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Kiskaddon AL, Goldenberg NA, Fierstein JL, Miller A, Quintessenza JA, Kartha VM. Dosing, Monitoring, Blood Product Utilization, and Thromboembolic Complications of Four-Factor Prothrombin Complex Concentrate as Part of an Institutional Protocol in Pediatric Cardiac Surgery: A Retrospective Cohort Study. Semin Thromb Hemost 2024; 50:873-882. [PMID: 38049114 DOI: 10.1055/s-0043-1777301] [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: 12/06/2023]
Abstract
Pediatric cardiac surgery patients are predisposed to blood loss. Blood product administration can lead to complications. Prothrombin complex concentrates (PCCs) offer potential advantages of factor composition, small volume, decreased immunogenicity/infectious risks, and accessibility. The objective of this study was to describe dosing, monitoring, blood product utilization, and thromboembolic complications of administering four-factor PCC (4F-PCC) in pediatric cardiac surgery. We performed a retrospective review of patients aged <18 years undergoing cardiac surgery from June 2020 to May 2022 (inclusive) who received 4F-PCC. Outcomes of interest included 4F-PCC dosing (units/kg) and number of doses administered, chest tube output, blood product administration, donor exposure, length of stay, and thromboembolic events. Eighty-six patients met eligibility criteria. The median (range) age and weight were 0.37 (0.01-16.3) years and 5.3 (1.6-98) kg, respectively. Median (range) total 4F-PCC dose per patient was 25 (9.2-50) units/kg, with 6 patients (7%) receiving a total of two doses. Median (range) 24-hour postoperative packed red blood cells, platelet, plasma, and cryoprecipitate administration volumes were 0 (0-2.57) mL/kg/24 h, 0 (0-1.09), 0 (0-2.64), and 0 (0-0.28 mL/kg/24 h), respectively. Median (range) length of stay and 24-hour postoperative chest tube output were 10 (6-26) days and 1.1 (0.1-4.2) mL/kg/h, respectively. Two (2%) patients experienced a thromboembolic event within 30 days of 4F-PCC administration. These retrospective findings suggest no worsening of hemostatic parameters, a mild median improvement in fibrinogen, low blood product utilization, and low thromboembolism rates following 4F-PCC use in pediatric cardiac surgery.
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Affiliation(s)
- Amy L Kiskaddon
- Department of Pharmacy, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
- Division of Cardiology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
- Heart Institute, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Neil A Goldenberg
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
- Division of Hematology, Departments of Medicine and Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
- Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Jamie L Fierstein
- Epidemiology and Biostatistics Shared Resource, Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Alexandra Miller
- Epidemiology and Biostatistics Shared Resource, Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | | | - Vyas M Kartha
- Department of Anesthesiology, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
- Division of Anesthesiology and Critical Care Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
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Willems A, Anders MM, Garcia AV, Vogel AM, Yates AR, Muszynski JA, Alexander PMA, Steffen K, Emani S, Gehred A, Lyman E, Raman L. Management of Extracorporeal Membrane Oxygenation Anticoagulation in the Perioperative Period: The Pediatric Extracorporeal Membrane Oxygenation Anticoagulation CollaborativE Consensus Conference. Pediatr Crit Care Med 2024; 25:e53-e65. [PMID: 38959360 PMCID: PMC11216378 DOI: 10.1097/pcc.0000000000003490] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
OBJECTIVES To derive systematic review-informed, modified Delphi consensus regarding the management of children on extracorporeal membrane oxygenation (ECMO) undergoing invasive procedures or interventions developed by the Pediatric Anticoagulation on ECMO CollaborativE (PEACE) Consensus Conference. DATA SOURCES A structured literature search was performed using PubMed, EMBASE, and Cochrane Library (CENTRAL) databases from January 1988 to May 2021. STUDY SELECTION ECMO anticoagulation and hemostasis management in the perioperative period and during procedures. DATA EXTRACTION Two authors reviewed all citations independently, with a third independent reviewer resolving any conflicts. Seventeen references were used for data extraction and informed recommendations. Evidence tables were constructed using a standardized data extraction form. DATA SYNTHESIS Risk of bias was assessed using the Quality in Prognosis Studies tool. The evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation system. Forty-eight experts met over 2 years to develop evidence-based recommendations and, when evidence was lacking, expert-based consensus statements for the management of bleeding and thrombotic complications in pediatric ECMO patients. A web-based modified Delphi process was used to build consensus via the Research And Development/University of California Appropriateness Method. Consensus was defined as greater than 80% agreement. Four good practice statements, 7 recommendations, and 18 consensus statements are presented. CONCLUSIONS Although agreement among experts was strong, important future research is required in this population for evidence-informed recommendations.
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Affiliation(s)
- Ariane Willems
- Pediatric Intensive Care Unit, Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
| | - Marc M Anders
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Alejandro V Garcia
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Adam M Vogel
- Departments of Surgery and Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Andrew R Yates
- Divisions of Cardiology and Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH
| | - Jennifer A Muszynski
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University of Medicine, Columbus, OH
| | - Peta M A Alexander
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Katherine Steffen
- Department of Pediatrics (Pediatric Critical Care Medicine), Stanford University, Palo Alto, CA
| | - Sitaram Emani
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, MA
- Department of Surgery, Harvard Medical School, Boston, MA
| | - Alison Gehred
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital, Columbus, OH
| | - Elizabeth Lyman
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital, Columbus, OH
| | - Lakshmi Raman
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
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Alexander PMA, Bembea MM, Cashen K, Cheifetz IM, Dalton HJ, Himebauch AS, Karam O, Moynihan KM, Nellis ME, Ozment C, Raman L, Rintoul NE, Said AS, Saini A, Steiner ME, Thiagarajan RR, Watt K, Willems A, Zantek ND, Barbaro RP, Steffen K, Vogel AM, Almond C, Anders MM, Annich GM, Brandão LR, Chandler W, Delaney M, DiGeronimo R, Emani S, Gadepalli SK, Garcia AV, Haileselassie B, Hyslop R, Kneyber MCJ, Baumann Kreuziger L, Le J, Loftis L, McMichael ABV, McMullan DM, Monagle P, Nicol K, Paden ML, Patregnani J, Priest J, Raffini L, Ryerson LM, Sloan SR, Teruya J, Yates AR, Gehred A, Lyman E, Muszynski JA. Executive Summary: The Pediatric Extracorporeal Membrane Oxygenation Anticoagulation CollaborativE (PEACE) Consensus Conference. Pediatr Crit Care Med 2024; 25:643-675. [PMID: 38959353 PMCID: PMC11216385 DOI: 10.1097/pcc.0000000000003480] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
OBJECTIVES To present recommendations and consensus statements with supporting literature for the clinical management of neonates and children supported with extracorporeal membrane oxygenation (ECMO) from the Pediatric ECMO Anticoagulation CollaborativE (PEACE) consensus conference. DATA SOURCES Systematic review was performed using PubMed, Embase, and Cochrane Library (CENTRAL) databases from January 1988 to May 2021, followed by serial meetings of international, interprofessional experts in the management ECMO for critically ill children. STUDY SELECTION The management of ECMO anticoagulation for critically ill children. DATA EXTRACTION Within each of eight subgroup, two authors reviewed all citations independently, with a third independent reviewer resolving any conflicts. DATA SYNTHESIS A systematic review was conducted using MEDLINE, Embase, and Cochrane Library databases, from January 1988 to May 2021. Each panel developed evidence-based and, when evidence was insufficient, expert-based statements for the clinical management of anticoagulation for children supported with ECMO. These statements were reviewed and ratified by 48 PEACE experts. Consensus was obtained using the Research and Development/UCLA Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. We developed 23 recommendations, 52 expert consensus statements, and 16 good practice statements covering the management of ECMO anticoagulation in three broad categories: general care and monitoring; perioperative care; and nonprocedural bleeding or thrombosis. Gaps in knowledge and research priorities were identified, along with three research focused good practice statements. CONCLUSIONS The 91 statements focused on clinical care will form the basis for standardization and future clinical trials.
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Affiliation(s)
- Peta M A Alexander
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Katherine Cashen
- Department of Pediatrics, Duke Children's Hospital, Duke University, Durham, NC
| | - Ira M Cheifetz
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Heidi J Dalton
- Department of Pediatrics, INOVA Fairfax Medical Center, Falls Church, VA
| | - Adam S Himebauch
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
| | - Oliver Karam
- Division of Critical Care Medicine, Children's Hospital of Richmond at VCU, Richmond, VA
- Division of Critical Care Medicine, Yale School of Medicine, New Haven, CT
| | - Katie M Moynihan
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA
- Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Marianne E Nellis
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, New York Presbyterian Hospital-Weill Cornell, New York, NY
| | - Caroline Ozment
- Division of Critical Care Medicine, Department of Pediatrics, Duke University and Duke University Health System, Durham, NC
| | - Lakshmi Raman
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Natalie E Rintoul
- Department of Pediatrics, Division of Neonatology, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Ahmed S Said
- Division of Pediatric Critical Care, Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
| | - Arun Saini
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Marie E Steiner
- Department of Pediatrics, Divisions of Hematology and Critical Care, University of Minnesota, Minneapolis, MN
| | - Ravi R Thiagarajan
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Kevin Watt
- Division of Clinical Pharmacology, Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Ariane Willems
- Pediatric Intensive Care Unit, Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
| | - Nicole D Zantek
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN
| | - Ryan P Barbaro
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, MI
| | - Katherine Steffen
- Department of Pediatrics (Pediatric Critical Care Medicine), Stanford University, Palo Alto, CA
| | - Adam M Vogel
- Departments of Surgery and Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Christopher Almond
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, CA
| | - Marc M Anders
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Gail M Annich
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Leonardo R Brandão
- Department of Pediatrics, The Hospital for Sick Children, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Wayne Chandler
- Department of Laboratories, Seattle Children's Hospital, Seattle, WA
| | - Megan Delaney
- Division of Pathology and Lab Medicine and Transfusion Medicine, Children's National Hospital, Washington, DC
- Departments of Pathology and Pediatrics, The George Washington University Health Sciences, Washington, DC
| | - Robert DiGeronimo
- Department of Pediatrics, Division of Neonatology, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
| | - Sitaram Emani
- Department of Cardiovascular Surgery, Boston Children's Hospital, and Department of Surgery, Harvard Medical School, Boston, MA
| | - Samir K Gadepalli
- Division of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Alejandro V Garcia
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Robert Hyslop
- Heart Institute, Children's Hospital of Colorado, Aurora, CO
| | - Martin C J Kneyber
- Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Lisa Baumann Kreuziger
- Versiti Blood Research Institute and Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - Jennifer Le
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA
| | - Laura Loftis
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Ali B V McMichael
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
- Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ
| | - D Michael McMullan
- Division of Pediatric Cardiac Surgery, Seattle Children's Hospital, Seattle, WA
| | - Paul Monagle
- University of Melbourne, and Kids Cancer Centre Sydney Children's Hospital, and Murdoch Children's Research Institute, and Royal Children's Hospital Melbourne Australia, Melbourne, VIC, Australia
| | - Kathleen Nicol
- Department of Pathology, Nationwide Children's Hospital, Columbus, OH
| | - Matthew L Paden
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Jason Patregnani
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Barbara Bush Children's Hospital, Portland, ME
| | - John Priest
- Department of Respiratory Care, Boston Children's Hospital, Boston MA
| | - Leslie Raffini
- Department of Pediatrics, Division of Hematology, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Lindsay M Ryerson
- Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada
| | - Steven R Sloan
- Department of Laboratory Medicine, Boston Children's Hospital, Boston, MA
- CSL Behring, King of Prussia, PA
| | - Jun Teruya
- Division of Transfusion Medicine and Coagulation, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Andrew R Yates
- Department of Pediatrics, Divisions of Cardiology and Critical Care Medicine, Nationwide Children's Hospital and the Ohio State University College of Medicine, Columbus, OH
| | - Alison Gehred
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital Columbus, Columbus, OH
| | - Elizabeth Lyman
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital Columbus, Columbus, OH
| | - Jennifer A Muszynski
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital and The Ohio State University of Medicine, Columbus, OH
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Vanstone MG, Krewulak K, Taneja S, Swinton M, Fiest K, Burns KEA, Debigare S, Dionne JC, Guyatt G, Marshall JC, Muscedere JG, Deane AM, Finfer S, Myburgh JA, Gouskos A, Rochwerg B, Ball I, Mele T, Niven DJ, English SW, Verhovsek M, Cook DJ. Patient-important upper gastrointestinal bleeding in the ICU: A mixed-methods study of patient and family perspectives. J Crit Care 2024; 81:154761. [PMID: 38447306 DOI: 10.1016/j.jcrc.2024.154761] [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] [Received: 01/03/2024] [Accepted: 02/23/2024] [Indexed: 03/08/2024]
Abstract
INTRODUCTION The objective of this study was to create a definition of patient-important upper gastrointestinal bleeding during critical illness as an outcome for a randomized trial. DESIGN This was a sequential mixed-methods qualitative-dominant multi-center study with an instrument-building aim. In semi-structured individual interviews or focus groups we elicited views from survivors of critical illness and family members of patients in the intensive care unit (ICU) regarding which features indicate important gastrointestinal bleeding. Quantitative demographic characteristics were collected. We analyzed qualitative data using inductive content analysis to develop a definition for patient-important upper gastrointestinal bleeding. SETTING Canada and the United States. PARTICIPANTS 51 ICU survivors and family members of ICU patients. RESULTS Participants considered gastrointestinal bleeding to be important if it resulted in death, disability, or prolonged hospitalization. The following also signaled patient-important upper gastrointestinal bleeding: blood transfusion, vasopressors, endoscopy, CT-angiography, or surgery. Whether an intervention evinced concern depended on its effectiveness, side-effects, invasiveness and accessibility; contextual influences included participant familiarity and knowledge of interventions and trust in the clinical team. CONCLUSIONS Survivors of critical illness and family members described patient-important upper gastrointestinal bleeding differently than current definitions of clinically-important upper gastrointestinal bleeding.
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Affiliation(s)
- Meredith G Vanstone
- Department of Family Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Karla Krewulak
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Shipra Taneja
- Department of Family Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Marilyn Swinton
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Kirsten Fiest
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Karen E A Burns
- Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, Canada
| | - Sylvie Debigare
- Patient and Family Partnership Committee, Commission Scolaire Central Québec, Canadian Critical Care Trials Group, Canada
| | - Joanna C Dionne
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada; Department of Critical Care, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Gordon Guyatt
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - John C Marshall
- Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, Canada; Department of Surgery, Unity Health Toronto, University of Toronto, Canada
| | - John G Muscedere
- Department of Critical Care Medicine, Queens University, Kingston Health Sciences Center
| | - Adam M Deane
- Department of Critical Care, University of Melbourne, Melbourne Medical School, Victoria, Australia
| | - Simon Finfer
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia; The George Institute for Global Health, School of Public Health, Imperial College London, London, England, United Kingdom
| | - John A Myburgh
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Audrey Gouskos
- Patient and Family Advisory Committee and Steering Committee representative, FAST-NAWC Trial, University of Toronto, Canada
| | - Bram Rochwerg
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada; Department of Critical Care, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Ian Ball
- Department of Medicine, Western University, London, Ontario, Canada.; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada; Department of Surgery, Western University, London, Ontario, Canada
| | - Tina Mele
- Department of Critical Care Medicine, Western University, London, Ontario, Canada; Department of Surgery, Western University, London, Ontario, Canada
| | - Daniel J Niven
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Shane W English
- Department of Medicine (Critical Care), University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Madeleine Verhovsek
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Deborah J Cook
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada; Department of Critical Care, St. Joseph's Healthcare Hamilton.
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Kiskaddon AL, Goldenberg NA, Abel T, Fierstein JL, Khayat D, Quintessenza JA, Stock AC. Ketorolac Dosing and Outcomes in Neonates Following Congenital Heart Surgery: A Retrospective Analysis. Crit Care Explor 2024; 6:e1078. [PMID: 38633134 PMCID: PMC11023609 DOI: 10.1097/cce.0000000000001078] [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] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Pain management is essential for postoperative surgery. Given the association of opioids with adverse outcomes, interest in the use of nonopioid analgesics, such as ketorolac, has increased. Published data on use in neonates are limited. OBJECTIVES To describe ketorolac dosing and safety and efficacy outcomes in the first 48 hours postcardiac surgery in neonates. DESIGN We performed a single-center retrospective cohort study of neonates (ages < 28 d) who received ketorolac following cardiac surgery from November 2020 to July 2023 (inclusive). The primary safety outcome was a clinically significant decline in renal function, as defined by the composite of an increase in serum creatinine by greater than or equal to 0.3 mg/dL from baseline within 96 hours of ketorolac initiation and urine output less than or equal to 0.5 mL/kg/hr for 6 hours. The secondary safety outcome was clinically significant bleeding, defined as the composite of major bleeding by the International Society on Thrombosis and Hemostasis pediatric criteria and severe/fatal bleeding by the criteria of Nellis et al (2019). Efficacy was measured by opioid utilization based on a standardized pain score-driven analgesia protocol. INTERVENTIONS Ketorolac was administered at 0.5 mg/kg every 6 hours as per an institutional clinical management algorithm. MEASUREMENTS AND MAIN RESULTS Thirty-nine patients met the eligibility criteria. The median ketorolac dose was 0.5 mg/kg/dose, and median (interquartile range [IQR]) duration of therapy was 48 hours (6-48 hr). No patients experienced a significant decline in renal function, and there were no clinically significant bleeding events. The median (IQR) IV morphine milligram equivalents (MMEs)/kg/d of opioid administration was 0.2 MME/kg/d (0.1-0.25 MME/kg/d) at the time of ketorolac initiation and 0.1 MME/kg/d (0.1-0.2 MME/kg/d) at 48 hours post-ketorolac initiation. CONCLUSIONS If validated prospectively, these findings suggest that a ketorolac regimen of 0.5 mg/kg/dose every 6 hours in neonates postcardiac surgery may be safe with regard to renal function and bleeding risk. Additional randomized studies would be needed to determine efficacy with regard to opioid-sparing capacity.
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Affiliation(s)
- Amy L Kiskaddon
- Department of Pharmacy, Johns Hopkins All Children's Hospital, St. Petersburg, FL
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, FL
- Heart Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Neil A Goldenberg
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, FL
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Trent Abel
- Department of Pharmacy, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Jamie L Fierstein
- Epidemiology and Biostatistics Shared Resource, Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Delia Khayat
- University of Florida College of Pharmacy, Gainesville, FL
| | | | - Arabela C Stock
- Heart Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL
- Division of Cardiac Critical Care, Heart Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL
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Kiskaddon AL, Stock AC, Fierstein JL, Miller A, Quintessenza JA, Goldenberg N. Ketorolac in neonates and infants following congenital heart surgery: a retrospective review. Cardiol Young 2023:1-7. [PMID: 38131146 DOI: 10.1017/s1047951123004262] [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] [Indexed: 12/23/2023]
Abstract
INTRODUCTION Pain management is essential in the immediate post-surgical period. We sought to describe the ketorolac dose regimen in neonates and infants following cardiac surgery. Secondary outcomes included renal dysfunction, bleeding, and pain management. METHODS We performed a single-centre retrospective cohort study of neonates and infants (aged < 12 months) who received ketorolac following cardiac surgery, from November 2020 through November 2021 (inclusive). Ketorolac was administered at 0.5 mg/kg every 6 hours. Safety was defined by absence of a clinically significant decline in renal function (i.e., increase in serum creatinine [SCr] by ≥ 0.3 mg/dL from baseline within 48 hours and/or urine output ≤ 0.5 mL/kg/hour for 6 hours) and absence of clinically significant bleeding defined as major by International Society on Thrombosis and Hemostasis paediatric criteria or Severe/Fatal Bleeding Events by Nellis et al. Efficacy measures included pain scores and opioid utilisation. RESULTS Fifty-five patients met eligibility criteria. The median (range) dose and duration of ketorolac administration was 0.5 mg/kg/dose for 48 (6-90) hours. Among all patients, there was not a statistically significant difference observed in median SCr within 48 hours of baseline (p > .9). There were no major or severe bleeding events. The median (range) opioid requirements (morphine intravenous equivalents per kg per day) at 48 hours post-ketorolac initiation was 0.1 (0-0.8) mg/kg/day. CONCLUSIONS If validated prospectively, these findings suggest that a ketorolac regimen 0.5 mg/kg/dose every 6 hours in neonates and infants post-cardiac surgery may be safe with regard to renal function and bleeding risk, and effective regarding opioid-sparing capacity.
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Affiliation(s)
- Amy L Kiskaddon
- Department of Pharmacy, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
- Division of Cardiology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Arabela C Stock
- Division of Cardiac Critical Care, Heart Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
- Heart Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Jamie L Fierstein
- Institute for Clinical and Translational Research, Epidemiology and Biostatistics Shared Resource, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Alexandra Miller
- Institute for Clinical and Translational Research, Epidemiology and Biostatistics Shared Resource, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | | | - Neil Goldenberg
- Institute for Clinical and Translational Research, Epidemiology and Biostatistics Shared Resource, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
- Division of Hematology, Departments of Medicine and Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
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Levasseur J, Fikse L, Mauguen A, Killinger JS, Karam O, Nellis ME. Bleeding in Critically Ill Children With Malignancy or Hematopoietic Cell Transplant: A Single-Center Prospective Cohort Study. Pediatr Crit Care Med 2023; 24:e602-e610. [PMID: 37678406 PMCID: PMC10843653 DOI: 10.1097/pcc.0000000000003374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
OBJECTIVES To determine the incidence of bleeding in critically ill children with malignancy and to describe associated patient characteristics, interventions, and clinical outcomes. DESIGN Prospective cohort study. SETTING PICU in a specialized cancer hospital. PATIENTS Children with malignancy or hematopoietic cell transplant 0-18 years of age were admitted to the PICU from November 2020 to November 2021. INTERVENTIONS None. MEASUREMENTS Patient demographic data, laboratory values, and PICU outcome data were collected. Bleeding was classified according to the Bleeding Assessment Scale in Critically Ill Children. MAIN RESULTS Ninety-three bleeding patients were enrolled, and a total of 322 bleeding days were recorded. The median (interquartile range [IQR]) age was 5.8 (2.9-11.8) years and 56% (52/93) of the patients were male. There were 121 new bleeding episodes, in 593 at-risk person-days, translating into a 20% incidence rate per day (95% CI, 17-24%). The incidence of severe, moderate, and minimal bleeding was 2% (95% CI, 1-3), 4% (95% CI, 3-6), and 14% (95% CI, 12-17), respectively. Of the new bleeding episodes, 9% were severe, 25% were moderate and 66% were minimal. Thrombocytopenia was the only laboratory value independently associated with severe bleeding ( p = 0.009), as compared to minimal and moderate bleeding episodes. History of radiation therapy was independently associated with severe bleeding ( p = 0.04). We failed to identify an association between a history of stem cell transplant ( p = 0.49) or tumor type ( p = 0.76), and bleeding severity. Patients were transfused any blood product on 28% (95% CI, 22-34) of the bleeding days. Severe bleeding was associated with increased length of mechanical ventilation ( p = 0.003), longer PICU stays ( p = 0.03), and higher PICU mortality ( p = 0.004). CONCLUSIONS In this prospective cohort of children with malignancy, the incidence rate of bleeding was 20%. Most events were classified as minimal bleeding. Low platelet count and radiation therapy were variables independently associated with severe bleeding episodes.
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Affiliation(s)
- Julie Levasseur
- Department of Pediatrics, New York Presbyterian Hospital, New York, NY
| | - Lauren Fikse
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Audrey Mauguen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - James S Killinger
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY
- Division of Pediatric Critical Care, Department of Pediatrics, Weill Cornell Medicine, New York, NY
| | - Oliver Karam
- Department of Pediatrics, Pediatric Critical Care Medicine, Yale School of Medicine, New Haven, CT
| | - Marianne E Nellis
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY
- Division of Pediatric Critical Care, Department of Pediatrics, Weill Cornell Medicine, New York, NY
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8
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Bartucca LM, Shaykh R, Stock A, Dayton JD, Bacha E, Haque KD, Nellis ME. Epidemiology of severe bleeding in children following cardiac surgery involving cardiopulmonary bypass: use of Bleeding Assessment Scale for critically Ill Children (BASIC). Cardiol Young 2023; 33:1913-1919. [PMID: 36373273 DOI: 10.1017/s1047951122003493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To describe the epidemiology of severe bleeding in the immediate post-operative period in children who undergo cardiopulmonary bypass surgery using the Bleeding Assessment Scale for critically Ill Children (BASIC). STUDY DESIGN Retrospective cohort study in a paediatric ICU from 2015 to 2020. RESULTS 356 children were enrolled; 59% were male with median (IQR) age 2.1 (0.5-8) years. Fifty-seven patients (16%) had severe bleeding in the first 24 hours post-operatively. Severe bleeding was observed more frequently in younger and smaller children with longer bypass and cross-clamp times (p-values <0.001), in addition to higher surgical complexity (p = 0.048). Those with severe bleeding received significantly more red blood cells, platelets, plasma, and cryoprecipitate in the paediatric ICU following surgery (all p-values <0.001). No laboratory values obtained on paediatric ICU admission were able to predict severe post-operative bleeding. Those with severe bleeding had significantly less paediatric ICU-free days (p = 0.010) and mechanical ventilation-free days (p = 0.013) as compared to those without severe bleeding. CONCLUSIONS Applying the BASIC definition to our cohort, severe bleeding occurred in 16% of children in the first day following cardiopulmonary bypass. Severe bleeding was associated with worse clinical outcomes. Standard laboratory assays do not predict bleeding warranting further study of available laboratory tests.
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Affiliation(s)
- Lisa M Bartucca
- Department of Pediatrics, New York-Presbyterian/Weill Cornell Medicine, New York, NY, USA
| | - Ramzi Shaykh
- Department of Pediatrics, New York-Presbyterian/Weill Cornell Medicine, New York, NY, USA
| | - Arabella Stock
- Department of Pediatrics, Division of Pediatric Critical Care, Weill Cornell Medicine, New York, NY, USA
| | - Jeffrey D Dayton
- Department of Pediatrics, Division of Pediatric Cardiology, Weill Cornell Medicine, New York, NY, USA
| | - Emile Bacha
- Section of Congenital and Pediatric Cardiac Surgery, Division of Cardiac, Thoracic and Vascular Surgery, Morgan Stanley Children's Hospital and Komansky Weill-Cornell, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Kelly D Haque
- Department of Pediatrics, Division of Pediatric Critical Care, Weill Cornell Medicine, New York, NY, USA
| | - Marianne E Nellis
- Department of Pediatrics, Division of Pediatric Critical Care, Weill Cornell Medicine, New York, NY, USA
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9
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Haftmann RJ, Pineda EM, Hall BA, Wilson MD, Mateev SN. Comparison of Time Within Therapeutic Range Using Anti-Factor Xa Versus Activated Partial Thromboplastin Time Monitoring of Unfractionated Heparin in Children. J Pediatr Pharmacol Ther 2023; 28:228-234. [PMID: 37303766 PMCID: PMC10249978 DOI: 10.5863/1551-6776-28.3.228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 07/19/2022] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To compare unfractionated heparin (UFH) monitoring using time in therapeutic range of activated partial thromboplastin time (aPTT) versus anti-factor Xa activity (anti-Xa) in children. METHODS This retrospective chart review, with data between October 2015 and October 2019, included pediatric patients younger than 18 years on therapeutic UFH infusion with aPTT or anti-Xa monitoring. Patients receiving extracorporeal membrane oxygenation, dialysis, concomitant anticoagulants, prophylactic UFH, no stated goal, and UFH administered for less than 12 hours were excluded. The primary outcome compared the percentage of time in therapeutic range between aPTT and anti-Xa. Secondary outcomes included time to first therapeutic value, UFH infusion rates, mean rate adjustments, and adverse events. RESULTS A total of 65 patients were included, with 33 aPTT patients and 32 anti-Xa patients, representing 39 UFH orders in each group. Baseline characteristics were similar between groups, with an overall mean age of 1.4 years and mean weight of 6.7 kg. The anti-Xa cohort demonstrated a statistically significantly higher percentage of time in therapeutic range compared with the aPTT group (50.3% vs 26.9%, p = 0.002). The anti-Xa group also demonstrated a trend toward decreased time to first therapeutic value compared with aPTT (14 vs 23.2 hours, p = 0.12). Two patients in each group experienced new or worsening thrombosis. Six patients in the aPTT cohort experienced bleeding. CONCLUSIONS This study demonstrated greater time was spent within therapeutic range for children receiving UFH monitored with anti-Xa compared with aPTT. Future studies should assess clinical outcomes in a larger population.
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Affiliation(s)
- Richard J. Haftmann
- Department of Pharmacy Services (RJH, BAH), University of California, Davis Health, Sacramento, CA
| | - Erika May Pineda
- Department of Pharmacy Services (EMP), Children's Hospital of Philadelphia, Philadelphia, PA
| | - Brent A. Hall
- Department of Pharmacy Services (RJH, BAH), University of California, Davis Health, Sacramento, CA
| | - Machelle D. Wilson
- Department of Public Health Sciences (MDW), Division of Biostatistics, Clinical and Translational Science Center, University of California, Davis Health, Sacramento, CA
| | - Stephanie N. Mateev
- Department of Pediatrics, Division of Pediatric Critical Care (SNM), University of California, Davis Health, Sacramento, CA
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10
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Alexander PMA, Habet V, Barbaro RP. Realizing Potential: Pediatric Extracorporeal Membrane Oxygenation Needs Common Adverse Event Definitions to Improve Outcomes. Pediatr Crit Care Med 2023; 24:528-530. [PMID: 37260339 PMCID: PMC10236131 DOI: 10.1097/pcc.0000000000003270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Peta M A Alexander
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Victoria Habet
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Ryan P Barbaro
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, MI
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11
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Abadeer M, Swartz MF, Martin SD, Groves AM, Kent AL, Schwartz GJ, Brophy P, Alfieris GM, Cholette JM. Using Serum Cystatin C to Predict Acute Kidney Injury Following Infant Cardiac Surgery. Pediatr Cardiol 2023; 44:855-866. [PMID: 36637459 DOI: 10.1007/s00246-022-03080-y] [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: 05/08/2022] [Accepted: 12/16/2022] [Indexed: 01/14/2023]
Abstract
Acute kidney injury (AKI) following cardiopulmonary bypass (CPB) is associated with increased morbidity and mortality. Serum Cystatin C (CysC) is a novel biomarker synthesized by all nucleated cells that may act as an early indicator of AKI following infant CPB. Prospective observational study of infants (< 1 year) requiring CPB during cardiac surgery. CysC was measured at baseline and 12, 24, 48, and 72 h following CPB initiation. Each post-op percent difference in CysC (e.g. %CysC12h) from baseline was calculated. Clinical variables along with urine output (UOP) and serum creatinine (SCr) were followed. Subjects were divided into two groups: AKI and non-AKI based upon the Kidney Disease Improving Global Outcomes (KDIGO) classification. AKI occurred in 41.9% (18) of the 43 infants enrolled. Patient demographics and baseline CysC levels were similar between groups. CysC levels were 0.97 ± 0.28 mg/L over the study period, and directly correlated with SCr (R = 0.71, p < 0.0001). Although absolute CysC levels were not significant between groups, the %CysC12h was significantly greater in the AKI group (AKI: - 16% ± 22% vs. Non-AKI - 28% ± 9% mg/L; p = 0.003). However, multivariate analysis demonstrated that a lower UOP (Odds Ratio:0.298; 95% CI 0.073, 0.850; p = 0.02) but not %CysC12h was independently associated with AKI. Despite a significant difference in the %CysC12h, only UOP was independently associated with AKI. Larger studies of a more homogenous population are needed to understand these results and to explore the variability in this biomarker seen across institutions.
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Affiliation(s)
- Maher Abadeer
- Department of Pediatrics, Golisano Children's Hospital, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Michael F Swartz
- Department of Surgery, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Susan D Martin
- Department of Pediatrics, Golisano Children's Hospital, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Angela M Groves
- Department of Pediatrics, Golisano Children's Hospital, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Alison L Kent
- Department of Pediatrics, Golisano Children's Hospital, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA.,College of Health and Medicine, Australian National University, Canberra, ACT, Australia
| | - George J Schwartz
- Department of Pediatrics, Golisano Children's Hospital, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Patrick Brophy
- Department of Pediatrics, Golisano Children's Hospital, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - George M Alfieris
- Department of Surgery, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Jill M Cholette
- Department of Pediatrics, Golisano Children's Hospital, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA.
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12
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Randolph AG, Bembea MM, Cheifetz IM, Curley MAQ, Flori HR, Khemani RG, Kudchadkar SR, Nishisaki A, Watson RS, Tucci M, Lacroix J, Thompson AE, Thomas NJ. Pediatric Acute Lung Injury and Sepsis Investigators (PALISI): Evolution of an Investigator-Initiated Research Network. Pediatr Crit Care Med 2022; 23:1056-1066. [PMID: 36454002 PMCID: PMC9747245 DOI: 10.1097/pcc.0000000000003100] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
The Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network originated over 20 years ago to foster research to optimize the care of critically ill infants and children. Over this period, PALISI has seen two major evolutions: formalization of our network infrastructure and a broadening of our clinical research focus. First, the network is unique in that its activities and meetings are funded by subscriptions from members who now comprise a multidisciplinary group of investigators from over 90 PICUs all over the United States (US) and Canada, with collaborations across the globe. In 2020, the network converted into a standalone, nonprofit organizational structure (501c3), making the PALISI Network formally independent of academic and clinical institutions or professional societies. Such an approach allows us to invest in infrastructure and future initiatives with broader opportunities for fund raising. Second, our research investigations have expanded beyond the original focus on sepsis and acute lung injury, to incorporate the whole field of pediatric critical care, for example, efficient liberation from mechanical ventilator support, prudent use of blood products, improved safety of intubation practices, optimal sedation practices and glucose control, and pandemic research on influenza and COVID-19. Our network approach in each field follows, where necessary, the full spectrum of clinical and translational research, including: immunobiology studies for understanding basic pathologic mechanisms; surveys to explore contemporary clinical practice; consensus conferences to establish agreement about literature evidence; observational prevalence and incidence studies to measure scale of a clinical issue or question; case control studies as preliminary best evidence for design of definitive prospective studies; and, randomized controlled trials for informing clinical care. As a research network, PALISI and its related subgroups have published over 350 peer-reviewed publications from 2002 through September 2022.
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Affiliation(s)
- Adrienne G Randolph
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Departments of Anaesthesia and Pediatrics, Harvard Medical School, Boston, MA
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ira M Cheifetz
- Division of Pediatric Critical Care Medicine, Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Martha A Q Curley
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, PA
- Research Institute, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Heidi R Flori
- Division of Critical Care Medicine, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, MI
| | - Robinder G Khemani
- Division of Critical Care Medicine, Department of Anesthesia, Children's Hospital Los Angeles, Los Angeles, CA
| | - Sapna R Kudchadkar
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Akira Nishisaki
- Division of Critical Care Medicine, Department of Anesthesia, Children's Hospital of Philadelphia, Philadelphia, PA
| | - R Scott Watson
- Division of Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital, Seattle, WA
| | - Marisa Tucci
- Division of Critical Care Medicine, CHU Sainte-Justine, Montreal, QC, Canada
| | - Jacques Lacroix
- Division of Critical Care Medicine, CHU Sainte-Justine, Montreal, QC, Canada
| | - Ann E Thompson
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Neal J Thomas
- Division of Critical Care Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA
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13
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Hsien S, Dayton JD, Chen D, Stock A, Bacha E, Cushing MM, Nellis ME. Hemostatic efficacy of pathogen-reduced platelets in children undergoing cardiopulmonary bypass. Transfusion 2022; 62:298-305. [PMID: 34904250 PMCID: PMC8837684 DOI: 10.1111/trf.16768] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 11/10/2021] [Accepted: 11/15/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Pediatric patients undergoing cardiopulmonary bypass (CPB) often require blood component transfusions. Pathogen-reduction (PR) of platelets reduces the risk of microbial contamination; however, its effect on hemostatic efficacy in this population is unclear. This study sought to characterize the hemostatic efficacy of PR platelets in children undergoing CPB. STUDY DESIGN AND METHODS We performed a retrospective chart review of patients admitted to a pediatric intensive care unit following CPB surgery from 2015 to 2019. Demographic data, validated scoring of repair complexity, products received, and outcomes were compared. The primary outcome was postoperative chest tube bleeding. RESULTS A total of 140 patients were enrolled. The majority of surgeries (124/140) were Risk Adjustment for Congenital Heart Surgery (RACHS) 1-3 repairs. Seventy-four percent of patients (104/140) received only standard platelets whereas 26% (36/140) received PR platelets. There were no differences between the groups in the age (p = .90), sex (p = .20) or RACHS score (p = .06). Postoperatively, there was no difference in the median chest tube output for 1 h (p = .27), 2 h (p = .26), 4 h (p = .09), 8 h (p = .16), or for the first 24 h following surgery (p = .23) in patients who received standard versus PR platelets. There was also no difference in receipt of platelets (p = .18), cell saver (p = .79), or cryoprecipitate (p = .28). CONCLUSION Patients receiving PR platelets did not have more blood loss or require more transfusions than those who received standard platelets. This suggests that PR platelets may provide acceptable hemostasis with the additional benefits of reduced risk of microbial contamination in pediatric patients undergoing CPB.
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Affiliation(s)
- Sophia Hsien
- Department of Pediatrics, New York Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| | - Jeffrey D Dayton
- Division of Pediatric Cardiology, Department of Pediatrics, Weill Cornell Medicine, New York, New York, USA
| | - Dennis Chen
- New York-Presbyterian Hospital, Weill Cornell Medical Center, Transfusion Medicine and Cellular Therapy Laboratory, New York, New York, USA
| | - Arabella Stock
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Weill Cornell Medicine, New York, New York, USA
| | - Emile Bacha
- Division of Cardiac, Thoracic and Vascular Surgery, Columbia University, New York, New York, USA
| | - Melissa M Cushing
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Marianne E Nellis
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Weill Cornell Medicine, New York, New York, USA
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14
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Nellis ME, Karam O, Valentine SL, Bateman ST, Remy KE, Lacroix J, Cholette JM, Bembea MM, Russell RT, Steiner ME, Goobie SM, Tucci M, Stricker PA, Stanworth SJ, Delaney M, Lieberman L, Muszynski JA, Bauer DF, Steffen K, Nishijima D, Ibla J, Emani S, Vogel AM, Haas T, Goel R, Crighton G, Delgado D, Demetres M, Parker RI. Executive Summary of Recommendations and Expert Consensus for Plasma and Platelet Transfusion Practice in Critically Ill Children: From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding (TAXI-CAB). Pediatr Crit Care Med 2022; 23:34-51. [PMID: 34989711 PMCID: PMC8820267 DOI: 10.1097/pcc.0000000000002851] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Critically ill children frequently receive plasma and platelet transfusions. We sought to determine evidence-based recommendations, and when evidence was insufficient, we developed expert-based consensus statements about decision-making for plasma and platelet transfusions in critically ill pediatric patients. DESIGN Systematic review and consensus conference series involving multidisciplinary international experts in hemostasis, and plasma/platelet transfusion in critically ill infants and children (Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding [TAXI-CAB]). SETTING Not applicable. PATIENTS Children admitted to a PICU at risk of bleeding and receipt of plasma and/or platelet transfusions. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A panel of 29 experts in methodology, transfusion, and implementation science from five countries and nine pediatric subspecialties completed a systematic review and participated in a virtual consensus conference series to develop recommendations. The search included MEDLINE, EMBASE, and Cochrane Library databases, from inception to December 2020, using a combination of subject heading terms and text words for concepts of plasma and platelet transfusion in critically ill children. Four graded recommendations and 49 consensus expert statements were developed using modified Research and Development/UCLA and Grading of Recommendations, Assessment, Development, and Evaluation methodology. We focused on eight subpopulations of critical illness (1, severe trauma, intracranial hemorrhage, or traumatic brain injury; 2, cardiopulmonary bypass surgery; 3, extracorporeal membrane oxygenation; 4, oncologic diagnosis or hematopoietic stem cell transplantation; 5, acute liver failure or liver transplantation; 6, noncardiac surgery; 7, invasive procedures outside the operating room; 8, sepsis and/or disseminated intravascular coagulation) as well as laboratory assays and selection/processing of plasma and platelet components. In total, we came to consensus on four recommendations, five good practice statements, and 44 consensus-based statements. These results were further developed into consensus-based clinical decision trees for plasma and platelet transfusion in critically ill pediatric patients. CONCLUSIONS The TAXI-CAB program provides expert-based consensus for pediatric intensivists for the administration of plasma and/or platelet transfusions in critically ill pediatric patients. There is a pressing need for primary research to provide more evidence to guide practitioners.
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Affiliation(s)
- Marianne E Nellis
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, NY Presbyterian Hospital-Weill Cornell Medicine, New York, NY
| | - Oliver Karam
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Hospital of Richmond at VCU, Richmond, VA
| | - Stacey L Valentine
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA
| | - Scot T Bateman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA
| | - Kenneth E Remy
- Division of Pediatric Critical Care Medicine and Pulmonary/Critical Care Medicine, Departments of Pediatrics and Internal Medicine, Washington University of St. Louis, St. Louis, MO
| | - Jacques Lacroix
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Jill M Cholette
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Rochester Golisano Children's Hospital, Rochester, NY
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Robert T Russell
- Department of Surgery, University of Alabama Birmingham, Birmingham, AL
| | - Marie E Steiner
- Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | - Susan M Goobie
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Marisa Tucci
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Paul A Stricker
- Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, PA
| | - Simon J Stanworth
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, NY Presbyterian Hospital-Weill Cornell Medicine, New York, NY
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Hospital of Richmond at VCU, Richmond, VA
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA
- Division of Pediatric Critical Care Medicine and Pulmonary/Critical Care Medicine, Departments of Pediatrics and Internal Medicine, Washington University of St. Louis, St. Louis, MO
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Rochester Golisano Children's Hospital, Rochester, NY
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Surgery, University of Alabama Birmingham, Birmingham, AL
- Department of Pediatrics, University of Minnesota, Minneapolis, MN
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
- Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, PA
- NHS Blood and Transplant, Oxford, United Kingdom
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
- Radcliffe Department of Medicine and Oxford BRC Haematology Theme, University of Oxford, Oxford, United Kingdom
- Division of Pathology & Laboratory Medicine, Children's National Hospital, Washington, DC
- Department of Pathology & Pediatrics, The George Washington University Health Sciences, Washington, DC
- Department of Clinical Pathology, University Health Network Hospitals, Toronto, ON, Canada
- Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, ON, Canada
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
- Division of Pediatric Neurosurgery Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, TX
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Stanford University, Palo Alto, CA
- Department of Emergency Medicine, University of California, Davis School of Medicine, Davis, CA
- Department of Cardiovascular Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
- Division of Pediatric Surgery Texas Children's Hospital, Department of Surgery, Baylor College of Medicine, Houston, TX
- Department of Pediatric Anesthesia, University Children's Hospital Zurich, Zurich, Switzerland
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, MD
- Department of Haematology, Royal Children's Hospital, Melbourne, VIC, Australia
- Samuel J. Wood Library & C.V. Starr Biomedical Information Center, Weill Cornell Medicine, New York, NY
- Department of Pediatric Hematology/Oncology, Renaissance School of Medicine, State University of New York at Stony Brook, Stony Brook, NY
| | - Meghan Delaney
- Division of Pathology & Laboratory Medicine, Children's National Hospital, Washington, DC
- Department of Pathology & Pediatrics, The George Washington University Health Sciences, Washington, DC
| | - Lani Lieberman
- Department of Clinical Pathology, University Health Network Hospitals, Toronto, ON, Canada
- Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Jennifer A Muszynski
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - David F Bauer
- Division of Pediatric Neurosurgery Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, TX
| | - Katherine Steffen
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Stanford University, Palo Alto, CA
| | - Daniel Nishijima
- Department of Emergency Medicine, University of California, Davis School of Medicine, Davis, CA
| | - Juan Ibla
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Sitaram Emani
- Department of Cardiovascular Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Adam M Vogel
- Division of Pediatric Surgery Texas Children's Hospital, Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Thorsten Haas
- Department of Pediatric Anesthesia, University Children's Hospital Zurich, Zurich, Switzerland
| | - Ruchika Goel
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, MD
| | - Gemma Crighton
- Department of Haematology, Royal Children's Hospital, Melbourne, VIC, Australia
| | - Diana Delgado
- Samuel J. Wood Library & C.V. Starr Biomedical Information Center, Weill Cornell Medicine, New York, NY
| | - Michelle Demetres
- Samuel J. Wood Library & C.V. Starr Biomedical Information Center, Weill Cornell Medicine, New York, NY
| | - Robert I Parker
- Department of Pediatric Hematology/Oncology, Renaissance School of Medicine, State University of New York at Stony Brook, Stony Brook, NY
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15
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Lieberman L, Karam O, Stanworth SJ, Goobie SM, Crighton G, Goel R, Lacroix J, Nellis ME, Parker RI, Steffen K, Stricker P, Valentine SL, Steiner ME. Plasma and Platelet Transfusion Strategies in Critically Ill Children With Malignancy, Acute Liver Failure and/or Liver Transplantation, or Sepsis: From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. Pediatr Crit Care Med 2022; 23:e37-e49. [PMID: 34989704 PMCID: PMC8769367 DOI: 10.1097/pcc.0000000000002857] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To present the consensus statements with supporting literature for plasma and platelet transfusions in critically ill neonates and children with malignancy, acute liver disease and/or following liver transplantation, and sepsis and/or disseminated intravascular coagulation from the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. DESIGN Systematic review and consensus conference of international, multidisciplinary experts in platelet and plasma transfusion management of critically ill children. SETTING Not applicable. PATIENTS Critically ill neonates and children with malignancy, acute liver disease and/or following liver transplantation, and sepsis and/or disseminated intravascular coagulation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A panel of 13 experts developed evidence-based and, when evidence was insufficient, expert-based statements for plasma and platelet transfusions in critically ill neonates and children with malignancy, acute liver disease and/or following liver transplantation, and sepsis and/or disseminated intravascular coagulation. These statements were reviewed and ratified by the 29 Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding experts. A systematic review was conducted using MEDLINE, EMBASE, and Cochrane Library databases, from inception to December 2020. Consensus was obtained using the Research and Development/University of California, Los Angeles Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. We developed 12 expert consensus statements. CONCLUSIONS In the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding program, the current absence of evidence for use of plasma and/or platelet transfusion in critically ill children with malignancy, acute liver disease and/or following liver transplantation, and sepsis means that only expert consensus statements are possible for these areas of practice.
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Affiliation(s)
- Lani Lieberman
- Department of Clinical Pathology, University Health Network Hospitals. Department of Laboratory Medicine & Pathobiology; University of Toronto, Toronto, Canada
| | - Oliver Karam
- Division of Pediatric Critical Care Medicine, Children’s Hospital of Richmond at VCU, Richmond, VA, USA
| | - Simon J. Stanworth
- NHS Blood and Transplant; Oxford University Hospitals NHS Foundation Trust; Radcliffe Department of Medicine and Oxford BRC Haematology Theme, University of Oxford, UK
| | - Susan M. Goobie
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Gemma Crighton
- Department of Haematology, Royal Children’s Hospital, Melbourne, Australia
| | - Ruchika Goel
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, MD and Simmons Cancer Institute, Division of Hematology Oncology at SIU School of Medicine, Springfield, IL, USA
| | - Jacques Lacroix
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, QC, Canada
| | - Marianne E. Nellis
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, NY Presbyterian Hospital – Weill Cornell Medicine, New York, NY, USA
| | - Robert I. Parker
- Department of Pediatric Hematology/Oncology, Renaissance School of Medicine, State University of New York at Stony Brook, Stony Brook, NY, USA
| | - Katherine Steffen
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Stanford University, Palo Alto, CA, USA
| | - Paul Stricker
- Department of Anesthesiology and Critical Care, The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Stacey L. Valentine
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA, USA
| | - Marie E. Steiner
- Divisions of Hematology and Critical Care, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
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Resch JC, Hedstrom R, Steiner ME, Said SM, Somani A. Hirudotherapy for limb ischemia in the pediatric intensive care unit: A retrospective observational cohort. Front Pediatr 2022; 10:1011171. [PMID: 36683785 PMCID: PMC9849792 DOI: 10.3389/fped.2022.1011171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 12/12/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Acute limb ischemia due to microvascular malperfusion may be refractory to initial therapies. Medicinal leech therapy (hirudotherapy) has been attempted in plastic and reconstructive surgery to improve venous congestion in ischemic flaps; however, there are minimal reports related to ischemia secondary to arterial malperfusion. We evaluated a pediatric cohort from an academic intensive care unit with refractory limb ischemia in whom hirudotherapy was attempted to elucidate its use and outcomes. METHOD Institutional patient database was queried to identify pediatric patients (<18 years) who received hirudotherapy in the pediatric critical care unit and met inclusion/exclusion criteria. Patient charts were evaluated for indices including demographics, primary disease, coagulative status, vascular access, vasoactive medication dosing, bleeding, leech use, limb and mortality outcomes. Data was evaluated to identify trends or suspected impact on outcomes. RESULTS Hirudotherapy was used in 7 patients for limb ischemia, 5 with congenital heart disease, and 2 others with viremic shock. Time to leech application following recognition of ischemia averaged 3 days, with duration of use averaging 3.9 days. Five patients discontinued therapy due to bleeding. Mortality rate was 57%, all secondary to multiorgan failure. In 3 surviving patients, 4 of 5 treated limbs resulted in at minimum partial amputation. Vasoactive-inotropic score tended higher prior to leech application, suggesting a vasoconstrictive pathway for arterial malperfusion. No identifiable trends appeared associated with salvaged limb or adverse effects. Blood loss predictably increased with leech application, as did total transfusion requirement. CONCLUSION This case series establishes baseline data for use of hirudotherapy in critically ill children with acute limb ischemia caused by arterial malperfusion. Based on this retrospective cohort, we cannot recommend routine use of hirudotherapy for acute limb ischemia from arterial malperfusion in the pediatric intensive care unit. Application of leeches should be aligned with a protocol defining start and stop parameters, standardized leech utilization, and monitoring for adverse outcomes. Future study would benefit from consensus definitions of study outcomes, including perfusion recovery, tissue/limb salvage and bleeding manifestations. Additional prospective studies are needed prior to any standard or systematic recommendations for use.
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Affiliation(s)
- Joseph C Resch
- Department of Pediatric Critical Care, University of Minnesota, M Health Fairview Masonic Children's Hospital, Minneapolis, MN, United States
| | - Rachel Hedstrom
- Department of Pediatric Critical Care, University of Minnesota, M Health Fairview Masonic Children's Hospital, Minneapolis, MN, United States
| | - Marie E Steiner
- Department of Pediatric Critical Care, University of Minnesota, M Health Fairview Masonic Children's Hospital, Minneapolis, MN, United States
| | - Sameh M Said
- Department of Pediatric Cardiac Surgery, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, United States
| | - Arif Somani
- Department of Pediatric Critical Care, University of Minnesota, M Health Fairview Masonic Children's Hospital, Minneapolis, MN, United States
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17
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Tucci M, Crighton G, Goobie SM, Russell RT, Parker RI, Haas T, Nellis ME, Vogel AM, Lacroix J, Stricker PA. Plasma and Platelet Transfusion Strategies in Critically Ill Children Following Noncardiac Surgery and Critically Ill Children Undergoing Invasive Procedures Outside the Operating Room: From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. Pediatr Crit Care Med 2022; 23:e50-e62. [PMID: 34989705 PMCID: PMC8769350 DOI: 10.1097/pcc.0000000000002858] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To present consensus statements and supporting literature for plasma and platelet transfusions in critically ill children following noncardiac surgery and critically ill children undergoing invasive procedures outside the operating room from the Transfusion and Anemia EXpertise Initiative - Control/Avoidance of Bleeding. DESIGN Systematic review and consensus conference of international, multidisciplinary experts in platelet and plasma transfusion management of critically ill children. SETTING Not applicable. PATIENTS Critically ill children undergoing invasive procedures outside of the operating room or noncardiac surgery. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A panel of 10 experts developed evidence-based and, when evidence was insufficient, expert-based statements for plasma and platelet transfusions in critically ill children following noncardiac surgery or undergoing invasive procedures outside of the operating room. These statements were reviewed and ratified by the 29 Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding experts. A systematic review was conducted using MEDLINE, EMBASE, and Cochrane Library databases, from inception to December 2020. Consensus was obtained using the Research and Development/University of California, Los Angeles Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. We developed eight expert consensus statements focused on the critically ill child following noncardiac surgery and 10 expert consensus statements on the critically ill child undergoing invasive procedures outside the operating room. CONCLUSIONS Evidence regarding plasma and platelet transfusion in critically ill children in this area is very limited. The Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding Consensus Conference developed 18 pediatric specific consensus statements regarding plasma and platelet transfusion management in these critically ill pediatric populations.
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Affiliation(s)
- Marisa Tucci
- Department of Pediatrics, Sainte-Justine University Hospital, University of Montreal, Montreal, QC, Canada
| | - Gemma Crighton
- Department of Haematology, Royal Children’s Hospital, Melbourne, Australia
| | - Susan M. Goobie
- Boston Children’s Hospital, Dept. of Anesthesiology, Critical Care & Pain Medicine, Boston Children’s Hospital, Boston, USA
| | - Robert T. Russell
- Department of Surgery, Division of Pediatric Surgery, Children’s of Alabama, University of Alabama at Birmingham, Birmingham, Alabama
| | - Robert I. Parker
- Department of Pediatrics, Stony Brook University, Stony Brook, NY
| | - Thorsten Haas
- Department of Anesthesia, Zurich University Children’s Hospital, Zurich, Switzerland
| | - Marianne E. Nellis
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, NY Presbyterian Hospital – Weill Cornell Medicine, New York, NY, USA
| | - Adam M. Vogel
- Division of Pediatric Surgery, Surgery and Pediatrics Baylor College of Medicine Texas Children’s Hospital, Houston, Texas
| | - Jacques Lacroix
- Department of Pediatrics, University of Montreal, Montreal, QC, Canada
| | - Paul A. Stricker
- Department of Anesthesiology and Critical Care, The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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18
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Nellis ME, Remy KE, Lacroix J, Cholette JM, Bembea MM, Russell RT, Steiner ME, Goobie SM, Vogel AM, Crighton G, Valentine SL, Delaney M, Parker RI. Research Priorities for Plasma and Platelet Transfusion Strategies in Critically Ill Children: From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. Pediatr Crit Care Med 2022; 23:e63-e73. [PMID: 34989706 PMCID: PMC8769351 DOI: 10.1097/pcc.0000000000002859] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To present a list of high-priority research initiatives for the study of plasma and platelet transfusions in critically ill children from the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. DESIGN Systematic review and consensus conference of international, multidisciplinary experts in platelet and plasma transfusion management of critically ill children. SETTING Not applicable. PATIENTS Critically ill pediatric patients at risk of bleeding and receiving plasma and/or platelet transfusions. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A panel of 13 experts developed research priorities for the study of plasma and platelet transfusions in critically ill children which were reviewed and ratified by the 29 Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding experts. The specific priorities focused on the following subpopulations: severe trauma, traumatic brain injury, intracranial hemorrhage, cardiopulmonary bypass surgery, extracorporeal membrane oxygenation, oncologic diagnosis or stem cell transplantation, acute liver failure and/or liver transplantation, noncardiac surgery, invasive procedures outside of the operating room, and sepsis and/or disseminated intravascular coagulation. In addition, tests to guide plasma and platelet transfusion, as well as component selection and processing, were addressed. We developed four general overarching themes and 14 specific research priorities using modified Research and Development/University of California, Los Angeles methodology. CONCLUSIONS Studies are needed to focus on the efficacy/harm, dosing, timing, and outcomes of critically ill children who receive plasma and/or platelet transfusions. The completion of these studies will facilitate the development of evidence-based recommendations.
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Affiliation(s)
- Marianne E Nellis
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, NY Presbyterian Hospital - Weill Cornell Medicine, New York, NY
| | - Kenneth E Remy
- Division of Pediatric Critical Care Medicine and Pulmonary/Critical Care Medicine, Departments of Pediatrics and Internal Medicine, Washington University of St. Louis, St. Louis, MO
| | - Jacques Lacroix
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Jill M Cholette
- Division of Pediatric Critical Care Medicine, University of Rochester Golisano Children's Hospital, Rochester, NY
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Robert T Russell
- Department of Surgery, University of Alabama Birmingham, Birmingham, AL
| | - Marie E Steiner
- Divisions of Critical Care and Hematology, Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | - Susan M Goobie
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Adam M Vogel
- Division of Pediatric Surgery Texas Children's Hospital, Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Gemma Crighton
- Department of Haematology, Royal Children's Hospital, Melbourne, Australia
| | - Stacey L Valentine
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA
| | - Meghan Delaney
- Division of Pathology and Laboratory Medicine, Children's National Hospital; Department of Pathology and Pediatrics, The George Washington University Health Sciences, Washington, DC
| | - Robert I Parker
- Department of Pediatric Hematology/Oncology, Renaissance School of Medicine, State University of New York at Stony Brook, Stony Brook, NY
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19
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Russell R, Bauer DF, Goobie SM, Haas T, Nellis ME, Nishijima DK, Vogel AM, Lacroix J. Plasma and Platelet Transfusion Strategies in Critically Ill Children Following Severe Trauma, Traumatic Brain Injury, and/or Intracranial Hemorrhage: From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. Pediatr Crit Care Med 2022; 23:e14-e24. [PMID: 34989702 PMCID: PMC8849603 DOI: 10.1097/pcc.0000000000002855] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To present consensus statements and supporting literature for plasma and platelet transfusions in critically ill children with severe trauma, traumatic brain injury, and/or intracranial hemorrhage from the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. DESIGN Systematic review and consensus conference of international, multidisciplinary experts in platelet and plasma transfusion management of critically ill children. SETTING Not applicable. PATIENTS Critically ill neonates and children with severe trauma, traumatic brain injury, and/or intracranial hemorrhage. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A panel of eight experts developed expert-based statements for plasma and platelet transfusions in critically ill neonates and children with severe trauma, traumatic brain injury, and/or intracranial hemorrhage. These statements were reviewed and ratified by the 29 Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding experts. A systematic review was conducted using MEDLINE, EMBASE, and Cochrane Library databases, from inception to December 2020. Consensus was obtained using the Research and Development/University of California, Los Angeles Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. We developed one good practice statement and six expert consensus statements. CONCLUSIONS The lack of evidence precludes proposing recommendations on monitoring of the coagulation system and on plasma and platelets transfusion in critically ill pediatric patients with severe trauma, severe traumatic brain injury, or nontraumatic intracranial hemorrhage.
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Affiliation(s)
- Robert Russell
- Pediatric General Surgery, Children's of Alabama, Birmingham, AL
| | - David F Bauer
- Pediatric Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Susan M Goobie
- Harvard Medical School, Boston, MA
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Thorsten Haas
- Department of Pediatric Anesthesia, Zurich University Children's Hospital, Zurich, Switzerland
| | - Marianne E Nellis
- Division of Pediatric Critical Care Medicine, Weill Cornell Medicine, New York, NY
| | - Daniel K Nishijima
- Department of Emergency Medicine, CTSC Clinical Research Center and Trial Innovation Network, University of California Davis School of Medicine, Sacramento, CA
| | - Adam M Vogel
- Surgery and Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Jacques Lacroix
- Division of Pediatric Critical Care, Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montreal, QC, Canada
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20
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Abstract
Supplemental Digital Content is available in the text. Critically ill children with malignancy have significant risk of bleeding but the exact epidemiology is unknown. We sought to describe severe bleeding events and associated risk factors in critically ill pediatric patients with an underlying oncologic diagnosis using the newly developed Bleeding Assessment Scale in Critically Ill Children definition.
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21
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Ceylan G, Sandal O, Sari F, Atakul G, Topal S, Colak M, Soydan E, Ağın H. Monitoring of near-infrared spectrum values during packed red blood cell transfusion in pediatric intensive care unit. Transfus Clin Biol 2021; 28:234-238. [PMID: 34058380 DOI: 10.1016/j.tracli.2021.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 04/30/2021] [Accepted: 05/24/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Packed red blood cell (PRBC) transfusion is one of the most common treatment options in pediatric intensive care unit (PICU) which targets a better cerebral oxygenation. This study aimed to show the cerebral near-infrared spectroscopy (cNIRS) changes during PRBC transfusions in PICU. MATERIAL AND METHODS In this prospective observational study, changes in regional cerebral tissue oxygen saturation (rSO2) in pediatric patients, who required PRBC transfusion were monitored. All the cNIRS and related values were classified as baseline values. The same values were measured and calculated at the end of transfusion and named as 4th-hour values. Further measurements and calculations were made three hours later and named as 7th-hour values. Changes in cNIRS, cerebral tissue fractional oxygen extraction (CTFOE), cNIRS variability index (cNIRS-VI) were compared using Friedman test. RESULTS A total of 53 PRBC transfusions were monitored. Baseline haemoglobin increased from 6.3 (5.9, 6.7) gr/dL to 8.6 (8.4, 9) gr/dL at the 7th-hour. cNIRS values improved during transfusion (P=0.012), with a concomitant decrease in cNIRS-VI and CTFOE values (P<0.001 and P=0.017 consecutively) CONCLUSION: Our study revealed that there is an increase in cNIRS and related values after transfusion compared to baseline values in critically ill children admitted to a PICU. Age of PRBC did not have an effect on delta-cNIRS or post-transfusion hemoglobin values. There is a moderate correlation between the baseline cNIRS values and delta-cNIRS value after the transfusion.
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Affiliation(s)
- G Ceylan
- Department of Pediatric Intensive Care Unit, Dr Behcet Uz Child Disease and Surgery Training and Research Hospital, Izmir, Turkey.
| | - O Sandal
- Department of Pediatric Intensive Care Unit, Dr Behcet Uz Child Disease and Surgery Training and Research Hospital, Izmir, Turkey.
| | - F Sari
- Department of Pediatric Intensive Care Unit, Dr Behcet Uz Child Disease and Surgery Training and Research Hospital, Izmir, Turkey.
| | - G Atakul
- Department of Pediatric Intensive Care Unit, Dr Behcet Uz Child Disease and Surgery Training and Research Hospital, Izmir, Turkey.
| | - S Topal
- Department of Pediatric Intensive Care Unit, Dr Behcet Uz Child Disease and Surgery Training and Research Hospital, Izmir, Turkey.
| | - M Colak
- Department of Pediatric Intensive Care Unit, Dr Behcet Uz Child Disease and Surgery Training and Research Hospital, Izmir, Turkey.
| | - E Soydan
- Department of Pediatric Intensive Care Unit, Dr Behcet Uz Child Disease and Surgery Training and Research Hospital, Izmir, Turkey.
| | - H Ağın
- Department of Pediatric Intensive Care Unit, Dr Behcet Uz Child Disease and Surgery Training and Research Hospital, Izmir, Turkey.
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22
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Aran AA, Karam O, Nellis ME. Bleeding in Critically Ill Children-Review of Literature, Knowledge Gaps, and Suggestions for Future Investigation. Front Pediatr 2021; 9:611680. [PMID: 33585373 PMCID: PMC7873638 DOI: 10.3389/fped.2021.611680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 01/04/2021] [Indexed: 11/13/2022] Open
Abstract
Clinically significant bleeding complicates up to 20% of admissions to the intensive care unit in adults and is associated with severe physiologic derangements, requirement for significant interventions and worse outcome. There is a paucity of published data on bleeding in critically ill children. In this manuscript, we will provide an overview of the epidemiology and characteristics of bleeding in critically ill children, address the association between bleeding and clinical outcomes, describe the current definitions of bleeding and their respective limitations, and finally provide an overview of current knowledge gaps and suggested areas for future research.
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Affiliation(s)
- Adi Avniel Aran
- Pediatric Cardiac Critical Care Division, Hadassah University Medical Center, Jerusalem, Israel
| | - Oliver Karam
- Division of Pediatric Critical Care Medicine, Children's Hospital of Richmond at VCU, Richmond, VA, United States
| | - Marianne E Nellis
- Pediatric Critical Care Medicine, NY Presbyterian Hospital-Weill Cornell Medicine, New York, NY, United States
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23
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Sequeira J, Nellis ME, Karam O. Epidemiology of Bleeding in Critically Ill Children. Front Pediatr 2021; 9:699991. [PMID: 34422724 PMCID: PMC8371326 DOI: 10.3389/fped.2021.699991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 07/15/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: Bleeding can be a severe complication of critical illness, but its true epidemiologic impact on children has seldom been studied. Our objective is to describe the epidemiology of bleeding in critically ill children, using a validated clinical tool, as well as the hemostatic interventions and clinical outcomes associated with bleeding. Design: Prospective observational cohort study. Setting: Tertiary pediatric critical care unit Patients: All consecutive patients (1 month to 18 years of age) admitted to a tertiary pediatric critical care unit Measurements and Main Results: Bleeding events were categorized as minimal, moderate, severe, or fatal, according to the Bleeding Assessment Scale in Critically Ill Children. We collected demographics and severity at admission, as evaluated by the Pediatric Index of Mortality. We used regression models to compare the severity of bleeding with outcomes adjusting for age, surgery, and severity. Over 12 months, 902 critically ill patients were enrolled. The median age was 64 months (IQR 17; 159), the median admission predicted risk of mortality was 0.5% (IQR 0.2; 1.4), and 24% were post-surgical. Eighteen percent of patients experienced at least one bleeding event. The highest severity of bleeding was minimal for 7.9% of patients, moderate for 5.8%, severe for 3.8%, and fatal for 0.1%. Adjusting for age, severity at admission, medical diagnosis, type of surgery, and duration of surgery, bleeding severity was independently associated with fewer ventilator-free days (p < 0.001) and fewer PICU-free days (p < 0.001). Adjusting for the same variables, bleeding severity was independently associated with an increased risk of mortality (adjusted odds ratio for each bleeding category 2.4, 95% CI 1.5; 3.7, p < 0.001). Conclusion: Our data indicate bleeding occurs in nearly one-fifth of all critically ill children, and that higher severity of bleeding was independently associated with worse clinical outcome. Further multicenter studies are required to better understand the impact of bleeding in critically ill children.
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Affiliation(s)
- Jake Sequeira
- Division of Pediatric Critical Care Medicine, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, VA, United States
| | - Marianne E Nellis
- Pediatric Critical Care Medicine, NY Presbyterian Hospital - Weill Cornell Medicine, New York, NY, United States
| | - Oliver Karam
- Division of Pediatric Critical Care Medicine, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, VA, United States
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24
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Bayesian analysis of the epidemiology of bleeding in critically ill children. J Crit Care 2020; 63:133-138. [PMID: 33012582 DOI: 10.1016/j.jcrc.2020.09.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 09/22/2020] [Accepted: 09/23/2020] [Indexed: 11/20/2022]
Abstract
PURPOSE We updated our findings on the epidemiology of clinically relevant bleeding (CRB) in critically ill children. We also determined the concordance of CRB as defined by the International Society of Thrombosis and Haemostasis, i.e., ISTH definition, and characteristics identified by pediatric intensivists in a recent survey, i.e., survey definition. METHODS In a prospective cohort study, we included children <18 years old who were admitted to the pediatric intensive care unit for >1 day. We followed them daily for bleeding. Bayesian inference was used as the primary analytic tool to incorporate our prior findings. RESULTS Using the ISTH definition, the estimated frequency of CRB was 10.0% (95% credible interval, CrI: 7.6%, 12.8%) from 41 of 405 children who had CRB. The estimated frequency from 4 of 12 adolescents >13 years old who received mechanical ventilation or vasopressor support and had CRB was 32.9% (95% CrI: 12.0%, 58.8%). Using the survey definition, the estimated frequency of CRB for the entire cohort was 10.8% (95% CrI: 8.3%, 13.8%). Concordance between definitions for each bleeding event was 0.40 (95% confidence interval: 0.27, 0.52). CONCLUSIONS Our updated findings highlight the high frequency of CRB regardless of definition used for CRB.
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25
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The Use of Hemostatic Blood Products in Children Following Cardiopulmonary Bypass and Associated Outcomes. Crit Care Explor 2020; 2:e0172. [PMID: 32832911 PMCID: PMC7418899 DOI: 10.1097/cce.0000000000000172] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
To describe the use of hemostatic transfusions in children following cardiac surgery with cardiopulmonary bypass and the association of hemostatic transfusions postoperatively with clinical outcomes.
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26
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Sochet AA, Wilson EA, Das JR, Berger JT, Ray PE. Plasma and Urinary FGF-2 and VEGF-A Levels Identify Children at Risk for Severe Bleeding after Pediatric Cardiopulmonary Bypass: A Pilot Study. MEDICAL RESEARCH ARCHIVES 2020; 8:2134. [PMID: 33043139 PMCID: PMC7546309 DOI: 10.18103/mra.v8i6.2134] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Severe bleeding after cardiothoracic surgery with cardiopulmonary bypass (CPB) is associated with increased morbidity and mortality in adults and children. Fibroblast Growth Factor-2 (FGF-2) and Vascular Endothelial Growth Factor-A (VEGF-A) induce hemorrhage in murine models with heparin exposure. We aim to determine if plasma and urine levels of FGF-2 and VEGF-A in the immediate perioperative period can identify children with severe bleeding after CPB. We performed a prospective, observational biomarker study in 64 children undergoing CPB for congenital heart disease repair from June 2015 - January 2017 in a tertiary pediatric referral center. Primary outcome was severe bleeding defined as ≥ 20% estimated blood volume loss within 24-hours. Independent variables included perioperative plasma and urinary FGF-2 and VEGF-A levels. Analyses included comparative (Wilcoxon rank sum, Fisher's exact, and Student's t tests) and discriminative (receiver operator characteristic [ROC] curve) analyses. Forty-eight (75%) children developed severe bleeding. Median plasma and urinary FGF-2 and VEGF-A levels were elevated in children with severe bleeding compared to without bleeding (preoperative: plasma FGF-2 = 16[10-35] vs. 9[2-13] pg/ml; urine FGF-2= 28[15-76] vs. 14.5[1.5-22] pg/mg; postoperative: plasma VEGF-A = 146[34-379] vs. 53 [0-134] pg/ml; urine VEGF-A = 132 [52-257] vs. 45[0.1-144] pg/mg; all p < 0.05). ROC curve analyses of combined plasma and urinary FGF-2 and VEGF-A levels discriminated severe postoperative bleeding (AUC: 0.73-0.77) with mean sensitivity and specificity above 80%. We conclude that the perioperative plasma and urinary levels of FGF-2 and VEGF-A discriminate risk of severe bleeding after pediatric CPB.
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Affiliation(s)
- Anthony A Sochet
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Health System, 111 Michigan Ave NW, Washington, DC 20010
| | - Elizabeth A Wilson
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Health System, 111 Michigan Ave NW, Washington, DC 20010
| | - Jharna R Das
- Nephrology, Department of Pediatrics, Children's National Health System, 111 Michigan Ave NW, Washington, DC 20010
| | - John T Berger
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Health System, 111 Michigan Ave NW, Washington, DC 20010
- Cardiology, Department of Pediatrics, Children's National Health System, 111 Michigan Ave NW, Washington, DC 20010
| | - Patricio E Ray
- Nephrology, Department of Pediatrics, Children's National Health System, 111 Michigan Ave NW, Washington, DC 20010
- Cardiology, Department of Pediatrics, Children's National Health System, 111 Michigan Ave NW, Washington, DC 20010
- Child Health Research Center, Department of Pediatrics, University of Virginia, School of Medicine, Charlottesville, VA 22980
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