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Jutras C, Sauthier M, Tucci M, Trottier H, Lacroix J, Robitaille N, Ducharme-Crevier L, Du Pont-Thibodeau G. Prevalence and determinants of anemia at discharge in pediatric intensive care survivors. Transfusion 2023; 63:973-981. [PMID: 36907652 DOI: 10.1111/trf.17309] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 12/06/2022] [Accepted: 01/11/2023] [Indexed: 03/13/2023]
Abstract
BACKGROUND Restrictive transfusion practices are increasingly being followed in pediatric intensive care units (PICU); consequently, more patients are discharged anemic from PICU. Given the possible impact of anemia on long-term neurodevelopmental outcomes, we aim to describe the epidemiology of anemia at PICU discharge in a mixed (pediatric and cardiac) cohort of PICU survivors and to characterize risk factors for anemia. STUDY DESIGN AND METHODS We performed a retrospective cohort study in the PICU of a multidisciplinary tertiary-care university-affiliated center. All consecutive PICU survivors for whom a hemoglobin level was available at PICU discharge were included. Baseline characteristics and hemoglobin levels were extracted from an electronic medical records database. RESULTS From January 2013 to January 2018, 4750 patients were admitted to the PICU (97.1% survival); discharge hemoglobin levels were available for 4124 patients. Overall, 50.9% (n = 2100) were anemic at PICU discharge. Anemia at PICU discharge was also common in the cardiac surgery population (53.3%), mainly in acyanotic patients; only 24.6% of cyanotic patients were anemic according to standard definitions of anemia. Cardiac surgery patients were transfused more often and at higher hemoglobin levels than medical and non-cardiac surgery patients. Anemia at admission was the strongest predictor of anemia at discharge (odds ratios (OR): 6.51, 95% confidence interval (CI:5.40;7.85)). DISCUSSION Half of PICU survivors are anemic at discharge. Further studies are required to determine the course of anemia after discharge and to ascertain whether anemia is associated with adverse long-term outcomes.
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Affiliation(s)
- Camille Jutras
- Department of Pediatrics, CHU Sainte-Justine, Montréal, Québec, Canada
| | - Michaël Sauthier
- Department of Pediatrics, CHU Sainte-Justine, Montréal, Québec, Canada
| | - Marisa Tucci
- Department of Pediatrics, CHU Sainte-Justine, Montréal, Québec, Canada
| | - Helen Trottier
- Public Health School, Université de Montréal and Research Center, CHU Sainte-Justine, Montréal, Québec, Canada
| | - Jacques Lacroix
- Department of Pediatrics, CHU Sainte-Justine, Montréal, Québec, Canada
| | - Nancy Robitaille
- Department of Pediatrics, CHU Sainte-Justine, Montréal, Québec, Canada.,Public Health School, Université de Montréal and Research Center, CHU Sainte-Justine, Montréal, Québec, Canada.,Héma-Québec, Montréal, Québec, Canada
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2
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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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3
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Adler AC, Hensch LAH, Bryant BE, Chandrakantan A, Nguyen HY, Nathanson BH, Rosenfeld SB. Factors affecting need for blood transfusion in paediatric patients undergoing open surgery for hip dysplasia. Vox Sang 2022; 117:1384-1390. [PMID: 36300858 PMCID: PMC9772120 DOI: 10.1111/vox.13372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 09/27/2022] [Accepted: 10/08/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND OBJECTIVES The management of intraoperative blood loss in the surgical treatment of paediatric hip dysplasia is resource intensive. There are numerous clinical factors that impact the need for intraoperative transfusion. Identification of patient and surgical factors associated with increased blood loss may reduce the unnecessary use of resources. This study aimed to identify factors predictive of intraoperative transfusion in children undergoing hip dysplasia surgery. MATERIALS AND METHODS This is a single-centre retrospective review of patients undergoing surgery for hip dysplasia from 1 January 2012 to 15 April 2021. Patient demographic factors, anaesthetic, surgical and transfusion histories were reviewed. Multivariable logistic regression analysis was performed to identify factors predictive of allogeneic red blood cell transfusion requirements during the intraoperative period. RESULTS This study includes 595 patients who underwent open surgery for hip dysplasia, including 297 (52.6%) classified as developmental dysplasia (DD) and 268 (47.3%) as neuromuscular (NM) with a mean age of 9.1 years (interquartile range 3-14). Intraoperative allogeneic transfusion was identified in 26/297 (8.8%) DD and 73/268 (27.2%) NM patients. Adjusted factors associated with increased odds of intraoperative transfusion were NM (odds ratio [OR] = 2.96, 95% confidence interval [CI] [1.76, 5.00]) and the number of osteotomies performed (OR = 1.82/osteotomy, 95% CI [1.40, 2.35]). Adjusted factors that reduced the odds of transfusion were the use of antifibrinolytics (OR = 0.35, 95% CI [0.17, 0.71]) and regional anaesthesia (OR = 0.52, 95% CI [0.29, 0.94]). CONCLUSION For children undergoing surgery for hip dysplasia, the number of osteotomies performed is predictive of the need for allogeneic blood transfusion. Antifibrinolytics and regional anaesthesia are associated with reduced risk for allogeneic blood transfusion. Blood management initiatives, such a preoperative optimization of haemoglobin and the use of antifibrinolytics, could target patients at increased risk of intraoperative bleeding and transfusion.
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Affiliation(s)
- Adam C. Adler
- Department of Anesthesiology, Perioperative and Pain Medicine; Texas Children’s Hospital; Houston TX, USA
- Baylor College of Medicine; Houston, TX, USA
| | - Lisa A. H. Hensch
- Department of Pathology & Immunology, Texas Children’s Hospital, Houston, Texas
- Baylor College of Medicine; Houston, TX, USA
| | - Brittany E. Bryant
- Department of Pathology & Immunology, Texas Children’s Hospital, Houston, Texas
- Baylor College of Medicine; Houston, TX, USA
| | - Arvind Chandrakantan
- Department of Anesthesiology, Perioperative and Pain Medicine; Texas Children’s Hospital; Houston TX, USA
- Baylor College of Medicine; Houston, TX, USA
| | - Hai-Yen Nguyen
- Department of Surgery, Baylor College of Medicine; Houston, TX, USA
| | | | - Scott B. Rosenfeld
- Baylor College of Medicine; Houston, TX, USA
- Department of Orthopaedic Surgery; Texas Children’s Hospital; Baylor College of Medicine; Houston, TX, USA
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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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5
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Elevated international normalized ratio is correlated with large volume transfusion in pediatric trauma patients. J Pediatr Surg 2022; 57:903-907. [PMID: 35078593 DOI: 10.1016/j.jpedsurg.2021.12.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 12/30/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Pediatric trauma patients may benefit from a balanced transfusion strategy, however, determining when to activate massive transfusion protocols remains uncertain. The purpose of this study was to explore whether certain scoring systems can predict the need for large volume transfusion. METHODS We conducted a retrospective review of pediatric trauma patients who presented to our center and required a transfusion of packed red blood cells. Baseline laboratory and clinical data were used to calculate Trauma Associated Severe Hemorrhage (TASH) score and a previously reported composite of acidosis and coagulopathy. RESULTS We identified 518 pediatric trauma patients who presented to our center between January 1, 2013 and December 31, 2018. These patients were less than 18 years of age (mean 9.6 years) and had an injury severity score ranging from 1 to 50 (mean 11.3). Forty-three patients (8.3%) received a transfusion within 24 hours of presentation, ranging from 4 to 139 mL/kg of packed red blood cells (mean 23.1 mL/kg). Transfusion volume was associated with acidosis and coagulopathy scores (r = 0.37, p = 0.033) and international normalized ratio (INR) (r = 0.34, p = 0.03) but not TASH (p = 0.72). Patients with INR≥1.3 received a higher mean volume of packed red cells compared to those with normal values (34 versus 18 mL/kg, p = 0.046). CONCLUSION Pediatric trauma patients who undergo transfusion of packed red blood cells are likely to require large volume transfusion if their baseline INR is ≥1.3. These patients may benefit from a balanced transfusion strategy, such as utilization of massive transfusion protocols or whole blood.
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6
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Flatman LK, Fergusson DA, Lacroix J, Ducruet T, Papenburg J, Fontela PS. Association between leukoreduced red blood cell transfusions and hospital-acquired infections in critically ill children: A secondary analysis of the TRIPICU study. Vox Sang 2021; 117:545-552. [PMID: 34820856 DOI: 10.1111/vox.13224] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 10/27/2021] [Accepted: 11/03/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVES Hospital-acquired infections (HAIs) are an important problem in critically ill children. Studies show associations between the transfusion of non-leukoreduced red blood cell units (RBC) and increased HAI incidence rates (IRs). We hypothesize that transfusing pre-storage leukoreduced RBC is also associated with increased HAI IR. We aim to evaluate the associations between (1) a leukoreduced RBC restrictive transfusion strategy and HAI IR, (2) leukoreduced RBC transfusions and HAI IR, and (3) the number or volume of leukoreduced RBC transfusions and HAI IR in critically ill children. MATERIALS AND METHODS This post hoc secondary analysis of the "Transfusion Requirement in Paediatric Intensive Care Units" (TRIPICU) randomized controlled trial (637 patients) used quasi-Poisson multivariable regression models to estimate HAI incidence rate ratios (IRRs) and 95% confidence intervals (CI). RESULTS A restrictive transfusion strategy yielded an IRR of 0.88 (95% CI 0.67, 1.16). The association between transfusing leukoreduced RBCs (IRR 1.25; 95% CI 0.73, 2.13) and HAI IR was not statistically significant. However, we observed significant associations between patients who received >20 cc/kg volume of leukoreduced RBC transfusions (IRR 2.14; 95% CI 1.15, 3.99) and ≥3 leukoreduced RBC transfusions (IRR 2.40; 95% CI 1.15, 4.99) and HAI IR. CONCLUSION Exposing critically ill children to >20 cc/kg or ≥3 leukoreduced RBC transfusions were associated with higher HAI IR, suggesting dose-response patterns.
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Affiliation(s)
- Leah K Flatman
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada.,Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Jacques Lacroix
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Université de Montréal, Montreal, Canada
| | - Thierry Ducruet
- Unité de Recherche Clinique Appliquée, Université de Montréal, Centre de Recherche, CHU Sainte-Justine, Montreal, Canada
| | - Jesse Papenburg
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada.,Division of Pediatric Infectious Diseases, Department of Pediatrics, McGill University, Montreal, Canada
| | - Patricia S Fontela
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada.,Division of Pediatric Critical Care Medicine, Department of Pediatrics, McGill University, Montreal, Canada
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Bhanudeep S, Rameshkumar R, Chidambaram M, Selvan T, Mahadevan S. Prospective Inverse Probability of Treatment-Weighting Analysis of the Clinical Outcome of Red Blood Cell Transfusion Practice in Critically Ill Children. Indian J Pediatr 2021; 88:985-990. [PMID: 33864604 DOI: 10.1007/s12098-021-03740-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 03/15/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To study the clinical outcomes of red blood cell (RBC) transfusion practices in critically ill children. METHOD This prospective cohort study was conducted in a tertiary care pediatric intensive care unit (PICU) from March-2015 to January-2018. Inverse probability of treatment weighting (IPTW) using propensity score analysis was used. Children aged 1 mo to 12 y admitted to the PICU were screened. Patients were classified into 'transfused' and 'nontransfused', based on whether they received a transfusion or not. Patients with hematological malignancies, or immunosuppressant drugs, or those who received repeated transfusions, or received transfusion before admission, or died within 24 h were excluded. The primary outcome was all-cause 28 d mortality. Secondary outcomes were new-onset organ dysfunction, mechanical ventilation duration, and length of PICU and hospital stay. RESULTS A total of 1014 patients [transfused = 277; nontransfused = 737) were included. In IPTW analysis, the risk of all-cause 28 d mortality was 53% higher in transfused than nontransfused patients [hazard ratio = 1.53, 95% CI: 1.18-1.98, p = 0.001 by Log-rank test]. Organ dysfunction was higher in transfused than nontransfused patients [3.8% vs. 1.3%, hazard ratio = 3.0, 95% CI: 1.40-6.48, p = 0.005]. The risk of staying in the mechanical ventilation was similar in both groups [hazard ratio = 1.03, 95% CI: 0.86-1.23, p = 0.756]. The risk of extended stay in the PICU and hospital was 16% and 21% higher in transfused than nontransfused patients [hazard ratio = 1.16, 95% CI: 1.03-1.30; p = 0.005; and 1.21, 95% CI: 1.08-1.36; p = 0.001], respectively. CONCLUSION Red blood cell transfusion was independently associated with higher all-cause 28 d mortality and morbidities in critically ill children.
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Affiliation(s)
- Singanamalla Bhanudeep
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605 006, India
| | - Ramachandran Rameshkumar
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605 006, India.
| | - Muthu Chidambaram
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605 006, India
| | - Tamil Selvan
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Subramanian Mahadevan
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605 006, India
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8
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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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9
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Blood manufacturing methods affect red blood cell product characteristics and immunomodulatory activity. Blood Adv 2019; 2:2296-2306. [PMID: 30217795 DOI: 10.1182/bloodadvances.2018021931] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 07/26/2018] [Indexed: 12/14/2022] Open
Abstract
Transfusion of red cell concentrates (RCCs) is associated with increased risk of adverse outcomes that may be affected by different blood manufacturing methods and the presence of extracellular vesicles (EVs). We investigated the effect of different manufacturing methods on hemolysis, residual cells, cell-derived EVs, and immunomodulatory effects on monocyte activity. Thirty-two RCC units produced using whole blood filtration (WBF), red cell filtration (RCF), apheresis-derived (AD), and whole blood-derived (WBD) methods were examined (n = 8 per method). Residual platelet and white blood cells (WBCs) and the concentration, cell of origin, and characterization of EVs in RCC supernatants were assessed in fresh and stored supernatants. Immunomodulatory activity of RCC supernatants was assessed by quantifying monocyte cytokine production capacity in an in vitro transfusion model. RCF units yielded the lowest number of platelet and WBC-derived EVs, whereas the highest number of platelet EVs was in AD (day 5) and in WBD (day 42). The number of small EVs (<200 nm) was greater than large EVs (≥200 nm) in all tested supernatants, and the highest level of small EVs were in AD units. Immunomodulatory activity was mixed, with evidence of both inflammatory and immunosuppressive effects. Monocytes produced more inflammatory interleukin-8 after exposure to fresh WBF or expired WBD supernatants. Exposure to supernatants from AD and WBD RCC suppressed monocyte lipopolysaccharide-induced cytokine production. Manufacturing methods significantly affect RCC unit EV characteristics and are associated with an immunomodulatory effect of RCC supernatants, which may affect the quality and safety of RCCs.
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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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11
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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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Recommendations on RBC Transfusions for Critically Ill Children With Nonhemorrhagic Shock From the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. Pediatr Crit Care Med 2018; 19:S121-S126. [PMID: 30161066 PMCID: PMC6126360 DOI: 10.1097/pcc.0000000000001620] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To present the recommendations and supporting literature for RBC transfusions in critically ill children with nonhemorrhagic shock 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 nonhemorrhagic shock subgroup included five 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 Consensus Conference experts developed and voted on a total of four clinical and four research recommendations focused on RBC transfusion in the critically ill child with nonhemorrhagic shock. All recommendations reached agreement (> 80%). Of the four clinical recommendations, three were based on consensus panel expertise, whereas one was based on weak pediatric evidence. In hemodynamically stabilized critically ill children with a diagnosis of severe sepsis or septic shock, we recommend not administering a RBC transfusion if the hemoglobin concentration is greater than or equal to 7 g/dL. Future studies are needed to determine optimum transfusion thresholds for critically ill children with nonhemorrhagic shock undergoing acute resuscitation. CONCLUSIONS The Transfusion and Anemia Expertise Initiative Consensus Conference developed pediatric-specific clinical and research recommendations regarding RBC transfusion in the critically ill child with nonhemorrhagic shock. Although agreement among experts was strong, available pediatric evidence was scant-revealing significant gaps in the existing literature.
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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 Selection and Processing of RBC Components for Pediatric Patients From the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. Pediatr Crit Care Med 2018; 19:S163-S169. [PMID: 30161072 PMCID: PMC6126365 DOI: 10.1097/pcc.0000000000001625] [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: 01/25/2023]
Abstract
OBJECTIVES To present the recommendations and supporting literature for selection and processing of RBC products in critically ill children 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 RBC processing subgroup included five 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 Five recommendations reached agreement (> 80%). Irradiated cellular products are recommended for children at risk of transfusion-associated graft versus host disease due to severe congenital or acquired causes of immune deficiency or when the blood donor is a blood relative. Washed cellular blood components and avoidance of other plasma-containing products are recommended for critically ill children with history of severe allergic reactions or anaphylaxis to blood transfusions, although patient factors appear to be important in the pathogenesis of reactions. For children with history of severe allergic transfusion reactions, evaluation for allergic stigmata prior to transfusion is recommended. In children with severe immunoglobulin A deficiency with evidence of antiimmunoglobulin A antibodies and/or a history of a severe transfusion reaction, immunoglobulin A-deficient blood components obtained either from an immunoglobulin A-deficient donor and/or washed cellular components is recommended. CONCLUSIONS The Transfusion and Anemia Expertise Initiative consensus conference developed recommendations for selection and processing of RBC units for critically ill children. Recommendations in this area are largely based on pediatric and adult case report data.
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Abstract
OBJECTIVES To determine the prevailing hemoglobin levels in PICU patients, and any potential correlates. DESIGN Post hoc analysis of prospective multicenter observational data. SETTINGS Fifty-nine PICUs in seven countries. PATIENTS PICU patients on four specific days in 2012. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patients' hemoglobin and other clinical and institutional data. Two thousand three hundred eighty-nine patients with median age of 1.9 years (interquartile range, 0.3-9.8 yr), weight 11.5 kg (interquartile range, 5.4-29.6 kg), and preceding PICU stay of 4.0 days (interquartile range, 1.0-13.0 d). Their median hemoglobin was 11.0 g/dL (interquartile range, 9.6-12.5 g/dL). The prevalence of transfusion in the 24 hours preceding data collection was 14.2%. Neonates had the highest hemoglobin at 13.1 g/dL (interquartile range, 11.2-15.0 g/dL) compared with other age groups (p < 0.001). The percentage of 31.3 of the patients had hemoglobin of greater than or equal to 12 g/dL, and 1.1% had hemoglobin of less than 7 g/dL. Blacks had lower median hemoglobin (10.5; interquartile range, 9.3-12.1 g/dL) compared with whites (median, 11.1; interquartile range, 9.0-12.6; p < 0.001). Patients in Spain and Portugal had the highest median hemoglobin (11.4; interquartile range, 10.0-12.6) compared with other regions outside of the United States (p < 0.001), and the highest proportion (31.3%) of transfused patients compared with all regions (p < 0.001). Patients in cardiac PICUs had higher median hemoglobin than those in mixed PICUs or noncardiac PICUs (12.3, 11.0, and 10.6 g/dL, respectively; p < 0.001). Cyanotic heart disease patients had the highest median hemoglobin (12.6 g/dL; interquartile range, 11.1-14.5). Multivariable regression analysis within diagnosis groups revealed that hemoglobin levels were significantly associated with the geographic location and history of complex cardiac disease in most of the models. In children with cancer, none of the variables tested correlated with patients' hemoglobin levels. CONCLUSIONS Patients' hemoglobin levels correlated with demographics like age, race, geographic location, and cardiac disease, but none found in cancer patients. Future investigations should account for the effects of these variables.
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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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17
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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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Chegondi M, Sasaki J, Raszynski A, Totapally BR. Hemoglobin Threshold for Blood Transfusion in a Pediatric Intensive Care Unit. Transfus Med Hemother 2016; 43:297-301. [PMID: 27721706 DOI: 10.1159/000446253] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 12/10/2015] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To evaluate the hemoglobin threshold for red cell transfusion in children admitted to a pediatric intensive care unit (PICU). METHODS Retrospective chart review study. Tertiary care PICU. Critically ill pediatric patients requiring blood transfusion. No intervention. RESULTS We analyzed the charts of all children between 1 month and 21 years of age who received packed red blood cell (PRBC) transfusions during a 2-year period. The target patients were identified from our blood bank database. For analysis, the patients were subdivided into four groups: acute blood loss (postsurgically, trauma, or acute gastrointestinal bleeding from other causes), hematologic (hematologic malignancies, bone marrow suppression, hemolytic anemia, or sickle cell disease), unstable (FiO2 > 0.6 and/or on inotropic support), and stable groups. We also compared the pre-transfusion hemoglobin threshold in all unstable patients with that of all stable patients. A total of 571 transfusion episodes in 284 patients were analyzed. 28% (n = 160) of transfusions were administered to patients in the acute blood loss group, 36% (n = 206) to hematologic patients, 17% (n = 99) to unstable patients, and 18% (n = 106) to stable patients. The mean pre-transfusion hemoglobin (± SD) in all children as well as in the acute blood loss, hematologic, unstable and stable groups was 7.3 ± 1.20, 7.83 ± 1.32, 6.97 ± 1.31, 7.96 ± 1.37, 7.31 ± 1.09 g/dl, respectively. The transfusion threshold for acute blood loss and unstable groups was higher compared to hematologic and stable groups (p < 0.001; ANOVA with multiple comparisons). The mean pre-transfusion hemoglobin threshold for stable and unstable patients among all groups was 7.3 ± 1.3 and 7.9 ± 1.3 (p < 0.0001), respectively. The observed mortality rate was higher among children who received transfusion compared to other children admitted to PICU. CONCLUSION The hemoglobin threshold for transfusion varied according to clinical conditions. Overall, the hemoglobin threshold for transfusion was 7.3 ± 1.20 g/dl.
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Affiliation(s)
- Madhuradhar Chegondi
- Division of Critical Care Medicine and Nicklaus Children's Hospital (Formerly Miami Children's Hospital), Miami, FL, USA
| | - Jun Sasaki
- Division of Critical Care Medicine and Nicklaus Children's Hospital (Formerly Miami Children's Hospital), Miami, FL, USA
| | - André Raszynski
- Division of Critical Care Medicine and Nicklaus Children's Hospital (Formerly Miami Children's Hospital), Miami, FL, USA; Herberth Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Balagangadhar R Totapally
- Division of Critical Care Medicine and Nicklaus Children's Hospital (Formerly Miami Children's Hospital), Miami, FL, USA; Herberth Wertheim College of Medicine, Florida International University, Miami, FL, USA
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19
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Abstract
OBJECTIVES To analyze the RBC transfusion practice patterns among pediatric intensivists in light of the new evidence advocating for a restrictive transfusion strategy. DESIGN Self-administered questionnaire. SETTING PICUs. SUBJECTS Intensivists and fellows in pediatric critical care medicine. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Scenario-based survey carried out among North American and European intensivists, working in tertiary-care PICUs. Respondents were asked to report their decisions with regard to RBC transfusion in stable critically ill children with bronchiolitis, septic shock, trauma, or tetralogy of Fallot repair scenarios. Answers were compared with those of a similar scenario-based survey administered to pediatric intensivists in 1997. Ninety-seven respondents were retained for the study, the majority from the United States, Canada, and France. In 2010, respondents reported that the mean (± SD) transfusion threshold was a hemoglobin level of 7.7 ± 1.0 g/dL for bronchiolitis, 8.1 ± 1.2 g/dL for trauma, 9.1 ± 1.2 g/dL for a tetralogy of Fallot repair, and 9.2 ± 1.0 g/dL for septic shock. For all clinical scenarios, there was a trend toward a more restrictive transfusion approach (a threshold ≤ 7 g/dL) in 2010 compared with 1997: a restrictive strategy was adopted by 55.7% of respondents in 2010 versus 37.0% in 1997 (p = 0.01) with the scenario of bronchiolitis, 8.3% versus 3.4% (p = 0.16) with septic shock, 38.1% versus 9.0% (p < 0.001) with trauma, and 16.0% versus 7.9% (p = 0.10) with tetralogy of Fallot repair. CONCLUSIONS Stated transfusion practice patterns of pediatric intensivists appear to be evolving toward a more restrictive approach two and a half years after the publication of the Transfusion Requirement in PICU trial. Incomplete implementation of new knowledge with regard to the safety of a restrictive transfusion approach in stable PICU patients is perplexing and requires further studies.
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22
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Toward a restrictive transfusion practice in the PICU: if not now, when? if not us, who? Pediatr Crit Care Med 2013; 14:895-6. [PMID: 24226555 DOI: 10.1097/pcc.0000000000000009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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