1097/pcc.0000000000002805] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe blood component usage in transfused children with congenital heart disease undergoing cardiopulmonary bypass surgery across perioperative settings and diagnostic categories. DESIGN Datasets from U.S. hospitals participating in the National Heart, Lung, and Blood Institute Recipient Epidemiology and Donor Evaluation Study-III were analyzed. SETTING Inpatient admissions from three U.S. hospitals from 2013 to 2016. PATIENTS Transfused children with congenital heart disease undergoing single ventricular, biventricular surgery, extracorporeal membrane oxygenation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Eight hundred eighty-two transfused patients were included. Most of the 185 children with single ventricular surgery received multiple blood products: 81% RBCs, 79% platelets, 86% plasma, and 56% cryoprecipitate. In the 678 patients undergoing biventricular surgery, 85% were transfused plasma, 75% platelets, 74% RBCs, and 48% cryoprecipitate. All 19 patients on extracorporeal membrane oxygenation were transfused RBCs, plasma, and cryoprecipitate, and 18 were transfused platelets. Intraoperatively, patients commonly received all three components, while postoperative transfusions were predominantly single blood components. Pretransfusion hemoglobin values were normal/low-normal for age for all phases of care for single ventricular surgery (median hemoglobin 13.2-13.5 g/dL). Pretransfusion hemoglobin values for biventricular surgeries were higher intraoperatively compared with other timing (12.2 g/dL vs 11.2 preoperative and postoperative; p < 0.0001). Plasma transfusions for all patients were associated with a near normal international normalized ratio: single ventricular surgeries median international normalized ratio was 1.3 postoperative versus 1.8 intraoperative and biventricular surgeries median international normalized ratio was 1.1 intraoperative versus 1.7 postoperative. Intraoperative platelet transfusions with biventricular surgeries had higher median platelet count compared with postoperative pretransfusion platelet count (244 × 109/L intraoperative vs 69 × 109/L postoperative). CONCLUSIONS Children with congenital heart disease undergoing cardiopulmonary bypass surgery are transfused many blood components both intraoperatively and postoperatively. Multiple blood components are transfused intraoperatively at seemingly normal/low-normal pretransfusion values. Pediatric evidence guiding blood component transfusion in this population at high risk of bleeding and with limited physiologic reserve is needed to advance safe and effective blood conservation practices.
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Affiliation(s)
| | - Oliver Karam
- Children’s Hospital of Richmond. Virginia Commonwealth University School of Medicine, Richmond, VA
| | | | - Ruchika Goel
- Johns Hopkins University School of Medicine, Baltimore, MD
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14
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Faraoni D, DiNardo JA. Red Blood Cell Transfusion and Adverse Outcomes in Pediatric Cardiac Surgery Patients: Where Does the Blame Lie? Anesth Analg 2021; 133:1074-1076. [PMID: 34673720 DOI: 10.1213/ane.0000000000005498] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- David Faraoni
- From the Division of Cardiac Anesthesia, Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - James A DiNardo
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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15
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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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16
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Understanding and managing the complex balance between bleeding and thrombosis following cardiopulmonary bypass in paediatric cardiac surgical patients. Cardiol Young 2021; 31:1251-1257. [PMID: 34024303 DOI: 10.1017/s1047951121001955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Bleeding in the perioperative period of congenital heart surgery with cardiopulmonary bypass is associated with increased morbidity and mortality both from the direct effects of haemorrhage as well as the therapies deployed to restore haemostasis. Perioperative bleeding is complex and multifactorial with both patient and procedural contributions. Moreover, neonates and infants are especially at risk. The objective of this review is to summarise the evidence regarding bleeding management in paediatric surgical patients and identify strategies that might facilitate appropriate bleeding management while minimising the risk of thrombosis. We will address the use of standard and point-of-care tests, and the role of contemporary coagulation factors and other novel drugs.
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17
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La KA, Jutras C, Gerardis G, Richard R, Pont-Thibodeau GD. Anemia after Pediatric Congenital Heart Surgery. J Pediatr Intensive Care 2021; 11:308-315. [DOI: 10.1055/s-0041-1725119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 01/23/2021] [Indexed: 10/21/2022] Open
Abstract
AbstractThe postoperative course of infants following congenital heart surgery is associated with significant blood loss and anemia. Optimal transfusion thresholds for cardiac surgery patients while in pediatric intensive care unit (PICU) remain a subject of debate. The goal of this study is to describe the epidemiology of anemia and the transfusion practices during the PICU stay of infants undergoing congenital heart surgery. A retrospective cohort study was performed in a PICU of a tertiary university-affiliated center. Infants undergoing surgery for congenital heart disease (CDH) before 6 weeks of age between February 2013 and June 2019 and who were subsequently admitted to the PICU were included. We identified 119 eligible patients. Mean age at surgery was 11 ± 7 days. Most common cardiac diagnoses were d-Transposition of the Great Arteries (55%), coarctation of the aorta (12.6%), and tetralogy of Fallot (11.8%). Mean hemoglobin level was 14.3 g/dL prior to surgery versus 12.1 g/dL at the PICU admission. Hemoglobin prior to surgery was systematically higher than hemoglobin at the PICU entry, except in infants with Hypoplastic Left Heart Syndrome. The average hemoglobin at PICU discharge was 11.7 ± 1.9 g/dL. Thirty-three (27.7%) patients were anemic at PICU discharge. Fifty-eight percent of patients received at least one red blood cell (RBC) transfusion during PICU stay. This study is the first to describe the epidemiology of anemia at PICU discharge in infants following cardiac surgery. Blood management of this distinctive and vulnerable population requires further investigation as anemia is a known risk factor for adverse neurodevelopment delays in otherwise healthy young children.
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Affiliation(s)
- Kim Anh La
- Research Center, CHU Sainte-Justine, Montréal, Canada
| | - Camille Jutras
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Montréal, Canada
| | | | | | - Geneviève Du Pont-Thibodeau
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Montréal, Canada
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18
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Rao A, Gourkanti B, Van Helmond N. Near-Infrared Spectroscopy Monitoring in Pediatric Anesthesiology: A Pro-Con Discussion. Cureus 2021; 13:e13875. [PMID: 33868839 PMCID: PMC8043135 DOI: 10.7759/cureus.13875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2021] [Indexed: 11/05/2022] Open
Abstract
Near-infrared spectroscopy (NIRS) has been increasingly used as a non-invasive measurement of cerebral tissue oxygen saturation. The aim of this short review is to discuss the benefits and drawbacks of its use in the pediatric anesthesia population. In the context of cardiac surgery, lower intraoperative NIRS values have shown a modest association with neurodevelopmental outcomes while lower neonatal intensive care unit NIRS values have been correlated with reduced neurodevelopment in children. However, it is still unclear if management aimed at increasing cerebral tissue oxygenation would have any benefit on these outcomes. Without prospective research looking into the effects of intervention given proper thresholds, the true benefit of NIRS use is still up for debate. Even with current research gaps, its use in the clinical setting continues.
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Affiliation(s)
- Anusha Rao
- Anesthesiology, West Virginia University, Morgantown, USA
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19
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Abstract
Children require transfusion of blood components for a vast array of medical conditions, including acute hemorrhage, hematologic and nonhematologic malignancies, hemoglobinopathy, and allogeneic and autologous stem cell transplant. Evidence-based literature on pediatric transfusion practices is limited, particularly for non-red blood cell products, and many recommendations are extrapolated from studies in adult populations. Recognition of these knowledge gaps has led to increasing numbers of clinical trials focusing on children and establishment of pediatric transfusion working groups in recent years. This article reviews existing literature on pediatric transfusion therapy within the larger context of analogous data in adult populations.
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Affiliation(s)
- Yunchuan Delores Mo
- Transfusion Medicine, Children's National Hospital, 111 Michigan Avenue Northwest, Laboratory Administration, Suite 2100, Washington, DC 20010, USA.
| | - Meghan Delaney
- Pathology and Laboratory Medicine Division, Transfusion Medicine, Children's National Hospital, 111 Michigan Avenue Northwest, Laboratory Administration, Suite 2100, Washington, DC 20010, USA
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20
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Transfusion Strategies for Pediatric Cardiac Surgery: A Meta-Analysis and Trial Sequential Analysis. Pediatr Cardiol 2021; 42:1241-1251. [PMID: 34050374 PMCID: PMC8162158 DOI: 10.1007/s00246-021-02644-8] [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: 10/01/2020] [Accepted: 05/19/2021] [Indexed: 02/08/2023]
Abstract
This study aimed to compare the effects of restrictive and liberal red blood cell (RBC) transfusion strategies on pediatric patients undergoing cardiac surgery, including cyanotic and non-cyanotic children. A literature search of the MEDLINE, EMBASE, PubMed, and the Cochrane Library database was conducted. Meta-analyses were carried out comparing restrictive and liberal transfusion strategies. Subgroup analyses were performed based on the basis of cyanotic status. Five randomized controlled trials with a total of 497 children were included. There was no significant difference in the risk of in-hospital mortality between the two transfusion strategies (risk ratio 1.21; 95% confidence interval 0.49 to 2.99; P = 0.68). The trial sequential analysis suggested that the current meta-analysis had an absence of evidence for in-hospital mortality, and the data were insufficient. Moreover, no significant differences existed between groups in terms of risk of infection, blood loss, duration of mechanical ventilation, pediatric intensive care unit (PICU) stay duration, or hospital stay duration. Cyanotic children treated with a liberal transfusion strategy had a shorter ventilator duration, but the transfusion strategy did not affect in-hospital mortality, infection, hospital stay, or PICU stay duration. On the basis of the available data, our analysis indicates that a liberal transfusion strategy did not lead to a better outcomes, but the data are extremely sparse, which highlights the need for clearer transfusion guidelines specific to this specific population.Trial registration number CRD42018102283.
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21
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Steffen KM, Spinella PC, Holdsworth LM, Ford MA, Lee GM, Asch SM, Proctor EK, Doctor A. Factors Influencing Implementation of Blood Transfusion Recommendations in Pediatric Critical Care Units. Front Pediatr 2021; 9:800461. [PMID: 34976903 PMCID: PMC8718763 DOI: 10.3389/fped.2021.800461] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 11/25/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose: Risks of red blood cell transfusion may outweigh benefits for many patients in Pediatric Intensive Care Units (PICUs). The Transfusion and Anemia eXpertise Initiative (TAXI) recommendations seek to limit unnecessary and potentially harmful transfusions, but use has been variable. We sought to identify barriers and facilitators to using the TAXI recommendations to inform implementation efforts. Materials and Methods: The integrated Promoting Action on Research Implementation in Health Services (iPARIHS) framework guided semi-structured interviews conducted in 8 U.S. ICUs; 50 providers in multiple ICU roles completed interviews. Adapted Framework analysis, a form of content analysis, used the iPARIHS innovation, recipient, context and facilitation constructs and subconstructs to categorize data and identify patterns as well as unique informative statements. Results: Providers perceived that the TAXI recommendations would reduce transfusion rates and practice variability, but adoption faced challenges posed by attitudes around transfusion and care in busy and complex units. Development of widespread buy-in and inclusion in implementation, integration into workflow, designating committed champions, and monitoring outcomes data were expected to enhance implementation. Conclusions: Targeted activities to create buy-in, educate, and plan for use are necessary for TAXI implementation. Recognition of contextual challenges posed by the PICU environment and an approach that adjusts for barriers may optimize adoption.
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Affiliation(s)
- Katherine M Steffen
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Stanford University, Palo Alto, CA, United States
| | - Philip C Spinella
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University in Saint Louis, Saint Louis, MO, United States
| | - Laura M Holdsworth
- Department of Medicine, Primary Care and Population Health, Stanford University, Stanford, CA, United States
| | - Mackenzie A Ford
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Palo Alto, CA, United States
| | - Grace M Lee
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Stanford University, Stanford, CA, United States
| | - Steven M Asch
- Department of Medicine, Primary Care and Population Health, Stanford University, Stanford, CA, United States
| | - Enola K Proctor
- George Warren Brown School of Social Work, Washington University in St. Louis, St. Louis, MO, United States
| | - Allan Doctor
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Maryland, Baltimore, MD, United States
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22
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Song K, Xu Q, Koenig HM, Kong M, Slaughter MS, Huang Y, Clifford SP, Huang J. Validation of a Novel NeurOs Cerebral Oximetry Monitor Against the INVOS Monitor During Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 35:2009-2018. [PMID: 33218956 DOI: 10.1053/j.jvca.2020.10.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 10/23/2020] [Accepted: 10/24/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To compare the performance of a novel NeurOs cerebral oximetry monitor against the INVOS monitor during the entire intraoperative phase of cardiac surgery, including periods of known fluctuation in brain oxygenation, such as preoxygenation, induction, cannulation, and cardiopulmonary bypass. DESIGN This study was a prospective, nonrandomized, healthcare-provider and outcome-assessor blinded study. SETTING Tertiary care university hospital; single institutional study. PARTICIPANTS Twenty-three patients who underwent cardiac surgery with cardiopulmonary bypass. INTERVENTIONS Both self-adhesive INVOS sensors and the assembled NeurOs sensors were placed accordingly when the patient arrived in the operating room. MEASUREMENTS AND MAIN RESULTS Ten out of 13 cases under the normal mode and eight out of the 10 cases under the high- sensitivity mode showed significant correlations between the NeurOs and INVOS groups (p < 0.05, r value from 0.24-0.88). When all cases were combined, NeurOs demonstrated significant correlation with INVOS (r = 0.5, 95% confidence interval [CI] 0.44-0.56, p < 0.01 for normal mode; r = 0.69, 95% CI 0.64 to 0.74, p < 0.01 for high-sensitivity mode) in both modes. To evaluate the data diversity, the authors performed a cluster analysis and found much less variation existed in the NeurOs normal mode when compared with INVOS (standard deviation [SD] 16.6% in INVOS, 4% in NeurOs normal mode) but similar patterns in the high-sensitivity mode (SD 17.6% in INVOS, 15.2% in NeurOs high-sensitivity mode). Bland-Altman plot analysis showed that most of the data fell between ± 1.96 SD lines, which demonstrated good consistency between these two methods under both modes of NeurOs (-28.8 to 30.8 in the normal mode; -36.6 to 32.7 in high-sensitivity mode). In the normal mode of NeurOs monitoring, receiver operating characteristic analysis suggested a 2% cutoff point was most optimal from the baseline for detecting hyperoxia (sensitivity 73%; specificity 66%) and minus 1% (sensitivity 66%; specificity 67%) for detecting hypoxia. Whereas in the high-sensitivity mode, the optimal cutoff point was 3% from baseline for detecting hyperoxia (sensitivity 75%; specificity 68%), and minus 3% for detecting hypoxia (sensitivity 90%; specificity 45%). CONCLUSIONS In conclusion, the novel NeurOs system was found to correlate with INVOS cerebral oximetry measurements during cardiac surgery.
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Affiliation(s)
- Kaicheng Song
- Department of Anesthesiology & Perioperative Medicine, University of Louisville, Louisville, KY; Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, PR China
| | - Qian Xu
- Department of Bioinformatics and Biostatistics, SPHIS, University of Louisville, Louisville, KY
| | - Heidi M Koenig
- Department of Anesthesiology & Perioperative Medicine, University of Louisville, Louisville, KY
| | - Maiying Kong
- Department of Bioinformatics and Biostatistics, SPHIS, University of Louisville, Louisville, KY
| | - Mark S Slaughter
- Department of Cardiovascular & Thoracic Surgery, University of Louisville, Louisville, KY
| | - Yuguang Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, PR China
| | - Sean P Clifford
- Department of Anesthesiology & Perioperative Medicine, University of Louisville, Louisville, KY
| | - Jiapeng Huang
- Department of Anesthesiology & Perioperative Medicine, University of Louisville, Louisville, KY; Department of Cardiovascular & Thoracic Surgery, University of Louisville, Louisville, KY.
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23
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Wissenschaftliche Erläuterungen zur Stellungnahme Transfusionsassoziierte Immunmodulation (TRIM) des Arbeitskreises Blut vom 13. Februar 2020. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2020; 63:1025-1053. [PMID: 32719887 PMCID: PMC7384277 DOI: 10.1007/s00103-020-03183-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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24
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Kato H, Chasovskyi K, Gandhi SK. Are Blood Products Routinely Required in Pediatric Heart Surgery? Pediatr Cardiol 2020; 41:932-938. [PMID: 32170329 DOI: 10.1007/s00246-020-02338-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 03/05/2020] [Indexed: 11/24/2022]
Abstract
A restrictive blood transfusion strategy has emerged in adult cardiac surgery. However, the feasibility in children is poorly investigated. 352 consecutive patients undergoing open-heart surgery were retrospectively reviewed, excluding patients requiring extracorporeal membrane oxygenation. Patient demographics, perioperative blood product usage, and clinical outcome parameters were investigated. Variables predicting the need for blood products were delineated. Of the 352 study patients, 148 patients (42%) underwent bloodless surgery and 204 (58%) were transfused. Of the 204 transfused patients, 170 (83.4%) patients received one blood transfusion and 34 (16.6%) received two or more blood transfusions. Patient's weight and preoperative hematocrit (Hct) were statistically significant in predicting the need for blood priming the CPB circuit (AUC 0.99, p < 0.001, sensitivity 96.6%, specificity 95.2%). A body weight of 8.5 kg carried a sensitivity of 100% and specificity of 94.5% (p < 0.001) for a blood prime. Among patients with a weight less than 8.5 kg (n = 171), only 27 patients (15.8%, p < 0.001) required additional transfusion of PRBCs. Factors impacting the need for a blood transfusion during CPB included redo surgery [odds ratio (OR) 4.61, p = 0.001] and the highest lactate level on CPB (OR 1.65, p = 0.006). Redo surgery had the highest impact (OR 7.27, p = 0.012) for requiring a postoperative PRBC transfusion. A restrictive transfusion strategy can be safely implemented in pediatric cardiac surgery. The majority of children with a BW > 8.5 kg required no blood products and those with a BW ≤ 8.5 kg required only 1 unit of blood, to prime the cardiopulmonary bypass circuit.
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Affiliation(s)
- Hideyuki Kato
- Division of Cardiovascular and Thoracic Surgery, BC Children's Hospital, 4480 Oak Street, Vancouver, BC, Canada
| | - Kyrylo Chasovskyi
- Division of Cardiovascular and Thoracic Surgery, BC Children's Hospital, 4480 Oak Street, Vancouver, BC, Canada. .,Division of Cardiovascular and Thoracic Surgery, Perfusion Services, BC Children's Hospital, 4480 Oak Street, Suite AB307, Vancouver, BC, V6H 3V4, Canada.
| | - Sanjiv K Gandhi
- Division of Cardiovascular and Thoracic Surgery, BC Children's Hospital, 4480 Oak Street, Vancouver, BC, Canada
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25
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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: 5] [Impact Index Per Article: 1.3] [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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26
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Mille FK, Badheka A, Yu P, Zhang X, Friedman DF, Kheir J, van den Bosch S, Cabrera AG, Lasa JJ, Katcoff H, Hu P, Borasino S, Hock K, Huskey J, Weller J, Kothari H, Blinder J. Red Blood Cell Transfusion After Stage I Palliation Is Associated With Worse Clinical Outcomes. J Am Heart Assoc 2020; 9:e015304. [PMID: 32390527 PMCID: PMC7660859 DOI: 10.1161/jaha.119.015304] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 03/27/2020] [Indexed: 12/13/2022]
Abstract
Background Packed red blood cell transfusion may improve oxygen content in single-ventricle neonates, but its effect on clinical outcomes after Stage 1 palliation is unknown. Methods and Results Retrospective multicenter analysis of packed red blood cell transfusion exposures in neonates after Stage 1 palliation, excluding those with intraoperative mortality or need for extracorporeal membrane oxygenation. Transfusion practice variability was assessed, and multivariable regression used to identify transfusion risk factors. After propensity score adjustment for severity of illness, clinical outcomes were compared between transfused and nontransfused subjects. Of 396 subjects, 323 (82%) received 930 postoperative red blood cell transfusions. Packed red blood cell volume (median 9-42 mL/kg [P<0.0001]), donor exposures (1-2 [P<0.0001]), transfusion number (1-3 [P<0.0001]), and pretransfusion hemoglobin (12.1-13 g/dL, P=0.0049) varied between sites. Cyanosis (P=0.02), chest tube output (P=0.0003), and delayed sternal closure (P=0.0033) increased transfusion risk. Transfusion was associated with prolonged mechanical ventilation (6 [interquartile range 4, 12] versus 3 [1, 5] days, P=0.02) and intensive care unit stay (19 [12, 33] versus 9 [6, 19] days, P=0.016). When stratified by number of transfusions (0, 1, or >1), duration of mechanical ventilation (3 [1, 5] versus 4 [3, 6] versus 9 [5, 16] days [P<0.0001]) and intensive care unit stay (9 [6, 19] versus 13 [8, 25] versus 21 [13, 38] days [P<0.0001]) increased for those transfused more than once. Most subjects who died were transfused, though the association with mortality was not significant. Conclusions Packed red blood cell transfusion after Stage 1 palliation is common, and transfusion practice is variable. Transfusion is a significant predictor of longer intensive care unit stay and mechanical ventilation. Further studies to define evidence-based transfusion thresholds are warranted.
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Affiliation(s)
| | - Aditya Badheka
- University of Iowa Stead Family Children’s HospitalIowa CityIA
| | - Priscilla Yu
- University of Texas Southwestern Medical CenterDallasTX
| | - Xuemei Zhang
- The Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | | | | | | | | | | | | | - Paula Hu
- The Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | | | | | | | - Jamie Weller
- University of Texas Southwestern Medical CenterDallasTX
| | - Harsh Kothari
- University of Iowa Stead Family Children’s HospitalIowa CityIA
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Red cell transfusion practices after stage 1 palliation: a survey of practitioners from the Pediatric Cardiac Intensive Care Society. Cardiol Young 2019; 29:1452-1458. [PMID: 31722769 DOI: 10.1017/s1047951119002385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Neonates may require increased red cell mass to optimise oxygen content after stage 1 palliation; however, data informing transfusion practices are limited. We hypothesise there is a patient-, provider-, and institution-based heterogeneity in red cell transfusion decision-making after stage 1 palliation. METHODS We conducted an online survey of Pediatric Cardiac Intensive Care Society practitioners in 2016. Respondents answered scenario-based questions that defined transfusion indications and identified haematocrit transfusion thresholds. Respondents were divided into restrictive and liberal groups based on a haematocrit score. Fisher's exact test was used to determine the associations between transfusion likelihood and patient, provider, and institutional characteristics. Bonferroni correction was applied to adjust the p-value to 0.004 for multiple comparisons. RESULTS There was a 21% response rate (116 responses). Most were male (58.6%), attending physicians (85.3%) with >5 year of intensive care experience (88.7%) and subspeciality training in critical care medicine (47.4%). The majority of institutions were academic (96.6%), with a separate cardiac ICU (86.2%), and performed >10 stage 1 palliation cases annually (68.1%). After Bonferroni correction, there were no significant patient, respondent, or institutional differences between the restrictive and liberal groups. No respondent or institutional characteristics influenced transfusion decision-making after stage 1 palliation. CONCLUSIONS Decision-making around red cell transfusion after stage 1 palliation is heterogeneous. We found no clear relationships between patient, respondent, or institutional characteristics and transfusion decision-making among surveyed respondents. Given the lack of existing data informing red cell transfusion after stage 1 palliation, further studies are necessary to inform evidence-based guidelines.
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Faraoni D, Meier J, New HV, Van der Linden PJ, Hunt BJ. Patient Blood Management for Neonates and Children Undergoing Cardiac Surgery: 2019 NATA Guidelines. J Cardiothorac Vasc Anesth 2019; 33:3249-3263. [DOI: 10.1053/j.jvca.2019.03.036] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 03/17/2019] [Accepted: 03/18/2019] [Indexed: 12/22/2022]
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Cholette JM, Faraoni D, Goobie SM, Ferraris V, Hassan N. Patient Blood Management in Pediatric Cardiac Surgery: A Review. Anesth Analg 2019; 127:1002-1016. [PMID: 28991109 DOI: 10.1213/ane.0000000000002504] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Efforts to reduce blood product transfusions and adopt blood conservation strategies for infants and children undergoing cardiac surgical procedures are ongoing. Children typically receive red blood cell and coagulant blood products perioperatively for many reasons, including developmental alterations of their hemostatic system, and hemodilution and hypothermia with cardiopulmonary bypass that incites inflammation and coagulopathy and requires systemic anticoagulation. The complexity of their surgical procedures, complex cardiopulmonary interactions, and risk for inadequate oxygen delivery and postoperative bleeding further contribute to blood product utilization in this vulnerable population. Despite these challenges, safe conservative blood management practices spanning the pre-, intra-, and postoperative periods are being developed and are associated with reduced blood product transfusions. This review summarizes the available evidence regarding anemia management and blood transfusion practices in the perioperative care of these critically ill children. The evidence suggests that adoption of a comprehensive blood management approach decreases blood transfusions, but the impact on clinical outcomes is less well studied and represents an area that deserves further investigation.
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Affiliation(s)
- Jill M Cholette
- From the Department of Pediatrics, Golisano Children's Hospital, University of Rochester, Rochester, New York
| | - David Faraoni
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Susan M Goobie
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston, Massachusetts.,Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Victor Ferraris
- Department of Surgery, University of Kentucky Chandler Medical Center & Lexington Veterans Affairs Medical Center, Lexington, Kentucky
| | - Nabil Hassan
- Division of Pediatric Critical Care, Children's Hospital of Illinois At OSF St Frances, University of Illinois at Peoria, Peoria, Illinois
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Frogel J, Kogan A, Augoustides JG, Berkenstadt H, Feduska E, Steyn J, Dwarakanath S, Nir EA, Stohl S. The Value of Cerebral Oximetry Monitoring in Cardiac Surgery: Challenges and Solutions in Adult and Pediatric Practice. J Cardiothorac Vasc Anesth 2019; 33:1778-1784. [DOI: 10.1053/j.jvca.2018.08.206] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Indexed: 02/04/2023]
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Swartz MF, Makhija P, Rubenstein J, Henrichs KF, Powers KS, Wang HY, Simon BV, Alfieris GM, Blumberg N, Cholette JM. Met-Hemoglobin Is a Biomarker for Poor Oxygen Delivery in Infants Following Surgical Palliation. World J Pediatr Congenit Heart Surg 2019; 10:485-491. [PMID: 31142197 DOI: 10.1177/2150135119852327] [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: 11/16/2022]
Abstract
BACKGROUND Infants with cyanotic congenital heart disease demonstrate wide fluctuations in hemoglobin (Hb), oxygen saturation, and cardiac output following palliation. Methemoglobin (Met-Hb), the product of Hb oxidation, may represent a compensatory mechanism during hypoxia and may be utilized as a biomarker. METHODS Arterial and venous Met-Hb levels were obtained from infants requiring palliation. The primary outcome was to describe the relationship between Met-Hb and other indices of tissue oxygenation (venous saturation, estimated arteriovenous oxygen difference [Est AV-Diff], and lactate). Secondary outcomes were to determine the impact of elevated Met-Hb levels ≥1.0% and the effect of red blood cell (RBC) transfusion on Met-Hb levels. RESULTS Fifty infants and 465 Met-Hb values were studied. Venous Met-Hb levels were significantly higher than arterial levels (venous: 0.84% ± 0.36% vs arterial: 0.45% ± 0.18%; P < .001). Venous Met-Hb demonstrated a significant inverse relationship with venous oxygen saturation (R = -0.6; P < .001) and Hb (R = -0.3, P < .001) and a direct relationship with the Est AV-Diff (R = 0.3, P < .001). A total of 129 (29.6%) venous Met-Hb values were elevated (≥1.0%) and were associated with significantly lower Hb and venous saturation levels and higher Est AV-Diff and lactate levels. Methemoglobin levels decreased significantly following 65 RBC transfusions (0.94 ± 0.40 vs 0.77 ± 0.34; P < .001). Linear mixed models demonstrated that higher venous Met-Hb levels were associated with lower measures of tissue oxygenation and not related to any preoperative clinical differences. CONCLUSION Methemoglobin may be a clinically useful marker of tissue oxygenation in infants following surgical palliation.
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Affiliation(s)
- Michael F Swartz
- 1 Department of Surgery, University of Rochester, Rochester, NY, USA
| | - Pooja Makhija
- 2 Department of Pediatrics, University of Buffalo, Buffalo, NY, USA
| | | | - Kelly F Henrichs
- 4 Department of Pathology and Laboratory Medicine, University of Rochester, Rochester, NY, USA
| | - Karen S Powers
- 3 Department of Pediatrics, University of Rochester, Rochester, NY, USA
| | - Hong Yue Wang
- 5 Department of Biostatistics, University of Rochester, Rochester, NY, USA
| | | | - George M Alfieris
- 1 Department of Surgery, University of Rochester, Rochester, NY, USA
| | - Neil Blumberg
- 4 Department of Pathology and Laboratory Medicine, University of Rochester, Rochester, NY, USA
| | - Jill M Cholette
- 3 Department of Pediatrics, University of Rochester, Rochester, NY, USA
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Standardized Implementation of Evidence-based Guidelines to Decrease Blood Transfusions in Pediatric Intensive Care Units. Pediatr Qual Saf 2019; 4:e165. [PMID: 31579865 PMCID: PMC6594784 DOI: 10.1097/pq9.0000000000000165] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 03/13/2019] [Indexed: 12/12/2022] Open
Abstract
Introduction Despite evidence that red blood cell (RBC) transfusions may be associated with more harm than benefit, current transfusion practices vary significantly. This multicenter, quality improvement study aimed to sustainably decrease the rate of RBC transfusions in pediatric intensive care units (PICUs). Methods This 16-month prospective study included 5 PICUs. We implemented a standardized project plan including education, bedside tools, real-time reminders, and email feedback. We collected data from consecutive transfusions during pre-implementation (Phase I), postimplementation (Phase II), and post-stabilization phases (Phase III). Results Of the 2,064 RBC transfusions, we excluded 35% (N = 729) from analysis in patients undergoing extracorporeal membrane oxygenation. Transfusion/1,000 admissions improved throughout the study periods from a baseline 209.6 -199.8 in Phase II and 195.8 in Phase III (P value < 0.05). There were fewer transfusions outside of the hemoglobin threshold guideline, decreasing from 81% of transfusions outside of guidelines in Phase I to 74% in Phases II and III, P < 0.05. Study phase, site, co-management status, service of requesting provider, admit reason, previous transfusion status, and age were associated with transfusion above guideline threshold. Conclusions Multicenter collaboration can successfully deploy a standardized plan that adheres to implementation science principles to sustainably decrease the rate of RBC transfusion outside of guideline thresholds. However, we did not decrease the total number of transfusions in our study. The complexity of multiple specialties co-managing patients is common in the contemporary PICU. Educational initiatives aimed at one specialty may have limited effectiveness in a multifaceted system of care.
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Shehata N, Mistry N, da Costa BR, Pereira TV, Whitlock R, Curley GF, Scott DA, Hare GMT, Jüni P, Mazer CD. Restrictive compared with liberal red cell transfusion strategies in cardiac surgery: a meta-analysis. Eur Heart J 2019; 40:1081-1088. [PMID: 30107514 PMCID: PMC6441852 DOI: 10.1093/eurheartj/ehy435] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 04/05/2018] [Accepted: 07/09/2018] [Indexed: 12/28/2022] Open
Abstract
AIMS To determine whether a restrictive strategy of red blood cell (RBC) transfusion at lower haemoglobin concentrations is inferior to a liberal strategy of RBC transfusion at higher haemoglobin concentrations in patients undergoing cardiac surgery. METHODS AND RESULTS We conducted a systematic review, meta-analysis, and trial sequential analysis of randomized controlled trials of the effect of restrictive and liberal RBC transfusion strategies on mortality within 30 days of surgery as the primary outcome. Secondary outcomes were those potentially resulting from anaemia-induced tissue hypoxia and transfusion outcomes. We searched the electronic databases MEDLINE, EMBASE, and the Cochrane Library until 17 November 2017. Thirteen trials were included. The risk ratio (RR) of mortality derived from 4545 patients assigned to a restrictive strategy when compared with 4547 transfused according to a liberal strategy was 0.96 [95% confidence interval (CI) 0.76-1.21, I2 = 0]. A restrictive strategy did not have a statistically significant effect on the risk of myocardial infarction (RR 1.01, 95% CI 0.81-1.26; I2=0), stroke (RR 0.93, 95% CI 0.68-1.27, I2 = 0), renal failure (RR 0.96, 95% CI 0.76-1.20, I2 = 0), or infection (RR 1.12, 95% CI 0.98-1.29, I2 = 0). Subgroup analysis of adult and paediatric trials did not show a significant interaction. At approximately 70% of the critical information size, the meta-analysis of mortality crossed the futility boundary for inferiority of the restrictive strategy. CONCLUSION The current evidence does not support the notion that restrictive RBC transfusion strategies are inferior to liberal RBC strategies in patients undergoing cardiac surgery.
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Affiliation(s)
- Nadine Shehata
- Division of Hematology, Departments of Medicine, Laboratory Medicine and Pathobiology, Institute of Health Policy Management and Evaluation, University of Toronto, Mount Sinai Hospital, 600 University Avenue, Toronto, ON, Canada
| | - Nikhil Mistry
- Department of Anesthesia, St. Michael’s Hospital, 30 Bond Street, Toronto, ON, Canada
| | - Bruno R da Costa
- Applied Health Research Center (AHRC), Li Ka Shing Knowledge Institute of St. Michael's Hospital, Institute of Health Policy Management and Evaluation, University of Toronto, 30 Bond Street, Toronto, ON, Canada
- Institute of Primary Health Care (BIHAM), University of Bern, Mittelstrasse 43, Bern, Switzerland
| | - Tiago V Pereira
- Applied Health Research Center (AHRC), Li Ka Shing Knowledge Institute of St. Michael's Hospital, Institute of Health Policy Management and Evaluation, University of Toronto, 30 Bond Street, Toronto, ON, Canada
| | - Richard Whitlock
- Department of Surgery, Population Health Research Institute, McMaster University, David Braley Cardiac Vascular and Stroke Research Institute, 237 Barton Street East, Hamilton, ON, Canada
| | - Gerard F Curley
- Department of Anesthesia and Critical Care, Royal College of Surgeons in Ireland, 123 St Stephen's Green, Dublin 2, Ireland
| | - David A Scott
- Department of Anesthesia and Acute Pain Medicine, St Vincent’s Hospital, University of Melbourne, 41 Victoria Parade, Fitzroy, Victoria, Australia
| | - Gregory M T Hare
- Departments of Anesthesia and Physiology and Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, St. Michael’s Hospital, 30 Bond Street, Toronto, ON, Canada
| | - Peter Jüni
- Department of Medicine and Institute of Health Policy, Management and Evaluation, Applied Health Research Centre (AHRC), Li Ka Shing Knowledge Institute of St. Michael’s Hospital, University of Toronto, 30 Bond Street, Toronto, ON, Canada
| | - C David Mazer
- Departments of Anesthesia and Physiology and Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, St. Michael’s Hospital, 30 Bond Street, Toronto, ON, Canada
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Complications of Transthoracic Intracardiac and Central Venous Lines in Neonates Undergoing Cardiac Surgery. Pediatr Cardiol 2019; 40:733-737. [PMID: 30701276 DOI: 10.1007/s00246-019-02057-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 01/16/2019] [Indexed: 12/16/2022]
Abstract
Neonates undergoing congenital heart surgery require central venous access for diagnostic information and medication administration. There are multiple options for central access including peripherally inserted central catheters, umbilical, central venous, and transthoracic intracardiac lines. We retrospectively identified all patients younger than 30 days who underwent cardiac surgery in a 1-year period. Data were collected on demographic and medical characteristics, adverse events, pre-emptive transfusion of blood products prior to line removal, and transfusion of blood products following removal of transthoracic intracardiac lines and central venous lines. In our cohort of 124 neonates, 176 transthoracic intracardiac lines were placed in 113 patients. Eighty-two patients had pre-existing central venous access including 35 umbilical venous lines, 21 PICC lines, and 18 CVLs. Ninety-eight patients received a CVL in the operating room by anesthesia. Five patients were transfused to correct laboratory derangement prior to transthoracic intracardiac line removal. Transfusion of packed red blood cells (pRBC) occurred after transthoracic intracardiac line removal in 25 patients. Thrombus formation was present in one patient with a transthoracic intracardiac line and three patients with CVLs. One patient underwent surgical intervention for repositioning of a transthoracic intracardiac line. There were no cases of cardiac arrest, extracorporeal life support, or deaths attributable to lines. In this cohort, transthoracic intracardiac lines were generally safe. There were very few complications of thrombus, infection, or requirement for surgical intervention; however, transfusion of pRBCs following transthoracic intracardiac line removal occurred in 20% of patients.
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Willems A, Patte P, De Groote F, Van der Linden P. Cyanotic heart disease is an independent predicting factor for fresh frozen plasma and platelet transfusion after cardiac surgery. Transfus Apher Sci 2019; 58:304-309. [PMID: 30904398 DOI: 10.1016/j.transci.2019.03.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 03/04/2019] [Accepted: 03/14/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Cyanotic heart disease is associated with increased risk of bleeding in children undergoing cardiac surgery. We studied if the presence of a cyanotic heart disease was an independent predictive factor for fresh frozen plasma (FFP) and platelets transfusion in these patients. In children with ROTEM measurements, we also tried to characterize the coagulation profile between both groups. DESIGN Retrospective observational study. SETTING Tertiary university hospital; single center. PARTICIPANTS All consecutive children admitted for cardiac surgery with cardiopulmonary bypass (CPB) from January 2006 to December 2014. Patients who received FFP in the CPB priming were excluded. Multivariate logistic regression was used to determine the predictive factors for FFP and platelet transfusions. INTERVENTION none. MEASUREMENTS AND MAIN RESULTS From the 1846 patients included for analysis: 1063 were acyanotic and 783 were cyanotic. The presence of cyanotic heart disease was an independent predicting factor for both FFP (OR: 2.09; 95%CI: 1.44-3.02) and platelets (OR:3.98; 95%CI: 2.28-6.70) transfusion. Cyanotic children exhibited also higher perioperative blood losses [Intraoperative: 31.1 (17.6-50.4) versus 26.7 (14.8-44.7); P < 0.001 and Postoperative: 31.2 (19.1-51.9) versus 16.9 (10.4-26.9); P < 0.001]. Thromboelastometry assays after separation from CPB and heparin reversal revealed more complex coagulation disturbances in cyanotic than acyanotic children. CONCLUSION Children with a cyanotic heart disease are at higher risk of FFP and platelet transfusion after cardiac surgery. Intraoperative monitoring should be used to guide administration of blood and haemostatic product in this population at high risk of postoperative bleeding.
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Affiliation(s)
- Ariane Willems
- Leids Universitair Medisch Centrum, Pediatric Intensive Care Unit, Albinusdreef 2, 2333 ZA Leiden, The Netherlands.
| | - Philippe Patte
- Hôpital Civil Marie Curie, Department of Anesthesiology, Chausée de Bruxelles 140, 6042 Lodelinsart, Belgium
| | - Françoise De Groote
- Hôpital des Enfants Reine Fabiola, Department of Anesthesiology, Avenue J.J. Crocq, 1020 Bruxelles, Belgium
| | - Philippe Van der Linden
- Hôpital des Enfants Reine Fabiola, Department of Anesthesiology, Avenue J.J. Crocq, 1020 Bruxelles, Belgium
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Deng X, Wang Y, Huang P, Luo J, Xiao Y, Qiu J, Yang G. Red blood cell transfusion threshold after pediatric cardiac surgery: A systematic review and meta-analysis. Medicine (Baltimore) 2019; 98:e14884. [PMID: 30882699 PMCID: PMC6426484 DOI: 10.1097/md.0000000000014884] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Restrictive red blood cell transfusion strategy is implemented to minimize risk following allogeneic blood transfusion in adult cardiac surgery. However, it is still unclear if it can be applied to pediatric cardiac patients. The purpose of this systematic review and meta-analysis was to determine the effect of postoperative restrictive transfusion thresholds on clinical outcomes based on up-to-date results of randomized controlled trials (RCTs) and observational studies in pediatric cardiac surgery. METHOD We searched for RCTs and observational studies in the following databases: the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and ClinicalTrials.gov from their inception to October 26, 2017. We also searched reference lists of published guidelines, reviews, and relevant articles, as well as conference proceedings. No language restrictions were applied and no observational study met the inclusion criteria. RESULTS Four RCTs on cardiac surgery involving 454 patients were included. There were no differences in the pooled fixed effects of intensive care unit (ICU) stay between the liberal and restrictive transfusion thresholds (standardized mean difference SMD, 0.007; 95% confidence interval CI, -0.18-0.19; P = .94). There were also no differences in the length of hospital stay (SMD, -0.062; 95% CI, -0.28-0.15; P = .57), ventilation duration (SMD, -0.015; 95% CI, -0.25-0.22; P = .90), mean arterial lactate level (SMD, 0.071; 95% CI, -0.22-0.36; P = .63), and mortality (risk ratio, 0.49; 95% CI, 0.13-1.94; P = .31). There was no inter-trial heterogeneity for any pooled analysis. Publication bias was tested using Egger, Begg, or the trim-and-fill test, and the results indicated no significant publication bias. CONCLUSION Evidence from RCTs in pediatric cardiac surgery, though limited, showed non-inferiority of restrictive thresholds over liberal thresholds in length of ICU stay and other outcomes following red blood cell transfusion. Further high-quality RCTs are necessary to confirm the findings.
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Affiliation(s)
| | | | | | | | | | - Jun Qiu
- Department of Emergency Center, Hunan Children's Hospital, Changsha, China
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Doctor A, Cholette JM, Remy KE, Argent A, Carson JL, Valentine SL, Bateman ST, Lacroix J. Recommendations on RBC Transfusion in General Critically Ill Children Based on Hemoglobin and/or Physiologic Thresholds From the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. Pediatr Crit Care Med 2018; 19:S98-S113. [PMID: 30161064 PMCID: PMC6125789 DOI: 10.1097/pcc.0000000000001590] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To present the consensus recommendations and supporting literature for RBC transfusions in general critically ill children from the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. DESIGN Consensus conference series of international, multidisciplinary experts in RBC transfusion management of critically ill children. METHODS The panel of 38 experts developed evidence-based and, when evidence was lacking, expert-based recommendations and research priorities regarding RBC transfusions in critically ill children. The subgroup on RBC transfusion in general critically ill children included six experts. Electronic searches were conducted using PubMed, EMBASE, and Cochrane Library databases from 1980 to May 30, 2017, using a combination of keywords to define concepts of RBC transfusion and critically ill children. Recommendation consensus was obtained using the Research and Development/UCLA Appropriateness Method. The results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. RESULTS Three adjudicators reviewed 4,399 abstracts; 71 papers were read, and 17 were retained. Three papers were added manually. The general Transfusion and Anemia Expertise Initiative subgroup developed, and all Transfusion and Anemia Expertise Initiative members voted on two good practice statements, six recommendations, and 11 research questions; in all instances, agreement was reached (> 80%). The good practice statements suggest a framework for RBC transfusion in PICU patients. The good practice statements and recommendations focus on hemoglobin as a threshold and/or target. The research questions focus on hemoglobin and physiologic thresholds for RBC transfusion, alternatives, and risk/benefit ratio of transfusion. CONCLUSIONS Transfusion and Anemia Expertise Initiative developed pediatric-specific good practice statements and recommendations regarding RBC transfusion management in the general PICU population, as well as recommendations to guide future research priorities. Clinical recommendations emphasized relevant hemoglobin thresholds, and research recommendations emphasized a need for further understanding of physiologic thresholds, alternatives to RBC transfusion, and hemoglobin thresholds in populations with limited pediatric literature.
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Affiliation(s)
- Allan Doctor
- Allan Doctor, MD, Professor of Pediatrics and Biochemistry, Division of Pediatric Critical Care Medicine, Washington University in St. Louis, St. Louis Children’s Hospital, United States
| | - Jill M. Cholette
- Jill M. Cholette, MD, Associate Professor of Pediatrics, Medical Director, Pediatric Cardiac Care Center, University of Rochester, Golisano Children’s Hospital, United States
| | - Kenneth E. Remy
- Kenneth E. Remy, MD, MHSc, Assistant Professor of Pediatrics. Division of Pediatric Critical Care Medicine, Washington University in St. Louis, St. Louis Children’s Hospital, United States
| | - Andrew Argent
- Andrew Argent, MD, Professor of Pediatrics, Medical Director, Paediatric Intensive Care, University of Cape Town and Red Cross War Memorial Children’s Hospital, South Africa
| | - Jeffrey L. Carson
- Jeffrey L. Carson, MD, Provost – New Brunswick Distinguished Professor of Medicine, Richard C. Reynolds Chair of General Internal Medicine; Rutgers Robert Wood Johnson Medical School, Rutgers, The State University of New Jersey, United States
| | - Stacey L. Valentine
- Stacey L. Valentine, MD, MPH, Assistant Professor of Pediatrics, University of Massachusetts Medical School, United States
| | - Scot T. Bateman
- Scot T. Bateman, MD, Professor of Pediatrics, Division Chief of Pediatric Critical Care Medicine, University of Massachusetts Medical School, United States
| | - Jacques Lacroix
- Jacques Lacroix, MD, Professor of Pediatrics, Division of Pediatric Critical Care, Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Canada
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Recommendations on RBC Transfusion in Infants and Children With Acquired and Congenital Heart Disease From the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. Pediatr Crit Care Med 2018; 19:S137-S148. [PMID: 30161069 PMCID: PMC6126364 DOI: 10.1097/pcc.0000000000001603] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To present the recommendations and supporting literature for RBC transfusions in critically ill children with acquired and congenital heart disease developed by the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. DESIGN Consensus conference series of 38 international, multidisciplinary experts in RBC transfusion management of critically ill children. METHODS Experts developed evidence-based and, when evidence was lacking, expert-based clinical recommendations and research priorities for RBC transfusions in critically ill children. The cardiac disease subgroup included three experts. Electronic searches were conducted using PubMed, EMBASE, and Cochrane Library databases from 1980 to May 2017. Agreement was obtained using the Research and Development/UCLA appropriateness method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. RESULTS Twenty-one recommendations were developed and reached agreement. For children with myocardial dysfunction and/or pulmonary hypertension, there is no evidence that transfusion greater than hemoglobin of 10 g/dL is beneficial. For children with uncorrected heart disease, we recommended maintaining hemoglobin greater than 7-9.0 g/dL depending upon their cardiopulmonary reserve. For stable children undergoing biventricular repairs, we recommend not transfusing if the hemoglobin is greater than 7.0 g/dL. For infants undergoing staged palliative procedures with stable hemodynamics, we recommend avoiding transfusions solely based upon hemoglobin, if hemoglobin is greater than 9.0 g/dL. We recommend intraoperative and postoperative blood conservation measures. There are insufficient data supporting shorter storage duration RBCs. The risks and benefits of RBC transfusions in children with cardiac disease requires further study. CONCLUSIONS We present RBC transfusion management recommendations for the critically ill child with cardiac disease. Clinical recommendations emphasize relevant hemoglobin thresholds, and research recommendations emphasize need for further understanding of physiologic and hemoglobin thresholds and alternatives to RBC transfusion in subpopulations lacking pediatric literature.
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Muszynski JA, Reeder RW, Hall MW, Berg RA, Shanley TP, Newth CJL, Pollack MM, Wessel D, Carcillo J, Harrison R, Meert KL, Dean JM, Jenkins T, Tamburro RF, Dalton HJ. RBC Transfusion Practice in Pediatric Extracorporeal Membrane Oxygenation Support. Crit Care Med 2018; 46:e552-e559. [PMID: 29517551 PMCID: PMC6085106 DOI: 10.1097/ccm.0000000000003086] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES To determine RBC transfusion practice and relationships between RBC transfusion volume and mortality in infants and children treated with extracorporeal membrane oxygenation. DESIGN Secondary analysis of a multicenter prospective observational study. SETTING Eight pediatric institutions within the Eunice Kennedy Shriver National Institute of Child Health and Human Development's Collaborative Pediatric Critical Care Research Network. PATIENTS Patients age less than 19 years old treated with extracorporeal membrane oxygenation at a participating center. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Clinical data and target hemoglobin or hematocrit values (if set) were recorded daily by trained bedside extracorporeal membrane oxygenation specialists and research coordinators. Laboratory values, including hemoglobin and hematocrit, were recorded daily using the value obtained closest to 8:00 AM. RBC transfusion was recorded as total daily volume in mL/kg. Multivariable logistic regression was used to determine the relationship between RBC transfusion volume and hospital mortality, accounting for potential confounders. Average goal hematocrits varied across the cohort with a range of 27.5-41.3%. Overall, actual average daily hematocrit was 36.8%, and average RBC transfusion volume was 29.4 mL/kg/d (17.4-49.7 mL/kg/d) on extracorporeal membrane oxygenation. On multivariable analysis, each additional 10 mL/kg/d of RBC transfusion volume was independently associated with a 9% increase in odds of hospital mortality (adjusted odds ratio, 1.09 [1.02-1.16]; p = 0.009). CONCLUSIONS In this multicenter cohort of pediatric extracorporeal membrane oxygenation patients, daily hematocrit levels were maintained at normal or near-normal values and RBC transfusion burden was high. RBC transfusion volume was independently associated with odds of mortality. Future clinical studies to identify optimum RBC transfusion thresholds for pediatric extracorporeal membrane oxygenation are urgently needed.
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Affiliation(s)
- Jennifer A Muszynski
- Division of Critical Care, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
- Center for Clinical and Translational Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Mark W Hall
- Division of Critical Care, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
- Center for Clinical and Translational Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Robert A Berg
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Thomas P Shanley
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI
| | - Christopher J L Newth
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Murray M Pollack
- Department of Pediatrics, Children's National Medical Center, Washington, DC
| | - David Wessel
- Department of Pediatrics, Children's National Medical Center, Washington, DC
| | - Joseph Carcillo
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Rick Harrison
- Department of Pediatrics, UCLA Mattel Children's Hospital, Los Angeles, CA
| | - Kathleen L Meert
- Division of Critical Care, Department of Pediatrics, Children's Hospital of Michigan/Wayne State University, Detroit, MI
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Tammara Jenkins
- Trauma and Critical Illness Branch, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
| | - Robert F Tamburro
- Trauma and Critical Illness Branch, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
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Abstract
Red cell transfusions are amongst the most common therapeutic procedures in seriously ill children, particularly in the inpatient setting. This is despite the fact that there is no evidence base for most clinical settings, with the exception of patients with hemoglobinopathies, particularly thalassemia and sickle cell anemia. Obviously exsanguinating hemorrhage and life threatening anemia are urgent indications for which no other therapeutic approach is currently available. Most transfusions are, however, given prophylactically to prevent the complications of hypoxia or hemodynamic stability, based upon expert opinion and a faith in the oxygen carrying capacity and beneficial hemodynamic properties of transfused red cells. The question confronting current day pediatric practice is to what extent transfused red cells prevent adverse events, other than in thalassemia and sickle cell anemia, as opposed to causing them. Do transfusions of red cells prevent organ failure, stroke, etc. or not? There is epidemiologic evidence in the adult randomized trial literature that liberal red cell transfusion likely causes more such adverse events than it prevents. The relevance of such studies to children, particularly neonates, is uncertain. Randomized trials in critically ill neonates have yielded little to no evidence that liberal red cell transfusion is beneficial, but the data are not definitive. In critically ill older children the data suggest there is no benefit to liberal red cell transfusion, but the indications for red cell transfusion are uncertain. Most practitioners would agree that combining laboratory data such hemoglobin/hematocrit with clinical indications for transfusions (evidence of end organ hypoxia such as tachycardia, shortness of breath, etc.) is the only viable strategy at present, until more definitive randomized trial data are available.
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Abstract
OBJECTIVES To determine the prevailing hemoglobin levels in PICU patients, and any potential correlates. DESIGN Post hoc analysis of prospective multicenter observational data. SETTINGS Fifty-nine PICUs in seven countries. PATIENTS PICU patients on four specific days in 2012. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patients' hemoglobin and other clinical and institutional data. Two thousand three hundred eighty-nine patients with median age of 1.9 years (interquartile range, 0.3-9.8 yr), weight 11.5 kg (interquartile range, 5.4-29.6 kg), and preceding PICU stay of 4.0 days (interquartile range, 1.0-13.0 d). Their median hemoglobin was 11.0 g/dL (interquartile range, 9.6-12.5 g/dL). The prevalence of transfusion in the 24 hours preceding data collection was 14.2%. Neonates had the highest hemoglobin at 13.1 g/dL (interquartile range, 11.2-15.0 g/dL) compared with other age groups (p < 0.001). The percentage of 31.3 of the patients had hemoglobin of greater than or equal to 12 g/dL, and 1.1% had hemoglobin of less than 7 g/dL. Blacks had lower median hemoglobin (10.5; interquartile range, 9.3-12.1 g/dL) compared with whites (median, 11.1; interquartile range, 9.0-12.6; p < 0.001). Patients in Spain and Portugal had the highest median hemoglobin (11.4; interquartile range, 10.0-12.6) compared with other regions outside of the United States (p < 0.001), and the highest proportion (31.3%) of transfused patients compared with all regions (p < 0.001). Patients in cardiac PICUs had higher median hemoglobin than those in mixed PICUs or noncardiac PICUs (12.3, 11.0, and 10.6 g/dL, respectively; p < 0.001). Cyanotic heart disease patients had the highest median hemoglobin (12.6 g/dL; interquartile range, 11.1-14.5). Multivariable regression analysis within diagnosis groups revealed that hemoglobin levels were significantly associated with the geographic location and history of complex cardiac disease in most of the models. In children with cancer, none of the variables tested correlated with patients' hemoglobin levels. CONCLUSIONS Patients' hemoglobin levels correlated with demographics like age, race, geographic location, and cardiac disease, but none found in cancer patients. Future investigations should account for the effects of these variables.
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Cerebral Oxygen Metabolism Before and After RBC Transfusion in Infants Following Major Surgical Procedures. Pediatr Crit Care Med 2018; 19:318-327. [PMID: 29406374 DOI: 10.1097/pcc.0000000000001483] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Although infants following major surgery frequently require RBC transfusions, there is still controversy concerning the best definition for requirement of transfusion in the individual patient. The aim of this study was to determine the impact of RBC transfusion on cerebral oxygen metabolism in noncardiac and cardiac postsurgical infants. DESIGN Prospective observational cohort study. SETTING Pediatric critical care unit of a tertiary referral center. PATIENTS Fifty-eight infants (15 after pediatric surgery and 43 after cardiac surgery) with anemia requiring RBC transfusion were included. INTERVENTIONS RBC transfusion. MEASUREMENTS AND MAIN RESULTS We measured noninvasively regional cerebral oxygen saturation and microperfusion (relative cerebral blood flow) using tissue spectrometry and laser Doppler flowmetry before and after RBC transfusion. Cerebral fractional tissue oxygen extraction and approximated cerebral metabolic rate of oxygen were calculated. Fifty-eight RBC transfusions in 58 patients were monitored (15 after general surgery, 24 after cardiac surgery resulting in acyanotic biventricular physiology and 19 in functionally univentricular hearts including hypoplastic left heart following neonatal palliation). The posttransfusion hemoglobin concentrations increased significantly (9.7 g/dL vs 12.8 g/dL; 9.7 g/dL vs 13.8 g/dL; 13.1 g/dL vs 15.6 g/dL; p < 0.001, respectively). Posttransfusion cerebral oxygen saturation was significantly higher than pretransfusion (61% [51-78] vs 72% [59-89]; p < 0.001; 58% [35-77] vs 71% [57-88]; p < 0.001; 51% [37-61] vs 58% [42-73]; p = 0.007). Cerebral fractional tissue oxygen extraction decreased posttransfusion significantly 0.37 (0.16-0.47) and 0.27 (0.07-039), p = 0.002; 0.40 (0.2-0.62) vs 0.26 (0.11-0.57), p = 0.001; 0.42 (0.23-0.52) vs 0.32 (0.1-0.42), p = 0.017. Cerebral blood flow and approximated cerebral metabolic rate of oxygen showed no significant change during the observation period. The increase in cerebral oxygen saturation and the decrease in cerebral fractional tissue oxygen extraction were most pronounced in patients after cardiac surgery with a pretransfusion cerebral fractional tissue oxygen extraction greater than or equal to 0.4. CONCLUSION Following RBC transfusion, cerebral oxygen saturation increases and cerebral fractional tissue oxygen extraction decreases. The data suggest that cerebral oxygenation in postoperative infants with cerebral fractional tissue oxygen extraction greater than or equal to 0.4 may be at risk in instable hemodynamic or respiratory situations.
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Hassan N. Pediatric Anemia: It Is in the Eye of the Beholder. Anesth Analg 2018; 123:1354-1355. [PMID: 27861443 DOI: 10.1213/ane.0000000000001684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Nabil Hassan
- From the Division of Pediatric Critical Care at Helen Devos Children's Hospital, and Department of Pediatrics, Michigan State College of Human Medicine, Grand Rapids, Michigan
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45
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Olshove V, Berndsen N, Sivarajan V, Nawathe P, Phillips A. Comprehensive blood conservation program in a new congenital cardiac surgical program allows bloodless surgery for the Jehovah Witness and a reduction for all patients. Perfusion 2017; 33:194-202. [PMID: 28985692 DOI: 10.1177/0267659117733810] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Cardiac surgery on Jehovah's Witnesses (JW) can be challenging, given the desire to avoid blood products. Establishment of a blood conservation program involving the pre-, intra- and post-operative stages for all patients may lead to a minimized need for blood transfusion in all patients. METHODS Pre-operatively, all JW patients were treated with high dose erythropoietin 500 IU/kg twice a week. JW patients were compared to matching non-JW patients from the congenital cardiac database, two per JW to serve as control. Blood use, ventilation time, bypass time, pre-operative hematocrit, first in intensive care unit (ICU) and at discharge and 24 hour chest drainage were compared. Pre-operative huddle, operating room huddle and post-operative bedside handoff were done with the congenital cardiac surgeon, perfusionist, anesthesiologist and intensive care team in all patients for goal alignment. RESULTS Five JW patients (mean weight 24.4 ± 25.0 Kg, range 6.3 - 60 Kg) were compared to 10 non-JW patients (weight 22.0 ± 22.8 Kg, range 6.2 - 67.8 Kg). There was no difference in bypass, cross-clamp, time to extubation (0.8 vs. 2.1 hours), peak inotrope score (2.0 vs. 2.3) or chest drainage. No JW patient received a blood product compared to 40% of non-JW. The pre-operative hematocrit (Hct) was statistically greater for the JW patients (46.1 ± 3.3% vs. 36.3 ± 4.7%, p<0.001) and both ICU and discharge Hct were higher for the JW (37 ± 1.8% vs 32.4 ± 8.0% and 41 ± 8.1% vs 34.8 ± 7.9%), but did not reach statistical significance. All patients had similar blood draws during the hospitalization (JW x 18 mL/admission vs non-JW 20 mL/admission). CONCLUSION The continuous application and development of blood conservation techniques across the continuum of care allowed bloodless surgery for JW and non-JW patients alike. Blood conservation is a team sport and to make significant strides requires participation and input by all care providers.
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Affiliation(s)
- Vincent Olshove
- 1 Congenital Heart Program, Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Nicole Berndsen
- 1 Congenital Heart Program, Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Veena Sivarajan
- 1 Congenital Heart Program, Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Pooja Nawathe
- 2 Critical Care Medicine, Congenital Cardiac Intensive Care Unit, Depart-ment of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Alistair Phillips
- 3 Division of Cardiothoracic Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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46
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Hemoglobin Level at Stage 1 Discharge has No Impact on Inter-stage Growth and Stability in Single Ventricle Infants. Pediatr Cardiol 2017; 38:1505-1514. [PMID: 28770308 DOI: 10.1007/s00246-017-1692-8] [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: 03/10/2017] [Accepted: 07/14/2017] [Indexed: 10/19/2022]
Abstract
Hemoglobin levels (Hgb) of infants with a single ventricle (SV) are traditionally maintained high to maximize oxygen-carrying capacity during stage 1 palliation (S1P), stage 2 palliation (S2P), and between stages (IS). A single-center observational cohort study was performed to determine if red blood cell transfusion during the convalescent phase of the S1P (late S1P transfusion) to achieve higher Hgb is associated with benefits during the IS including improved growth and decreased acute medical events. 137 infants <1 year with SV with SIP undergoing care from January 2008 to June 2015 were retrospectively evaluated. 78 (57%) infants received a late S1P transfusion. Median Hgb at S1P discharge was 15.9 g/dL (IQR 14.7-17.1) and median Hgb S2P at admission was 15.3 g/dL (IQR 14-16.3). Median daily weight gain was 22 g/day during IS (IQR 17-26) and median daily length gain was 0.09 cm (IQR 0.06-0.11). Hgb at SIP discharge was not associated with IS growth or fewer IS acute events. However, late S1P transfusions were associated with illness severity at S1P and more complicated S1P care. Our data suggest that SV infants after S1P, who are steadily recovering, do not benefit from late transfusion to raise their hemoglobin level at discharge.
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47
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Karimi M, Sullivan JM, Linthicum C, Mathew A. Blood conservation pediatric cardiac surgery in all ages and complexity levels. World J Cardiol 2017; 9:332-338. [PMID: 28515851 PMCID: PMC5411967 DOI: 10.4330/wjc.v9.i4.332] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 12/21/2016] [Accepted: 01/14/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To demonstrate the feasibility of blood conservation methods and practice across all ages and risk categories in congenital cardiac surgery.
METHODS We retrospectively analyzed a collected database of 356 patients who underwent cardiac surgery using cardiopulmonary bypass (CPB) from 2010-2015. The patients were grouped into blood conservation (n = 138) and non-conservation (n = 218) groups and sub-grouped based on their ages and procedural complexity scores.
RESULTS There were no statistical differences in gender, weight, pre-operative and pre-CPB hematocrit levels in both groups. Despite equivalent hematocrit levels during and after CPB for both groups, there was significantly less operative homologous blood utilized in blood conservation group across all ages and complexity levels.
CONCLUSION Blood conservation surgery can be performed in congenital patients needing cardiac surgery in all age groups and complexity categories. The above findings in addition to attendant risks and side effects of blood transfusion and the rising cost of safer blood products justify blood conservation in congenital cardiac surgery.
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48
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Abstract
Cardiac surgery accounts for the majority of blood transfusions in a hospital. Blood transfusion has been associated with complications and major adverse events after cardiac surgery. Compared to adults it is more difficult to avoid blood transfusion in children after cardiac surgery. This article takes into account the challenges and emphasizes on the various strategies that could be implemented, to conserve blood during pediatric cardiac surgery.
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Affiliation(s)
- Sarvesh Pal Singh
- Department of CTVS, Cardiac Surgical Intensive Care Unit, Cardiothoracic Sciences Centre, All India Institute of Medical Sciences, New Delhi, India
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49
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The intensive care medicine clinical research agenda in paediatrics. Intensive Care Med 2017; 43:1210-1224. [PMID: 28315043 DOI: 10.1007/s00134-017-4729-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 02/16/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Intensive Care Medicine set us the task of outlining a global clinical research agenda for paediatric intensive care (PIC). In line with the clinical focus of this journal, we have limited this to research that may directly influence patient care. METHODS Clinician researchers from PIC research networks of varying degrees of formality from around the world were invited to answer two main questions: (1) What have been the major recent advances in paediatric critical care research? (2) What are the top 10 studies for the next 10 years? RESULTS (1) Inclusive databases are well established in many countries. These registries allow detailed observational studies and feasibility testing of clinical trial protocols. Recent trials are larger and more valuable, and (2) most common interventions in PIC are not evidenced-based. Clinical studies for the next 10 years should address this deficit, including: ventilation techniques and interfaces; fluid, transfusion and feeding strategies; optimal targets for vital signs; multiple organ failure definitions, mechanisms and treatments; trauma, prevention and treatment; improving safety; comfort of the patient and their family; appropriate care in the face of medical complexity; defining post-PICU outcomes; and improving knowledge generation and adoption, with novel trial design and implementation strategies. The group specifically highlighted the need for research in resource-limited environments wherein mortality remains often tenfold higher than in well-resourced settings. CONCLUSION Paediatric intensive care research has never been healthier, but many gaps in knowledge remain. We need to close these urgently. The impact of new knowledge will be greatest in resource-limited environments.
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50
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Estcourt LJ, Malouf R, Trivella M, Fergusson DA, Hopewell S, Murphy MF. Restrictive versus liberal red blood cell transfusion strategies for people with haematological malignancies treated with intensive chemotherapy or radiotherapy, or both, with or without haematopoietic stem cell support. Cochrane Database Syst Rev 2017; 1:CD011305. [PMID: 28128441 PMCID: PMC5298168 DOI: 10.1002/14651858.cd011305.pub2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Many people diagnosed with haematological malignancies experience anaemia, and red blood cell (RBC) transfusion plays an essential supportive role in their management. Different strategies have been developed for RBC transfusions. A restrictive transfusion strategy seeks to maintain a lower haemoglobin level (usually between 70 g/L to 90 g/L) with a trigger for transfusion when the haemoglobin drops below 70 g/L), whereas a liberal transfusion strategy aims to maintain a higher haemoglobin (usually between 100 g/L to 120 g/L, with a threshold for transfusion when haemoglobin drops below 100 g/L). In people undergoing surgery or who have been admitted to intensive care a restrictive transfusion strategy has been shown to be safe and in some cases safer than a liberal transfusion strategy. However, it is not known whether it is safe in people with haematological malignancies. OBJECTIVES To determine the efficacy and safety of restrictive versus liberal RBC transfusion strategies for people diagnosed with haematological malignancies treated with intensive chemotherapy or radiotherapy, or both, with or without a haematopoietic stem cell transplant (HSCT). SEARCH METHODS We searched for randomised controlled trials (RCTs) and non-randomised trials (NRS) in MEDLINE (from 1946), Embase (from 1974), CINAHL (from 1982), Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2016, Issue 6), and 10 other databases (including four trial registries) to 15 June 2016. We also searched grey literature and contacted experts in transfusion for additional trials. There was no restriction on language, date or publication status. SELECTION CRITERIA We included RCTs and prospective NRS that evaluated a restrictive compared with a liberal RBC transfusion strategy in children or adults with malignant haematological disorders or undergoing HSCT. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by Cochrane. MAIN RESULTS We identified six studies eligible for inclusion in this review; five RCTs and one NRS. Three completed RCTs (156 participants), one completed NRS (84 participants), and two ongoing RCTs. We identified one additional RCT awaiting classification. The completed studies were conducted between 1997 and 2015 and had a mean follow-up from 31 days to 2 years. One study included children receiving a HSCT (six participants), the other three studies only included adults: 218 participants with acute leukaemia receiving chemotherapy, and 16 with a haematological malignancy receiving a HSCT. The restrictive strategies varied from 70 g/L to 90 g/L. The liberal strategies also varied from 80 g/L to 120 g/L.Based on the GRADE rating methodology the overall quality of the included studies was very low to low across different outcomes. None of the included studies were free from bias for all 'Risk of bias' domains. One of the three RCTs was discontinued early for safety concerns after recruiting only six children, all three participants in the liberal group developed veno-occlusive disease (VOD). Evidence from RCTsA restrictive RBC transfusion policy may make little or no difference to: the number of participants who died within 100 days (two trials, 95 participants (RR: 0.25, 95% CI 0.02 to 2.69, low-quality evidence); the number of participants who experienced any bleeding (two studies, 149 participants; RR:0.93, 95% CI 0.73 to 1.18, low-quality evidence), or clinically significant bleeding (two studies, 149 participants, RR: 1.03, 95% CI 0.75 to 1.43, low-quality evidence); the number of participants who required RBC transfusions (three trials; 155 participants: RR: 0.97, 95% CI 0.90 to 1.05, low-quality evidence); or the length of hospital stay (restrictive median 35.5 days (interquartile range (IQR): 31.2 to 43.8); liberal 36 days (IQR: 29.2 to 44), low-quality evidence).We are uncertain whether the restrictive RBC transfusion strategy: decreases quality of life (one trial, 89 participants, fatigue score: restrictive median 4.8 (IQR 4 to 5.2); liberal median 4.5 (IQR 3.6 to 5) (very low-quality evidence); or reduces the risk of developing any serious infection (one study, 89 participants, RR: 1.23, 95% CI 0.74 to 2.04, very low-quality evidence).A restrictive RBC transfusion policy may reduce the number of RBC transfusions per participant (two trials; 95 participants; mean difference (MD) -3.58, 95% CI -5.66 to -1.49, low-quality evidence). Evidence from NRSWe are uncertain whether the restrictive RBC transfusion strategy: reduces the risk of death within 100 days (one study, 84 participants, restrictive 1 death; liberal 1 death; very low-quality evidence); decreases the risk of clinically significant bleeding (one study, 84 participants, restrictive 3; liberal 8; very low-quality evidence); or decreases the number of RBC transfusions (adjusted for age, sex and acute myeloid leukaemia type geometric mean 1.25; 95% CI 1.07 to 1.47 - data analysis performed by the study authors)No NRS were found that looked at: quality of life; number of participants with any bleeding; serious infection; or length of hospital stay.No studies were found that looked at: adverse transfusion reactions; arterial or venous thromboembolic events; length of intensive care admission; or readmission to hospital. AUTHORS' CONCLUSIONS Findings from this review were based on four studies and 240 participants.There is low-quality evidence that a restrictive RBC transfusion policy reduces the number of RBC transfusions per participant. There is low-quality evidence that a restrictive RBC transfusion policy has little or no effect on: mortality at 30 to 100 days, bleeding, or hospital stay. This evidence is mainly based on adults with acute leukaemia who are having chemotherapy. Although, the two ongoing studies (530 participants) are due to be completed by January 2018 and will provide additional information for adults with haematological malignancies, we will not be able to answer this review's primary outcome. If we assume a mortality rate of 3% within 100 days we would need 1492 participants to have a 80% chance of detecting, as significant at the 5% level, an increase in all-cause mortality from 3% to 6%. Further RCTs are required in children.
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Affiliation(s)
- Lise J Estcourt
- NHS Blood and TransplantHaematology/Transfusion MedicineLevel 2, John Radcliffe HospitalHeadingtonOxfordUKOX3 9BQ
| | - Reem Malouf
- University of OxfordNational Perinatal Epidemiology Unit (NPEU)Old Road CampusOxfordUKOX3 7LF
| | - Marialena Trivella
- University of OxfordCentre for Statistics in MedicineBotnar Research CentreWindmill RoadOxfordUKOX3 7LD
| | - Dean A Fergusson
- Ottawa Hospital Research InstituteClinical Epidemiology Program501 Smyth RoadOttawaONCanadaK1H 8L6
| | - Sally Hopewell
- University of OxfordOxford Clinical Trials Research UnitNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal SciencesWindmill RoadOxfordOxfordshireUKOX3 7LD
| | - Michael F Murphy
- Oxford University Hospitals NHS Foundation Trust and University of OxfordNHS Blood and Transplant; National Institute for Health Research (NIHR) Oxford Biomedical Research CentreJohn Radcliffe HospitalHeadingtonOxfordUK
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