Respiratory Dysfunction Associated With RBC Transfusion in Critically Ill Children: A Prospective Cohort Study

Transfusion policy in pediatric extracorporeal membrane oxygenation patients: Less could be more

OBJECTIVE

To evaluate a restrictive transfusion policy of red blood cells (RBC) and platelets in pediatric patients submitted to extracorporeal membrane oxygenation (ECMO).

METHODS

Retrospective descriptive study of pediatric patients supported with ECMO, from January 2010 to December 2019. Hemoglobin, platelet, lactate and mixed venous oxygen saturation (SvO2) values of each patient while on ECMO, were collected. Transfusion efficiency and tissue oxygenation were statistically evaluated comparing pre-transfusion hemoglobin, lactate and SvO2 with post-transfusion values. Ranges of hemoglobin and platelets were established, and the number of transfusions registered. The bleeding complications and outcome were documented.

RESULTS

Of a total of 1016 hemoglobin values, the mean value before transfusion was 8.6 g/dl. Hemoglobin and SvO2 increased significantly post-transfusion. Red blood cell transfusion varied with hemoglobin values: when hemoglobin value was less than 7 g/dl, 89% (41/46) were transfused but just 23% (181/794) when greater or equal to 7 g/dl. In the presence of active bleeding, the frequency of RBC transfusion increased from 32% to 62%, with hemoglobin between 7 g/dl and 8 g/dl.The mean value for platelet transfusion was 32 x 109/L. Thirty-eight (43%) platelet values between 20 x 109/L and 30x109/L, and 31 (40%) between 30 x 109/L and 40 x 109/L led to platelet transfusion; between 40 x 109/L and 50 x 109/L, only 7 (9%) prompted platelet transfusion.Comparing the 2010-2015 to 2016-2019 periods there was a decrease in RBC and platelet transfusion threshold with similar survival (p = .528). Survival to discharge was 68%.

CONCLUSIONS

Using a restrictive RBC and platelet transfusion policy was safe and allowed a good outcome in this case series. The presence of active bleeding was an important decision factor when hemoglobin was above 7 g/dl and platelets were above 30 x 109/L.

Nonpulmonary Treatments for Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference

OBJECTIVES

To provide an updated review of the literature on nonpulmonary treatments for pediatric acute respiratory distress syndrome (PARDS) from the Second Pediatric Acute Lung Injury Consensus Conference.

DATA SOURCES

MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost).

STUDY SELECTION

Searches were limited to children with PARDS or hypoxic respiratory failure focused on nonpulmonary adjunctive therapies (sedation, delirium management, neuromuscular blockade, nutrition, fluid management, transfusion, sleep management, and rehabilitation).

DATA EXTRACTION

Title/abstract review, full-text review, and data extraction using a standardized data collection form.

DATA SYNTHESIS

The Grading of Recommendations Assessment, Development, and Evaluation approach was used to identify and summarize evidence and develop recommendations. Twenty-five studies were identified for full-text extraction. Five clinical practice recommendations were generated, related to neuromuscular blockade, nutrition, fluid management, and transfusion. Thirteen good practice statements were generated on the use of sedation, iatrogenic withdrawal syndrome, delirium, sleep management, rehabilitation, and additional information on neuromuscular blockade and nutrition. Three research statements were generated to promote further investigation in nonpulmonary therapies for PARDS.

CONCLUSIONS

These recommendations and statements about nonpulmonary treatments in PARDS are intended to promote optimization and consistency of care for patients with PARDS and identify areas of uncertainty requiring further investigation.

Transfusion-Associated Adverse Events: A Case Report of Nurse Hemovigilance and Recognition of Respiratory Distress

Although blood transfusions are considered a potentially life-saving therapy, noninfectious and infectious adverse events can lead to significant morbidities and even mortality. Vital signs and visual observation of patients during blood transfusions are thoroughly taught in nursing school. Updated terms of hemovigilance and transfusion-associated adverse events ( TAAEs ) are presented through this case study. A patient with factor V deficiency, which requires chronic plasma transfusions, experienced 2 types of TAAEs, anaphylaxis and transfusion-associated circulatory overload. The patient's history and TAAEs are presented and discussed to provide evidence for the importance of vigilant bedside surveillance. Early identification of TAAEs may prevent unnecessary morbidity and/or mortality. The primary nursing functions and responsibilities are presented with algorithmic supplementation to facilitate better understanding of best practice. Ongoing assessment of hemovigilance practices is indicated to ascertain which monitoring tools can lead to optimal patient care.

Sepsis-related anemia in a pediatric intensive care unit: transfusion-associated outcomes

BACKGROUND

Pediatric patients with sepsis in intensive care units are at high risk of developing anemia, which might have adverse effects on their prognosis. This study aimed to evaluate the impact of red blood cell (RBC) transfusion on the outcomes of patients admitted to a pediatric intensive care unit (PICU) with sepsis.

METHODS

We conducted a prospective randomized clinical trial, enrolling 67 children, aged 2 to 144 months who were admitted to a PICU with a new episode of sepsis from November 2017 to April 2018. Patients were allocated randomly to two groups: Group 1, liberal transfusion strategy group, including 33 patients who had initial hemoglobin (Hb) between 7 or greater and less than 10 g/dL and received an RBC top-up transfusion to 12 g/dL; and Group 2, restrictive strategy group, including 34 patients who had the same Hb range and did not receive RBCs. Patients with Hb less than 7 or greater than 10 g/dL were excluded.

RESULTS

Of 33 patients who received liberal transfusions, 31 (93.94%) required ventilation, and 29 (87.88%) had multiorgan dysfunction. They had a significantly lengthier hospital stay and a higher incidence of acute respiratory distress syndrome and acute lung injury. Moreover, mortality was significantly higher in the liberal transfusion group (42.4% vs. 17.6%).

CONCLUSIONS

Compared to the restrictive transfusion strategy, liberal transfusion might be associated with a worse outcome. However, the possible role of other known and unknown confounding factors and minor protocol violations should be taken into consideration. We recommend minimizing factors worsening anemia in PICU patients to reduce the need for transfusion.

Transfusion in the mechanically ventilated patient

Red blood cell transfusions are a frequent intervention in critically ill patients, including in those who are receiving mechanical ventilation. Both these interventions can impact negatively on lung function with risks of transfusion-related acute lung injury (TRALI) and other forms of acute respiratory distress syndrome (ARDS). The interactions between transfusion, mechanical ventilation, TRALI and ARDS are complex and other patient-related (e.g., presence of sepsis or shock, disease severity, and hypervolemia) or blood product-related (e.g., presence of antibodies or biologically active mediators) factors also play a role. We propose several strategies targeted at these factors that may help limit the risks of associated lung injury in critically ill patients being considered for transfusion.

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

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

Shock Severity Modifies Associations Between RBC Transfusion in the First 48 Hours of Sepsis Onset and the Duration of Organ Dysfunction in Critically Ill Septic Children

OBJECTIVE

To test the hypothesis that early RBC transfusion is associated with duration of organ dysfunction in critically ill septic children.

DESIGN

Secondary analysis of a single-center prospective observational study. Multivariable negative binomial regression was used to determine relationships between RBC transfusion within 48 hours of sepsis onset and number of days in 14 with organ dysfunction, or with multiple organ dysfunction syndrome.

SETTING

A PICU at a quaternary care children's hospital.

PATIENTS

Children less than 18 years old with severe sepsis/septic shock by consensus criteria were included. Patients with RBC transfusion prior to sepsis onset and those on extracorporeal membrane oxygenation support within 48 hours of sepsis onset were excluded.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Ninety-four patients were included. Median age was 6 years (0-13 yr); 61% were male. Seventy-eight percentage had septic shock, and 41 (44%) were transfused RBC within 48 hours of sepsis onset (early RBC transfusion). On multivariable analyses, early RBC transfusion was independently associated with 44% greater organ dysfunction days (adjusted relative risk, 1.44 [1.04-2.]; p = 0.03), although risk differed by severity of illness (interaction p = 0.004) and by shock severity (interaction p = 0.04 for Vasoactive Inotrope Score and 0.03 for shock index). Relative risks for multiple organ dysfunction syndrome days varied by shock severity (interaction p = 0.008 for Vasoactive Inotrope Score and 0.01 for shock index). Risks associated with early RBC transfusion were highest for the children with the lowest shock severities.

CONCLUSIONS

In agreement with previous studies, early RBC transfusion was independently associated with longer duration of organ dysfunction. Ours is among the first studies to document different transfusion-associated risks based on clinically available measures of shock severity, demonstrating greater transfusion-associated risks in children with less severe shock. Larger multicenter studies to verify these interaction effects are essential to plan much-needed RBC transfusion trials for critically ill septic children.

Transfusion in children with acute respiratory distress syndrome

Transfusion is a frequent treatment in pediatric patients with acute respiratory distress syndrome (PARDS) although evidence to support transfusion decision-making is lacking. The purpose of this review is to review the current state of knowledge on the issue of transfusion in children with PARDS and to detail the possible beneficial effects and potential deleterious impacts of transfusion in this patient population. Based on the current literature and recent guidelines, a restrictive red blood cell (RBC) transfusion strategy (avoidance of transfusion when the haemoglobin level is above 7 g/dL) is indicated in stable patients without severe PARDS, as these were excluded from the large trials. In children with severe PARDS, further research is needed to determine if factors other than the haemoglobin level might guide RBC transfusion decision-making by better characterizing the presence of low oxygen delivery (DO₂). Additionally, appropriate indications for prophylactic transfusion of hemostatic products (plasma or platelets) in children with PARDS are lacking.

Transfusion-related Acute Lung Injury in the Perioperative Patient

Transfusion-related acute lung injury is a leading cause of death associated with the use of blood products. Transfusion-related acute lung injury is a diagnosis of exclusion which can be difficult to identify during surgery amid the various physiologic and pathophysiologic changes associated with the perioperative period. As anesthesiologists supervise delivery of a large portion of inpatient prescribed blood products, and since the incidence of transfusion-related acute lung injury in the perioperative patient is higher than in nonsurgical patients, anesthesiologists need to consider transfusion-related acute lung injury in the perioperative setting, identify at-risk patients, recognize early signs of transfusion-related acute lung injury, and have established strategies for its prevention and treatment.

Restrictive guideline for red blood cell transfusions in preterm neonates: effect of a protocol change

OBJECTIVE

To evaluate red blood cell (RBC) transfusion practices in preterm neonates before and after protocol change.

METHODS

All preterm neonates (<32 weeks of gestation) admitted between 2008 and 2017 at our neonatal intensive care unit were included in this retrospective study. Since 2014, a more restrictive transfusion guideline was implemented in our unit. We compared transfusion practices before and after this guideline change. Primary outcome was the number of transfusions per neonate and the percentage of neonates receiving a blood transfusion. Secondary outcomes were neonatal morbidities and mortality during admission.

RESULTS

The percentage of preterm neonates requiring a blood transfusion was 37·5% (405/1079) before and 32·7% (165/505) after the protocol change (P = 0·040). The mean number of transfusions given to each transfused neonate decreased from 2·93 (standard deviation (SD) ± 2·26) to 2·20 (SD ±1·29) (P = 0·007). We observed no association between changes in transfusion practices and neonatal outcome.

CONCLUSION

The use of a more restrictive transfusion guideline leads to a reduction in red blood cell transfusions in preterm neonates, without evidence of an increase in mortality or short-term morbidity.

Hemolysis During Pediatric Extracorporeal Membrane Oxygenation: Associations With Circuitry, Complications, and Mortality

OBJECTIVES

To describe factors associated with hemolysis during pediatric extracorporeal membrane oxygenation and the relationships between hemolysis, complications, and mortality.

DESIGN

Secondary analysis of data collected prospectively by the Collaborative Pediatric Critical Care Research Network between December 2012 and September 2014.

SETTING

Three Collaborative Pediatric Critical Care Research Network-affiliated hospitals.

PATIENTS

Age less than 19 years and treated with extracorporeal membrane oxygenation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Hemolysis was defined based on peak plasma free hemoglobin levels during extracorporeal membrane oxygenation and categorized as none (< 0.001 g/L), mild (0.001 to < 0.5 g/L), moderate (0.5 to < 1.0 g/L), or severe (≥ 1.0 g/L). Of 216 patients, four (1.9%) had no hemolysis, 67 (31.0%) had mild, 51 (23.6%) had moderate, and 94 (43.5%) had severe. On multivariable analysis, variables independently associated with higher daily plasma free hemoglobin concentration included the use of in-line hemofiltration or other continuous renal replacement therapy, higher hemoglobin concentration, higher total bilirubin concentration, lower mean heparin infusion dose, lower body weight, and lower platelet count. Using multivariable Cox modeling, daily plasma free hemoglobin was independently associated with development of renal failure during extracorporeal membrane oxygenation (defined as creatinine > 2 mg/dL [> 176.8 μmol/L] or use of in-line hemofiltration or continuous renal replacement therapy) (hazard ratio, 1.04; 95% CI, 1.02-1.06; p < 0.001), but not mortality (hazard ratio, 1.01; 95% CI, 0.99-1.04; p = 0.389).

CONCLUSIONS

Hemolysis is common during pediatric extracorporeal membrane oxygenation. Hemolysis may contribute to the development of renal failure, and therapies used to manage renal failure such as in-line hemofiltration and other forms of continuous renal replacement therapy may contribute to hemolysis. Hemolysis was not associated with mortality after controlling for other factors. Monitoring for hemolysis should be a routine part of extracorporeal membrane oxygenation practice, and efforts to reduce hemolysis may improve patient care.

Recommendations on RBC Transfusion in General Critically Ill Children Based on Hemoglobin and/or Physiologic Thresholds From the Pediatric Critical Care Transfusion and Anemia Expertise Initiative

OBJECTIVES

To present the consensus recommendations and supporting literature for RBC transfusions in general critically ill children from the Pediatric Critical Care Transfusion and Anemia Expertise Initiative.

DESIGN

Consensus conference series of international, multidisciplinary experts in RBC transfusion management of critically ill children.

METHODS

The panel of 38 experts developed evidence-based and, when evidence was lacking, expert-based recommendations and research priorities regarding RBC transfusions in critically ill children. The subgroup on RBC transfusion in general critically ill children included six experts. Electronic searches were conducted using PubMed, EMBASE, and Cochrane Library databases from 1980 to May 30, 2017, using a combination of keywords to define concepts of RBC transfusion and critically ill children. Recommendation consensus was obtained using the Research and Development/UCLA Appropriateness Method. The results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method.

RESULTS

Three adjudicators reviewed 4,399 abstracts; 71 papers were read, and 17 were retained. Three papers were added manually. The general Transfusion and Anemia Expertise Initiative subgroup developed, and all Transfusion and Anemia Expertise Initiative members voted on two good practice statements, six recommendations, and 11 research questions; in all instances, agreement was reached (> 80%). The good practice statements suggest a framework for RBC transfusion in PICU patients. The good practice statements and recommendations focus on hemoglobin as a threshold and/or target. The research questions focus on hemoglobin and physiologic thresholds for RBC transfusion, alternatives, and risk/benefit ratio of transfusion.

CONCLUSIONS

Transfusion and Anemia Expertise Initiative developed pediatric-specific good practice statements and recommendations regarding RBC transfusion management in the general PICU population, as well as recommendations to guide future research priorities. Clinical recommendations emphasized relevant hemoglobin thresholds, and research recommendations emphasized a need for further understanding of physiologic thresholds, alternatives to RBC transfusion, and hemoglobin thresholds in populations with limited pediatric literature.

Recommendations on RBC Transfusions in Critically Ill Children With Acute Respiratory Failure From the Pediatric Critical Care Transfusion and Anemia Expertise Initiative

OBJECTIVES

To present the recommendations and supporting literature for RBC transfusions in critically ill children with bleeding developed by the Pediatric Critical Care Transfusion and Anemia Expertise Initiative.

DESIGN

Consensus conference series of international, multidisciplinary experts in RBC transfusion management of critically ill children.

METHODS

The panel of 38 experts developed evidence-based and, when evidence was lacking, expert-based clinical recommendations as well as research priorities for RBC transfusions in critically ill children. The respiratory subgroup included six experts. Electronic searches were conducted using PubMed, EMBASE, and Cochrane Library databases from 1980 to May 2017. Agreement was obtained using the Research and Development/UCLA Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method.

RESULTS

Transfusion and Anemia Expertise Initiative experts developed seven recommendations focused on children with acute respiratory failure. All recommendations reached agreement (> 80%). Transfusion of RBCs in children with respiratory failure with an hemoglobin level less than 5 g/dL was strongly recommended. It was strongly recommended that RBCs not be systematically administered to children with respiratory failure who are hemodynamically stable and who have a hemoglobin level greater than or equal to 7 g/dL. Experts could not make a recommendation for children with hemodynamic instability, with severe hypoxemia and/or with an hemoglobin level between 5 and 7 g/dL. Specific RBC transfusion strategies using physiologic-based metrics and biomarkers could not be elaborated.

CONCLUSIONS

The Transfusion and Anemia Expertise Initiative Consensus Conference developed specific recommendations regarding RBC transfusion management in critically ill children with respiratory failure, as well as recommendations to guide future research. Clinical recommendations emphasize relevant hemoglobin thresholds. Research recommendations emphasize the need to identify appropriate physiologic thresholds, suggest a better understanding of alternatives to RBC transfusion, and identify the need for better evidence on hemoglobin thresholds that might be used in specific subpopulations of critically ill children.

RBC Transfusion Practice in Pediatric Extracorporeal Membrane Oxygenation Support

OBJECTIVES

To determine RBC transfusion practice and relationships between RBC transfusion volume and mortality in infants and children treated with extracorporeal membrane oxygenation.

DESIGN

Secondary analysis of a multicenter prospective observational study.

SETTING

Eight pediatric institutions within the Eunice Kennedy Shriver National Institute of Child Health and Human Development's Collaborative Pediatric Critical Care Research Network.

PATIENTS

Patients age less than 19 years old treated with extracorporeal membrane oxygenation at a participating center.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Clinical data and target hemoglobin or hematocrit values (if set) were recorded daily by trained bedside extracorporeal membrane oxygenation specialists and research coordinators. Laboratory values, including hemoglobin and hematocrit, were recorded daily using the value obtained closest to 8:00 AM. RBC transfusion was recorded as total daily volume in mL/kg. Multivariable logistic regression was used to determine the relationship between RBC transfusion volume and hospital mortality, accounting for potential confounders. Average goal hematocrits varied across the cohort with a range of 27.5-41.3%. Overall, actual average daily hematocrit was 36.8%, and average RBC transfusion volume was 29.4 mL/kg/d (17.4-49.7 mL/kg/d) on extracorporeal membrane oxygenation. On multivariable analysis, each additional 10 mL/kg/d of RBC transfusion volume was independently associated with a 9% increase in odds of hospital mortality (adjusted odds ratio, 1.09 [1.02-1.16]; p = 0.009).

CONCLUSIONS

In this multicenter cohort of pediatric extracorporeal membrane oxygenation patients, daily hematocrit levels were maintained at normal or near-normal values and RBC transfusion burden was high. RBC transfusion volume was independently associated with odds of mortality. Future clinical studies to identify optimum RBC transfusion thresholds for pediatric extracorporeal membrane oxygenation are urgently needed.

RBC Transfusions Are Associated With Prolonged Mechanical Ventilation in Pediatric Acute Respiratory Distress Syndrome

OBJECTIVES

Blood products are often transfused in critically ill children, although recent studies have recognized their potential for harm. Translatability to pediatric acute respiratory distress syndrome is unknown given that hypoxemia has excluded pediatric acute respiratory distress syndrome patients from clinical trials. We aimed to determine whether an association exists between blood product transfusion and survival or duration of ventilation in pediatric acute respiratory distress syndrome.

DESIGN

Retrospective analysis of prospectively enrolled cohort.

SETTING

Large, academic PICU.

PATIENTS

Invasively ventilated children meeting Berlin Acute Respiratory Distress Syndrome and Pediatric Acute Lung Injury Consensus Conference Pediatric Acute Respiratory Distress Syndrome criteria from 2011 to 2015.

INTERVENTIONS

We recorded transfusion of RBC, fresh frozen plasma, and platelets within the first 3 days of pediatric acute respiratory distress syndrome onset. Each product was tested for independent association with survival (Cox) and duration of mechanical ventilation (competing risk regression with extubation as primary outcome and death as competing risk). A sensitivity analysis using 1:1 propensity matching was also performed.

MEASUREMENTS AND MAIN RESULTS

Of 357 pediatric acute respiratory distress syndrome patients, 155 (43%) received RBC, 82 (23%) received fresh frozen plasma, and 92 (26%) received platelets. Patients who received RBC, fresh frozen plasma, or platelets had higher severity of illness score, lower PaO2/FIO2, and were more often immunocompromised (all p < 0.05). Patients who received RBC, fresh frozen plasma, or platelets had worse survival and longer duration of ventilation by univariate analysis (all p < 0.05). After multivariate adjustment for above confounders, no blood product was associated with survival. After adjustment for the same confounders, RBC were associated with decreased probability of extubation (subdistribution hazard ratio, 0.65; 95% CI, 0.51-0.83). The association between RBC and prolonged ventilation was confirmed in propensity-matched subgroup analysis.

CONCLUSIONS

RBC transfusion was independently associated with longer duration of mechanical ventilation in pediatric acute respiratory distress syndrome. Hemoglobin transfusion thresholds should be tested specifically within pediatric acute respiratory distress syndrome to establish whether a more restrictive transfusion strategy would improve outcomes.

Transfusion-associated circulatory overload in a pediatric intensive care unit: different incidences with different diagnostic criteria

BACKGROUND

The incidence of transfusion-associated circulatory overload (TACO) is not well known in children, especially in pediatric intensive care unit (PICU) patients.

STUDY DESIGN AND METHODS

All consecutive patients admitted over 1 year to the PICU of CHU Sainte-Justine were included after they received their first red blood cell transfusion. TACO was diagnosed using the criteria of the International Society of Blood Transfusion, with two different ways of defining abnormal values: 1) using normal pediatric values published in the Nelson Textbook of Pediatrics and 2) by using the patient as its own control and comparing pre- and posttransfusion values with either 10 or 20% difference threshold. We monitored for TACO up to 24 hours posttransfusion.

RESULTS

A total of 136 patients were included. Using the "normal pediatric values" definition, we diagnosed 63, 88, and 104 patients with TACO at 6, 12, and 24 hours posttransfusion, respectively. Using the "10% threshold" definition we detected 4, 15, and 27 TACO cases in the same periods, respectively; using the "20% threshold" definition, the number of TACO cases was 2, 6, and 17, respectively. Chest radiograph was the most frequent missing item, especially at 6 and 12 hours posttransfusion. Overall, the incidence of TACO varied from 1.5% to 76% depending on the definition.

CONCLUSION

A more operational definition of TACO is needed in PICU patients. Using a threshold could be more optimal but more studies are needed to confirm the best threshold.

Factors Associated with Bleeding and Thrombosis in Children Receiving Extracorporeal Membrane Oxygenation

RATIONALE

Extracorporeal membrane oxygenation (ECMO) is used for respiratory and cardiac failure in children but is complicated by bleeding and thrombosis.

OBJECTIVES

(1) To measure the incidence of bleeding (blood loss requiring transfusion or intracranial hemorrhage) and thrombosis during ECMO support; (2) to identify factors associated with these complications; and (3) to determine the impact of these complications on patient outcome.

METHODS

This was a prospective, observational cohort study in pediatric, cardiac, and neonatal intensive care units in eight hospitals, carried out from December 2012 to September 2014.

MEASUREMENTS AND MAIN RESULTS

ECMO was used on 514 consecutive patients under age 19 years. Demographics, anticoagulation practices, severity of illness, circuitry components, bleeding, thrombotic events, and outcome were recorded. Survival was 54.9%. Bleeding occurred in 70.2%, including intracranial hemorrhage in 16%, and was independently associated with higher daily risk of mortality. Circuit component changes were required in 31.1%, and patient-related clots occurred in 12.8%. Laboratory sampling contributed to transfusion requirement in 56.6%, and was the sole reason for at least one transfusion in 42.2% of patients. Pump type was not associated with bleeding, thrombosis, hemolysis, or mortality. Hemolysis was predictive of subsequent thrombotic events. Neither hemolysis nor thrombotic events increased the risk of mortality.

CONCLUSIONS

The incidences of bleeding and thrombosis are high during ECMO support. Laboratory sampling is a major contributor to transfusion during ECMO. Strategies to reduce the daily risk of bleeding and thrombosis, and different thresholds for transfusion, may be appropriate subjects of future trials to improve outcomes of children requiring this supportive therapy.

Neonatal outcome of small for gestational age preterm infants

Small for gestational age (SGA) preterm neonates (birth weight < -2 SDS) are considered to have increased risk of bronchopulmonary dysplasia (BPD) compared to appropriate for GA (AGA) neonates. It is unclear if SGA infants have increased risk for respiratory distress syndrome (RDS) and mortality. We analyzed data from 515 neonates born <30 weeks GA, 98(19%) were SGA. SGA were compared to AGA by univariate analysis and logistic regression analysis (LRA). Significant variables at univariate analysis were IUGR (67 vs 7%, p = 0.000), chorioamnionitis (1 vs 13%, p = 0.017), pre-eclampsia (62 vs 18%, p = 0.000), surfactant retreatment (47 vs 25%, p = 0.000), BPD (32 vs 20%, p = 0.015), death (30 vs 12%, p = 0.000), SatO2/FiO2 on day 3 (376 vs 433, p = 0.013), and SatO2/FiO2 ratio on day 28 (400 vs 448, p = 0.000). LRA found the following associations: regarding mortality, a decreased Sat/FiO2 ratio on day 3 (OR 1.99, 95% CI 1.26-3.16, p = 0.003); regarding BPD, surfactant retreatment (3.70, 2.11-6.49, p = 0.000), being SGA (2.69, 1.36-5.36, p = 0.005), decreasing GA (1.05, 1.03-1.08, p = 0.000), decreasing SatO2/FiO2 ratio on day 3 (1.25, 1.11-1.40, p = 0.000); and regarding severe RDS, pre-eclampsia (2.68, 1.58-4.55, p = 0.000) and decreasing GA (1.06, 1.04-1.08, p = 0.000).

CONCLUSIONS

In our cohort of preterm infants, being SGA was significantly associated with BPD, but not with increased risk of mortality or RDS due to multiple pathophysiologic mechanisms. What is Known: • Small for gestational age preterm neonates are considered to have increased risk of bronchopulmonary dysplasia (BPD) compared to appropriate for GA neonates. • It is still unclear if SGA infants have increased risk for respiratory distress syndrome (RDS) and mortality. What is New: • In our cohort of 515 preterm infants (19% SGA), being SGA was significantly associated with BPD, but not with increased risk of mortality or RDS. • These results may be explained by the heterogeneity of mechanisms leading to SGA condition and by multiple mechanisms involving lung growth impairment and other factors.

Transfusion-related immunomodulation: review of the literature and implications for pediatric critical illness

Transfusion-related immunomodulation (TRIM) in the intensive care unit (ICU) is difficult to define and likely represents a complicated set of physiologic responses to transfusion, including both proinflammatory and immunosuppressive effects. Similarly, the immunologic response to critical illness in both adults and children is highly complex and is characterized by both acute inflammation and acquired immune suppression. How transfusion may contribute to or perpetuate these phenotypes in the ICU is poorly understood, despite the fact that transfusion is common in critically ill patients. Both hyperinflammation and severe immune suppression are associated with poor outcomes from critical illness, underscoring the need to understand potential immunologic consequences of blood product transfusion. In this review we outline the dynamic immunologic response to critical illness, provide clinical evidence in support of immunomodulatory effects of blood product transfusion, review preclinical and translational studies to date of TRIM, and provide insight into future research directions.

Multiple organ dysfunction syndrome in critically ill children: clinical value of two lists of diagnostic criteria

Background

Two sets of diagnostic criteria of paediatric multiple organ dysfunction syndrome (MODS) were published by Proulx in 1996 and by Goldstein in 2005. We hypothesized that this changes the epidemiology of MODS. Thus, we determined the epidemiology of MODS, according to these two sets of diagnostic criteria, we studied the intra- and inter-observer reproducibility of each set of diagnostic criteria, and we compared the association between cases of MODS at paediatric intensive care unit (PICU) entry, as diagnosed by each set of diagnostic criteria, and 90-day all-cause mortality.

Methods

All consecutive patients admitted to the tertiary care PICU of Sainte-Justine Hospital, from April 21, 2009 to April 20, 2010, were considered eligible for enrolment into this prospective observational cohort study. The exclusion criteria were gestational age < 40 weeks, age < 3 days or > 18 years at PICU entry, pregnancy, admission immediately after delivery. No patients were censored. Daily monitoring using medical chart ended when the patient died or was discharged from PICU. Mortality was monitored up to death, hospital discharge, or 90 days post PICU entry, whatever happened first. Concordance rate and kappa score were calculated to assess reproducibility. The number of MODS identified with Proulx and Goldstein definitions was compared using 2-by-2 contingency tables. Student’s t test or Wilcoxon signed-ranked test was used to compare continuous variables with normal or abnormal distribution, respectively. We performed a Kaplan–Meier survival analysis to assess the association between MODS at PICU entry and 90-day mortality.

Results

The occurrence of MODS was monitored daily and prospectively in 842 consecutive patients admitted to the PICU of Sainte-Justine Hospital over 1 year. According to Proulx and Goldstein diagnostic criteria, 180 (21.4 %) and 314 patients (37.3 %) had MODS over PICU stay, respectively. Concordance of MODS diagnosis over PICU stay was 81.3 % (95 % CI 78.6–83.9 %), and kappa score was 0.56 (95 % CI 0.50–0.61). Discordance was mainly attributable to cardiovascular or neurological dysfunction criteria. The proportion of patients with MODS at PICU entry who died within 90 days was higher with MODS diagnosed with Proulx criteria (17.8 vs. 11.5 %, p = 0.038), as well as the likelihood ratio of death (4.84 vs. 2.37). On the other hand, 90-day survival rate of patients without MODS at PICU entry was similar (98.6 vs. 98.9 % (p = 0.73).

Conclusions

Proulx and Goldstein diagnostic criteria of paediatric MODS are not equivalent. The epidemiology of paediatric MODS varies depending on which set of diagnostic criteria is applied.

Electronic supplementary material

The online version of this article (doi:10.1186/s13613-016-0144-6) contains supplementary material, which is available to authorized users.