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Doctor A, Cholette JM, Remy KE, Argent A, Carson JL, Valentine SL, Bateman ST, Lacroix J. Recommendations on RBC Transfusion in General Critically Ill Children Based on Hemoglobin and/or Physiologic Thresholds From the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. Pediatr Crit Care Med 2018; 19:S98-S113. [PMID: 30161064 PMCID: PMC6125789 DOI: 10.1097/pcc.0000000000001590] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To present the consensus recommendations and supporting literature for RBC transfusions in general critically ill children from the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. DESIGN Consensus conference series of international, multidisciplinary experts in RBC transfusion management of critically ill children. METHODS The panel of 38 experts developed evidence-based and, when evidence was lacking, expert-based recommendations and research priorities regarding RBC transfusions in critically ill children. The subgroup on RBC transfusion in general critically ill children included six experts. Electronic searches were conducted using PubMed, EMBASE, and Cochrane Library databases from 1980 to May 30, 2017, using a combination of keywords to define concepts of RBC transfusion and critically ill children. Recommendation consensus was obtained using the Research and Development/UCLA Appropriateness Method. The results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. RESULTS Three adjudicators reviewed 4,399 abstracts; 71 papers were read, and 17 were retained. Three papers were added manually. The general Transfusion and Anemia Expertise Initiative subgroup developed, and all Transfusion and Anemia Expertise Initiative members voted on two good practice statements, six recommendations, and 11 research questions; in all instances, agreement was reached (> 80%). The good practice statements suggest a framework for RBC transfusion in PICU patients. The good practice statements and recommendations focus on hemoglobin as a threshold and/or target. The research questions focus on hemoglobin and physiologic thresholds for RBC transfusion, alternatives, and risk/benefit ratio of transfusion. CONCLUSIONS Transfusion and Anemia Expertise Initiative developed pediatric-specific good practice statements and recommendations regarding RBC transfusion management in the general PICU population, as well as recommendations to guide future research priorities. Clinical recommendations emphasized relevant hemoglobin thresholds, and research recommendations emphasized a need for further understanding of physiologic thresholds, alternatives to RBC transfusion, and hemoglobin thresholds in populations with limited pediatric literature.
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Affiliation(s)
- Allan Doctor
- Allan Doctor, MD, Professor of Pediatrics and Biochemistry, Division of Pediatric Critical Care Medicine, Washington University in St. Louis, St. Louis Children’s Hospital, United States
| | - Jill M. Cholette
- Jill M. Cholette, MD, Associate Professor of Pediatrics, Medical Director, Pediatric Cardiac Care Center, University of Rochester, Golisano Children’s Hospital, United States
| | - Kenneth E. Remy
- Kenneth E. Remy, MD, MHSc, Assistant Professor of Pediatrics. Division of Pediatric Critical Care Medicine, Washington University in St. Louis, St. Louis Children’s Hospital, United States
| | - Andrew Argent
- Andrew Argent, MD, Professor of Pediatrics, Medical Director, Paediatric Intensive Care, University of Cape Town and Red Cross War Memorial Children’s Hospital, South Africa
| | - Jeffrey L. Carson
- Jeffrey L. Carson, MD, Provost – New Brunswick Distinguished Professor of Medicine, Richard C. Reynolds Chair of General Internal Medicine; Rutgers Robert Wood Johnson Medical School, Rutgers, The State University of New Jersey, United States
| | - Stacey L. Valentine
- Stacey L. Valentine, MD, MPH, Assistant Professor of Pediatrics, University of Massachusetts Medical School, United States
| | - Scot T. Bateman
- Scot T. Bateman, MD, Professor of Pediatrics, Division Chief of Pediatric Critical Care Medicine, University of Massachusetts Medical School, United States
| | - Jacques Lacroix
- Jacques Lacroix, MD, Professor of Pediatrics, Division of Pediatric Critical Care, Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Canada
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Recommendations on RBC Transfusions in Critically Ill Children With Acute Respiratory Failure From the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. Pediatr Crit Care Med 2018; 19:S114-S120. [PMID: 30161065 PMCID: PMC6126368 DOI: 10.1097/pcc.0000000000001619] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
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.
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Muszynski JA, Spinella PC, Cholette JM, Acker JP, Hall MW, Juffermans NP, Kelly DP, Blumberg N, Nicol K, Liedel J, Doctor A, Remy KE, Tucci M, Lacroix J, Norris PJ. Transfusion-related immunomodulation: review of the literature and implications for pediatric critical illness. Transfusion 2016; 57:195-206. [PMID: 27696473 DOI: 10.1111/trf.13855] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 08/01/2016] [Accepted: 08/15/2016] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Jennifer A Muszynski
- Division of Critical Care Medicine, Canadian Blood Services, Edmonton, Alberta, Canada.,The Research Institute, Canadian Blood Services, Edmonton, Alberta, Canada
| | - Philip C Spinella
- Department of Pediatrics, Division Pediatric Critical Care, Canadian Blood Services, Edmonton, Alberta, Canada
| | - Jill M Cholette
- Pediatric Critical Care and Cardiology, Canadian Blood Services, Edmonton, Alberta, Canada
| | - Jason P Acker
- Centre for Innovation, Canadian Blood Services.,Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Mark W Hall
- Division of Critical Care Medicine, Canadian Blood Services, Edmonton, Alberta, Canada.,The Research Institute, Canadian Blood Services, Edmonton, Alberta, Canada
| | - Nicole P Juffermans
- Department of Intensive Care Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - Daniel P Kelly
- Division of Critical Care, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Neil Blumberg
- Transfusion Medicine/Blood Bank and Clinical Laboratories, Departments of Pathology and Laboratory Medicine, University of Rochester, Rochester, New York
| | - Kathleen Nicol
- Department of Pathology, Nationwide Children's Hospital, Columbus, Ohio
| | - Jennifer Liedel
- Pediatric Critical Care Medicine, Albert Einstein College of Medicine, Children's Hospital at Montefiore, Bronx, New York
| | - Allan Doctor
- Departments of Pediatrics and Biochemistry, Washington University in St Louis, St Louis, Missouri
| | - Kenneth E Remy
- Department of Pediatrics, Division Pediatric Critical Care, Canadian Blood Services, Edmonton, Alberta, Canada
| | - Marisa Tucci
- Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montreal, Quebec, Canada
| | - Jacques Lacroix
- Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montreal, Quebec, Canada
| | - Philip J Norris
- Blood Systems Research Institute.,Departments of Laboratory Medicine and Medicine, University of California, San Francisco, San Francisco, California
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Nguyen TT, Hill S, Austin TM, Whitney GM, Wellons JC, Lam HV. Use of blood-sparing surgical techniques and transfusion algorithms: association with decreased blood administration in children undergoing primary open craniosynostosis repair. J Neurosurg Pediatr 2015; 16:556-563. [PMID: 26230459 PMCID: PMC4733600 DOI: 10.3171/2015.3.peds14663] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECT Craniofacial reconstruction surgery (CFR) is often associated with significant blood loss, coagulopathy, and perioperative blood transfusion. Due to transfusion risks, many different approaches have been used to decrease allogeneic blood transfusion for these patients during the perioperative period. Protocols have decreased blood administration during the perioperative period for many types of surgeries. The object of this study was to determine if a protocol involving blood-sparing surgical techniques and a transfusion algorithm decreased intraoperative blood transfusion and blood loss. METHODS A protocol using transfusion algorithms and implementation of blood-sparing surgical techniques for CFR was implemented at Vanderbilt University on January 1, 2013. Following Institutional Review Board approval, blood loss and transfusion data were gathered retrospectively on all children undergoing primary open CFR, using the protocol, for the calendar year 2013. This postprotocol cohort was compared with a preprotocol cohort, which consisted of all children undergoing primary open CFR during the previous calendar year, 2012. RESULTS There were 41 patients in the preprotocol and 39 in the postprotocol cohort. There was no statistical difference between the demographics of the 2 groups. When compared with the preprotocol cohort, intraoperative packed red blood cell transfusion volume decreased from 36.9 ± 21.2 ml/kg to 19.2 ± 10.9 ml/kg (p = 0.0001), whereas fresh-frozen plasma transfusion decreased from 26.8 ± 25.4 ml/kg to 1.5 ± 5.7 ml/kg (p < 0.0001) following implementation of the protocol. Furthermore, estimated blood loss decreased from 64.2 ± 32.4 ml/kg to 52.3 ± 33.3 ml/kg (p = 0.015). Use of fresh-frozen plasma in the postoperative period also decreased when compared with the period before implementation of the protocol. There was no significant difference in morbidity and mortality between the 2 groups. CONCLUSIONS The results of this study suggested that using a multidisciplinary protocol consisting of transfusion algorithms and implementation of blood-sparing surgical techniques during major CFR in pediatric patients is associated with reduced intraoperative administration of blood product, without shifting the transfusion burden to the postoperative period.
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Affiliation(s)
- Thanh T. Nguyen
- Department of Anesthesiology, Vanderbilt University, Nashville, Tennessee
| | - Sarah Hill
- Department of Nursing, Vanderbilt University, Nashville, Tennessee
| | - Thomas M. Austin
- Department of Anesthesiology, Vanderbilt University, Nashville, Tennessee
| | - Gina M. Whitney
- Department of Anesthesiology, University of Colorado, Aurora, Colorado
| | - John c. Wellons
- Department of Neurosurgery and Pediatrics, Vanderbilt University, Nashville, Tennessee
| | - Humphrey V. Lam
- Department of Anesthesiology, Vanderbilt University, Nashville, Tennessee
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Muszynski J, Nateri J, Nicol K, Greathouse K, Hanson L, Hall M. Immunosuppressive effects of red blood cells on monocytes are related to both storage time and storage solution. Transfusion 2011; 52:794-802. [PMID: 21981316 DOI: 10.1111/j.1537-2995.2011.03348.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Reduced monocyte function is associated with adverse outcomes from critical illness. Red blood cells (RBCs) are thought to impair monocyte function but relationships between RBC storage solution and monocyte suppression are unknown. This study was designed to test the hypothesis that immunosuppressive effects of RBCs on monocytes are related to both storage time and preservative solution. STUDY DESIGN AND METHODS Monocytes from healthy adult donors were co-cultured with RBCs that had been stored in AS-1, AS-3, or CPD only for 7, 14, or 21 days. Cells were then stimulated with lipopolysaccharide (LPS) and their supernatants assayed for tumor necrosis factor (TNF)-α and interleukin (IL)-10. Transwell experiments were performed to evaluate the role of cell-to-cell contact. Monocyte mRNA expression was quantified by real-time-polymerase chain reaction. RESULTS LPS-induced TNF-α production capacity was reduced compared to controls for all groups, but CPD-only RBCs suppressed monocyte function more than RBCs stored in AS-1 (p = 0.007) and AS-3 (p = 0.006). IL-10 production was preserved or augmented in all groups. A longer storage time was associated with reduced TNF-α production capacity for AS-1 and AS-3 groups but not CPD. Preventing cell-to-cell contact did not eliminate the inhibitory effect of RBCs on monocyte responsiveness. RBC exposure was associated with decreased LPS-induced TNFA mRNA expression (p < 0.05 for all groups). CONCLUSIONS CPD-only RBCs suppressed monocyte function more than RBCs stored with additive solutions. TNF-α production was reduced even in the absence of cell-to-cell contact and was impaired at the mRNA level. Further work is needed to understand the role of preservative solutions in this process.
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Affiliation(s)
- Jennifer Muszynski
- Division of Critical Care Medicine, The Research Institute, Department of Pathology, Nationwide Children's Hospital, Columbus, Ohio 43205, USA
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