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Rintoul NE, McMichael ABV, Bembea MM, DiGeronimo R, Patregnani J, Alexander PMA, Muszynski JA, Steffen K, Gehred A, Lyman E, Cheifetz IM. Management of Bleeding and Thrombotic Complications During Pediatric Extracorporeal Membrane Oxygenation: The Pediatric Extracorporeal Membrane Oxygenation Anticoagulation CollaborativE Consensus Conference. Pediatr Crit Care Med 2024; 25:e66-e77. [PMID: 38959361 PMCID: PMC11216396 DOI: 10.1097/pcc.0000000000003489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
OBJECTIVES To derive systematic-review informed, modified Delphi consensus regarding the management of bleeding and thrombotic complications during pediatric extracorporeal membrane oxygenation (ECMO) for the Pediatric ECMO Anticoagulation CollaborativE Consensus Conference. DATA SOURCES A structured literature search was performed using PubMed, EMBASE, and Cochrane Library (CENTRAL) databases from January 1988 to May 2021. STUDY SELECTION The management of bleeding and thrombotic complications of ECMO. DATA EXTRACTION Two authors reviewed all citations independently, with a third independent reviewer resolving conflicts. Twelve references were used for data extraction and informed recommendations. Evidence tables were constructed using a standardized data extraction form. DATA SYNTHESIS Risk of bias was assessed using the Quality in Prognosis Studies tool. The evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation system. Forty-eight experts met over 2 years to develop evidence-based recommendations and, when evidence was lacking, expert-based consensus statements for the management of bleeding and thrombotic complications in pediatric ECMO patients. A web-based modified Delphi process was used to build consensus via the Research And Development/University of California Appropriateness Method. Consensus was defined as greater than 80% agreement. Two good practice statements, 5 weak recommendations, and 18 consensus statements are presented. CONCLUSIONS Although bleeding and thrombotic complications during pediatric ECMO remain common, limited definitive data exist to support an evidence-based approach to treating these complications. Research is needed to improve hemostatic management of children supported with ECMO.
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Affiliation(s)
- Natalie E Rintoul
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Ali B V McMichael
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
- Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Robert DiGeronimo
- Division of Neonatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
| | - Jason Patregnani
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Barbara Bush Children's Hospital, Portland, ME
| | - Peta M A Alexander
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Jennifer A Muszynski
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University of Medicine, Columbus, OH
| | - Katherine Steffen
- Department of Pediatrics (Pediatric Critical Care Medicine), Stanford University, Palo Alto, CA
| | - Alison Gehred
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital Columbus, Columbus, OH
| | - Elizabeth Lyman
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital Columbus, Columbus, OH
| | - Ira M Cheifetz
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, OH
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Nellis ME, Moynihan KM, Sloan SR, Delaney M, Kneyber MCJ, DiGeronimo R, Alexander PMA, Muszynski JA, Gehred A, Lyman E, Karam O. Prophylactic Transfusion Strategies in Children Supported by Extracorporeal Membrane Oxygenation: The Pediatric Extracorporeal Membrane Oxygenation Anticoagulation CollaborativE Consensus Conference. Pediatr Crit Care Med 2024; 25:e25-e34. [PMID: 38959357 PMCID: PMC11216389 DOI: 10.1097/pcc.0000000000003493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
OBJECTIVES To derive systematic-review informed, modified Delphi consensus regarding prophylactic transfusions in neonates and children supported with extracorporeal membrane oxygenation (ECMO) from the Pediatric ECMO Anticoagulation CollaborativE. DATA SOURCES A structured literature search was performed using PubMed, EMBASE, and Cochrane Library (CENTRAL) databases from January 1988 to May 2020, with an update in May 2021. STUDY SELECTION Included studies assessed use of prophylactic blood product transfusion in pediatric ECMO. DATA EXTRACTION Two authors reviewed all citations independently, with a third independent reviewer resolving conflicts. Thirty-three references were used for data extraction and informed recommendations. Evidence tables were constructed using a standardized data extraction form. MEASUREMENTS AND MAIN RESULTS The evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation system. Forty-eight experts met over 2 years to develop evidence-informed recommendations and, when evidence was lacking, expert-based consensus statements or good practice statements for prophylactic transfusion strategies for children supported with ECMO. A web-based modified Delphi process was used to build consensus via the Research And Development/University of California Appropriateness Method. Consensus was based on a modified Delphi process with agreement defined as greater than 80%. We developed two good practice statements, 4 weak recommendations, and three expert consensus statements. CONCLUSIONS Despite the frequency with which pediatric ECMO patients are transfused, there is insufficient evidence to formulate evidence-based prophylactic transfusion strategies.
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Affiliation(s)
- Marianne E Nellis
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, NY Presbyterian Hospital-Weill Cornell Medicine, New York, NY
| | - Katie M Moynihan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, NY Presbyterian Hospital-Weill Cornell Medicine, New York, NY
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Department of Laboratory Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
- Division of Pathology and Laboratory Medicine, Children's National Hospital, Washington, DC
- Department of Pathology and Pediatrics, George Washington University Health Sciences, Washington, DC
- Pediatric Intensive Care Unit, Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
- The Ohio State University of Medicine, Columbus, OH
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital Columbus, OH
- Division of Critical Care Medicine, Children's Hospital of Richmond at VCU, Richmond, VA
- Division of Critical Care Medicine, Yale School of Medicine, New Haven, CT
| | - Steven R Sloan
- Department of Laboratory Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Meghan Delaney
- Division of Pathology and Laboratory Medicine, Children's National Hospital, Washington, DC
- Department of Pathology and Pediatrics, George Washington University Health Sciences, Washington, DC
| | - Martin C J Kneyber
- Pediatric Intensive Care Unit, Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
| | - Robert DiGeronimo
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA
| | - Peta M A Alexander
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Jennifer A Muszynski
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
- The Ohio State University of Medicine, Columbus, OH
| | - Alison Gehred
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital Columbus, OH
| | - Elizabeth Lyman
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital Columbus, OH
| | - Oliver Karam
- Division of Critical Care Medicine, Children's Hospital of Richmond at VCU, Richmond, VA
- Division of Critical Care Medicine, Yale School of Medicine, New Haven, CT
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Shenker J, Abuelhija H, Karam O, Nellis M. Transfusion Strategies in the 21st Century: A Case-Based Narrative Report. Crit Care Clin 2023; 39:287-298. [PMID: 36898774 DOI: 10.1016/j.ccc.2022.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The transfusion of all blood components (red blood cells, plasma, and platelets) has been associated with increased morbidity and mortality in children. It is essential that pediatric providers weigh the risks and benefits before transfusing a critically ill child. A growing body of evidence has demonstrated the safety of restrictive transfusion practices in critically ill children.
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Affiliation(s)
- Jennifer Shenker
- Department of Pediatrics, New York Presbyterian Hospital - Weill Cornell Medicine, 525 East 68th Street, M508, New York, NY 10065, USA
| | - Hiba Abuelhija
- Pediatric Critical Care, Hadassah University Medical Center, Hadassah Ein Kerem, POB 12000, Jerusalem 911200, Israel
| | - Oliver Karam
- Department of Pediatrics, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06520, USA
| | - Marianne Nellis
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Weill Cornell Medicine, 525 East 68th Street, M512, New York, NY 10065, USA.
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Hukkinen M, Wong M, Demir Z, Salem RH, Debray D, Renolleau S, Sissaoui S, Lacaille F, Girard M, Oualha M, Querciagrossa S, Fabre M, Lozach C, Clement R, Lasne D, Borgel D, Capito C, Chardot C. Antithrombin supplementation for prevention of vascular thrombosis after pediatric liver transplantation. J Pediatr Surg 2022; 57:666-675. [PMID: 35871859 DOI: 10.1016/j.jpedsurg.2022.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 05/23/2022] [Accepted: 06/12/2022] [Indexed: 11/27/2022]
Abstract
AIMS After liver transplantation (LT), synthesis of coagulation factors by the graft recovers faster for pro thrombotic than anti thrombotic factors, resulting in a potential pro thrombotic imbalance. We studied the thrombotic and hemorrhagic complications in our pediatric LT series, providing supplementation of fresh frozen plasma (FFP) and/or antithrombin (AT) in the prophylactic antithrombotic regimen. METHODS This was a retrospective observational single center study. All isolated pediatric LTs performed between 1/11/2009 and 31/12/2019 (n = 181) were included. Postoperatively, in addition to low molecular weight heparin, 22 patients (12%) received FFP (10 ml/kg twice daily for 10 days), 27 patients (15%) were given FFP (reduced duration) and AT (50-100 IU/kg/day if AT activity remained <70%), and 132 (73%) received AT only. Complications, outcome, and coagulation profiles in postoperative days 0-10 were analyzed. RESULTS In all three treatment groups, AT activity normalized by day 4 while prothrombin remained <70% of normal until day 9. Hepatic artery thrombosis (HAT), portal vein thrombosis (PVT), and hemorrhagic complications occurred in 2.8%, 3.3%, and 3.9% of LTs. One- and 5-year patient and graft survival were 88% (±2.4% Standard Error) and 84% (±2.5%), and 86% (±2.6%) and 84% (±2.7%), respectively, without difference between groups. HAT were associated with low AT on days 0 and 1, and PVT with low AT on day 0. CONCLUSIONS Low antithrombin activity after LT was associated with postoperative thromboses. FFP and/or AT supplementation allowed early normalization of AT activity, while thrombotic or hemorrhagic complications were rare, suggesting efficient and safe management of post-LT coagulopathy.
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Affiliation(s)
- Maria Hukkinen
- Pediatric Surgery Unit, Hôpital Universitaire Necker-Enfants Malades, 149 rue de Sèvres, Paris 75015, France
| | - Michela Wong
- Pediatric Surgery Unit, Hôpital Universitaire Necker-Enfants Malades, 149 rue de Sèvres, Paris 75015, France
| | - Zeynep Demir
- Pediatric Hepatology Unit, Hôpital Universitaire Necker-Enfants Malades, 149 rue de Sèvres, Paris 75015, France
| | - Radhia Hadj Salem
- Pediatric Hepatology Unit, Hôpital Universitaire Necker-Enfants Malades, 149 rue de Sèvres, Paris 75015, France
| | - Dominique Debray
- Pediatric Hepatology Unit, Hôpital Universitaire Necker-Enfants Malades, 149 rue de Sèvres, Paris 75015, France; Université Paris Cité, 85 Bd Saint Germain, Paris 75006, France
| | - Sylvain Renolleau
- Pediatric Intensive Care Unit, Hôpital Universitaire Necker-Enfants Malades, 149 rue de Sèvres, Paris 75015, France; Université Paris Cité, 85 Bd Saint Germain, Paris 75006, France
| | - Samira Sissaoui
- Pediatric Hepatology Unit, Hôpital Universitaire Necker-Enfants Malades, 149 rue de Sèvres, Paris 75015, France
| | - Florence Lacaille
- Pediatric Hepatology Unit, Hôpital Universitaire Necker-Enfants Malades, 149 rue de Sèvres, Paris 75015, France
| | - Muriel Girard
- Pediatric Hepatology Unit, Hôpital Universitaire Necker-Enfants Malades, 149 rue de Sèvres, Paris 75015, France; Université Paris Cité, 85 Bd Saint Germain, Paris 75006, France
| | - Mehdi Oualha
- Pediatric Intensive Care Unit, Hôpital Universitaire Necker-Enfants Malades, 149 rue de Sèvres, Paris 75015, France; Université Paris Cité, 85 Bd Saint Germain, Paris 75006, France
| | - Stefania Querciagrossa
- Pediatric Anesthesiology Department, Hôpital Universitaire Necker-Enfants Malades, 149 rue de Sèvres, Paris 75015, France
| | - Monique Fabre
- Pathology Department, Hôpital Universitaire Necker-Enfants Malades, 149 rue de Sèvres, Paris 75015, France
| | - Cecile Lozach
- Radiology Department, Hôpital Universitaire Necker-Enfants Malades, 149 rue de Sèvres, Paris 75015, France
| | - Rozenn Clement
- Pharmacy, Hôpital Universitaire Necker-Enfants Malades, 149 rue de Sèvres, Paris 75015, France
| | - Dominique Lasne
- Université Paris Cité, 85 Bd Saint Germain, Paris 75006, France; Biological Hematology Laboratories, Hôpital Universitaire Necker-Enfants Malades, 149 rue de Sèvres, Paris 75015, France
| | - Delphine Borgel
- Université Paris Cité, 85 Bd Saint Germain, Paris 75006, France; Biological Hematology Laboratories, Hôpital Universitaire Necker-Enfants Malades, 149 rue de Sèvres, Paris 75015, France
| | - Carmen Capito
- Pediatric Surgery Unit, Hôpital Universitaire Necker-Enfants Malades, 149 rue de Sèvres, Paris 75015, France; Université Paris Cité, 85 Bd Saint Germain, Paris 75006, France.
| | - Christophe Chardot
- Pediatric Surgery Unit, Hôpital Universitaire Necker-Enfants Malades, 149 rue de Sèvres, Paris 75015, France; Université Paris Cité, 85 Bd Saint Germain, Paris 75006, France
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Valentine SL, Cholette JM, Goobie SM. Transfusion Strategies for Hemostatic Blood Products in Critically Ill Children: A Narrative Review and Update on Expert Consensus Guidelines. Anesth Analg 2022; 135:545-557. [PMID: 35977364 DOI: 10.1213/ane.0000000000006149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Critically ill children commonly receive coagulant products (plasma and/or platelet transfusions) to prevent or treat hemorrhage or correct coagulopathy. Unique aspects of pediatric developmental physiology, and the complex pathophysiology of critical illness must be considered and balanced against known transfusion risks. Transfusion practices vary greatly within and across institutions, and high-quality evidence is needed to support transfusion decision-making. We present recent recommendations and expert consensus statements to direct clinicians in the decision to transfuse or not to transfuse hemostatic blood products, including plasma, platelets, cryoprecipitate, and recombinant products to critically ill children.
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Affiliation(s)
- Stacey L Valentine
- From the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jill M Cholette
- Department of Pediatrics, Divisions of Critical Care Medicine and Cardiology, University of Rochester Golisano Children's Hospital, Rochester, New York
| | - Susan M Goobie
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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6
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GÖKÇEBAY DGÜRLEK, YILMAZ ATURGUTOGLU, SANTAFLIOGLU B, BECERIR C, TAYMAN C, YARALI N, ÖZBEK NY. Analysis of Fresh Frozen Plasma utilization indications in children: an audit of a tertiary care hospital in Turkey. Transfus Apher Sci 2022; 61:103469. [DOI: 10.1016/j.transci.2022.103469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 04/28/2022] [Accepted: 05/23/2022] [Indexed: 10/18/2022]
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Nellis ME, Karam O, Valentine SL, Bateman ST, Remy KE, Lacroix J, Cholette JM, Bembea MM, Russell RT, Steiner ME, Goobie SM, Tucci M, Stricker PA, Stanworth SJ, Delaney M, Lieberman L, Muszynski JA, Bauer DF, Steffen K, Nishijima D, Ibla J, Emani S, Vogel AM, Haas T, Goel R, Crighton G, Delgado D, Demetres M, Parker RI. Executive Summary of Recommendations and Expert Consensus for Plasma and Platelet Transfusion Practice in Critically Ill Children: From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding (TAXI-CAB). Pediatr Crit Care Med 2022; 23:34-51. [PMID: 34989711 PMCID: PMC8820267 DOI: 10.1097/pcc.0000000000002851] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Critically ill children frequently receive plasma and platelet transfusions. We sought to determine evidence-based recommendations, and when evidence was insufficient, we developed expert-based consensus statements about decision-making for plasma and platelet transfusions in critically ill pediatric patients. DESIGN Systematic review and consensus conference series involving multidisciplinary international experts in hemostasis, and plasma/platelet transfusion in critically ill infants and children (Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding [TAXI-CAB]). SETTING Not applicable. PATIENTS Children admitted to a PICU at risk of bleeding and receipt of plasma and/or platelet transfusions. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A panel of 29 experts in methodology, transfusion, and implementation science from five countries and nine pediatric subspecialties completed a systematic review and participated in a virtual consensus conference series to develop recommendations. The search included MEDLINE, EMBASE, and Cochrane Library databases, from inception to December 2020, using a combination of subject heading terms and text words for concepts of plasma and platelet transfusion in critically ill children. Four graded recommendations and 49 consensus expert statements were developed using modified Research and Development/UCLA and Grading of Recommendations, Assessment, Development, and Evaluation methodology. We focused on eight subpopulations of critical illness (1, severe trauma, intracranial hemorrhage, or traumatic brain injury; 2, cardiopulmonary bypass surgery; 3, extracorporeal membrane oxygenation; 4, oncologic diagnosis or hematopoietic stem cell transplantation; 5, acute liver failure or liver transplantation; 6, noncardiac surgery; 7, invasive procedures outside the operating room; 8, sepsis and/or disseminated intravascular coagulation) as well as laboratory assays and selection/processing of plasma and platelet components. In total, we came to consensus on four recommendations, five good practice statements, and 44 consensus-based statements. These results were further developed into consensus-based clinical decision trees for plasma and platelet transfusion in critically ill pediatric patients. CONCLUSIONS The TAXI-CAB program provides expert-based consensus for pediatric intensivists for the administration of plasma and/or platelet transfusions in critically ill pediatric patients. There is a pressing need for primary research to provide more evidence to guide practitioners.
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Affiliation(s)
- Marianne E Nellis
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, NY Presbyterian Hospital-Weill Cornell Medicine, New York, NY
| | - Oliver Karam
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Hospital of Richmond at VCU, Richmond, VA
| | - Stacey L Valentine
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA
| | - Scot T Bateman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA
| | - Kenneth E Remy
- Division of Pediatric Critical Care Medicine and Pulmonary/Critical Care Medicine, Departments of Pediatrics and Internal Medicine, Washington University of St. Louis, St. Louis, MO
| | - Jacques Lacroix
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Jill M Cholette
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Rochester Golisano Children's Hospital, Rochester, NY
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Robert T Russell
- Department of Surgery, University of Alabama Birmingham, Birmingham, AL
| | - Marie E Steiner
- Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | - Susan M Goobie
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Marisa Tucci
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Paul A Stricker
- Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, PA
| | - Simon J Stanworth
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, NY Presbyterian Hospital-Weill Cornell Medicine, New York, NY
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Hospital of Richmond at VCU, Richmond, VA
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA
- Division of Pediatric Critical Care Medicine and Pulmonary/Critical Care Medicine, Departments of Pediatrics and Internal Medicine, Washington University of St. Louis, St. Louis, MO
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Rochester Golisano Children's Hospital, Rochester, NY
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Surgery, University of Alabama Birmingham, Birmingham, AL
- Department of Pediatrics, University of Minnesota, Minneapolis, MN
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
- Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, PA
- NHS Blood and Transplant, Oxford, United Kingdom
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
- Radcliffe Department of Medicine and Oxford BRC Haematology Theme, University of Oxford, Oxford, United Kingdom
- Division of Pathology & Laboratory Medicine, Children's National Hospital, Washington, DC
- Department of Pathology & Pediatrics, The George Washington University Health Sciences, Washington, DC
- Department of Clinical Pathology, University Health Network Hospitals, Toronto, ON, Canada
- Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, ON, Canada
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
- Division of Pediatric Neurosurgery Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, TX
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Stanford University, Palo Alto, CA
- Department of Emergency Medicine, University of California, Davis School of Medicine, Davis, CA
- Department of Cardiovascular Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
- Division of Pediatric Surgery Texas Children's Hospital, Department of Surgery, Baylor College of Medicine, Houston, TX
- Department of Pediatric Anesthesia, University Children's Hospital Zurich, Zurich, Switzerland
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, MD
- Department of Haematology, Royal Children's Hospital, Melbourne, VIC, Australia
- Samuel J. Wood Library & C.V. Starr Biomedical Information Center, Weill Cornell Medicine, New York, NY
- Department of Pediatric Hematology/Oncology, Renaissance School of Medicine, State University of New York at Stony Brook, Stony Brook, NY
| | - Meghan Delaney
- Division of Pathology & Laboratory Medicine, Children's National Hospital, Washington, DC
- Department of Pathology & Pediatrics, The George Washington University Health Sciences, Washington, DC
| | - Lani Lieberman
- Department of Clinical Pathology, University Health Network Hospitals, Toronto, ON, Canada
- Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Jennifer A Muszynski
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - David F Bauer
- Division of Pediatric Neurosurgery Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, TX
| | - Katherine Steffen
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Stanford University, Palo Alto, CA
| | - Daniel Nishijima
- Department of Emergency Medicine, University of California, Davis School of Medicine, Davis, CA
| | - Juan Ibla
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Sitaram Emani
- Department of Cardiovascular Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Adam M Vogel
- Division of Pediatric Surgery Texas Children's Hospital, Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Thorsten Haas
- Department of Pediatric Anesthesia, University Children's Hospital Zurich, Zurich, Switzerland
| | - Ruchika Goel
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, MD
| | - Gemma Crighton
- Department of Haematology, Royal Children's Hospital, Melbourne, VIC, Australia
| | - Diana Delgado
- Samuel J. Wood Library & C.V. Starr Biomedical Information Center, Weill Cornell Medicine, New York, NY
| | - Michelle Demetres
- Samuel J. Wood Library & C.V. Starr Biomedical Information Center, Weill Cornell Medicine, New York, NY
| | - Robert I Parker
- Department of Pediatric Hematology/Oncology, Renaissance School of Medicine, State University of New York at Stony Brook, Stony Brook, NY
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8
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Delaney M, Karam O, Lieberman L, Steffen K, Muszynski JA, Goel R, Bateman ST, Parker RI, Nellis ME, Remy KE. What Laboratory Tests and Physiologic Triggers Should Guide the Decision to Administer a Platelet or Plasma Transfusion in Critically Ill Children and What Product Attributes Are Optimal to Guide Specific Product Selection? From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. Pediatr Crit Care Med 2022; 23:e1-e13. [PMID: 34989701 PMCID: PMC8769352 DOI: 10.1097/pcc.0000000000002854] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To present consensus statements and supporting literature for plasma and platelet product variables and related laboratory testing for transfusions in general critically ill children from the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. DESIGN Systematic review and consensus conference of international, multidisciplinary experts in platelet and plasma transfusion management of critically ill children. SETTING Not applicable. PATIENTS Critically ill pediatric patients at risk of bleeding and receiving plasma and/or platelet transfusions. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A panel of 10 experts developed evidence-based and, when evidence was insufficient, expert-based statements for laboratory testing and blood product attributes for platelet and plasma transfusions. These statements were reviewed and ratified by the 29 Transfusion and Anemia EXpertise Initiative - Control/Avoidance of Bleeding experts. A systematic review was conducted using MEDLINE, EMBASE, and Cochrane Library databases, from inception to December 2020. Consensus was obtained using the Research and Development/University of California, Los Angeles Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. We developed five expert consensus statements and two recommendations in answer to two questions: what laboratory tests and physiologic triggers should guide the decision to administer a platelet or plasma transfusion in critically ill children; and what product attributes are optimal to guide specific product selection? CONCLUSIONS The Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding program provides some guidance and expert consensus for the laboratory and blood product attributes used for decision-making for plasma and platelet transfusions in critically ill pediatric patients.
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Affiliation(s)
- Meghan Delaney
- Division of Pathology & Laboratory Medicine, Children’s National Hospital; Department of Pathology & Pediatrics, The George Washington University Health Sciences, Washington, DC
| | - Oliver Karam
- Division of Pediatric Critical Care Medicine, Children’s Hospital of Richmond at VCU, Richmond, VA
| | - Lani Lieberman
- Department of Clinical Pathology, University Health Network Hospitals. Department of Laboratory Medicine & Pathobiology; University of Toronto, Toronto, Canada
| | - Katherine Steffen
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Stanford University, Palo Alto, CA
| | - Jennifer A. Muszynski
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children’s Hospital and the Ohio State University College of Medicine, Columbus, OH
| | - Ruchika Goel
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, MD
| | - Scot T. Bateman
- Division of Pediatric Critical Care, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA
| | - Robert I. Parker
- Emeritus, Renaissance School of Medicine, State University of New York at Stony Brook, Stony Brook, NY
| | - Marianne E. Nellis
- Pediatric Critical Care Medicine, NY Presbyterian Hospital-Weill Cornell Medicine, New York, NY
| | - Kenneth E. Remy
- Department of Pediatrics, Division of Critical Care Medicine, Washington University in St. Louis School of Medicine, St. Louis, MO
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9
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Lieberman L, Karam O, Stanworth SJ, Goobie SM, Crighton G, Goel R, Lacroix J, Nellis ME, Parker RI, Steffen K, Stricker P, Valentine SL, Steiner ME. Plasma and Platelet Transfusion Strategies in Critically Ill Children With Malignancy, Acute Liver Failure and/or Liver Transplantation, or Sepsis: From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. Pediatr Crit Care Med 2022; 23:e37-e49. [PMID: 34989704 PMCID: PMC8769367 DOI: 10.1097/pcc.0000000000002857] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To present the consensus statements with supporting literature for plasma and platelet transfusions in critically ill neonates and children with malignancy, acute liver disease and/or following liver transplantation, and sepsis and/or disseminated intravascular coagulation from the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. DESIGN Systematic review and consensus conference of international, multidisciplinary experts in platelet and plasma transfusion management of critically ill children. SETTING Not applicable. PATIENTS Critically ill neonates and children with malignancy, acute liver disease and/or following liver transplantation, and sepsis and/or disseminated intravascular coagulation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A panel of 13 experts developed evidence-based and, when evidence was insufficient, expert-based statements for plasma and platelet transfusions in critically ill neonates and children with malignancy, acute liver disease and/or following liver transplantation, and sepsis and/or disseminated intravascular coagulation. These statements were reviewed and ratified by the 29 Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding experts. A systematic review was conducted using MEDLINE, EMBASE, and Cochrane Library databases, from inception to December 2020. Consensus was obtained using the Research and Development/University of California, Los Angeles Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. We developed 12 expert consensus statements. CONCLUSIONS In the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding program, the current absence of evidence for use of plasma and/or platelet transfusion in critically ill children with malignancy, acute liver disease and/or following liver transplantation, and sepsis means that only expert consensus statements are possible for these areas of practice.
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Affiliation(s)
- Lani Lieberman
- Department of Clinical Pathology, University Health Network Hospitals. Department of Laboratory Medicine & Pathobiology; University of Toronto, Toronto, Canada
| | - Oliver Karam
- Division of Pediatric Critical Care Medicine, Children’s Hospital of Richmond at VCU, Richmond, VA, USA
| | - Simon J. Stanworth
- NHS Blood and Transplant; Oxford University Hospitals NHS Foundation Trust; Radcliffe Department of Medicine and Oxford BRC Haematology Theme, University of Oxford, UK
| | - Susan M. Goobie
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Gemma Crighton
- Department of Haematology, Royal Children’s Hospital, Melbourne, Australia
| | - Ruchika Goel
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, MD and Simmons Cancer Institute, Division of Hematology Oncology at SIU School of Medicine, Springfield, IL, USA
| | - Jacques Lacroix
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, QC, Canada
| | - Marianne E. Nellis
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, NY Presbyterian Hospital – Weill Cornell Medicine, New York, NY, USA
| | - Robert I. Parker
- Department of Pediatric Hematology/Oncology, Renaissance School of Medicine, State University of New York at Stony Brook, Stony Brook, NY, USA
| | - Katherine Steffen
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Stanford University, Palo Alto, CA, USA
| | - Paul Stricker
- Department of Anesthesiology and Critical Care, The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Stacey L. Valentine
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA, USA
| | - Marie E. Steiner
- Divisions of Hematology and Critical Care, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
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10
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Tucci M, Crighton G, Goobie SM, Russell RT, Parker RI, Haas T, Nellis ME, Vogel AM, Lacroix J, Stricker PA. Plasma and Platelet Transfusion Strategies in Critically Ill Children Following Noncardiac Surgery and Critically Ill Children Undergoing Invasive Procedures Outside the Operating Room: From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. Pediatr Crit Care Med 2022; 23:e50-e62. [PMID: 34989705 PMCID: PMC8769350 DOI: 10.1097/pcc.0000000000002858] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To present consensus statements and supporting literature for plasma and platelet transfusions in critically ill children following noncardiac surgery and critically ill children undergoing invasive procedures outside the operating room from the Transfusion and Anemia EXpertise Initiative - Control/Avoidance of Bleeding. DESIGN Systematic review and consensus conference of international, multidisciplinary experts in platelet and plasma transfusion management of critically ill children. SETTING Not applicable. PATIENTS Critically ill children undergoing invasive procedures outside of the operating room or noncardiac surgery. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A panel of 10 experts developed evidence-based and, when evidence was insufficient, expert-based statements for plasma and platelet transfusions in critically ill children following noncardiac surgery or undergoing invasive procedures outside of the operating room. These statements were reviewed and ratified by the 29 Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding experts. A systematic review was conducted using MEDLINE, EMBASE, and Cochrane Library databases, from inception to December 2020. Consensus was obtained using the Research and Development/University of California, Los Angeles Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. We developed eight expert consensus statements focused on the critically ill child following noncardiac surgery and 10 expert consensus statements on the critically ill child undergoing invasive procedures outside the operating room. CONCLUSIONS Evidence regarding plasma and platelet transfusion in critically ill children in this area is very limited. The Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding Consensus Conference developed 18 pediatric specific consensus statements regarding plasma and platelet transfusion management in these critically ill pediatric populations.
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Affiliation(s)
- Marisa Tucci
- Department of Pediatrics, Sainte-Justine University Hospital, University of Montreal, Montreal, QC, Canada
| | - Gemma Crighton
- Department of Haematology, Royal Children’s Hospital, Melbourne, Australia
| | - Susan M. Goobie
- Boston Children’s Hospital, Dept. of Anesthesiology, Critical Care & Pain Medicine, Boston Children’s Hospital, Boston, USA
| | - Robert T. Russell
- Department of Surgery, Division of Pediatric Surgery, Children’s of Alabama, University of Alabama at Birmingham, Birmingham, Alabama
| | - Robert I. Parker
- Department of Pediatrics, Stony Brook University, Stony Brook, NY
| | - Thorsten Haas
- Department of Anesthesia, Zurich University Children’s Hospital, Zurich, Switzerland
| | - Marianne E. Nellis
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, NY Presbyterian Hospital – Weill Cornell Medicine, New York, NY, USA
| | - Adam M. Vogel
- Division of Pediatric Surgery, Surgery and Pediatrics Baylor College of Medicine Texas Children’s Hospital, Houston, Texas
| | - Jacques Lacroix
- Department of Pediatrics, University of Montreal, Montreal, QC, Canada
| | - Paul A. Stricker
- Department of Anesthesiology and Critical Care, The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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11
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Nellis ME, Remy KE, Lacroix J, Cholette JM, Bembea MM, Russell RT, Steiner ME, Goobie SM, Vogel AM, Crighton G, Valentine SL, Delaney M, Parker RI. Research Priorities for Plasma and Platelet Transfusion Strategies in Critically Ill Children: From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. Pediatr Crit Care Med 2022; 23:e63-e73. [PMID: 34989706 PMCID: PMC8769351 DOI: 10.1097/pcc.0000000000002859] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To present a list of high-priority research initiatives for the study of plasma and platelet transfusions in critically ill children from the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. DESIGN Systematic review and consensus conference of international, multidisciplinary experts in platelet and plasma transfusion management of critically ill children. SETTING Not applicable. PATIENTS Critically ill pediatric patients at risk of bleeding and receiving plasma and/or platelet transfusions. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A panel of 13 experts developed research priorities for the study of plasma and platelet transfusions in critically ill children which were reviewed and ratified by the 29 Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding experts. The specific priorities focused on the following subpopulations: severe trauma, traumatic brain injury, intracranial hemorrhage, cardiopulmonary bypass surgery, extracorporeal membrane oxygenation, oncologic diagnosis or stem cell transplantation, acute liver failure and/or liver transplantation, noncardiac surgery, invasive procedures outside of the operating room, and sepsis and/or disseminated intravascular coagulation. In addition, tests to guide plasma and platelet transfusion, as well as component selection and processing, were addressed. We developed four general overarching themes and 14 specific research priorities using modified Research and Development/University of California, Los Angeles methodology. CONCLUSIONS Studies are needed to focus on the efficacy/harm, dosing, timing, and outcomes of critically ill children who receive plasma and/or platelet transfusions. The completion of these studies will facilitate the development of evidence-based recommendations.
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Affiliation(s)
- Marianne E Nellis
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, NY Presbyterian Hospital - Weill Cornell Medicine, New York, NY
| | - Kenneth E Remy
- Division of Pediatric Critical Care Medicine and Pulmonary/Critical Care Medicine, Departments of Pediatrics and Internal Medicine, Washington University of St. Louis, St. Louis, MO
| | - Jacques Lacroix
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Jill M Cholette
- Division of Pediatric Critical Care Medicine, University of Rochester Golisano Children's Hospital, Rochester, NY
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Robert T Russell
- Department of Surgery, University of Alabama Birmingham, Birmingham, AL
| | - Marie E Steiner
- Divisions of Critical Care and Hematology, Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | - Susan M Goobie
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Adam M Vogel
- Division of Pediatric Surgery Texas Children's Hospital, Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Gemma Crighton
- Department of Haematology, Royal Children's Hospital, Melbourne, Australia
| | - Stacey L Valentine
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA
| | - Meghan Delaney
- Division of Pathology and Laboratory Medicine, Children's National Hospital; Department of Pathology and Pediatrics, The George Washington University Health Sciences, Washington, DC
| | - Robert I Parker
- Department of Pediatric Hematology/Oncology, Renaissance School of Medicine, State University of New York at Stony Brook, Stony Brook, NY
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12
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Russell R, Bauer DF, Goobie SM, Haas T, Nellis ME, Nishijima DK, Vogel AM, Lacroix J. Plasma and Platelet Transfusion Strategies in Critically Ill Children Following Severe Trauma, Traumatic Brain Injury, and/or Intracranial Hemorrhage: From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. Pediatr Crit Care Med 2022; 23:e14-e24. [PMID: 34989702 PMCID: PMC8849603 DOI: 10.1097/pcc.0000000000002855] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To present consensus statements and supporting literature for plasma and platelet transfusions in critically ill children with severe trauma, traumatic brain injury, and/or intracranial hemorrhage from the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. DESIGN Systematic review and consensus conference of international, multidisciplinary experts in platelet and plasma transfusion management of critically ill children. SETTING Not applicable. PATIENTS Critically ill neonates and children with severe trauma, traumatic brain injury, and/or intracranial hemorrhage. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A panel of eight experts developed expert-based statements for plasma and platelet transfusions in critically ill neonates and children with severe trauma, traumatic brain injury, and/or intracranial hemorrhage. These statements were reviewed and ratified by the 29 Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding experts. A systematic review was conducted using MEDLINE, EMBASE, and Cochrane Library databases, from inception to December 2020. Consensus was obtained using the Research and Development/University of California, Los Angeles Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. We developed one good practice statement and six expert consensus statements. CONCLUSIONS The lack of evidence precludes proposing recommendations on monitoring of the coagulation system and on plasma and platelets transfusion in critically ill pediatric patients with severe trauma, severe traumatic brain injury, or nontraumatic intracranial hemorrhage.
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Affiliation(s)
- Robert Russell
- Pediatric General Surgery, Children's of Alabama, Birmingham, AL
| | - David F Bauer
- Pediatric Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Susan M Goobie
- Harvard Medical School, Boston, MA
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Thorsten Haas
- Department of Pediatric Anesthesia, Zurich University Children's Hospital, Zurich, Switzerland
| | - Marianne E Nellis
- Division of Pediatric Critical Care Medicine, Weill Cornell Medicine, New York, NY
| | - Daniel K Nishijima
- Department of Emergency Medicine, CTSC Clinical Research Center and Trial Innovation Network, University of California Davis School of Medicine, Sacramento, CA
| | - Adam M Vogel
- Surgery and Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Jacques Lacroix
- Division of Pediatric Critical Care, Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montreal, QC, Canada
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13
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Abstract
Supplemental Digital Content is available in the text. Critically ill children with malignancy have significant risk of bleeding but the exact epidemiology is unknown. We sought to describe severe bleeding events and associated risk factors in critically ill pediatric patients with an underlying oncologic diagnosis using the newly developed Bleeding Assessment Scale in Critically Ill Children definition.
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14
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Hanson SJ, Karam O, Birch R, Goel R, Patel RM, Sola-Visner M, Sachais BS, Hauser RG, Luban NLC, Gottschall J, Josephson CD, Hendrickson JE, Karafin MS, Nellis ME. Transfusion Practices in Pediatric Cardiac Surgery Requiring Cardiopulmonary Bypass: A Secondary Analysis of a Clinical Database. Pediatr Crit Care Med 2021; 22:978-987. [PMID: 34261944 PMCID: PMC8570986 DOI: 10.1097/pcc.0000000000002805] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe blood component usage in transfused children with congenital heart disease undergoing cardiopulmonary bypass surgery across perioperative settings and diagnostic categories. DESIGN Datasets from U.S. hospitals participating in the National Heart, Lung, and Blood Institute Recipient Epidemiology and Donor Evaluation Study-III were analyzed. SETTING Inpatient admissions from three U.S. hospitals from 2013 to 2016. PATIENTS Transfused children with congenital heart disease undergoing single ventricular, biventricular surgery, extracorporeal membrane oxygenation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Eight hundred eighty-two transfused patients were included. Most of the 185 children with single ventricular surgery received multiple blood products: 81% RBCs, 79% platelets, 86% plasma, and 56% cryoprecipitate. In the 678 patients undergoing biventricular surgery, 85% were transfused plasma, 75% platelets, 74% RBCs, and 48% cryoprecipitate. All 19 patients on extracorporeal membrane oxygenation were transfused RBCs, plasma, and cryoprecipitate, and 18 were transfused platelets. Intraoperatively, patients commonly received all three components, while postoperative transfusions were predominantly single blood components. Pretransfusion hemoglobin values were normal/low-normal for age for all phases of care for single ventricular surgery (median hemoglobin 13.2-13.5 g/dL). Pretransfusion hemoglobin values for biventricular surgeries were higher intraoperatively compared with other timing (12.2 g/dL vs 11.2 preoperative and postoperative; p < 0.0001). Plasma transfusions for all patients were associated with a near normal international normalized ratio: single ventricular surgeries median international normalized ratio was 1.3 postoperative versus 1.8 intraoperative and biventricular surgeries median international normalized ratio was 1.1 intraoperative versus 1.7 postoperative. Intraoperative platelet transfusions with biventricular surgeries had higher median platelet count compared with postoperative pretransfusion platelet count (244 × 109/L intraoperative vs 69 × 109/L postoperative). CONCLUSIONS Children with congenital heart disease undergoing cardiopulmonary bypass surgery are transfused many blood components both intraoperatively and postoperatively. Multiple blood components are transfused intraoperatively at seemingly normal/low-normal pretransfusion values. Pediatric evidence guiding blood component transfusion in this population at high risk of bleeding and with limited physiologic reserve is needed to advance safe and effective blood conservation practices.
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Affiliation(s)
| | - Oliver Karam
- Children’s Hospital of Richmond. Virginia Commonwealth University School of Medicine, Richmond, VA
| | | | - Ruchika Goel
- Johns Hopkins University School of Medicine, Baltimore, MD
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15
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Goel R, Nellis ME, Karam O, Hanson SJ, Tormey CA, Patel RM, Birch R, Sachais BS, Sola-Visner MC, Hauser RG, Luban NLC, Gottschall J, Josephson CD, Hendrickson JE, Karafin MS. Transfusion practices for pediatric oncology and hematopoietic stem cell transplantation patients: Data from the National Heart Lung and Blood Institute Recipient Epidemiology and Donor Evaluation Study-III (REDS-III). Transfusion 2021; 61:2589-2600. [PMID: 34455598 DOI: 10.1111/trf.16626] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 06/26/2021] [Accepted: 06/27/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND To evaluate transfusion practices in pediatric oncology and hematopoietic stem cell transplant (HSCT) patients. STUDY DESIGN AND METHODS This is a multicenter retrospective study of children with oncologic diagnoses treated from 2013 to 2016 at hospitals participating in the National Heart Lung and Blood Institute Recipient Epidemiology and Donor Evaluation Study-III. Transfusion practices were evaluated by diagnosis codes and pre-transfusion laboratory values. RESULTS A total of 4766 inpatient encounters of oncology and HSCT patients were evaluated, with 39.3% (95% confidence interval [CI]: 37.9%-40.7%) involving a transfusion. Red blood cells (RBCs) were the most commonly transfused component (32.4%; 95% CI: 31.1%-33.8%), followed by platelets (22.7%; 95% CI: 21.5%-23.9%). Patients in the 1 to <6 years of range were most likely to be transfused and HSCT, acute myeloid leukemia, and aplastic anemia were the diagnoses most often associated with transfusion. The median hemoglobin (Hb) prior to RBC transfusion was 7.5 g/dl (10-90th percentile: 6.4-8.8 g/dl), with 45.7% of transfusions being given at 7 to <8 g/dl. The median platelet count prior to platelet transfusion was 20 × 109 /L (10-90th percentile: 8-51 × 109 /L), and 37.9% of transfusions were given at platelet count of >20-50 × 109 /L. The median international normalized ratio (INR) prior to plasma transfusion was 1.7 (10-90th percentile: 1.3-2.7), and 36.3% of plasma transfusions were given at an INR between 1.4 and 1.7. DISCUSSION Transfusion of blood components is common in hospitalized pediatric oncology/HSCT patients. Relatively high pre-transfusion Hb and platelet values and relatively low INR values prior to transfusion across the studied diagnoses highlight the need for additional studies in this population.
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Affiliation(s)
- Ruchika Goel
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Departments of Internal Medicine and Pediatrics, Division of Hematology Oncology, Simmons Cancer Institute at SIU School of Medicine and ImpactLife (Mississippi Valley Regional Blood Center), Springfield, Illinois, USA
| | - Marianne E Nellis
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Weill Cornell Medicine, New York, New York, USA
| | - Oliver Karam
- Department of Pediatrics, Division of Critical Care, Children's Hospital of Richmond at VCU, Richmond, Virginia, USA
| | - Sheila J Hanson
- Department of Pediatrics, Division of Critical Care, Medical College of Wisconsin and Children's Wisconsin, Milwaukee, Wisconsin, USA
| | | | - Ravi M Patel
- Department of Pediatrics, Division of Neonatology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Rebecca Birch
- Public Health and Epidemiology Practice, Westat, Rockville, Maryland, USA
| | | | - Martha C Sola-Visner
- Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Ronald G Hauser
- Department of Laboratory Medicine, Yale University, New Haven, Connecticut, USA.,Department of Pathology & Laboratory Medicine Service, Veterans Affairs, Connecticut Healthcare System, West Haven, CT
| | - Naomi L C Luban
- Children's Research Institute, Children's National Health System, Washington, District of Columbia, USA
| | | | - Cassandra D Josephson
- Department of Pediatrics, Division of Neonatology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jeanne E Hendrickson
- Department of Laboratory Medicine, Yale University, New Haven, Connecticut, USA.,Department of Pediatrics, Yale University, New Haven, CT
| | - Matthew S Karafin
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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16
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Nellis ME, Goel R, Hendrickson JE, Birch R, Patel RM, Karafin MS, Hanson SJ, Sachais BS, Hauser RG, Luban NLC, Gottschall J, Sola-Visner M, Josephson CD, Karam O. Transfusion practices in a large cohort of hospitalized children. Transfusion 2021; 61:2042-2053. [PMID: 33973660 DOI: 10.1111/trf.16443] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 04/10/2021] [Accepted: 04/10/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND While previous studies have described the use of blood components in subsets of children, such as the critically ill, little is known about transfusion practices in hospitalized children across all departments and diagnostic categories. We sought to describe the utilization of red blood cell, platelet, plasma, and cryoprecipitate transfusions across hospital settings and diagnostic categories in a large cohort of hospitalized children. STUDY DESIGN AND METHODS The public datasets from 11 US academic and community hospitals that participated in the National Heart Lung and Blood Institute Recipient Epidemiology and Donor Evaluation Study-III (REDS-III) were accessed. All nonbirth inpatient encounters of children 0-18 years of age from 2013 to 2016 were included. RESULTS 61,770 inpatient encounters from 41,943 unique patients were analyzed. Nine percent of encounters involved the transfusion of at least one blood component. RBC transfusions were most common (7.5%), followed by platelets (3.9%), plasma (2.5%), and cryoprecipitate (0.9%). Children undergoing cardiopulmonary bypass were most likely to be transfused. For the entire cohort, the median (interquartile range) pretransfusion laboratory values were as follows: hemoglobin, 7.9 g/dl (7.1-10.4 g/dl); platelet count, 27 × 109 cells/L (14-54 × 109 cells/L); and international normalized ratio was 1.6 (1.4-2.0). Recipient age differences were observed in the frequency of RBC irradiation (95% in infants, 67% in children, p < .001) and storage duration of RBC transfusions (median storage duration of 12 [8-17] days in infants and 20 [12-29] days in children, p < .001). CONCLUSION Based on a cohort of patients from 2013 to 2016, the transfusion of blood components is relatively common in the care of hospitalized children. The frequency of transfusion across all pediatric hospital settings, especially in children undergoing cardiopulmonary bypass, highlights the opportunities for the development of institutional transfusion guidelines and patient blood management initiatives.
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Affiliation(s)
- Marianne E Nellis
- Department of Pediatrics, Weill Cornell Medicine, New York, New York, USA
| | - Ruchika Goel
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jeanne E Hendrickson
- Departments of Pediatrics and Laboratory Medicine, Yale University, New Haven, Connecticut, USA
| | - Rebecca Birch
- Public Health and Epidemiology Practice, Westat, Rockville, Maryland, USA
| | - Ravi M Patel
- Department of Pediatrics, Division of Neonatology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Matthew S Karafin
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, NC
| | - Sheila J Hanson
- Department of Pediatrics, Division of Critical Care, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | - Ronald George Hauser
- Departments of Pediatrics and Laboratory Medicine, Yale University, New Haven, Connecticut, USA
| | - Naomi L C Luban
- Children's Research Institute, Children's National Health System, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | | | - Martha Sola-Visner
- Division of Newborn Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Cassandra D Josephson
- Department of Pathology and Laboratory Medicine, Center for Transfusion and Cellular Therapies, Emory University School of Medicine, Atlanta, GA
| | - Oliver Karam
- Department of Pediatrics, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
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17
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Mo YD, Delaney M. Transfusion in Pediatric Patients: Review of Evidence-Based Guidelines. Clin Lab Med 2021; 41:1-14. [PMID: 33494878 DOI: 10.1016/j.cll.2020.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Children require transfusion of blood components for a vast array of medical conditions, including acute hemorrhage, hematologic and nonhematologic malignancies, hemoglobinopathy, and allogeneic and autologous stem cell transplant. Evidence-based literature on pediatric transfusion practices is limited, particularly for non-red blood cell products, and many recommendations are extrapolated from studies in adult populations. Recognition of these knowledge gaps has led to increasing numbers of clinical trials focusing on children and establishment of pediatric transfusion working groups in recent years. This article reviews existing literature on pediatric transfusion therapy within the larger context of analogous data in adult populations.
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Affiliation(s)
- Yunchuan Delores Mo
- Transfusion Medicine, Children's National Hospital, 111 Michigan Avenue Northwest, Laboratory Administration, Suite 2100, Washington, DC 20010, USA.
| | - Meghan Delaney
- Pathology and Laboratory Medicine Division, Transfusion Medicine, Children's National Hospital, 111 Michigan Avenue Northwest, Laboratory Administration, Suite 2100, Washington, DC 20010, USA
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18
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Karam O, Nellis ME. Transfusion management for children supported by extracorporeal membrane oxygenation. Transfusion 2021; 61:660-664. [PMID: 33491189 DOI: 10.1111/trf.16272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 01/03/2021] [Accepted: 01/04/2021] [Indexed: 11/30/2022]
Abstract
Due to the patients' underlying illness, in combination with circuit-induced coagulopathy, as well as PLT dysfunction, children supported by ECMO are a risk of receiving large volumes of blood components. Given the increasing use of modified blood products and newer biologics, it is unknown whether these products have equal efficacy and safety, in ECMO. The majority of guidance for transfusion therapy is based on expert opinion alone, and research on indications for RBC, plasma, and PLT transfusions for children on ECMO should be a priority.
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Affiliation(s)
- Oliver Karam
- Division of Pediatric Critical Care Medicine, Children's Hospital of Richmond at VCU, Richmond, Virginia
| | - Marianne E Nellis
- Pediatric Critical Care Medicine, NY Presbyterian Hospital - Weill Cornell Medicine, New York, New York
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Sequeira J, Nellis ME, Karam O. Epidemiology of Bleeding in Critically Ill Children. Front Pediatr 2021; 9:699991. [PMID: 34422724 PMCID: PMC8371326 DOI: 10.3389/fped.2021.699991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 07/15/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: Bleeding can be a severe complication of critical illness, but its true epidemiologic impact on children has seldom been studied. Our objective is to describe the epidemiology of bleeding in critically ill children, using a validated clinical tool, as well as the hemostatic interventions and clinical outcomes associated with bleeding. Design: Prospective observational cohort study. Setting: Tertiary pediatric critical care unit Patients: All consecutive patients (1 month to 18 years of age) admitted to a tertiary pediatric critical care unit Measurements and Main Results: Bleeding events were categorized as minimal, moderate, severe, or fatal, according to the Bleeding Assessment Scale in Critically Ill Children. We collected demographics and severity at admission, as evaluated by the Pediatric Index of Mortality. We used regression models to compare the severity of bleeding with outcomes adjusting for age, surgery, and severity. Over 12 months, 902 critically ill patients were enrolled. The median age was 64 months (IQR 17; 159), the median admission predicted risk of mortality was 0.5% (IQR 0.2; 1.4), and 24% were post-surgical. Eighteen percent of patients experienced at least one bleeding event. The highest severity of bleeding was minimal for 7.9% of patients, moderate for 5.8%, severe for 3.8%, and fatal for 0.1%. Adjusting for age, severity at admission, medical diagnosis, type of surgery, and duration of surgery, bleeding severity was independently associated with fewer ventilator-free days (p < 0.001) and fewer PICU-free days (p < 0.001). Adjusting for the same variables, bleeding severity was independently associated with an increased risk of mortality (adjusted odds ratio for each bleeding category 2.4, 95% CI 1.5; 3.7, p < 0.001). Conclusion: Our data indicate bleeding occurs in nearly one-fifth of all critically ill children, and that higher severity of bleeding was independently associated with worse clinical outcome. Further multicenter studies are required to better understand the impact of bleeding in critically ill children.
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Affiliation(s)
- Jake Sequeira
- Division of Pediatric Critical Care Medicine, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, VA, United States
| | - Marianne E Nellis
- Pediatric Critical Care Medicine, NY Presbyterian Hospital - Weill Cornell Medicine, New York, NY, United States
| | - Oliver Karam
- Division of Pediatric Critical Care Medicine, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, VA, United States
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Zerra PE, Josephson CD. Transfusion in Neonatal Patients: Review of Evidence-Based Guidelines. Clin Lab Med 2020; 41:15-34. [PMID: 33494882 DOI: 10.1016/j.cll.2020.10.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Transfusion of red blood cells, platelets, and fresh frozen plasma in neonatal patients has not been well characterized in the literature, with guidelines varying greatly between institutions. However, anemia and thrombocytopenia are highly prevalent, especially in preterm neonates. When transfusing a neonatal patient, clinicians must take into consideration physiologic differences, gestational and postnatal age, congenital disorders, and maternal factors while weighing the risks and benefits of transfusion. This review of existing literature summarizes current evidence-based neonatal transfusion guidelines and highlights areas of current ongoing research and those in need of future studies.
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Affiliation(s)
- Patricia E Zerra
- Department of Pathology and Laboratory Medicine, Emory University Hospital, 1364 Clifton Road NE, Atlanta, GA 30322, USA; Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Egleston Hospital, 1405 Clifton Rd, Atlanta, GA 30322, USA
| | - Cassandra D Josephson
- Department of Pathology and Laboratory Medicine, Emory University Hospital, 1364 Clifton Road NE, Atlanta, GA 30322, USA; Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Egleston Hospital, 1405 Clifton Rd, Atlanta, GA 30322, USA.
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21
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Karam O, Goel R, Dalton H, Nellis ME. Epidemiology of Hemostatic Transfusions in Children Supported by Extracorporeal Membrane Oxygenation. Crit Care Med 2020; 48:e698-e705. [PMID: 32697511 DOI: 10.1097/ccm.0000000000004417] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To evaluate the epidemiology of hemostatic transfusions (plasma, platelet, and cryoprecipitate) in children supported by extracorporeal membrane oxygenation. DESIGN Secondary analysis of a large observational cohort study. SETTING Eight pediatric institutions within the Eunice Kennedy Shriver National Institute of Child Health and Human Development's Collaborative Pediatric Critical Care Research Network. PATIENTS Critically ill children supported by extracorporeal membrane oxygenation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Extracorporeal membrane oxygenation was used in the care of 514 consecutive children. Platelets were transfused on 68% of extracorporeal membrane oxygenation days, plasma on 34% of the days on extracorporeal membrane oxygenation, and cryoprecipitate on 14%. Only 24% of the days on extracorporeal membrane oxygenation were free of any hemostatic transfusions. Daily platelet transfusion dose was independently associated with chest tube output (p < 0.001), other bleeding requiring RBC transfusion (p = 0.03), and daily set platelet goal (p = 0.009), but not with total platelet count (p = 0.75). Daily plasma transfusion dose was independently associated with chest tube output (p < 0.001), other bleeding requiring RBC transfusion (p = 0.01), activated clotting time (p = 0.001), and antithrombin levels (p = 0.02), but not with international normalized ratio (p = 0.99) or activated partial thromboplastin time (p = 0.29). Daily cryoprecipitate transfusion dose was independently associated with younger age (p = 0.009), but not with chest tube bleeding (p = 0.18), other bleeding requiring RBC transfusion (p = 0.75), fibrinogen level (p = 0.67), or daily fibrinogen goal (p = 0.81). CONCLUSIONS Platelets were transfused on two third of the days on extracorporeal membrane oxygenation, plasma on one third, and cryoprecipitate on one sixth of the days. Although most hemostatic transfusions were independently associated with bleeding, they were not independently associated with the majority of hemostatic testing. Further studies are warranted to evaluate the appropriateness of these transfusion strategies.
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Affiliation(s)
- Oliver Karam
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Hospital of Richmond at VCU, Richmond, VA
| | - Ruchika Goel
- Division of Hematology/Oncology, Simmons Cancer Institute at SIU School of Medicine, Springfield, IL
- Department of Pathology, Johns Hopkins University, Baltimore, MD
| | - Heidi Dalton
- Adult and Pediatric ECLS, INOVA Fairfax Hospital, Falls Church, VA
| | - Marianne E Nellis
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Weill Cornell Medicine, New York, NY
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22
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Goel R, Josephson CD, Patel EU, Petersen MR, Packman Z, Gehrie E, Bloch EM, Lokhandwala P, Ness PM, Katz L, Nellis M, Karam O, Tobian AAR. Individual- and hospital-level correlates of red blood cell, platelet, and plasma transfusions among hospitalized children and neonates: a nationally representative study in the United States. Transfusion 2020; 60:1700-1712. [PMID: 32589286 DOI: 10.1111/trf.15855] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 03/30/2020] [Accepted: 04/08/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Factors associated with red blood cell (RBC), plasma, and platelet transfusions in hospitalized neonates and children across the United States have not been well characterized. METHODS Data from the Kids' Inpatient Database (KID) 2016 were analyzed. KID is a random sample of 10% of all uncomplicated in-hospital births and 80% of remaining pediatric discharges from approximately 4200 US hospitals. Sampling weights were applied to generate nationally representative estimates. Primary outcome was one or more RBC transfusion procedures; plasma and platelet transfusions were assessed as secondary outcomes. Analysis was stratified by age: neonates (NEO; ≤28 d), and nonneonates (PED; >28 d and <18 y). Multivariable logistic regression was used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (95% CIs). RESULTS Among 5,604,984 total hospitalizations, overall prevalence of transfusions was 1.07% (95% CI, 0.94%-1.22%) for RBCs, 0.17% (95% CIs, 0.15%-0.21%) for plasma and 0.35% (95% CI, 0.30%-0.40%) for platelet transfusions. RBC transfusions occurred among 0.43% NEO admissions and 2.63% PED admissions. For NEO admissions, RBC transfusion was positively associated with nonwhite race, longer length of hospitalization, highest risk of mortality (aOR, 86.58; 95% CI, 64.77-115.73) and urban teaching hospital location. In addition to the above factors, among PED admissions, RBC transfusion was positively associated with older age, female sex (aOR, 1.10; 95% CI, 1.07-1.13), and elective admission status (aOR, 1.62; 95% CI, 1.46-1.80). Factors associated with plasma and platelet transfusions were largely similar to those associated with RBC transfusion, except older age groups had lower odds of plasma transfusion among PED admissions. CONCLUSIONS While there is substantial variability in the proportion of neonates and nonneonatal children transfused nationally, there are several similar, yet unique, nonlaboratory predictors of transfusion identified in these age groups.
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Affiliation(s)
- Ruchika Goel
- Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA.,Mississippi Valley Regional Blood Center, and Simmons Cancer Institute at SIU SOM, Springfield, Illinois, USA
| | - Cassandra D Josephson
- Department of Pathology, Center for Transfusion and Cellular Therapies, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia, USA.,Department of Pediatrics, Aflac Cancer Center and Blood Disorders Service, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Eshan U Patel
- Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Molly R Petersen
- Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Zoe Packman
- Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Eric Gehrie
- Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Evan M Bloch
- Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Parvez Lokhandwala
- Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Paul M Ness
- Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Louis Katz
- Mississippi Valley Regional Blood Center, Davenport, Iowa, USA
| | - Marianne Nellis
- Department of Pediatrics, New York Presbyterian Hospital - Weill Cornell Medicine, New York, New York, USA
| | - Oliver Karam
- Department of Pediatrics, Children's Hospital of Richmond at VCU, Richmond, Virginia, USA
| | - Aaron A R Tobian
- Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA
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Burggraf M, Polan C, Husen M, Mester B, Wegner A, Spodeck D, Dudda M, Kauther MD. Trauma induced clotting factor depletion in severely injured children: a single center observational study. World J Emerg Surg 2020; 15:31. [PMID: 32375899 PMCID: PMC7201748 DOI: 10.1186/s13017-020-00311-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 04/22/2020] [Indexed: 01/09/2023] Open
Abstract
Background Coagulopathy following severe trauma contributes significantly to mortality. Impaired clotting factors have been observed in adult trauma patients, but in pediatric trauma victims their activity has not yet been investigated. Methods Sixteen pediatric trauma patients were evaluated according to the ISS and assigned to two cohorts. An additional control group (CO; n = 10) was formed. Routine coagulation parameters and the soluble clotting factors (F) were tested. Nonparametric data was analyzed using the Mann-Whitney U test. Results are reported as median and interquartile range. Results The ISS of severely (SI, n = 8) and mildly (MI, n = 8) injured children differed significantly (25 [19–28] vs. 5 [4–6]; p < 0.001). INR was elevated in the SI cohort only when compared to the CO (1.21 [1.04-1.58] vs. 0.96 [0.93-1.00]; p = 0.001). Differences between SI and MI were found for FII (67 [53-90] vs. 82 [76-114] %; p = 0.028), FV (76 [47-88] vs. 92 [82-99] %; p = 0.028), and FXIII (67 [62-87] vs. 90 [77-102] %; p = 0.021). Comparison of the SI with the CO (FII 122 [112-144] %; p < 0.001; FV 123 [100-142] %; p = 0.002; and FXIII 102 [79-115] %; p = 0.006) also revealed a reduction in the activity of these factors. Furthermore, fibrinogen (198 [80-242] vs. 296 [204-324] mg/dl; p = 0.034), FVII (71 [63-97] vs. 114 [100-152] %; p = 0.009), FIX (84 [67-103] vs. 110 [90-114] %; p = 0.043), and FX (70 [61-85] vs. 122 [96-140] %; p = 0.001) were reduced in the SI in comparison with the CO. Finally, FVIII was considerably, yet not significantly, increased in both patient cohorts (235 [91-320] % and 197 [164-238] %, respectively). Conclusions This study proves that children suffer a depletion of clotting factors following severe injury which basically reflects the findings for adult trauma patients. Attempts to correct the impaired clotting factor activity could be based on a specific hemostatic therapy involving administration of coagulation factors. Nevertheless, therapeutic implications need to be investigated in future studies.
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Affiliation(s)
- Manuel Burggraf
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany.
| | - Christina Polan
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Martin Husen
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Bastian Mester
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Alexander Wegner
- Department of Orthopedics and Trauma Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Daniel Spodeck
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Marcel Dudda
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Max Daniel Kauther
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
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Pediatric non-red cell blood product transfusion practices: what's the evidence to guide transfusion of the 'yellow' blood products? Curr Opin Anaesthesiol 2020; 33:259-267. [PMID: 32049883 DOI: 10.1097/aco.0000000000000838] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW Research studies pertaining to the management of pediatric non-red cell blood product transfusion is limited. Clinical practices vary within disciplines and regions. Anesthesiologists need evidence-based guidelines to make appropriate and safe decisions regarding transfusion of the 'yellow' blood products for pediatric patients. RECENT FINDINGS This review outlines clinical indications for transfusion of fresh frozen plasma, cryoprecipitate, platelets, and fibrinogen concentrate in pediatrics. Recent studies of non-red blood cell transfusions in critical, but stable situations are highlighted. Recommendations to guide transfusion of the 'yellow' blood products in operative and non-operative settings are summarized. Special attention is drawn to guidelines in massive hemorrhage and trauma situations. SUMMARY Evidence-based guidelines and expert consensus recommendations exist to guide the transfusion of pediatric non-red blood products and should be followed when transfusing the 'yellow' blood components. As high-quality studies in neonates, infants and children are limited, future research should broaden our knowledge in this direction with the goal to use restrictive strategies to improve patient outcomes.
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Pediatric Plasma and Platelet Transfusions on Extracorporeal Membrane Oxygenation: A Subgroup Analysis of Two Large International Point-Prevalence Studies and the Role of Local Guidelines. Pediatr Crit Care Med 2020; 21:267-275. [PMID: 31644453 PMCID: PMC7060816 DOI: 10.1097/pcc.0000000000002160] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe the indications and thresholds for plasma and platelet transfusions for pediatric extracorporeal membrane oxygenation, to compare responses to these transfusions and to describe institutional protocols directing their administration. DESIGN Subgroup analysis of two prospective, observational studies paired with survey of sites who enrolled subjects into this cohort. SETTING Fifty-one PICUs in 13 countries. PATIENTS Children (3 d to 16 yr old) were enrolled if they received a plasma or platelet transfusion while on extracorporeal membrane oxygenation during one of the predefined screening weeks. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Forty-eight children on extracorporeal membrane oxygenation received plasma transfusions and 90 received platelet transfusions. Sixty percent of plasma transfusions (29/48) and 79% of the platelet transfusions (71/90) were given for prophylaxis of bleeding. The median (interquartile range) international normalized ratio prior to transfusion, known in 75% of the patients (36/48), was 1.45 (1.20-1.85). The median (interquartile range) total platelet count prior to transfusion, known in all of the patients, was 70 × 10/L (52-90 × 10/L). The international normalized ratio and total platelet count values prior to transfusion did not vary based on bleeding versus nonbleeding indications. The median (interquartile range) reduction in international normalized ratio for mild coagulopathies (international normalized ratio ≤ 2.0) was 0.1 (0.4-0), median (interquartile range) increase in fibrinogen was 0.2 g/L (0.1-0.4 g/L) and median increase in total platelet count was 34 × 10/L (10-74 × 10/L). Through the course of their admission, children supported by extracorporeal membrane oxygenation received a total median (interquartile range) dose of 75 mL/kg (36-159 mL/kg) of plasma transfusions and 92 mL/kg (42-239 mL/kg) of platelet transfusions. Institutional protocols varied but provided guidance for platelet transfusions more commonly. CONCLUSIONS Children supported by extracorporeal membrane oxygenation receive large volumes of plasma and platelet transfusions with some institutional guidance in the form of protocols, but significant variation in practice. Interventional studies are necessary to provide evidence to direct the transfusion of hemostatic products in children supported by extracorporeal membrane oxygenation.
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Kahn S, Chegondi M, Nellis ME, Karam O. Overview of Plasma and Platelet Transfusions in Critically Ill Children. Front Pediatr 2020; 8:601659. [PMID: 33282804 PMCID: PMC7691248 DOI: 10.3389/fped.2020.601659] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 10/21/2020] [Indexed: 01/19/2023] Open
Abstract
Critically ill children are a unique population who frequently receive plasma and platelet transfusions for both active bleeding and mitigation of bleeding risk. While these products are frequently administered, transfusion indications in this population remain unclear, and practice varies across institutions and providers. In this manuscript, we will outline the current evidence regarding plasma and platelet transfusions for hemostasis in the pediatric intensive care setting. For both products, we will describe the product composition, epidemiology, and product indications and discuss the potential risks and benefits involved with the transfusion. We will also discuss knowledge gaps and future areas of research.
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Affiliation(s)
- Stacie Kahn
- Division of Pediatric Critical Care Medicine, NewYork-Presbyterian, Morgan Stanley Children's Hospital, New York, NY, United States
| | - Madhuradhar Chegondi
- Division of Pediatric Critical Care Medicine, Stead Family Children's Hospital- Carver College of Medicine, University of Iowa, Iowa, IA, United States
| | - Marianne E Nellis
- Pediatric Critical Care Medicine, NewYork-Presbyterian Hospital - Weill Cornell Medicine, New York, NY, United States
| | - Oliver Karam
- Division of Pediatric Critical Care Medicine, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, VA, United States
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Spinella PC, Borasino S, Alten J. Solvent/Detergent-Treated Plasma in the Management of Pediatric Patients Who Require Replacement of Multiple Coagulation Factors: An Open-Label, Multicenter, Post-marketing Study. Front Pediatr 2020; 8:572. [PMID: 33042916 PMCID: PMC7527419 DOI: 10.3389/fped.2020.00572] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 08/05/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Octaplas is a solvent/detergent-treated, pooled plasma used for the management of preoperative or bleeding patients who require replacement of single or multiple coagulation factors. The aim of this post-marketing study was to collect real-world data on octaplas treatment in pediatric patients, with the primary focus being safety. Methods: This was an open-label, multicenter, phase IV study conducted in patients <16 years old who required replacement of multiple coagulation factors due to liver dysfunction associated with coagulopathy and/or required cardiac surgery or liver surgery. Octaplas was administered intravenously based on ABO-group compatibility. The primary endpoints included the incidence of serious adverse events (SAEs), adverse drug reactions (ADRs), thrombotic events (TEs), thromboembolic events (TEEs) and hyperfibrinolytic events (HFEs). Results: A total of 50 patients were enrolled (≤2 years old, n = 37; >2 years old, n = 13; female, n = 24) and 49 patients completed the study. Indications for the use of octaplas included planned cardiac surgery (n = 40, 80.0%), liver transplant surgery (n = 5, 10.0%) and liver dysfunction (n = 5, 10.0%). No ADRs, HFEs or treatment-related TEs and TEEs occurred during the study. Five patients had SAEs, one of which was fatal (iatrogenic injury). Other SAEs included hemorrhage, hypotension, hemorrhagic shock, coronary artery hemorrhage, intracardiac thrombus, supraventricular tachycardia, portal vein thrombosis and respiratory failure (1 each). None of the SAEs were considered to be related to octaplas. Conclusions: Results of the present study support the use of octaplas in the management of preoperative or bleeding pediatric patients who require replacement of multiple plasma coagulation factors. Clinical Trial Registration: ClinicalTrials.gov identifier: NCT02050841.
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Affiliation(s)
- Philip C Spinella
- Division of Critical Care, Department of Pediatrics, Washington University at St. Louis, St. Louis, MO, United States
| | - Santiago Borasino
- Cardiovascular Intensive Care Unit, Division of Pediatric Cardiology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Jeffrey Alten
- Cardiovascular Intensive Care Unit, Division of Pediatric Cardiology, University of Alabama at Birmingham, Birmingham, AL, United States
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François T, Emeriaud G, Karam O, Tucci M. Transfusion in children with acute respiratory distress syndrome. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:511. [PMID: 31728364 DOI: 10.21037/atm.2019.08.28] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Transfusion is a frequent treatment in pediatric patients with acute respiratory distress syndrome (PARDS) although evidence to support transfusion decision-making is lacking. The purpose of this review is to review the current state of knowledge on the issue of transfusion in children with PARDS and to detail the possible beneficial effects and potential deleterious impacts of transfusion in this patient population. Based on the current literature and recent guidelines, a restrictive red blood cell (RBC) transfusion strategy (avoidance of transfusion when the haemoglobin level is above 7 g/dL) is indicated in stable patients without severe PARDS, as these were excluded from the large trials. In children with severe PARDS, further research is needed to determine if factors other than the haemoglobin level might guide RBC transfusion decision-making by better characterizing the presence of low oxygen delivery (DO2). Additionally, appropriate indications for prophylactic transfusion of hemostatic products (plasma or platelets) in children with PARDS are lacking.
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Affiliation(s)
- Tine François
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Guillaume Emeriaud
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Oliver Karam
- Division of Pediatric Critical Care Medicine, Children's Hospital of Richmond at VCU, Richmond, VA, USA
| | - Marisa Tucci
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
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Abstract
OBJECTIVES Little is known about platelet transfusions in pediatric critical illness. We sought to describe the epidemiology, indications, and outcomes of platelet transfusions among critically ill children. DESIGN Prospective cohort study. SETTING Multicenter (82 PICUs), international (16 countries) from September 2016 to April 2017. PATIENTS Children ages 3 days to 16 years prescribed a platelet transfusion in the ICU during screening days. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Over 6 weeks, 16,934 patients were eligible, and 559 received at least one platelet transfusion (prevalence, 3.3%). The indications for transfusion included prophylaxis (67%), minor bleeding (21%), and major bleeding (12%). Thirty-four percent of prophylactic platelet transfusions were prescribed when the platelet count was greater than or equal to 50 × 10 cells/L. The median (interquartile range) change in platelet count post transfusion was 48 × 10 cells/L (17-82 × 10 cells/L) for major bleeding, 42 × 10 cells/L (16-80 × 10 cells/L) for prophylactic transfusions to meet a defined threshold, 38 × 10 cells/L (17-72 × 10 cells/L) for minor bleeding, and 25 × 10 cells/L (10-47 × 10 cells/L) for prophylaxis in patients at risk of bleeding from a device. Overall ICU mortality was 25% but varied from 18% to 35% based on indication for transfusion. Upon adjusted analysis, total administered platelet dose was independently associated with increased ICU mortality (odds ratio for each additional 1 mL/kg platelets transfused, 1.002; 95% CI, 1.001-1.003; p = 0.005). CONCLUSIONS The majority of platelet transfusions are given as prophylaxis to nonbleeding children, and significant variation in platelet thresholds exists. Studies are needed to clarify appropriate indications, with focus on prophylactic transfusions.
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Abstract
Pediatric oncology patients will likely require numerous transfusions of blood products, including red blood cell, platelet, and plasma transfusions, during the course of their treatment. Although strong evidence-based guidelines for these products in this patient population do not exist, given the morbidities associated with the receipt of blood products, practitioners should attempt to use restrictive transfusion strategies.
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Bleeding in Critically Ill Children: How Much Is Too Much? Pediatr Crit Care Med 2019; 20:674-675. [PMID: 31274792 DOI: 10.1097/pcc.0000000000001959] [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: 11/26/2022]
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Criteria for Clinically Relevant Bleeding in Critically Ill Children: An International Survey. Pediatr Crit Care Med 2019; 20:e137-e144. [PMID: 30575698 DOI: 10.1097/pcc.0000000000001828] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Bleeding, a feared complication of critical illness, is frequent in critically ill children. However, the concept of clinically relevant bleeding is ill-defined in this population. There are many established diagnostic criteria for bleeding, but only one estimates bleeding in critically ill adults, and none exist for critically ill children. Our objective was to identify the factors that influence pediatric intensivists' perception of clinically relevant bleeding. DESIGN Self-administered, web-based survey with 9-point Likert scales, to qualify the clinical significance of 103 bleeding characteristics in critically ill children. SETTING Online survey. SUBJECTS Pediatric critical care physicians and nurse practitioners. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The response rate was 40%, with 225 respondents from 16 countries. Characteristics most frequently identified as clinically relevant were bleeding in critical locations (e.g., pericardium, pleural space, CNS, and lungs); requiring interventions; leading to physiologic repercussions, including organ failure; and of prolonged duration. Quantifiable bleeding greater than 5 mL/kg/hr for more than 1 hour was frequently considered clinically relevant. Respondents identified the following characteristics as clinically irrelevant: dressings required to be changed no less frequently than every 6 hours, streaks of blood in gastric tubes, streaks of blood in endotracheal tubes or blood in endotracheal tubes only during suctioning, lightly blood-tinged urine, quantifiable bleeding less than 1 mL/kg/hr, and noncoalescing petechiae. Perception of the clinical relevance of bleeding was not associated with the respondent's geographical location of clinical practice or years of experience. CONCLUSIONS This international survey provides a better understanding of the factors that influence the pediatric intensivists' assessment of the clinical relevance of bleeding in critically ill children. It provides the foundation for the development of a validated, diagnostic definition of clinically relevant bleeding in this population.
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Transfusion-Associated Circulatory Overload: A Clinical Perspective. Transfus Med Rev 2019; 33:69-77. [PMID: 30853167 DOI: 10.1016/j.tmrv.2019.01.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 01/20/2019] [Accepted: 01/26/2019] [Indexed: 01/28/2023]
Abstract
For 30 years, transfusion-associated circulatory overload (TACO) has been recognized as a serious transfusion complication. Currently, TACO is the leading cause of transfusion-related morbidity and mortality worldwide which occurs in 1% to 12% of at-risk populations. Despite an incomplete understanding of the underlying pathophysiology, TACO is defined as a collection of signs and symptoms of acute pulmonary edema due to circulatory overload occurring within 6 to 12 hours of transfusion. In the past decade, large observational cohort studies resulted in better insight into the associated transfusion risk factors leading to the development of TACO. In this clinical review, we critically analyze the pathogenesis of TACO, associated risk factors, clinical presentation, diagnostic modalities, and treatment options to guide clinicians with early detection of this syndrome and intervention to improve clinical outcomes. Future research should focus on better understanding of the pathogenesis to help advance the field of volume kinetics and endothelial barrier function.
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Abstract
Transfusions of red blood cells (RBCs), platelets, and plasma are critical therapies for infants and neonates (particularly preterm neonates) in the neonatal intensive care unit, who are the most frequently transfused subpopulation across all ages. Although traditionally a significant gap has existed between the blood utilization and the evidence base essential to adequately guide transfusion practices in infants and neonates, pediatric transfusion medicine is evolving from infancy and gradually coming of age. It is entering an exciting era with recognition as an independent discipline, a new and evolving high-quality evidence base for transfusion practices, novel technologies and therapeutics, and national/international collaborative research, educational, and clinical efforts. Triggers and thresholds for red cell transfusion are accumulating evidence with current phase III clinical trials. Ongoing trials and studies of platelet and plasma transfusions in neonates are anticipated to provide high-quality evidence in years to come. This article aims to summarize the most current evidence-based practices regarding blood component therapy in neonates. Data on the use of specific components (RBCs, plasma, and platelets) are provided. We attempt to define thresholds for anemia, thrombocytopenia, and abnormal coagulation profile in neonates to highlight the difficulties in having a specific cutoff value in neonates and preterm infants. Indications for transfusion of specific products, transfusion thresholds, and current practices and guidelines are provided, and possible adverse outcomes and complications are discussed. Finally, the critical research knowledge gaps in these practices as well as ongoing and future research areas are discussed. In an era of personalized medicine, neonatal transfusion decisions guided by a strong evidence base must be the overarching goal, and this underlies all of the strategic initiatives in pediatric and neonatal transfusion research highlighted in this article.
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Affiliation(s)
- Ruchika Goel
- Division of Transfusion Medicine, Department of Pathology and Division of Pediatric Hematology/Oncology, Department of Pediatrics, New York Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA
| | - Cassandra D Josephson
- Departments of Pathology and Pediatrics, Center for Transfusion and Cellular Therapies, Emory University School of Medicine and AFLAC Cancer Center and Blood Disorders Service, Children's Healthcare of Atlanta, Atlanta, GA, USA
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Arni D, Wildhaber BE, McLin V, Rimensberger PC, Ansari M, Fontana P, Karam O. Effects of plasma transfusions on antithrombin levels after paediatric liver transplantation. Vox Sang 2018; 113:569-576. [PMID: 29761839 DOI: 10.1111/vox.12664] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Revised: 03/19/2018] [Accepted: 04/20/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVES Thrombotic complications affect 3-10% of patients after liver transplantation (LT), leading to potentially life-threatening complications. In the days following LT, antithrombin (AT) is decreased longer than pro-coagulant factors, thus favouring a pro-thrombotic profile. Plasma transfusions are given empirically in some centres to correct AT levels following LT. We assessed the effect of plasma transfusion on AT levels after paediatric LT. MATERIALS AND METHODS Prospective single-centre observational study in 20 consecutive paediatric LT recipients over a 24-month period. Plasma was administered twice daily (10 ml/kg/dose) according to an existing protocol. AT levels were measured once daily, immediately prior to and one hour after the morning plasma transfusion. Sample size was calculated based on a non-inferiority hypothesis. RESULTS The median age and weight were 11.6 years (IQR 2.8; 14.7) and 40 kg (IQR 12.75; 44.8), respectively. We collected 85-paired blood samples. The median AT level prior to plasma transfusion was 58%. The median difference in AT levels before and after plasma transfusion was 4.2% (P = 0.001). Changes in AT levels after plasma transfusion were not correlated with baseline AT levels (R = 0.19) or patient weight (R = 0.18). CONCLUSION Plasma transfusions only marginally increase AT levels in children after LT. Therefore, prophylactic plasma transfusions probably do not seem to confer an advantage in the routine management of paediatric LT patients. Randomized controlled trials are needed to identify the optimal anticoagulation strategy in this specific population.
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Affiliation(s)
- D Arni
- Pediatric Surgery, University Center of Pediatric Surgery of Western Switzerland, Geneva University Hospital, Geneva, Switzerland
| | - B E Wildhaber
- Pediatric Surgery, University Center of Pediatric Surgery of Western Switzerland, Geneva University Hospital, Geneva, Switzerland
- Swiss Center for Liver Disease in Children, Geneva University Hospital, Geneva, Switzerland
| | - V McLin
- Swiss Center for Liver Disease in Children, Geneva University Hospital, Geneva, Switzerland
- Pediatric Gastro-Enterology, Geneva University Hospital, Geneva, Switzerland
| | - P C Rimensberger
- Pediatric Critical Care Unit, Geneva University Hospital, Geneva, Switzerland
| | - M Ansari
- Pediatric Oncology and Hematology, Geneva University Hospital, Geneva, Switzerland
| | - P Fontana
- Angiology and Hemostasis, Geneva University Hospital, Geneva, Switzerland
| | - O Karam
- Pediatric Critical Care Unit, Geneva University Hospital, Geneva, Switzerland
- Division of Pediatric Critical Care Medicine, Children's Hospital of Richmond at VCU, Richmond, VA, USA
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Stanworth SJ, Desborough MJR, Simons G, Seeney F, Powter G, MacDonald S, McKechnie S, Green L, Young N, Walsh T, Laffan MA. Clinical bleeding and thrombin generation in admissions to critical care with prolonged prothrombin time: an exploratory study. Transfusion 2018; 58:1388-1398. [PMID: 29637582 DOI: 10.1111/trf.14605] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 01/19/2018] [Accepted: 01/25/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Prolongation of prothrombin time (PT) is often recorded in critical illness, but has limited ability to predict risk of bleeding. This exploratory study was aimed at assessing a role for thrombin generation (TG) to predict bleeding. STUDY DESIGN AND METHODS TG was measured by calibrated automated thrombography in admissions to intensive care with prolonged PT. Bleeding events were recorded up to Day 5 after enrollment and correlated with results of PT ratio (PTR) and variables of TG. RESULTS A total of 306 patients were recruited. A total of 101 bleeding events developed in 46 patients during the period of observation. Many patients with prolonged PT had endogenous thrombin potential (ETP), which was within the normal range (120/251 patients, 47.8%) or even elevated (8%). Although some patients had a reduction in ETP or peak thrombin, these were present over a wide range of PTR. There was no suggestion by receiver operating characteristic analysis that variables of conventional TG were sensitive at predicting bleeding. No bleeding events were documented in patients defined as ETP high, despite elevated PTR. CONCLUSION Future studies need to explore a role for alternatives tests of coagulation in critical illness. Development of TG assays is required to positively identify more patients at increased bleeding risk or to exclude a larger number at low risk and how this relates to subgroups, such as patients with liver disease, and the need for prophylactic plasma transfusion.
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Affiliation(s)
- Simon J Stanworth
- Transfusion Medicine, NHS Blood and Transplant, Oxford, UK.,Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford and Oxford BRC Haematology Theme, Oxford, UK
| | - Michael J R Desborough
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Gemma Simons
- Department of Anaesthetics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Gillian Powter
- Clinical Trials Unit, NHS Blood and Transplant, Oxford, UK
| | - Stephen MacDonald
- The Specialist Haemostasis Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Stuart McKechnie
- Nuffield Division of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Laura Green
- Barts Health NHS Trust, London, UK.,NHS Blood and Transplant, London, UK.,Blizard Institute, Queen Mary, University of London, London, UK
| | - Neil Young
- Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - Mike A Laffan
- Centre for Haematology, Imperial College London, London, UK
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Lieberman L, Lin Y, Cserti-Gazdewich C, Yi QL, Pendergrast J, Lau W, Callum J. Utilization of frozen plasma, cryoprecipitate, and recombinant factor VIIa for children with hemostatic impairments: An audit of transfusion appropriateness. Pediatr Blood Cancer 2018; 65. [PMID: 29286568 DOI: 10.1002/pbc.26933] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 11/08/2017] [Accepted: 11/22/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Blood transfusions and fractionated products are not without risk and may lead to acute and long-term adverse events. The objective of this study was to evaluate the appropriateness of usage of frozen plasma (FP), cryoprecipitate (CRYO), and recombinant factor VIIa (rVIIa) in a pediatric setting. METHODS All orders for FP, CRYO, and rVIIa were prospectively audited over 6 weeks. Data collected included demographics, laboratory values, indication, and adverse reactions. The appropriateness of each order was independently evaluated using adjudication criteria rated by two hematologists. RESULTS Two hundred sixty-five products were ordered; 67% of the orders were issued to operating rooms or intensive care units. The most common indication for all products was cardiac surgery. FP was ordered as fluid replacement (15/215; 7%) to correct abnormal coagulation tests (23/215; 11%) and for patients with minor or no bleeding (111/242; 46%). FP was more likely to alter the international normalized ratio (INR) if the INR was over 2.0 (P < 0.0001). The rate of inappropriate products was judged as FP 19%, CRYO 21%, and rVIIa 91%. CONCLUSION FP, CRYO, and rVIIa are most commonly used in the operating room and intensive care units. FP was often used for fluid resuscitation and for patients with mild to no bleeding. FP was only effective in lowering the INR when the INR was over 2.0. Use of rVIIa was rarely ordered for an appropriate indication. Results of this study inform its readers where trials of pediatric transfusion should be performed to clarify how these products should be used in clinical practice.
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Affiliation(s)
- Lani Lieberman
- Department of Clinical Pathology, University Health Network, Toronto, Ontario, Canada.,Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Yulia Lin
- Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Department of Clinical Pathology, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Christine Cserti-Gazdewich
- Department of Clinical Pathology, University Health Network, Toronto, Ontario, Canada.,Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Qi Long Yi
- Canadian Blood Services, Ottawa, Ontario, Canada
| | - Jacob Pendergrast
- Department of Clinical Pathology, University Health Network, Toronto, Ontario, Canada.,Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Wendy Lau
- Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jeannie Callum
- Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Department of Clinical Pathology, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
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- Department of Clinical Pathology, University Health Network, Toronto, Ontario, Canada
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Abstract
OBJECTIVES Duplicative institutional review board/research ethics committee review for multicenter studies may impose administrative burdens and inefficiencies affecting study implementation and quality. Understanding variability in site-specific institutional review board/research ethics committee assessment and barriers to using a single review committee (an increasingly proposed solution) can inform a more efficient process. We provide needed data about the regulatory oversight process for the Sepsis PRevalence, OUtcomes, and Therapies multicenter point prevalence study. DESIGN Survey. SETTING Sites invited to participate in Sepsis PRevalence, OUtcomes, and Therapies. SUBJECTS Investigators at sites that expressed interest and/or participated in Sepsis PRevalence, OUtcomes, and Therapies. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Using an electronic survey, we collected data about 1) logistics of protocol submission, 2) institutional review board/research ethics committee requested modifications, and 3) use of a single institutional review board (for U.S. sites). We collected surveys from 104 of 167 sites (62%). Of the 97 sites that submitted the protocol for institutional review board/research ethics committee review, 34% conducted full board review, 54% expedited review, and 4% considered the study exempt. Time to institutional review board/research ethics committee approval required a median of 34 (range 3-186) days, which took longer at sites that required protocol modifications (median [interquartile range] 50 d [35-131 d] vs 32 d [14-54 d)]; p = 0.02). Enrollment was delayed at eight sites due to prolonged (> 50 d) time to approval. Of 49 U.S. sites, 43% considered using a single institutional review board, but only 18% utilized this option. Time to final approval for U.S. sites using the single institutional review board was 62 days (interquartile range, 34-70 d) compared with 34 days (interquartile range, 15-54 d) for nonsingle institutional review board sites (p = 0.16). CONCLUSIONS Variability in regulatory oversight was evident for this minimal-risk observational research study, most notably in the category of type of review conducted. Duplicative review prolonged time to protocol approval at some sites. Use of a single institutional review board for U.S. sites was rare and did not improve efficiency of protocol approval. Suggestions for minimizing these challenges are provided.
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Red Cell Transfusion and Prolonged Mechanical Ventilation-The Perpetrator Finally Identified or Guilt by Association Again? Pediatr Crit Care Med 2018; 19:174-175. [PMID: 29394231 DOI: 10.1097/pcc.0000000000001417] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Abstract
PURPOSE OF REVIEW Managing the bleeding pediatric patient perioperatively can be extremely challenging. The primary goals include avoiding hypotension, maintaining adequate tissue perfusion and oxygenation, and maintaining hemostasis. Traditional bleeding management has consisted of transfusion of autologous blood products, however, there is strong evidence that transfusion-related side-effects are associated with increased morbidity and mortality in children. Especially concerning is the increased reported incidence of noninfectious adverse events such as transfusion-related acute lung injury, transfusion-related circulatory overload and transfusion-related immunomodulation. The current approach in perioperative bleeding management of the pediatric patient should focus on the diagnosis and treatment of anemia and coagulopathy with the transfusion of blood products only when clinically indicated and guided by goal-directed strategies. RECENT FINDINGS Current guidelines recommend that a comprehensive multimodal patient blood management strategy is critical in optimizing patient care, avoiding unnecessary transfusion of blood and blood product and limiting transfusion-related side-effects. SUMMARY This article will highlight current guidelines in perioperative bleeding management for our most vulnerable pediatric patients with emphasis on individualized targeted intervention using point-of-care testing and specific coagulation products.
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Nellis ME, Karam O. Assessing our current practice: point prevalence studies in transfusion medicine. Transfusion 2018; 58:843-845. [PMID: 29380394 DOI: 10.1111/trf.14492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 12/13/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Marianne E Nellis
- Pediatric Critical Care Medicine, NY Presbyterian Hospital-Weill Cornell Medicine, New York, New York
| | - Oliver Karam
- Division of Pediatric Critical Care Medicine, Children's Hospital of Richmond at VCU, Richmond, Virginia
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A Prospective Study of the Association Between Clinically Significant Bleeding in PICU Patients and Thrombocytopenia or Prolonged Coagulation Times. Pediatr Crit Care Med 2017; 18:e455-e462. [PMID: 28737597 DOI: 10.1097/pcc.0000000000001281] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE There are no proven methods to predict the risk of clinically significant bleeding in the PICU. A retrospective study identified platelet count as a risk marker for clinically significant bleeding. We conducted a study to examine any association of platelet count, international normalized ratio, and activated partial thromboplastin time with bleeding risk in PICU patients. DESIGN Prospective observational cohort study. SETTING The PICU at the Children's Hospital of Eastern Ontario, a university-affiliated tertiary care pediatric center. PATIENTS Consecutive patients admitted to the PICU. Exclusion criteria were prior inclusion, admission with bleeding, inherited bleeding disorders, weight less than 3 kg, and age less than 60 days or 18 years or more. INTERVENTIONS There were no interventions in this observational study. MEASUREMENTS AND MAIN RESULTS Patients were monitored in real time for clinically significant bleeding, using a broadly inclusive definition of clinically significant bleeding, for up to 72 hours after admission to the PICU, or until death or discharge. All measurements of platelet count, international normalized ratio, and activated partial thromboplastin time obtained during the study period were included as time-varying covariates in Cox proportional hazard models. Two hundred thirty-four patients were eligible, and 25 (11%) had one or more episodes of clinically significant bleeding. Platelet count was associated with increased hazard of clinically significant bleeding (hazard ratio, 0.96 per 10 × 10/L increase in platelet count; 95% CI (0.93-0.997; p = 0.03). Increasing hazard for clinically significant bleeding was seen with decreasing platelet count. Neither international normalized ratio nor activated partial thromboplastin time was significantly associated with clinically significant bleeding. CONCLUSIONS There is a statistically significant association in PICU patients between decrease in platelet count and clinically significant bleeding, and this association is stronger with lower platelet counts. Further study is required to determine whether platelet transfusion can reduce bleeding risk. International normalized ratio and activated partial thromboplastin time do not predict clinically significant bleeding, and these tests should not be used for this purpose in a general PICU patient population.
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Predicting Risk of Bleeding in Critically Ill Children. Pediatr Crit Care Med 2017; 18:999-1000. [PMID: 28976469 DOI: 10.1097/pcc.0000000000001291] [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: 11/26/2022]
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Plasma: A Rose by Any Other Name. Pediatr Crit Care Med 2017; 18:496-497. [PMID: 28475537 DOI: 10.1097/pcc.0000000000001157] [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: 11/26/2022]
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Outcomes Related to the Use of Frozen Plasma or Pooled Solvent/Detergent-Treated Plasma in Critically Ill Children. Pediatr Crit Care Med 2017; 18:e215-e223. [PMID: 28350560 DOI: 10.1097/pcc.0000000000001149] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine if the use of fresh frozen plasma/frozen plasma 24 hours compared to solvent detergent plasma is associated with international normalized ratio reduction or ICU mortality in critically ill children. DESIGN This is an a priori secondary analysis of a prospective, observational study. Study groups were defined as those transfused with either fresh frozen plasma/frozen plasma 24 hours or solvent detergent plasma. Outcomes were international normalized ratio reduction and ICU mortality. Multivariable logistic regression was used to determine independent associations. SETTING One hundred one PICUs in 21 countries. PATIENTS All critically ill children admitted to a participating unit were included if they received at least one plasma unit during six predefined 1-week (Monday to Friday) periods. All children were exclusively transfused with either fresh frozen plasma/frozen plasma 24 hours or solvent detergent plasma. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS There were 443 patients enrolled in the study. Twenty-four patients (5%) were excluded because no plasma type was recorded; the remaining 419 patients were analyzed. Fresh frozen plasma/frozen plasma 24 hours group included 357 patients, and the solvent detergent plasma group included 62 patients. The median (interquartile range) age and weight were 1 year (0.2-6.4) and 9.4 kg (4.0-21.1), respectively. There was no difference in reason for admission, severity of illness score, pretransfusion international normalized ratio, or lactate values; however, there was a difference in primary indication for plasma transfusion (p < 0.001). There was no difference in median (interquartile range) international normalized ratio reduction, between fresh frozen plasma/frozen plasma 24 hours and solvent detergent plasma study groups, -0.2 (-0.4 to 0) and -0.2 (-0.3 to 0), respectively (p = 0.80). ICU mortality was lower in the solvent detergent plasma versus fresh frozen plasma/frozen plasma 24 hours groups, 14.5% versus 29.1%%, respectively (p = 0.02). Upon adjusted analysis, solvent detergent plasma transfusion was independently associated with reduced ICU mortality (odds ratio, 0.40; 95% CI, 0.16-0.99; p = 0.05). CONCLUSIONS Solvent detergent plasma use in critically ill children may be associated with improved survival. This hypothesis-generating data support a randomized controlled trial comparing solvent detergent plasma to fresh frozen plasma/frozen plasma 24 hours.
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Karam O, Demaret P, Duhamel A, Shefler A, Spinella PC, Tucci M, Leteurtre S, Stanworth SJ. Factors influencing plasma transfusion practices in paediatric intensive care units around the world. Vox Sang 2017; 112:140-149. [PMID: 28176380 DOI: 10.1111/vox.12490] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 12/23/2016] [Accepted: 12/28/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND OBJECTIVES Plasma transfusions are a frequent treatment worldwide, but many studies have reported a wide variation in the indications to transfuse. Recently, an international paediatric study also showed wide variation in frequency in the use of plasma transfusions: 25% of the centres transfused plasma to >5% of their patients, whereas another 25% transfused plasma to <1% of their patients. The objective of this study was to explore the factors associated with different plasma transfusion practices in these centres. MATERIALS AND METHODS Online survey sent to the local investigators of the 101 participating centres, in February 2016. Four areas were explored: beliefs regarding plasma transfusion, patients' case-mix in each unit, unit's characteristics, and local blood product transfusion policies and processes. RESULTS The response rate was 82% (83/101). 43% of the respondents believed that plasma transfusions can arrest bleeding, whereas 27% believe that plasma transfusion can prevent bleeding. Centres with the highest plasma transfusion rate were more likely to think that hypovolaemia and mildly abnormal coagulation tests are appropriate indications for plasma transfusions (P = 0·02 and P = 0·04, respectively). Case-mix, centre characteristics or local transfusion services were not identified as significant relevant factors. CONCLUSION Factors influencing plasma transfusion practices reflect beliefs about indications and the efficacy of transfusion in the prevention and management of bleeding as well as effects on coagulation tests. Educational and other initiatives to target these beliefs should be the focus of research.
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Affiliation(s)
- O Karam
- Pediatric Intensive Care Unit, Geneva University Hospital, Geneva, Switzerland.,Univ. Lille, EA 2694 - Santé Publique : épidémiologie et qualité des soins, Lille, France
| | - P Demaret
- Univ. Lille, EA 2694 - Santé Publique : épidémiologie et qualité des soins, Lille, France.,Pediatric Intensive Care Unit, CHC Liège, Liège, Belgium
| | - A Duhamel
- Univ. Lille, EA 2694 - Santé Publique : épidémiologie et qualité des soins, Lille, France.,CHU Lille, Service de Biostatistique, Lille, France
| | - A Shefler
- Pediatric Intensive Care Unit, Oxford University Hospitals, Oxford, UK
| | - P C Spinella
- Division of Critical Care, Department of Pediatrics, Washington University in St Louis, St. Louis, MO, USA
| | - M Tucci
- Pediatric Intensive Care Unit, CHU Sainte-Justine, Montreal, QC, Canada
| | - S Leteurtre
- Univ. Lille, EA 2694 - Santé Publique : épidémiologie et qualité des soins, Lille, France.,CHU Lille, Service de réanimation pédiatrique, Lille, France
| | - S J Stanworth
- NHS Blood and Transplant/Oxford University Hospital NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, Oxford, UK
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Abstract
OBJECTIVE We determined whether in critically ill children with an untunneled central venous catheter, the risk of catheter-associated deep venous thrombosis can be predicted within 24 hours after insertion of the catheter. DESIGN Secondary analysis of two multicenter prospective cohort studies. SETTING PICUs in Northeastern United States. PATIENTS A total of 175 children admitted to the PICU within 24 hours after insertion of an untunneled central venous catheter who did not receive anticoagulation were included. Of these, 53 (30.3%) developed catheter-associated thrombosis detected with active surveillance with ultrasonography. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We used logistic regression (models 1 and 2) and recursive partitioning (models 3 and 4) methods to develop risk prediction models with predictors present at any time while catheterized (models 1 and 3), or within 24 hours after insertion of the catheter (models 2 and 4). Age, recent surgery, catheter in the subclavian vein, and blood product transfusion were included in models 1 and 2. Areas under the receiver operating characteristic curves were similar for these models (model 1: 0.80 vs model 2: 0.80; p = 0.44). Except for recent surgery, predictors in model 1 were identified as partitioning variables for model 3. In addition to the predictors in model 2, severity of illness was used in partitioning for model 4. The area under the curve of model 3 appeared smaller than that of model 4 (0.75 vs 0.80; p = 0.08). Groups of children at low, intermediate, and high risks of catheter-associated thrombosis were identified using model 4. CONCLUSIONS Critically ill children at high risk of catheter-associated thrombosis can be identified within 24 hours after insertion of an untunneled central venous catheter.
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Karam O, Demaret P, Duhamel A, Shefler A, Spinella PC, Stanworth SJ, Tucci M, Leteurtre S. Performance of the PEdiatric Logistic Organ Dysfunction-2 score in critically ill children requiring plasma transfusions. Ann Intensive Care 2016; 6:98. [PMID: 27714707 PMCID: PMC5053948 DOI: 10.1186/s13613-016-0197-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Accepted: 09/24/2016] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Organ dysfunction scores, based on physiological parameters, have been created to describe organ failure. In a general pediatric intensive care unit (PICU) population, the PEdiatric Logistic Organ Dysfunction-2 score (PELOD-2) score had both a good discrimination and calibration, allowing to describe the clinical outcome of critically ill children throughout their stay. This score is increasingly used in clinical trials in specific subpopulation. Our objective was to assess the performance of the PELOD-2 score in a subpopulation of critically ill children requiring plasma transfusions. METHODS This was an ancillary study of a prospective observational study on plasma transfusions over a 6-week period, in 101 PICUs in 21 countries. All critically ill children who received at least one plasma transfusion during the observation period were included. PELOD-2 scores were measured on days 1, 2, 5, 8, and 12 after plasma transfusion. Performance of the score was assessed by the determination of the discrimination (area under the ROC curve: AUC) and the calibration (Hosmer-Lemeshow test). RESULTS Four hundred and forty-three patients were enrolled in the study (median age and weight: 1 year and 9.1 kg, respectively). Observed mortality rate was 26.9 % (119/443). For PELOD-2 on day 1, the AUC was 0.76 (95 % CI 0.71-0.81) and the Hosmer-Lemeshow test was p = 0.76. The serial evaluation of the changes in the daily PELOD-2 scores from day 1 demonstrated a significant association with death, adjusted for the PELOD-2 score on day 1. CONCLUSIONS In a subpopulation of critically ill children requiring plasma transfusion, the PELOD-2 score has a lower but acceptable discrimination than in an entire population. This score should therefore be used cautiously in this specific subpopulation.
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Affiliation(s)
- Oliver Karam
- Pediatric Intensive Care Unit, Geneva University Hospital, Geneva, Switzerland. .,Univ. Lille, EA 2694 - Santé Publique: épidémiologie et qualité des soins, 59000, Lille, France.
| | - Pierre Demaret
- Univ. Lille, EA 2694 - Santé Publique: épidémiologie et qualité des soins, 59000, Lille, France.,Pediatric Intensive Care Unit, CHC Liège, Liège, Belgium
| | - Alain Duhamel
- Univ. Lille, EA 2694 - Santé Publique: épidémiologie et qualité des soins, 59000, Lille, France.,Department of Biostatistics, CHU Lille, 59000, Lille, France
| | - Alison Shefler
- Pediatric Intensive Care Unit, Oxford University Hospitals, Oxford, UK
| | - Philip C Spinella
- Division of Critical Care, Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, USA
| | | | - Marisa Tucci
- Pediatric Intensive Care Unit, CHU Sainte-Justine, Montreal, Canada
| | - Stéphane Leteurtre
- Univ. Lille, EA 2694 - Santé Publique: épidémiologie et qualité des soins, 59000, Lille, France.,Pediatric Intensive Care Unit, CHU Lille, 59000, Lille, France
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50
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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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