Noninvasive hemoglobin measurement in pediatric trauma patients

Management of Pediatric Solid Organ Injuries

Solid organ injury (SOI) is common in children who experience abdominal trauma, and the management of such injuries has evolved significantly over the past several decades. In 2000, the American Pediatric Surgical Association (APSA) published the first societal guidelines for the management of blunt spleen and/or liver injury (BLSI), advocating for optimized resource utilization while maintaining patient safety. Nonoperative management (NOM) has become the mainstay of treatment for SOI, and since the publication of the APSA guidelines, numerous groups have evaluated how invasive procedures, hospitalization, and activity restrictions may be safely minimized in children with SOI. Here, we review the current evidence-based management guidelines in place for the treatment of injuries to the spleen, liver, kidney, and pancreas in children, including initial evaluation, inpatient management, and long-term care, as well as gaps that exist in the current literature that may be targeted for further optimization of protocols for pediatric SOI.

Utility of continuous pulse CO-oximetry for hemoglobin monitoring in pediatric patients with solid organ injuries at level 1 trauma centers: A pilot study

INTRODUCTION

Hemorrhage is a major cause of preventable death in injured children. Monitoring after admission often requires multiple blood draws, which have been shown to be stressful in pediatric patients. The Rainbow-7 device is a continuous pulse CO-oximeter that measures multiple wavelengths of light, permitting continuous estimation of the total hemoglobin (Hb) level. The purpose of this study was to evaluate the utility of the noninvasive Hb measurement for monitoring pediatric trauma patients admitted with solid organ injury.

METHODS

This is a prospective, dual-center, observational trial for patients younger than age 18 years admitted to a Level I pediatric trauma center. Following admission, blood was routinely measured as per current solid organ injury protocols. Noninvasive Hb monitoring was initiated after admission. Time-synced data for Hb levels were compared with that taken using blood draws. Data were evaluated using bivariate correlation, linear regression, and Bland-Altman analysis.

RESULTS

Over a 1-year period, 39 patients were enrolled. The mean ± SD age was 11 ± 3.8 years. Forty-six percent (n = 18) of patients were male. The mean ± SD Injury Severity Score was 19 ± 13. The average change in Hb levels between laboratory measurements was -0.34 ± 0.95 g/dL, and the average change in noninvasive Hb was -0.12 ± 1.0 g/dL per measurement. Noninvasive Hb values were significantly correlated with laboratory measurements ( p < 0.001). Trends in laboratory Hb measurements were highly correlated with changes in noninvasive levels ( p < 0.001). Bland-Altman analysis demonstrated similar deviation from the mean throughout the range of Hb values, but the differences between measurements were increased by anemia, African American race, and elevated shock index, pediatric age-adjusted score and Injury Severity Score.

CONCLUSION

Noninvasive Hb values demonstrated correlation with measured Hb concentration as isolated measurements and trends, although results were affected by skin pigmentation, shock, and injury severity. Given the rapid availability of results and the lack of requirement of venipuncture, noninvasive Hb monitoring may be a valuable adjunct for pediatric solid organ injury protocols. Further study is required to determine its role in management.

LEVEL OF EVIDENCE

Dianostic Test or Criteria; Level III.

Reliability of transcutaneous hemoglobin measurements in an outpatient pediatric clinic

OBJECTIVE

Our study assessed the reliability of a transcutaneous hemoglobin (tcHgb) measurement as compared to a standard capillary hemoglobin (cHgb) measurement in screening for iron deficiency anemia in a single university-based pediatric outpatient clinic.

METHODS

Study participants included all pediatric patients requiring a hemoglobin (Hgb) assessment from July 2019 to June 2020. A tcHgb measurement was attempted on all children who received a cHgb measurement. Additional variables evaluated were age, visit type, gender, insurance type, weight, BMI percentile and presence of comorbid conditions.

RESULTS

Of 777 attempts, both cHgb and tcHgb were obtained in 196 children aged 9 months to 21 years. Attempts were most successful in children > 2 years of age due to finger size and ability to remain still for one to two minutes. The mean cHgb was 12.5 ± 1.5 g/dL, mean tcHgb value 13.1 ± 2.1 g/dL, and the mean difference was 0.6 ± 2.1 g/dL (tcHgb-cHgb). An intraclass correlation coefficient was 0.29. There were no differences with regards to age, visit type, gender, insurance type, weight, BMI percentile and presence of comorbid conditions. Bland-Altman analysis displayed a lack of agreement between the tcHgb and cHgb measurements and tcHgb tended to over-estimate Hgb values when the cHgb was low.

CONCLUSIONS

The measurement of a transcutaneous Hgb is less invasive for pediatric patients but has significant limitations. Smaller children (probe specifications) and movement limited the ability to obtain a tcHgb measurement in ~75% of children tested. Falsely normal tcHgb values occurred due to overestimation of hemoglobin when compared to the traditional cHgb device. The suboptimal sensitivity of the tcHgb device may cause providers to miss a diagnosis of anemia. Future research should compare both methods of Hgb assessment to the gold standard laboratory-analyzed complete blood count and use a smaller probe for children under 2, once available.

Evaluation of the accuracy of a non-invasive hemoglobin-monitoring device in schoolchildren

BACKGROUND

Iron deficiency anemia (IDA) is a public health problem in children and adolescents that is characterized by reduced hemoglobin (Hb) levels. Non-invasive monitoring devices can measure Hb levels continuously without pain or discomfort; however, little is known about their accuracy in children and adolescents. This study estimated the accuracy of a non-invasive Hb monitor in this age group.

METHODS

Participants were outpatients visiting the Tokyo Metropolitan Children's Medical Center for blood tests between January and March 2019. Hb levels were measured using both non-invasive Astrim Fit monitoring devices and invasive blood collection followed by automated analysis. Bland-Altman analysis assessed the agreement between the two measurements.

RESULTS

Overall, 120 schoolchildren (9-15 years old, 51 % female) were enrolled. The non-invasive measuring device recorded Hb levels of 13.5 ± 1.6 g/dL (mean ± standard deviation [SD]), while the mean Hb level obtained from the collected blood was 13.7 ± 1.7 g/dL. Therefore, the mean difference of bias and SD of precision was 0.17 ± 1.95 g/dL. Values of lower and upper limits of agreement were -3.65 and 3.99, respectively. There was no systematic fixed or proportion bias. Fifty-nine participants (49 %) had a relative error of ± 0.10.

CONCLUSION

The Astrim Fit non-invasive Hb monitor can be used to evaluate Hb levels among schoolchildren for health promotion or research purposes because of its extremely low bias (or precision), no systematic biases (including fixed or proportion biases), and positive correlation between non-invasive monitoring and blood drawing. However, it is difficult to assess Hb levels in children and adolescents using the Astrim Fit device for diagnostic purposes.

Progressive evaluation in spectroscopic sensors for non-invasive blood haemoglobin analysis - a review

Frequent monitoring of haemoglobin concentration is highly recommended by physicians to diagnose anaemia and polycythemia Vera. Moreover, Some other conditions also demand assessment of haemoglobin, and these conditions are blood loss, before blood donation, during pregnancy, preoperative, perioperative and postoperative conditions. Cyanmethaemoglobin/haemiglobincyanide method, portable haemoglobinometers and haematology analyzers are few standard methods to diagnose mentioned ailments. However, discomfort, delay and risk of infection are typical limitations of traditional measuring solutions. These limitations create the necessity to develop a non-invasive haemoglobin monitoring technique for a better lifestyle. Various methods and products are already developed and popular due to their non-invasiveness; however, invasive solutions are still considered as the reference standard method. Therefore, this review summarizes the attributes of existing non-invasive solutions. These attributes are finalized as brief details, accuracy, optimal benefits, and research challenges for exploring potential gaps, advancements and possibilities to consider as futuristic alternative methodologies. Non-invasive total haemoglobin assessing techniques are mainly based on optical spectroscopy (reflectance/transmittance) or digital photography or spectroscopic imaging in spot check/continuous monitoring mode. In all these techniques, we have noticed that there is a need to consider different light conditions, motion artefacts, melanocytes, other blood constituents, smoking and precise fixing of the sensor from the sensing spot for exact formulation. Moreover, based on careful and critical analysis of outcomes, none of these techniques or products is used independently or intended to replace invasive laboratory testing. Therefore there is a requirement for a more accurate technique that can eliminate the requirement of blood samples and likely end up as a reference standard method.

Continuous noninvasive hemoglobin monitoring estimates timing for detecting anemia better than clinicians: a randomized controlled trial

BACKGROUND

Hemoglobin measurement is important for transfusion decision-making. Pulse CO-Oximetry provides real-time continuous hemoglobin (SpHb) monitoring. The triage role of SpHb trends based on hemoglobin measurements was investigated.

METHODS

In this diagnostic randomized controlled trial, 69 patients undergoing spine or cytoreductive surgery were randomly enrolled into SpHb-monitoring and standard-care groups. Diagnostic blood samples were drawn for CO-oximetry Hb (CoOxHb) when the SpHb decreased by 1 g/dl or at the clinician's discretion in the standard-care group. The positive predictive value (PPV) was defined as the ability to detect a decrease in CoOxHb > 1 g/dl or a CoOxHb < 10 g/dl; the PPVs were compared using Fisher's exact test. The SpHb and trend accuracies were calculated. The transfusion units and postoperative hemoglobin levels were compared.

RESULTS

The PPV of a decrease in CoOxHb > 1 g/dl was 93.3% in the SpHb group vs 54.5% without SpHb monitoring (p = 0.002). The PPV of CoOxHb < 10 g/dl was 86.7% vs. 50.0% for these groups (p = 0.015). The CoOxHb was never < 7 g/dl with SpHb monitoring. Sixty SpHb-CoOxHb data pairs and 28 delta pairs (ΔSpHb-ΔCoOxHb) were collected. The bias, precision and limits of agreement were - 0.29, 1.03 and - 2.30 to 1.72 g/dl, respectively. When ΔSpHb and ΔCoOxHb were > 1 g/dl, the concordance rate for changes in hemoglobin reached 100%. The delta pairs revealed a positive correlation [ΔSpHb = 0.49 * ΔCoOxHb - 0.13; r = 0.69, 95% confidence interval (0.53, 0.82)]. No significant differences were found in the transfusion volume or postoperative anemia state.

CONCLUSIONS

The SpHb trend tracked changes in hemoglobin satisfactorily during surgery and more accurately estimated the appropriate timing for invasive hemoglobin measurements than the clinicians.

TRIAL REGISTRATION

ChiCTR1800016290 (Prospective registered). Initial registration date was 24/05/2018.

The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition

BACKGROUND

Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources.

METHODS

The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated.

RESULTS

Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group's belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms.

CONCLUSIONS

A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient.

Evaluation of Noninvasive Hemoglobin Monitoring in Trauma Patients with Low Hemoglobin Levels

OBJECTIVE

Bleeding is a leading cause of death among trauma patients. Delayed assessment of blood hemoglobin level might result in either unnecessary blood transfusion in nonindicated patients or delayed blood transfusion in critically bleeding patients. In this study, we evaluate the precision of noninvasive hemoglobin monitoring in trauma patients with low hemoglobin levels.

METHODS

We included trauma patients with low hemoglobin levels (less than 8 g/dL) scheduled for surgical intervention. Blood samples were obtained on admission and after each blood unit with concomitant measurement of serum hemoglobin using radical-7 Masimo device. The change in blood hemoglobin after every transfused blood unit was also assessed by both methods (change in noninvasive Masimo hemoglobin [Delta-Sp-Hb] and change in laboratory hemoglobin [Delta-Lab-Hb]). The precision of Masimo hemoglobin level (Sp-Hb) compared with Laboratory hemoglobin level (Lab-Hb) was determined using both Bland-Altman and Pearson correlation analyses.

RESULTS

One hundred eighty-four time-matched samples were available for final analysis. Bland-Altman analysis showed excellent accuracy of Sp-Hb compared with Lab-Hb with mean bias of 0.12 g/dL and limits of agreement between -0.56 g/dL and 0.79 g/dL. Excellent correlation was reported between both measures with Pearson correlation coefficient of 0.872. Excellent agreement was also reported between both Delta-Sp-Hb and Delta-Lab-Hb with mean bias of -0.05 and limits of agreement from -0.62 to 0.51 CONCLUSIONS:: Sp-Hb showed accurate precision in both absolute values and trend values compared with Lab-Hb measurement in trauma patients with low hemoglobin levels.

To save a child's spleen: 50 years from Toronto to ATOMAC

Pediatric surgeons brought forth non-operative treatment for children with blunt spleen injury more than 50 years ago. At the time, this proposal was deemed reckless by many adult surgeons, and debate ensued for decades. Despite criticisms, pediatric surgeons refined the clinical pathways for children with spleen injury leading to current safe and efficient outcomes. These outcomes are defined by rare splenectomies, few blood transfusions, and short length of hospital stay. This review will address the role of the spleen through historical perceptions and scientific evidence. In addition, evolution of contemporary clinical pathways will be outlined.

Continuous hemoglobin monitoring in pediatric trauma patients with solid organ injury

BACKGROUND/PURPOSE

Hemoglobin monitoring is required in pediatric trauma patients with solid organ injury. We hypothesized that noninvasive hemodynamic monitoring (NIHM) represents an effective, safe alternative to laboratory hemoglobin (LabHb) monitoring in clinically stable patients.

METHODS

A retrospective cohort study was conducted regarding pediatric trauma patients (<18 years old) with blunt solid organ injury over six consecutive months. Continuous NIHM was initiated at the time of admission, and LabHb measurements were obtained per institutional guidelines. Measurements were correlated within two hours of assessment and patient outcomes were analyzed.

RESULTS

Twenty-one patients met inclusion criteria and had evaluable data. Blunt trauma was the exclusive mechanism of injury, and mean injury severity score was 16.6 for the cohort. Bland Altman analysis showed an average deviation of 0.80 g/dL between NIHM and LabHb values for all data pairs. Measurement trends were highly correlated in patients with stable hemoglobin levels and those requiring blood transfusion.

CONCLUSIONS

NIHM demonstrated clinically acceptable accuracy when following hemoglobin trends in the defined pediatric trauma patient population. Slight variances between NIHM and LabHb values were occasionally noted, but did not affect clinical management. Continuous NIHM represents a potentially valuable adjunct to traditional laboratory hemoglobin monitoring.

LEVEL OF EVIDENCE RATING

IV.

The Kids Are Alright: Pediatric Trauma Pearls

Pediatric patients with trauma pose unique challenges, both practical and cognitive, to front-line care providers. The combination of anatomic, physiologic, and metabolic factors leads to unique injury patterns with different approaches and responses to treatment compared with adults. A similar traumatic mechanism can lead to slightly different internal injuries with unique management and treatment strategies between the two groups. This article is intended for community, nonpediatric trauma centers, and emergency physicians who are frequently required to assess, resuscitate, and stabilize injured children before they can be safely transferred to a pediatric trauma center for ongoing definitive care and rehabilitation.