Tailing growth, neonatal jaundice and anaemia

At medical school, there is a phrase to help us remember that common things are common: 'If you hear hooves think horses, not zebras'. However, zebras do exist, and from time to time in general paediatric and neonatal practice, we will encounter these rare diagnoses, more of which we can now accurately diagnose through the ever-expanding field of genomics. Our case demonstrates how a rare diagnosis can present with common features of growth restriction, jaundice and anaemia. Paediatricians therefore require a high index of suspicion and increasing knowledge of the logistics of genetic testing.

Validation of the HOSPITAL score as predictor of 30-day potentially avoidable readmissions in pediatric hospitalized population: retrospective cohort study

Potentially avoidable pediatric readmissions are a burden to patients and their families. Identifying patients with higher risk of readmission could help minimize hospital costs and facilitate the targeting of care interventions. HOSPITAL score is a tool developed and widely used to predict adult patient's readmissions; however its predictive capacity for pediatric readmissions has not yet been evaluated. The aim of the study was to validate the HOSPITAL score application to predict 30-day potentially avoidable readmissions in a pediatric hospitalized population. This is a retrospective cohort study with patients under 18 years old admitted to a tertiary university hospital (n = 6,344). The HOSPITAL score was estimated for each admission. Subsequently, we classified the patients as low (0-4), intermediate (5-6), and high (7-12) risk groups. In order to estimate the discrimination power, the sensitivity, specificity, and accuracy were determined by the receiver operating characteristics (ROC) and the calibration by the Hosmer-Lemeshow goodness-of-fit. The 30-day hospital readmission was 11.70% (745). The accuracy was 0.80 (CI 95%, 0.77, 0.83), with a sensitivity of 70.96% and specificity of 78.29%, and a good calibration (p = 0.34).    Conclusion: HOSPITAL score showed a good discrimination and can be used to predict 30-day potentially avoidable readmission in a large pediatric population with different medical diagnoses. Our study validates and expands the usefulness of the HOSPITAL score as a tool to predict avoidable hospital readmissions for pediatric population. What is Known: •   Pediatric readmissions burden patients, the family network, and the health system. In addition, it influences negatively child development. •   The HOSPITAL score is one of the tools developed and widely used to identify patients at high risk of hospital readmission, but its predictive capacity for pediatric readmissions has not been yet assessed. What is New: • The HOSPITAL score showed good ability to identify a risk of 30-day potentially avoidable readmission in a pediatric population in different clinical contexts and diagnoses. • Our study expands the usefulness of the HOSPITAL score as a tool for predicting hospital readmissions for children and adolescents.

Strategies to Reduce Diagnostic Blood Loss and Anemia in Hospitalized Patients: A Scoping Review

OBJECTIVES

Blood sampling is a recognized contributor to hospital-acquired anemia. We aimed to bundle all published neonatal, pediatric, and adult data regarding clinical interventions to reduce diagnostic blood loss.

DATA SOURCES

Four electronic databases were searched for eligible studies from inception until May 2021.

STUDY SELECTION

Two reviewers independently selected studies, using predefined criteria.

DATA EXTRACTION

One author extracted data, including study design, population, period, intervention type and comparator, and outcome variables (diagnostic blood volume and frequency, anemia, and transfusion).

DATA SYNTHESIS

Of 16,132 articles identified, we included 39 trials; 12 (31%) were randomized controlled trials. Among six types of interventions, 27 (69%) studies were conducted in adult patients, six (15%) in children, and six (15%) in neonates. Overall results were heterogeneous. Most studies targeted a transfusion reduction ( n = 28; 72%), followed by reduced blood loss ( n = 24; 62%) and test frequency ( n = 15; 38%). Small volume blood tubes ( n = 7) and blood conservation devices ( n = 9) lead to a significant reduction of blood loss in adults (8/9) and less transfusion of adults (5/8) and neonates (1/1). Point-of-care testing ( n = 6) effectively reduced blood loss (4/4) and transfusion (4/6) in neonates and adults. Bundles including staff education and protocols reduced blood test frequency and volume in adults (7/7) and children (5/5).

CONCLUSIONS

Evidence on interventions to reduce diagnostic blood loss and associated complications is highly heterogeneous. Blood conservation devices and smaller tubes appear effective in adults, whereas point-of-care testing and bundled interventions including protocols and teaching seem promising in adults and children.

Hospital-acquired anemia among patients in a university hospital and the affiliated general practices in the capital region of Denmark, 2019

INTRODUCTION

Approximately 25% of the patients with hospital acquired anemia (HAA) develop moderate to severe HAA during hospitalization. This is related to an increased risk of prolonged stay, readmission and mortality. The primary aim was during one year to characterize a population with very frequent phlebotomies based on a university hospital in the Capital Region of Denmark and the related general practitioners.

MATERIAL AND METHODS

We conducted a retrospective cohort study using administrative data on phlebotomies from 1 January 2019 to 31 December 2019 analyzed at a university hospital.

RESULTS

A total of 203,811 patients had 10,083,207 requisitions and 1,373,013 tubes. One percent, 1985 patients, had an extreme of frequent phlebotomies >60 tubes and formed the basis for the study population. The study population was significantly older as compared to the excluded patients (<60 tubes) (mean 65.7 vs. 51.6 years, p < .001).The likelihood of hemoglobin decrease per 100 mL blood drawn were calculated at four levels of decreases: Hemoglobin decrease of 2 mmol/L (adjusted OR; 95%; 2.03, CI 1.79-2.31), hemoglobin decrease of 3 mmol/L (adjusted OR; 95%, 1.36, CI 1.28-1.45), hemoglobin decrease of 4 mmol/L, (adjusted OR; 95%, 1.27, CI 1.19-1.35) and hemoglobin decrease of 5 mmol/L, (adjusted OR; 95% 1.22, CI 1.13-1.31).

CONCLUSIONS

Moderate to severe HAA occurred in a limited group with excessive many phlebotomies. It was a worrisome trend that the frailest patients had the highest risk of developing HAA.

Impact of Blood Sampling on Anemia in the PICU: A Prospective Cohort Study

OBJECTIVES

Fifty percent of children are anemic after a critical illness. Iatrogenic blood testing may be a contributor to this problem. The objectives of this study were to describe blood sampling practice in a PICU, determine patient factors associated with increased sampling, and examine the association among blood sampling volume, anemia at PICU discharge, and change in hemoglobin from PICU entry to PICU discharge.

DESIGN

Prospective observational cohort study.

SETTING

PICU of Sainte-Justine University Hospital.

PATIENTS

All children consecutively admitted during a 4-month period.

MEASUREMENTS AND MAIN RESULTS

Four hundred twenty-three children were enrolled. Mean blood volume sampled was 3.9 (±19) mL/kg/stay, of which 26% was discarded volume. Children with central venous or arterial access were sampled more than those without access (p < 0.05). Children with sepsis, shock, or cardiac surgery were most sampled, those with a primary respiratory diagnosis; the least (p < 0.001). We detected a strong association between blood sample volume and mechanical ventilation (H, 81.35; p < 0.0001), but no association with severity of illness (Worst Pediatric Logistic Organ Dysfunction score) (R, -0.044; p = 0.43). Multivariate analysis (n = 314) showed a significant association between the volume of blood sampled (as continuous variable) and anemia at discharge (adjusted OR, 1.63; 95% CI, 1.18-2.45; p = 0.003). We lacked power to detect an association between blood sampling and change in hemoglobin from PICU admission to PICU discharge.

CONCLUSIONS

Diagnostic blood sampling in PICU is associated with anemia at discharge. Twenty-five percent of blood losses from sampling is wasted. Volumes are highest for patients with sepsis, shock, or cardiac surgery, and in patients with vascular access or ventilatory support.

Diagnostic Modalities in Critical Care: Point-of-Care Approach

The concept of intensive care units (ICU) has existed for almost 70 years, with outstanding development progress in the last decades. Multidisciplinary care of critically ill patients has become an integral part of every modern health care system, ensuing improved care and reduced mortality. Early recognition of severe medical and surgical illnesses, advanced prehospital care and organized immediate care in trauma centres led to a rise of ICU patients. Due to the underlying disease and its need for complex mechanical support for monitoring and treatment, it is often necessary to facilitate bed-side diagnostics. Immediate diagnostics are essential for a successful treatment of life threatening conditions, early recognition of complications and good quality of care. Management of ICU patients is incomprehensible without continuous and sophisticated monitoring, bedside ultrasonography, diverse radiologic diagnostics, blood gas analysis, coagulation and blood management, laboratory and other point-of-care (POC) diagnostic modalities. Moreover, in the time of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, particular attention is given to the POC diagnostic techniques due to additional concerns related to the risk of infection transmission, patient and healthcare workers safety and potential adverse events due to patient relocation. This review summarizes the most actual information on possible diagnostic modalities in critical care, with a special focus on the importance of point-of-care approach in the laboratory monitoring and imaging procedures.