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The Impact of Restrictive Transfusion Practices on Hemodynamically Stable Critically Ill Children Without Heart Disease: A Secondary Analysis of the Age of Blood in Children in the PICU Trial. Pediatr Crit Care Med 2023; 24:84-92. [PMID: 36661416 DOI: 10.1097/pcc.0000000000003128] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES Guidelines recommend against RBC transfusion in hemodynamically stable (HDS) children without cardiac disease, if hemoglobin is greater than or equal to 7 g/dL. We sought to assess the clinical and economic impact of compliance with RBC transfusion guidelines. DESIGN A nonprespecified secondary analysis of noncardiac, HDS patients in the randomized trial Age of Blood in Children (NCT01977547) in PICUs. Costs analyzed included ICU stay and physician fees. Stabilized inverse propensity for treatment weighting was used to create a cohort balanced with respect to potential confounding variables. Weighted regression models were fit to evaluate outcomes based on guideline compliance. SETTING Fifty international tertiary care centers. PATIENTS Critically ill children 3 days to 16 years old transfused RBCs at less than or equal to 7 days of ICU admission. Six-hundred eighty-seven subjects who met eligibility criteria were included in the analysis. INTERVENTIONS Initial RBC transfusions administered when hemoglobin was less than 7 g/dL were considered "compliant" or "non-compliant" if hemoglobin was greater than or equal to 7 g/dL. MEASUREMENTS AND MAIN RESULTS Frequency of new or progressive multiple organ system dysfunction (NPMODS), ICU survival, and associated costs. The hypothesis was formulated after data collection but exposure groups were masked until completion of planned analyses. Forty-nine percent of patients (338/687) received a noncompliant initial transfusion. Weighted cohorts were balanced with respect to confounding variables (absolute standardized differences < 0.1). No differences were noted in NPMODS frequency (relative risk, 0.86; 95% CI, 0.61-1.22; p = 0.4). Patients receiving compliant transfusions had more ICU-free days (mean difference, 1.73; 95% CI, 0.57-2.88; p = 0.003). Compliance reduced mean costs in ICU by $38,845 U.S. dollars per patient (95% CI, $65,048-$12,641). CONCLUSIONS Deferring transfusion until hemoglobin is less than 7 g/dL is not associated with increased organ dysfunction in this population but is independently associated with increased likelihood of live ICU discharge and lower ICU costs.
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Gammon RR, Al-Mozain N, Auron M, Bocquet C, Clem S, Gupta GK, Hensch L, Klein N, Lea NC, Mandal S, Pelletier P, Resheidat A, Yossi Schwartz J. Transfusion therapy of neonatal and paediatric patients: They are not just little adults. Transfus Med 2022; 32:448-459. [PMID: 36207985 DOI: 10.1111/tme.12921] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 08/01/2022] [Accepted: 09/11/2022] [Indexed: 11/28/2022]
Abstract
Patient blood management (PBM) strategies are needed in the neonate and paediatric population, given that haemoglobin thresholds used are often higher than recommended by evidence, with exposure of children to potential complications without meaningful benefit. A literature review was performed on the following topics: evidence-based transfusions of blood components and pharmaceutical agents. Other topics reviewed included perioperative coagulation assessment and perioperative PBM. The Transfusion and Anaemia Expertise Initiative (TAXI) consortium published a consensus statement addressing haemoglobin (Hb) transfusion threshold in multiple subsets of patients. A multicentre trial (PlaNeT-2) reported a higher risk of bleeding and death or serious new bleeding among infants who received platelet transfusion at a higher (50 000/μl) compared to a lower (25 000/μl) threshold. Recent data support the use of a restrictive transfusion threshold of 25 000/μl for prophylactic platelet transfusions in preterm neonates. The TAXI-CAB consortium mentioned that in critically ill paediatric patients undergoing invasive procedures outside of the operating room, platelet transfusion might be considered when the platelet count is less than or equal to 20 000/μl and there is no benefit of platelet transfusion when the platelet count is more than 50 000/μl. There are limited controlled studies in paediatric and neonatal population regarding plasma transfusion. Blood conservation strategies to minimise allogenic blood exposure are essential to positive patient outcomes neonatal and paediatric transfusion practices have changed significantly in recent years since randomised controlled trials were published to guide practice. Additional studies are needed in order to provide practice change recommendations.
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Affiliation(s)
| | - Nour Al-Mozain
- King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia.,Whittington Health NHS Trust, London, UK
| | | | - Christopher Bocquet
- Association for the Advancement of Blood and Biotherapies, Bethesda, Maryland, USA
| | - Sam Clem
- American Red Cross, Fort Wayne, Indiana, USA
| | - Gaurav K Gupta
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Lisa Hensch
- Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Norma Klein
- University of California, Davis, California, USA
| | | | | | | | - Ashraf Resheidat
- Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
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Steffen KM, Spinella PC, Holdsworth LM, Ford MA, Lee GM, Asch SM, Proctor EK, Doctor A. Factors Influencing Implementation of Blood Transfusion Recommendations in Pediatric Critical Care Units. Front Pediatr 2021; 9:800461. [PMID: 34976903 PMCID: PMC8718763 DOI: 10.3389/fped.2021.800461] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 11/25/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose: Risks of red blood cell transfusion may outweigh benefits for many patients in Pediatric Intensive Care Units (PICUs). The Transfusion and Anemia eXpertise Initiative (TAXI) recommendations seek to limit unnecessary and potentially harmful transfusions, but use has been variable. We sought to identify barriers and facilitators to using the TAXI recommendations to inform implementation efforts. Materials and Methods: The integrated Promoting Action on Research Implementation in Health Services (iPARIHS) framework guided semi-structured interviews conducted in 8 U.S. ICUs; 50 providers in multiple ICU roles completed interviews. Adapted Framework analysis, a form of content analysis, used the iPARIHS innovation, recipient, context and facilitation constructs and subconstructs to categorize data and identify patterns as well as unique informative statements. Results: Providers perceived that the TAXI recommendations would reduce transfusion rates and practice variability, but adoption faced challenges posed by attitudes around transfusion and care in busy and complex units. Development of widespread buy-in and inclusion in implementation, integration into workflow, designating committed champions, and monitoring outcomes data were expected to enhance implementation. Conclusions: Targeted activities to create buy-in, educate, and plan for use are necessary for TAXI implementation. Recognition of contextual challenges posed by the PICU environment and an approach that adjusts for barriers may optimize adoption.
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Affiliation(s)
- Katherine M Steffen
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Stanford University, Palo Alto, CA, United States
| | - Philip C Spinella
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University in Saint Louis, Saint Louis, MO, United States
| | - Laura M Holdsworth
- Department of Medicine, Primary Care and Population Health, Stanford University, Stanford, CA, United States
| | - Mackenzie A Ford
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Palo Alto, CA, United States
| | - Grace M Lee
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Stanford University, Stanford, CA, United States
| | - Steven M Asch
- Department of Medicine, Primary Care and Population Health, Stanford University, Stanford, CA, United States
| | - Enola K Proctor
- George Warren Brown School of Social Work, Washington University in St. Louis, St. Louis, MO, United States
| | - Allan Doctor
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Maryland, Baltimore, MD, United States
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Abstract
OBJECTIVES To critically assess available high-level clinical studies regarding RBC transfusion strategies, with a focus on hemoglobin transfusion thresholds in the ICU. DATA SOURCES Source data were obtained from a PubMed literature review. STUDY SELECTION English language studies addressing RBC transfusions in the ICU with a focus on the most recent relevant studies. DATA EXTRACTION Relevant studies were reviewed and the following aspects of each study were identified, abstracted, and analyzed: study design, methods, results, and implications for critical care practice. DATA SYNTHESIS Approximately 30-50% of ICU patients receive a transfusion during their hospitalization with anemia being the indication for 75% of transfusions. A significant body of clinical research evidence supports using a restrictive transfusion strategy (e.g., hemoglobin threshold < 7 g/dL) compared with a more liberal approach (e.g., hemoglobin threshold < 10 g/dL). A restrictive strategy (hemoglobin < 7 g/dL) is recommended in patients with sepsis and gastrointestinal bleeds. A slightly higher restrictive threshold is recommended in cardiac surgery (hemoglobin < 7.5 g/dL) and stable cardiovascular disease (hemoglobin < 8 g/dL). Although restrictive strategies are generally supported in hematologic malignancies, acute neurologic injury, and burns, more definitive studies are needed, including acute coronary syndrome. Massive transfusion protocols are the mainstay of treatment for hemorrhagic shock; however, the exact RBC to fresh frozen plasma ratio is still unclear. There are also emerging complimentary practices including nontransfusion strategies to avoid and treat anemia and the reemergence of whole blood transfusion. CONCLUSIONS The current literature supports the use of restrictive transfusion strategies in the majority of critically ill populations. Continued studies of optimal transfusion strategies in various patient populations, coupled with the integration of novel complementary ICU practices, will continue to enhance our ability to treat critically ill patients.
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Abstract
OBJECTIVES To summarize current bleeding scales and their validation to assess applicability to bleeding in critically ill children. DATA SOURCES We conducted electronic searches of Ovid MEDLINE, Ovid EMBASE, Cochrane Library, and Web of Science Core Collection databases from database inception to 2017. STUDY SELECTION Included studies contained a bleeding score, bleeding measurement tool, or clinical measurement of hemorrhage. DATA EXTRACTION We identified 2,097 unique citations; 20 full-text articles were included in the final review. DATA SYNTHESIS Of the 18 studies that included subjects (two others were expert consensus definitions), seven (39%) were pediatric-only, seven (39%) were adult-only, and four (22%) included both adults and children. Nine (50%) occurred with inpatients (two studies in critical care units), seven (39%) involved outpatients and two (11%) included both inpatients and outpatients. Thirty-nine percent of the scales were developed for those with idiopathic thrombocytopenic purpura and only two (12%) described critically ill patients. The majority (80%) included need for treatment (either RBC transfusion or surgical intervention). The majority (65%) did not report measures of reliability or validation to clinical outcomes. CONCLUSIONS There is a lack of validated bleeding scales to adequately assess bleeding and outcomes in critically ill children. Validated scales of bleeding are necessary and urgently needed.
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Sauro K, Bagshaw SM, Niven D, Soo A, Brundin-Mather R, Parsons Leigh J, Cook DJ, Stelfox HT. Barriers and facilitators to adopting high value practices and de-adopting low value practices in Canadian intensive care units: a multimethod study. BMJ Open 2019; 9:e024159. [PMID: 30878979 PMCID: PMC6429967 DOI: 10.1136/bmjopen-2018-024159] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To compare and contrast illustrative examples of the adoption of high value practices and the de-adoption of low value practices. DESIGN (1) Retrospective, population-based audit of low molecular weight heparin (LMWH) for venous thromboembolism (VTE) prophylaxis (high value practice) and albumin for fluid resuscitation (low value practice) and (2) cross-sectional survey of healthcare providers. SETTING Data were collected from nine adult medical-surgical intensive care units (ICUs) in two large Canadian cities. Patients are managed in these ICUs by a group of multiprofessional and multidisciplinary healthcare providers. PARTICIPANTS Participants included 6946 ICU admissions and 309 healthcare providers from the same ICUs. MAIN OUTCOME MEASURES (1) The use of LMWH for VTE prophylaxis (per cent ICU days) and albumin for fluid resuscitation (per cent of patients); and (2) provider knowledge of evidence underpinning these practices, and barriers and facilitators to adopt and de-adopt these practices. RESULTS LMWH was administered on 38.7% of ICU days, and 20.0% of patients received albumin.Most participants had knowledge of evidence underpinning VTE prophylaxis and fluid resuscitation (59.1% and 84.2%, respectively). Providers perceived these practices to be followed. The most commonly reported barrier to adoption was insufficient knowledge/understanding (32.8%), and to de-adoption was clinical leader preferences (33.2%). On-site education was the most commonly identified facilitator for adoption and de-adoption (67.8% and 68.6%, respectively). CONCLUSIONS Despite knowledge of and self-reported adherence to best practices, the audit demonstrated opportunity to improve. Provider-reported barriers and facilitators to adoption and de-adoption are broadly similar.
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Affiliation(s)
- Khara Sauro
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sean M Bagshaw
- Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Daniel Niven
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Andrea Soo
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Jeanna Parsons Leigh
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Deborah J Cook
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Henry Thomas Stelfox
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
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7
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Voigt CD, Hundeshagen G, Malagaris I, Watson K, Obiarinze RN, Hasanpour H, Woodson LC, Capek KD, Lee JO, Nunez Lopez O, Cambiaso-Daniel J, Branski LK, Norbury WB, Finnerty CC, Herndon DN. Effects of a restrictive blood transfusion protocol on acute pediatric burn care: Transfusion threshold in pediatric burns. J Trauma Acute Care Surg 2018; 85:1048-1054. [PMID: 30252776 PMCID: PMC6280964 DOI: 10.1097/ta.0000000000002068] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Blood transfusion is costly and associated with various medical risks. Studies in critically ill adult and pediatric patients suggest that implementation of more restrictive transfusion protocols based on lower threshold hemoglobin concentrations can be medically and economically advantageous. The purpose of this study was to evaluate the implications of a hemoglobin threshold change in pediatric burn patients. METHODS We implemented a change in hemoglobin threshold from 10 g/dL to 7 g/dL and compared data from patients before and after this protocol change in a retrospective review. Primary endpoints were hemoglobin concentration at baseline, before transfusion, and after transfusion; amount of blood product administered; and mortality. Secondary endpoints were the incidence of sepsis based on the American Burn Association physiological criteria for sepsis and mean number of septic days per patient. All endpoint analyses were adjusted for relevant clinical covariates via generalized additive models or Cox proportional hazard model. Statistical significance was accepted at p less than 0.05. RESULTS Patient characteristics and baseline hemoglobin concentrations (pre, 13.5 g/dL; post, 13.3 g/dL; p > 0.05) were comparable between groups. The group transfused based on the more restrictive hemoglobin threshold had lower hemoglobin concentrations before and after transfusion throughout acute hospitalization, received lower volumes of blood during operations (pre, 1012 mL; post, 824 mL; p < 0.001) and on days without surgical procedures (pre, 602 mL; post, 353 mL; p < 0.001), and had a lower mortality (pre, 8.0%; post, 3.9%; mortality hazard decline, 0.55 [45%]; p < 0.05). Both groups had a comparable incidence of physiological sepsis, though the more restrictive threshold group had a lower number of sepsis days per patient. CONCLUSION More restrictive transfusion protocols are safe and efficacious in pediatric burn patients. The associated reduction of transfused blood may lessen medical risks of blood transfusion and lower economic burden. LEVEL OF EVIDENCE Therapeutic, level IV.
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Affiliation(s)
- Charles D Voigt
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
- Shriners Hospitals for Children®—Galveston, 815 Market St, Galveston, TX 77550
- Department of Surgery, Creighton University, 7710 Mercy Road, Omaha, NE 68124
| | - Gabriel Hundeshagen
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
- Shriners Hospitals for Children®—Galveston, 815 Market St, Galveston, TX 77550
- Department of Hand, Plastic and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen; University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
| | - Ioannis Malagaris
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
- Shriners Hospitals for Children®—Galveston, 815 Market St, Galveston, TX 77550
| | - Kaitlin Watson
- School of Allied Health Sciences, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030
| | - Ruth N Obiarinze
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
- Shriners Hospitals for Children®—Galveston, 815 Market St, Galveston, TX 77550
| | - Houman Hasanpour
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
- Shriners Hospitals for Children®—Galveston, 815 Market St, Galveston, TX 77550
| | - Lee C Woodson
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
- Shriners Hospitals for Children®—Galveston, 815 Market St, Galveston, TX 77550
| | - Karel D Capek
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
- Shriners Hospitals for Children®—Galveston, 815 Market St, Galveston, TX 77550
| | - Jong O Lee
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
- Shriners Hospitals for Children®—Galveston, 815 Market St, Galveston, TX 77550
- Institute for Translational Sciences, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
| | - Omar Nunez Lopez
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
- Shriners Hospitals for Children®—Galveston, 815 Market St, Galveston, TX 77550
| | - Janos Cambiaso-Daniel
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
- Shriners Hospitals for Children®—Galveston, 815 Market St, Galveston, TX 77550
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Austria
| | - Ludwik K Branski
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
- Shriners Hospitals for Children®—Galveston, 815 Market St, Galveston, TX 77550
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Austria
| | - William B Norbury
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
- Shriners Hospitals for Children®—Galveston, 815 Market St, Galveston, TX 77550
| | - Celeste C Finnerty
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
- Shriners Hospitals for Children®—Galveston, 815 Market St, Galveston, TX 77550
- Institute for Translational Sciences, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
| | - David N Herndon
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
- Shriners Hospitals for Children®—Galveston, 815 Market St, Galveston, TX 77550
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Austria
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Valentine SL, Bembea MM, Muszynski JA, Cholette JM, Doctor A, Spinella PC, Steiner ME, Tucci M, Hassan NE, Parker RI, Lacroix J, Argent A, Carson JL, Remy KE, Demaret P, Emeriaud G, Kneyber MCJ, Guzzetta N, Hall MW, Macrae D, Karam O, Russell RT, Stricker PA, Vogel AM, Tasker RC, Turgeon AF, Schwartz SM, Willems A, Josephson CD, Luban NLC, Lehmann LE, Stanworth SJ, Zantek ND, Bunchman TE, Cheifetz IM, Fortenberry JD, Delaney M, van de Watering L, Robinson KA, Malone S, Steffen KM, Bateman ST. Consensus Recommendations for RBC Transfusion Practice in Critically Ill Children From the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. Pediatr Crit Care Med 2018; 19:884-898. [PMID: 30180125 PMCID: PMC6126913 DOI: 10.1097/pcc.0000000000001613] [Citation(s) in RCA: 105] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES To date, there are no published guidelines to direct RBC transfusion decision-making specifically for critically ill children. We present the recommendations from the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. DESIGN Consensus conference series of multidisciplinary, international experts in RBC transfusion management of critically ill children. SETTING Not applicable. INTERVENTION None. SUBJECTS Children with, or children at risk for, critical illness who receive or are at risk for receiving a RBC transfusion. METHODS A panel of 38 content and four methodology experts met over the course of 2 years to develop evidence-based, and when evidence lacking, expert consensus-based recommendations regarding decision-making for RBC transfusion management and research priorities for transfusion in critically ill children. The experts focused on nine specific populations of critically ill children: general, respiratory failure, nonhemorrhagic shock, nonlife-threatening bleeding or hemorrhagic shock, acute brain injury, acquired/congenital heart disease, sickle cell/oncology/transplant, extracorporeal membrane oxygenation/ventricular assist/ renal replacement support, and alternative processing. Data to formulate evidence-based and expert consensus recommendations were selected based on searches of PubMed, EMBASE, and Cochrane Library from 1980 to May 2017. Agreement was obtained using the Research and Development/UCLA Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. MEASUREMENTS AND RESULTS The Transfusion and Anemia Expertise Initiative consensus conference developed and reached consensus on a total of 102 recommendations (57 clinical [20 evidence based, 37 expert consensus], 45 research recommendations). All final recommendations met agreement, defined a priori as greater than 80%. A decision tree to aid clinicians was created based on the clinical recommendations. CONCLUSIONS The Transfusion and Anemia Expertise Initiative recommendations provide important clinical guidance and applicable tools to avoid unnecessary RBC transfusions. Research recommendations identify areas of focus for future investigation to improve outcomes and safety for RBC transfusion.
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Affiliation(s)
- Stacey L Valentine
- Division of Pediatric Critical Care, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Jennifer A Muszynski
- Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH
- The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Jill M Cholette
- Department of Pediatrics, University of Rochester, Rochester, NY
| | - Allan Doctor
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Phillip C Spinella
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Marie E Steiner
- Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | - Marisa Tucci
- Department of Pediatrics, University of Montreal, Montreal, QC, Canada
| | - Nabil E Hassan
- Department of Pediatrics, University of Illinois College of Medicine, Peoria, IL
| | - Robert I Parker
- Department of Pediatrics, Stony Brook University, Stony Brook, NY
| | - Jacques Lacroix
- Department of Pediatrics, University of Montreal, Montreal, QC, Canada
| | - Andrew Argent
- Department of Pediatrics, University of Cape Town, Cape Town, South Africa
| | - Jeffrey L Carson
- Department of Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Kenneth E Remy
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | | | | | - Martin C J Kneyber
- Department of Pediatrics, University of Groningen, Groningen, The Netherlands
| | - Nina Guzzetta
- Department of Anesthesiology, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA
| | - Mark W Hall
- Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH
- The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Duncan Macrae
- Pediatric Critical Care, Royal Brompton Hospital, London, United Kingdom
| | - Oliver Karam
- Department of Pediatrics, Professor and Director Pediatric Nephrology, Childrens Hospital of Richmond, Virginia Commonwealth University, Richmond, VA
| | - Robert T Russell
- Department of Surgery, University of Alabama Birmingham, Birmingham, AL
| | - Paul A Stricker
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA
| | - Adam M Vogel
- Division of Pediatric Surgery and Pediatrics, Baylor College of Medicine, Houston, TX
| | - Robert C Tasker
- Departments of Neurology and Anesthesia (Pediatrics), Harvard Medical School, Boston, MA
| | - Alexis F Turgeon
- Department of Anesthesiology and Critical Care Medicine, Univesite Laval Research Center, Quebec City, QC, Canada
| | - Steven M Schwartz
- Department of Critical Care Medicine and Paediatrics, University of Toronto, ON, Canada
| | - Ariane Willems
- Pediatric Intensive Care Unit, University of Brussels, Brussels, Belgium
| | - Cassandra D Josephson
- Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA
| | - Naomi L C Luban
- Department of Pediatrics and Pathology, George Washington University, Washington, DC
| | | | - Simon J Stanworth
- Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Nicole D Zantek
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN
| | - Timothy E Bunchman
- Department of Pediatrics, Professor and Director Pediatric Nephrology, Childrens Hospital of Richmond, Virginia Commonwealth University, Richmond, VA
| | | | - James D Fortenberry
- Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA
| | - Meghan Delaney
- Division of Pathology and Laboratory Medicine, Children's National Health System, Washington, DC
| | | | - Karen A Robinson
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sara Malone
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Katherine M Steffen
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | - Scot T Bateman
- Division of Pediatric Critical Care, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA
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Walsh TS, Juffermans NP. New blood for old? High quality evidence that fresh red blood cells confer no benefit for critically ill patients. Intensive Care Med 2018. [PMID: 29541789 DOI: 10.1007/s00134-018-5106-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Timothy S Walsh
- Department of Anaesthesia, Critical Care and Pain Medicine, University of Edinburgh, Royal Infirmary of Edinburgh, Room S8208, 2nd Floor, 51 Little France Crescent, Edinburgh, EH16 4SA, Scotland
| | - Nicole P Juffermans
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, Room G3-206, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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10
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Affiliation(s)
- Scott D. Halpern
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania Perelman School of Medicine, Philadelphia PA, 19146
- Center for Health Incentives and Behavioral Economics (CHIBE), Leonard Davis Institute of Health Economics, University of Pennsylvania
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine
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11
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Determinants and time to blood transfusion among thermal burn patients admitted to Mulago Hospital. BMC Res Notes 2017; 10:258. [PMID: 28683773 PMCID: PMC5501556 DOI: 10.1186/s13104-017-2580-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Accepted: 06/28/2017] [Indexed: 11/28/2022] Open
Abstract
Background Blood transfusion, a practice under re-evaluation in general, remains common among thermal burn patients due to the hematological alterations associated with burns that manifest as anemia. Today advocacy is for restrictive blood transfusion taking into account individual patient characteristics. We went out to identify the parameters that may determine transfusion requirement and the time to blood transfusion for thermal burn patients in Mulago Hospital in order to build statistics and a basis to standardize future practice and Hospital protocol. Methods 112 patients with thermal burns were enrolled into a prospective cohort study conducted in the Surgical Unit of the Accidents and Emergency Department and Burns Unit of Mulago Hospital. Relevant data on pre-injury, injury and post-injury factors was collected including relevant laboratory investigations and treatment modalities like surgical intervention. Patients were clinically followed up for a maximum period of 28 days and we identified those that were transfused. Results 22.3% of patients were transfused. The median time to transfusion was 17 days from time of injury and varied with different patient characteristics. The median pre-transfusion hemoglobin (Hb) level was 8.2 g/dL. Transfusion was significantly related to; admission to the intensive care unit (p = 0.001), a body mass index (BMI) <2 kg/m2 (p = 0.021), % total burn surface area (TBSA) >20 (p = 0.049), pre-existing illness (p = 0.046), and white blood cell (WBC) count <4000 or >12,000/μL (p = 0.05). Conclusion Pre-existing illnesses, a low BMI, TBSA of >20%, admission to the intensive care unit and abnormalities in the WBC count are useful predictors of blood transfusion among thermal burns patients admitted to Mulago Hospital. The precise time to transfusion from time of burns injury cannot be generalized. With close monitoring of each individual patient lies the appropriateness and timeliness of their management.
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Evaluation of RBC Transfusion Practice in Adult ICUs and the Effect of Restrictive Transfusion Protocols on Routine Care. Crit Care Med 2017; 45:271-281. [PMID: 27632673 DOI: 10.1097/ccm.0000000000002077] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Research supports the efficacy and safety of restrictive transfusion protocols to reduce avoidable RBC transfusions, but evidence of their effectiveness in practice is limited. This study assessed whether admission to an ICU with an restrictive transfusion protocol reduces the likelihood of transfusion for adult patients. DESIGN Observational study using data from the multicenter, cohort Critical Illness Outcomes Study. Patient-level analyses were conducted with RBC transfusion on day of enrollment as the outcome and admission to an ICU with a restrictive transfusion protocol as the exposure of interest. Covariates included demographics, hospital course (e.g., lowest hematocrit, blood loss), severity of illness (e.g., Sequential Organ Failure Assessment score), interventions (e.g., sedation/analgesia), and ICU characteristics (e.g., size). Multivariable logistic regression modeling assessed the independent effects of restrictive transfusion protocols on transfusions. SETTING Fifty-nine U.S. ICUs. PATIENTS A total of 6,027 adult ICU patients. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of the 59 study ICUs, 24 had an restrictive transfusion protocol; 2,510 patients (41.6%) were in an ICU with an restrictive transfusion protocol. The frequency of RBC transfusion among patients with severe (hematocrit, < 21%), moderate (hematocrit, 21-30%), and mild (hematocrit, > 30%) anemia in restrictive transfusion protocol ICUs was 67%, 19%, and 4%, respectively, compared with 60%, 14%, and 2% for those in ICUs without an restrictive transfusion protocol. Only 27% of transfusions were associated with a hematocrit less than 21%. Adjusting for confounding factors, restrictive transfusion protocols independently reduced the odds of transfusion in moderate anemia with an odds ratio of 0.59 (95% CI, 0.36-0.96) while demonstrating no effect in mild (p = 0.93) or severe (p = 0.52) anemia. CONCLUSIONS In this sample of ICU patients, transfusions often occurred outside evidence-based guidelines, but admission to an ICU with an restrictive transfusion protocol did reduce the risk of transfusion in moderately anemic patients controlling for patient and ICU factors. This study supports the effectiveness of restrictive transfusion protocols for influencing transfusions in clinical practice.
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Fusaro MV, Nielsen ND, Nielsen A, Fontaine MJ, Hess JR, Reed RM, DeLisle S, Netzer G. Restrictive versus liberal red blood cell transfusion strategy after hip surgery: a decision model analysis of healthcare costs. Transfusion 2016; 57:357-366. [DOI: 10.1111/trf.13936] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 08/26/2016] [Accepted: 08/26/2016] [Indexed: 01/28/2023]
Affiliation(s)
- Mario V. Fusaro
- Division of Pulmonary and Critical Care Medicine; Tulane University School of Medicine; New Orleans Louisiana
| | - Nathan D. Nielsen
- Section of Pulmonary Diseases, Critical Care and Environmental Medicine; Tulane University School of Medicine; New Orleans Louisiana
| | - Alexandra Nielsen
- Department of Systems Science; Portland State University; Portland Oregon
| | - Magali J. Fontaine
- Department of Pathology; University of Maryland School of Medicine; Baltimore Maryland
| | - John R. Hess
- Division of Laboratory Medicine and Hematology; University of Washington Harborview Medical Center; Seattle Washington
| | - Robert M. Reed
- Division of Pulmonary and Critical Care Medicine; Tulane University School of Medicine; New Orleans Louisiana
| | - Sylvain DeLisle
- Division of Pulmonary and Critical Care Medicine; Tulane University School of Medicine; New Orleans Louisiana
| | - Giora Netzer
- Division of Pulmonary and Critical Care Medicine; Tulane University School of Medicine; New Orleans Louisiana
- Department of Epidemiology and Public Health; University of Maryland School of Medicine; Baltimore Maryland
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Niven DJ, Mrklas KJ, Holodinsky JK, Straus SE, Hemmelgarn BR, Jeffs LP, Stelfox HT. Towards understanding the de-adoption of low-value clinical practices: a scoping review. BMC Med 2015; 13:255. [PMID: 26444862 PMCID: PMC4596285 DOI: 10.1186/s12916-015-0488-z] [Citation(s) in RCA: 206] [Impact Index Per Article: 22.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 09/15/2015] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Low-value clinical practices are common in healthcare, yet the optimal approach to de-adopting these practices is unknown. The objective of this study was to systematically review the literature on de-adoption, document current terminology and frameworks, map the literature to a proposed framework, identify gaps in our understanding of de-adoption, and identify opportunities for additional research. METHODS MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, the Cochrane Database of Abstracts and Reviews of Effects, and CINAHL Plus were searched from 1 January 1990 to 5 March 2014. Additional citations were identified from bibliographies of included citations, relevant websites, the PubMed 'related articles' function, and contacting experts in implementation science. English-language citations that referred to de-adoption of clinical practices in adults with medical, surgical, or psychiatric illnesses were included. Citation selection and data extraction were performed independently and in duplicate. RESULTS From 26,608 citations, 109 were included in the final review. Most citations (65%) were original research with the majority (59%) published since 2010. There were 43 unique terms referring to the process of de-adoption-the most frequently cited was "disinvest" (39% of citations). The focus of most citations was evaluating the outcomes of de-adoption (50%), followed by identifying low-value practices (47%), and/or facilitating de-adoption (40%). The prevalence of low-value practices ranged from 16% to 46%, with two studies each identifying more than 100 low-value practices. Most articles cited randomized clinical trials (41%) that demonstrate harm (73%) and/or lack of efficacy (63%) as the reason to de-adopt an existing clinical practice. Eleven citations described 13 frameworks to guide the de-adoption process, from which we developed a model for facilitating de-adoption. Active change interventions were associated with the greatest likelihood of de-adoption. CONCLUSIONS This review identified a large body of literature that describes current approaches and challenges to de-adoption of low-value clinical practices. Additional research is needed to determine an ideal strategy for identifying low-value practices, and facilitating and sustaining de-adoption. In the meantime, this study proposes a model that providers and decision-makers can use to guide efforts to de-adopt ineffective and harmful practices.
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Affiliation(s)
- Daniel J Niven
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, T1Y 6J4, Canada. .,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, T2N 4Z6, Canada.
| | - Kelly J Mrklas
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, T2N 4Z6, Canada.
| | - Jessalyn K Holodinsky
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, T2N 4Z6, Canada.
| | - Sharon E Straus
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, M5B 1T8, Canada.
| | - Brenda R Hemmelgarn
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, T2N 4Z6, Canada. .,Department of Medicine, University of Calgary, Calgary, Alberta, T2N 4Z6, Canada.
| | - Lianne P Jeffs
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, M5B 1T8, Canada.
| | - Henry Thomas Stelfox
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, T1Y 6J4, Canada. .,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, T2N 4Z6, Canada. .,Department of Medicine, University of Calgary, Calgary, Alberta, T2N 4Z6, Canada.
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Mirski MA, Frank SM, Kor DJ, Vincent JL, Holmes DR. Restrictive and liberal red cell transfusion strategies in adult patients: reconciling clinical data with best practice. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:202. [PMID: 25939346 PMCID: PMC4419449 DOI: 10.1186/s13054-015-0912-y] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Red blood cell (RBC) transfusion guidelines correctly promote a general restrictive transfusion approach for anemic hospitalized patients. Such recommendations have been derived from evaluation of specific patient populations, and it is important to recognize that engaging a strict guideline approach has the potential to incur harm if the clinician fails to provide a comprehensive review of the patient’s physiological status in determining the benefit and risks of transfusion. We reviewed the data in support of a restrictive or a more liberal RBC transfusion practice, and examined the quality of the datasets and manner of their interpretation to provide better context by which a physician can make a sound decision regarding RBC transfusion therapy. Reviewed studies included PubMed-cited (1974 to 2013) prospective randomized clinical trials, prospective subset analyses of randomized studies, nonrandomized controlled trials, observational case series, consecutive and nonconsecutive case series, and review articles. Prospective randomized clinical trials were acknowledged and emphasized as the best-quality evidence. The results of the analysis support that restrictive RBC transfusion practices appear safe in the hospitalized populations studied, although patients with acute coronary syndromes, traumatic brain injury and patients at risk for brain or spinal cord ischemia were not well represented in the reviewed studies. The lack of quality data regarding the purported adverse effects of RBC transfusion at best suggests that restrictive strategies are no worse than liberal strategies under the studied protocol conditions, and RBC transfusion therapy in the majority of instances represents a marker for greater severity of illness. The conclusion is that in the majority of clinical settings a restrictive RBC transfusion strategy is cost-effective, reduces the risk of adverse events specific to transfusion, and introduces no harm. In anemic patients with ongoing hemorrhage, with risk of significant bleeding, or with concurrent ischemic brain, spinal cord, or myocardium, the optimal hemoglobin transfusion trigger remains unknown. Broad-based adherence to guideline approaches of therapy must respect the individual patient condition as interpreted by comprehensive clinical review.
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Affiliation(s)
- Marek A Mirski
- Johns Hopkins Medical Institutions, 1800 Orleans Street, Phipps 455b, Baltimore, MD, 21287, USA.
| | - Steven M Frank
- Johns Hopkins Medical Institutions, 1800 Orleans Street, Phipps 455b, Baltimore, MD, 21287, USA.
| | - Daryl J Kor
- Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Jean-Louis Vincent
- Erasme Hospital, Free University of Brussels, Route de Lennik 808, 1070, Bruxelles, Belgium.
| | - David R Holmes
- Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN, 55905, USA.
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Corwin HL, Theus JW, Cargile CS, Lang NP. Red blood cell transfusion: impact of an education program and a clinical guideline on transfusion practice. J Hosp Med 2014; 9:745-9. [PMID: 25044275 DOI: 10.1002/jhm.2237] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Revised: 06/20/2014] [Accepted: 06/28/2014] [Indexed: 11/09/2022]
Abstract
BACKGROUND Red blood cell (RBC) transfusion guidelines have been developed by professional societies. These guidelines recommend a restrictive RBC transfusion practice for most clinical populations. Despite the consistency of guidelines and limited evidence for RBC transfusion efficacy, there is variability in RBC transfusion practice. METHODS A program was initiated in a tertiary medical center to align RBC transfusion practice with best-practice RBC transfusion guidelines. The program included an educational program, followed after 6 months by RBC transfusion decision support that included the approval of a best-practice RBC transfusion guideline by the hospital medical board and an RBC transfusion order form that included the guideline recommendations. RBC transfusion practice was followed over an 18-month period and compared with transfusion practice over the prior 18 months. The primary outcome variables were adult inpatient RBC units transfused, RBC units per admission, and RBC units per 100 patient-days. RESULTS The mean RBC units transfused decreased with initiation of each component of the program: from 923 ± 68 units to 852 ± 40 (P = 0.025) with education and further to 690 ± 52 (P < 0.0001) with the RBC transfusion decision support. Similarly, RBC transfusions per 100 patient-days fell from 10.56 ± 0.80 to 9.69 ± 0.49 (P = 0.02) and to 7.68 ± 0.63 (P = 0.0001) during the 3 time periods. CONCLUSION An education program coupled with institutional adoption of a best-practice RBC transfusion guideline and RBC transfusion order set resulted in a reduction in total RBC units transfused.
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Affiliation(s)
- Howard L Corwin
- Department of Medicine, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
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Halpern SD, Becker D, Curtis JR, Fowler R, Hyzy R, Kaplan LJ, Rawat N, Sessler CN, Wunsch H, Kahn JM. An Official American Thoracic Society/American Association of Critical-Care Nurses/American College of Chest Physicians/Society of Critical Care Medicine Policy Statement: The Choosing Wisely® Top 5 List in Critical Care Medicine. Am J Respir Crit Care Med 2014; 190:818-26. [DOI: 10.1164/rccm.201407-1317st] [Citation(s) in RCA: 104] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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