Publications by authors named "Oliver Karam"

72 Publications

Variation in Neonatal Transfusion Practice.

J Pediatr 2021 Apr 7. Epub 2021 Apr 7.

Division of Newborn Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA.

Objective: To estimate the incidence of blood product transfusion, including red blood cells, platelets, and plasma, and characterize pretransfusion hematologic values for infants during their initial hospitalization after birth.

Study Design: Retrospective cohort study using data from 7 geographically diverse US academic and community hospitals that participated in the National Heart Lung and Blood Institute Recipient Epidemiology and Donor Evaluation Study-III (REDS-III) from 2013 to 2016. Pretransfusion hematologic values were evaluated closest to each transfusion and no more than 24 hours beforehand.

Results: Data from 60 243 infants were evaluated. The incidence of any transfusion differed by gestational age (P < .0001), with 80% (95% CI 76%-84%) transfused at <27 weeks of gestation (n = 329) and 0.5% (95% CI 0.5%-0.6%) transfused at ≥37 weeks of gestation (n = 53 919). The median pretransfusion hemoglobin was 11.2 g/dL (10th-90th percentile 8.8-14.1) for the entire cohort, ranging from 10.5 g/dL (8.8-12.3) for infants born extremely preterm at <27 weeks of gestation to 13.0 g/dL (10.5-15.5) for infants born at term. The median pretransfusion platelet count (×10/L) was 71 (10th-90th percentile 26-135) for the entire cohort, and was >45 for all gestational age groups examined. The median pretransfusion international normalized ratio for the entire cohort was 1.7 (10th-90th percentile 1.2-2.8).

Conclusions: There is wide variability in pretransfusion hemoglobin, platelet count, and international normalized ratio values for neonatal transfusions. Our findings suggest that a large proportion of neonatal transfusions in the US are administered at thresholds greater than supported by the best-available evidence and highlight an opportunity for improved patient blood management.
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http://dx.doi.org/10.1016/j.jpeds.2021.04.002DOI Listing
April 2021

Bleeding in Critically Ill Children-Review of Literature, Knowledge Gaps, and Suggestions for Future Investigation.

Front Pediatr 2021 27;9:611680. Epub 2021 Jan 27.

Pediatric Critical Care Medicine, NY Presbyterian Hospital-Weill Cornell Medicine, New York, NY, United States.

Clinically significant bleeding complicates up to 20% of admissions to the intensive care unit in adults and is associated with severe physiologic derangements, requirement for significant interventions and worse outcome. There is a paucity of published data on bleeding in critically ill children. In this manuscript, we will provide an overview of the epidemiology and characteristics of bleeding in critically ill children, address the association between bleeding and clinical outcomes, describe the current definitions of bleeding and their respective limitations, and finally provide an overview of current knowledge gaps and suggested areas for future research.
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http://dx.doi.org/10.3389/fped.2021.611680DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7873638PMC
January 2021

A new tool to assess Clinical Diversity In Meta-analyses (CDIM) of interventions.

J Clin Epidemiol 2021 Feb 6;135:29-41. Epub 2021 Feb 6.

Copenhagen Trial Unit (CTU), Centre for Clinical Intervention Research, Capital Region of Denmark, Denmark.

Objective: To develop and validate Clinical Diversity In Meta-analyses (CDIM), a new tool for assessing clinical diversity between trials in meta-analyses of interventions.

Study Design And Setting: The development of CDIM was based on consensus work informed by empirical literature and expertise. We drafted the CDIM tool, refined it, and validated CDIM for interrater scale reliability and agreement in three groups.

Results: CDIM measures clinical diversity on a scale that includes four domains with 11 items overall: setting (time of conduct/country development status/units type); population (age, sex, patient inclusion criteria/baseline disease severity, comorbidities); interventions (intervention intensity/strength/duration of intervention, timing, control intervention, cointerventions); and outcome (definition of outcome, timing of outcome assessment). The CDIM is completed in two steps: first two authors independently assess clinical diversity in the four domains. Second, after agreeing upon scores of individual items a consensus score is achieved. Interrater scale reliability and agreement ranged from moderate to almost perfect depending on the type of raters.

Conclusion: CDIM is the first tool developed for assessing clinical diversity in meta-analyses of interventions. We found CDIM to be a reliable tool for assessing clinical diversity among trials in meta-analysis.
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http://dx.doi.org/10.1016/j.jclinepi.2021.01.023DOI Listing
February 2021

Transfusion management for children supported by extracorporeal membrane oxygenation.

Transfusion 2021 Mar 25;61(3):660-664. Epub 2021 Jan 25.

Pediatric Critical Care Medicine, NY Presbyterian Hospital - Weill Cornell Medicine, New York, New York.

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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http://dx.doi.org/10.1111/trf.16272DOI Listing
March 2021

Overview of Plasma and Platelet Transfusions in Critically Ill Children.

Front Pediatr 2020 13;8:601659. Epub 2020 Nov 13.

Division of Pediatric Critical Care Medicine, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, VA, United States.

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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http://dx.doi.org/10.3389/fped.2020.601659DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7691248PMC
November 2020

Brighter Days May Be Ahead: Continuous Measurement of Pediatric Intensive Care Unit Light and Sound.

Front Pediatr 2020 26;8:590715. Epub 2020 Oct 26.

Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, VA, United States.

To describe light and sound characteristics in the rooms of critically ill children. Prospective observational cohort study, with continuously measured light and sound levels. Tertiary care pediatric intensive care unit (PICU), with a newly constructed expansion and an older, pre-existing section. Critically ill patients 0-18 years old, requiring respiratory or cardiovascular support. Patients with severe cognitive pre-conditions were excluded. One hundred patients were enrolled, totaling 602 patient-days. The twenty-four hour median illuminance was 16 (IQR 5-53) lux (lx). Daytime (07:00-21:00) median light level was 27 lx (IQR 13-82), compared with 4 lx (IQR 1-10) overnight (22:00-06:00). Peak light levels occurred midday between 11:00 and 14:00, with a median of 48 lx (IQR 24-119). Daytime median illuminance trended higher over the course of admission, whereas light levels overnight were consistent. Midday light levels were higher in newly constructed rooms: 78 lx (IQR 30-143) vs. 26 lx (IQR 20-40) in existing rooms. The twenty-four hour median equivalent sound level (LAeq) was 60 (IQR 55-64) decibels (dB). Median daytime LAeq was 62 dB (IQR 58-65) and 56 dB (IQR 52-61) overnight. On average, 35% of patients experienced at least one sound peak >80 dB every hour from 22:00 to 06:00. Overnight peaks, but not median sound levels nor daytime peaks, decreased over the course of admission. There was no difference in sound between new and pre-existing rooms. This study describes continuously measured light and sound in PICU rooms. Light levels were low even during daytime hours, while sound levels were consistently higher than World Health Organization hospital room recommendations of <35 dB. Given the relevance of light and sound to sleep/wake patterns, and evidence of post-intensive care syndromes, the clinical effects of light and sound on critically ill children should be further explored as potentially modifiable environmental factors.
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http://dx.doi.org/10.3389/fped.2020.590715DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7649178PMC
October 2020

Effect of platelet storage duration on clinical outcomes and incremental platelet change in critically ill children.

Transfusion 2020 Dec 22;60(12):2849-2858. Epub 2020 Sep 22.

Division of Pediatric Critical Care Medicine, Children's Hospital of Richmond at VCU, Richmond, Virginia.

The safety of platelet (PLT) concentrates with longer storage duration has been questioned due to biochemical and functional changes that occur during blood collection and storage. Some studies have suggested that transfusion efficacy is decreased and immune system dysfunction is worsened with increased storage age. We sought to describe the effect of PLT storage age on laboratory and clinical outcomes in critically ill children receiving PLT transfusions.

Study Design And Methods: We performed a secondary analysis of a prospective, observational point-prevalence study. Children (3 days to 16 years of age) from 82 pediatric intensive care units in 16 countries were enrolled if they received a PLT transfusion during one of the predefined screening weeks. Outcomes (including PLT count increments, organ dysfunction, and transfusion reactions) were evaluated by PLT storage age.

Results: Data from 497 patients were analyzed. The age of the PLT transfusions ranged from 1 to 7 days but the majority were 4 (24%) or 5 (36%) days of age. Nearly two-thirds of PLT concentrates were transfused to prevent bleeding. The indication for transfusion did not differ between storage age groups (P = .610). After patient and product variables were adjusted for, there was no association between storage age and incremental change in total PLT count or organ dysfunction scoring. A significant association between fresher storage age and febrile transfusion reactions (P = .002) was observed.

Conclusion: The results in a large, diverse cohort of critically ill children raise questions about the impact of storage age on transfusion and clinical outcomes which require further prospective evaluation.
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http://dx.doi.org/10.1111/trf.16094DOI Listing
December 2020

Anti-Xa versus time-guided anticoagulation strategies in extracorporeal membrane oxygenation: a systematic review and meta-analysis.

Perfusion 2020 Aug 29:267659120952982. Epub 2020 Aug 29.

Division of Pediatric Critical Care Medicine, Children's Hospital of Richmond at VCU, Richmond, VA, USA.

The purpose was to compare time-based vs anti-Xa-based anticoagulation strategies in patients on ECMO. We conducted a systematic review and meta-analysis using multiple electronic databases and included studies from inception to July 19, 2019. The proportion of bleeding, thrombosis, and mortality were evaluated.Twenty-six studies (2,086 patients) were included. Bleeding occurred in 34.2% (95%CI 25.1;43.9) of the patients with anti-Xa-based versus 41.6% (95%CI 24.9;59.4) of the patients with time-based anticoagulation strategies. Thrombosis occurred in 32.6% (95%CI 19.1;47.7) of the patients with anti-Xa-based versus 38.4% (95%CI 22.2;56.1) of the patients with time-based anticoagulation strategies. And mortality rate was 35.4% (95%CI 28.9;42.1) of the patients with anti-Xa-based versus 42.9% (95%CI 36.9;48.9) of the patients with time-based anticoagulation strategies. Among the seven studies providing results from both anticoagulation strategies, significantly fewer bleeding events occurred in the anti-Xa-based anticoagulation strategy (adjusted OR 0.49 (95%CI 0.32;0.74),  < 0.001) and a significantly lower mortality rate (adjusted OR 0.61 (95%CI 0.40;0.95),  = 0.03). There was no significant difference in thrombotic events (adjusted OR 0.91 (95%CI 0.56;1.49),  = 0.71). In these seven observational studies, only a small fraction of the patients were adults, and data were insufficient to analyze the effect of the type of ECMO.In this meta-analysis of observational studies of patients on ECMO, an anti-Xa-based anticoagulation strategy, when compared to a time-based strategy, was associated with fewer bleeding events and mortality rate, without an increase in thrombotic events.
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http://dx.doi.org/10.1177/0267659120952982DOI Listing
August 2020

Designing Appropriate and Individualized Transfusion Strategies: Finding the Sweet Spot.

Pediatr Crit Care Med 2020 08;21(8):770-772

Division of Pediatric Critical Care Medicine, Children's Hospital of Richmond at VCU, Richmond, VA.

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http://dx.doi.org/10.1097/PCC.0000000000002369DOI Listing
August 2020

Epidemiology of Hemostatic Transfusions in Children Supported by Extracorporeal Membrane Oxygenation.

Crit Care Med 2020 Aug;48(8):e698-e705

Division of Pediatric Critical Care Medicine, Department of Pediatrics, Weill Cornell Medicine, New York, NY.

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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http://dx.doi.org/10.1097/CCM.0000000000004417DOI Listing
August 2020

Preoperative erythropoietin within a patient blood management program decreases both blood transfusion and postoperative anemia: a prospective observational study.

Transfusion 2020 Aug 18;60(8):1732-1740. Epub 2020 Jul 18.

Department of Anesthesiology and Critical Care Medicine, Hôpital Lapeyronie, Montpellier, France.

Background: In orthopedic surgery, a patient blood management program (PBM) has been proposed to reduce blood transfusion. The aim of this observational study was to assess, within a PBM, the specific efficacy of preoperative erythropoietin (EPO).

Study Design And Methods: In a single hospital, 723 patients undergoing elective primary hip or knee arthroplasty were prospectively studied. The PBM included EPO if preoperative hemoglobin was lower than 13 g/dL, intraoperative administration of tranexamic acid, use of recommended transfusion thresholds, and postoperative infusion of iron. Blood transfusion and hemoglobin were noted until discharge. Major thromboembolic or cardiovascular events were assessed during admission and 1 month after discharge.

Results: Transfusion was noted in 2.5% patients with EPO. Transfusion rate was higher in patient for whom EPO was not indicated (13.6% transfusion rate; odds ratio [OR], 13.7; 95% confidence interval [CI], 2.6-66; p = 10 ) or if erythropoietin was indicated but not administrated (36.8% transfusion rate; OR, 18.2; 95% CI, 3.9-84.5; p < 10 ). Hemoglobin was significantly higher during the postoperative period in patients with erythropoietin. At hospital discharge, 57% of patients were anemic if EPO was used compared to 88% when EPO was not indicated and 87% when EPO was indicated but not administered (p < 10 ). There were no significant differences in the odds of major complications between patients with or without EPO.

Conclusions: Within a PBM, preoperative treatment of anemia with EPO decreased both the rate of blood transfusion and postoperative anemia. Further studies are necessary to confirm these results.
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http://dx.doi.org/10.1111/trf.15900DOI Listing
August 2020

Association Between Lactates, Blood Glucose, and Systemic Oxygen Delivery in Children After Cardiopulmonary Bypass.

Front Pediatr 2020 23;8:332. Epub 2020 Jun 23.

Division of Pediatric Critical Care Medicine, Children's Hospital of Richmond at VCU, Richmond, VA, United States.

Lactate is often used as a surrogate marker of inappropriate oxygen delivery. It has been shown that hyperlactatemia is associated with worse clinical outcome in children after cardiac surgery. The purpose of this study is to evaluate the association of hyperlactatemia, low systemic oxygen delivery, and hyperglycemia, in children admitted to the pediatric critical care unit after cardiopulmonary bypass. Secondary analysis of an observational cohort study. Tertiary pediatric critical care unit (PICU). Ninety-three patients, aged 6 months to 16 years, undergoing cardiac surgery with cardiopulmonary bypass. None. Metabolic tests (blood glucose, lactate, lactate/pyruvate ratio, and ketones) and oxygen extraction (SaO-SvO) were performed before anesthesia, at the end of cardiopulmonary bypass, at PICU admission, and at 4 and 12 h after PICU admission. Four hours after PICU admission, 62% of the patients had hyperlactatemia (>2 mmol/L), of whom 55% had normal oxygen extraction (SaO-SvO < 30%). There was no correlation between lactate and oxygen extraction (R = -0.09, = 0.41) but there was a moderate correlation between lactate and blood glucose (R = 0.55, < 0.001). Using a logistic regression model, hyperlactatemia at 4 h after PICU admission was independently associated with hyperglycemia ( = 0.007) and lactate/pyruvate ratio ( = 0.007) at the same timepoint, as well as with lactate at PICU admission ( = 0.002), but not with weight ( = 0.45), severity of the cardiac lesion ( = 0.85), duration of bypass ( = 0.16), or oxygen extraction, as evaluated by SaO-SvO ( = 0.54). At 12 h after PICU admission, there was a very week correlation between lactate and blood glucose (R = 0.27, = 0.007), but none between lactate and oxygen extraction (R = 0.13, = 0.20). In children after cardiopulmonary bypass, lactates are not correlated with higher oxygen extraction, but are correlated with hyperglycemia, at both 4 and 12 h after PICU admission. Future research is warranted to better define this relationship.
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http://dx.doi.org/10.3389/fped.2020.00332DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7325592PMC
June 2020

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 Aug 26;60(8):1700-1712. Epub 2020 Jun 26.

Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA.

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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http://dx.doi.org/10.1111/trf.15855DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7951993PMC
August 2020

Potential Neurodevelopmental Effects of Pediatric Intensive Care Sedation and Analgesia: Repetitive Benzodiazepine and Opioid Exposure Alters Expression of Glial and Synaptic Proteins in Juvenile Rats.

Crit Care Explor 2020 Apr 29;2(4):e0105. Epub 2020 Apr 29.

Department of Biochemistry and Molecular Biology, Virginia Commonwealth University School of Medicine, Richmond, VA.

Sedatives are suspected contributors to neurologic dysfunction in PICU patients, to whom they are administered during sensitive neurodevelopment. Relevant preclinical modeling has largely used comparatively brief anesthesia in infant age-approximate animals, with insufficient study of repetitive combined drug administration during childhood. We hypothesized that childhood neurodevelopment is selectively vulnerable to repeated treatment with benzodiazepine and opioid. We report a preclinical model of combined midazolam and morphine in early childhood age-approximate rats.

Design: Animal model.

Setting: Basic science laboratory.

Subjects: Male and female Long-Evans rats.

Interventions: Injections of morphine + midazolam were administered twice daily from postnatal days 18-22, tapering on postnatal days 23 and 24. Control groups included saline, morphine, or midazolam. To screen for acute neurodevelopmental effects, brain homogenates were analyzed by western blot for synaptophysin, drebrin, glial fibrillary acidic protein, S100 calcium-binding protein B, ionized calcium-binding adaptor molecule 1, and myelin basic proteins. Data analysis used Kruskal-Wallis with Dunn posttest, with a value of less than 0.05 significance.

Measurements And Main Results: Morphine + midazolam and morphine animals gained less weight than saline or midazolam ( ≤ 0.01). Compared with saline, morphine + midazolam expressed significantly higher drebrin levels ( = 0.01), with numerically but not statistically decreased glial fibrillary acidic protein. Similarly, morphine animals exhibited less glial fibrillary acidic protein and more S100 calcium-binding protein B and synaptophysin. Midazolam animals expressed significantly more S100 calcium-binding protein B ( < 0.001) and 17-18.5 kDa myelin basic protein splicing isoform ( = 0.01), with numerically increased synaptophysin, ionized calcium-binding adaptor molecule 1, and 21.5 kDa myelin basic protein, and decreased glial fibrillary acidic protein.

Conclusions: Analysis of brain tissue in this novel rodent model of repetitive morphine and midazolam administration showed effects on synaptic, astrocytic, microglial, and myelin proteins. These findings warrant further investigation because they may have implications for critically ill children requiring sedation and analgesia.
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http://dx.doi.org/10.1097/CCE.0000000000000105DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7188419PMC
April 2020

Pleural Effusions After Congenital Cardiac Surgery Requiring Readmission: A Systematic Review and Meta-analysis.

Pediatr Cardiol 2020 Aug 18;41(6):1145-1152. Epub 2020 May 18.

Division of Pediatric Critical Care Medicine, Children's Hospital of Richmond at VCU, Richmond, VA, USA.

Patients with congenital heart disease (CHD) are surviving longer thanks to improved surgical techniques and increasing knowledge of natural history. Pleural effusions continue to be a complication that affect many surgical patients and are associated with increased morbidity, many times requiring readmission and additional invasive procedures. The risks for development of pleural effusion after hospital discharge are ill-defined, which leads to uncertainty related to strategies for prevention. Our primary objective was to determine, in patients with CHD requiring cardiopulmonary bypass, the prevalence of post-surgical pleural effusions leading to readmission. The secondary objective was to identify risk factors associated with post-surgical pleural effusions requiring readmission. We identified 4417 citations; 10 full-text articles were included in the final review. Of the included studies, eight focused on single-ventricle palliation, one looked at Tetralogy of Fallot patients, and another on pleural effusion in the setting of post-pericardiotomy syndrome. Using a random-effect model, the overall prevalence of pleural effusion requiring readmission was 10.2% (95% CI 4.6; 17.6). Heterogeneity was high (I = 91%). In a subpopulation of patients after single-ventricle palliation, the prevalence was 13.0% (95% CI 6.0;21.0), whereas it was 3.0% (95% CI 0.4;6.75) in patients mostly with biventricular physiology. We were unable to accurately assess risk factors. A better understanding of this complication with a focus on single-ventricle physiology will allow for improved risk stratification, family counseling, and earlier recognition of pleural effusion in this patient population.
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http://dx.doi.org/10.1007/s00246-020-02365-4DOI Listing
August 2020

How 217 Pediatric Intensivists Manage Anemia at PICU Discharge: Online Responses to an International Survey.

Pediatr Crit Care Med 2020 06;21(6):e342-e353

Univ. Lille, EA 2694 - Santé Publique: épidémiologie et qualité des soins, F-59000 Lille, France.

Objective: To describe the management of anemia at PICU discharge by pediatric intensivists.

Design: Self-administered, online, scenario-based survey.

Setting: PICUs in Australia/New Zealand, Europe, and North America.

Subjects: Pediatric intensivists.

Interventions: None.

Measurements And Main Results: Respondents were asked to report their decisions regarding RBC transfusions, iron, and erythropoietin prescription to children ready to be discharged from PICU, who had been admitted for hemorrhagic shock, cardiac surgery, craniofacial surgery, and polytrauma. Clinical and biological variables were altered separately in order to assess their effect on the management of anemia. Two-hundred seventeen responses were analyzed. They reported that the mean (± SEM) transfusion threshold was a hemoglobin level of 6.9 ± 0.09 g/dL after hemorrhagic shock, 7.6 ± 0.10 g/dL after cardiac surgery, 7.0 ± 0.10 g/dL after craniofacial surgery, and 7.0 ± 0.10 g/dL after polytrauma (p < 0.001). The most important increase in transfusion threshold was observed in the presence of a cyanotic heart disease (mean increase ranging from 1.80 to 2.30 g/dL when compared with baseline scenario) or left ventricular dysfunction (mean increase, 1.41-2.15 g/dL). One third of respondents stated that they would not prescribe iron at PICU discharge, regardless of the hemoglobin level or the baseline scenario. Most respondents (69.4-75.0%, depending on the scenario) did not prescribe erythropoietin.

Conclusions: Pediatric intensivists state that they use restrictive transfusion strategies at PICU discharge similar to those they use during the acute phase of critical illness. Supplemental iron is less frequently prescribed than RBCs, and prescription of erythropoietin is uncommon. Optimal management of post-PICU anemia is currently unknown. Further studies are required to highlight the consequences of this anemia and to determine appropriate management.
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http://dx.doi.org/10.1097/PCC.0000000000002307DOI Listing
June 2020

Perioperative Transfusions and Venous Thromboembolism.

Pediatrics 2020 04 20;145(4). Epub 2020 Mar 20.

Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, Maryland.

Background And Objectives: Annual incidence of venous thromboembolism (VTE) including postoperative VTE in hospitalized children is rising significantly. A growing body of evidence supports the role of red blood cells (RBCs) in pathologic thrombosis. In this study, we examined the association of perioperative RBC transfusion with postoperative VTE in pediatric patients.

Methods: The pediatric databases of the American College of Surgeons' National Surgical Quality Improvement Project from 2012 to 2017 were used. Multivariable logistic regression was used to examine the association between perioperative RBC transfusion status and the development of new or progressive VTE within 30 days of surgery. The analyses were age stratified, as follows: neonates (≤28 days), infants (>28 days and <1 year), and children (≥1 year).

Results: In this study, we included 20 492 neonates, 79 744 infants, and 382 862 children. Postoperative development of VTE was reported in 99 (0.48%) neonates, 147 (0.2%) infants, and 374 (0.1%) children. In all age groups, development of VTE was significantly more common among patients with a perioperative RBC transfusion than patients without a perioperative RBC transfusion (neonates: adjusted odds ratio [aOR] = 4.1, 95% confidence interval [CI] = 2.5-6.7; infants: aOR = 2.4, 95% CI = 1.7-3.6; children: aOR = 2.2, 95% CI = 1.7-2.9). Among children who received an intra- or postoperative transfusion, the weight-based volume of RBCs (mL/kg) transfused was associated with postoperative VTE in a dose-dependent manner: second tertile (odds ratio = 2.3, 95% CI = 1.3-4.1) and third tertile (odds ratio = 4.1, 95% CI = 2.3-7.4) versus first tertile.

Conclusions: Perioperative RBC transfusions are independently associated with development of new or progressive postoperative VTE in children, infants, and neonates. These findings need further validation in prospective studies and emphasize the need for evidence-based perioperative pediatric blood transfusion decisions.
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http://dx.doi.org/10.1542/peds.2019-2351DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7111487PMC
April 2020

Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children.

Pediatr Crit Care Med 2020 02;21(2):e52-e106

Radboud University Medical Centre, Nijmegen, The Netherlands.

Objectives: To develop evidence-based recommendations for clinicians caring for children (including infants, school-aged children, and adolescents) with septic shock and other sepsis-associated organ dysfunction.

Design: A panel of 49 international experts, representing 12 international organizations, as well as three methodologists and three public members was convened. Panel members assembled at key international meetings (for those panel members attending the conference), and a stand-alone meeting was held for all panel members in November 2018. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. Teleconferences and electronic-based discussion among the chairs, co-chairs, methodologists, and group heads, as well as within subgroups, served as an integral part of the guideline development process.

Methods: The panel consisted of six subgroups: recognition and management of infection, hemodynamics and resuscitation, ventilation, endocrine and metabolic therapies, adjunctive therapies, and research priorities. We conducted a systematic review for each Population, Intervention, Control, and Outcomes question to identify the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak, or as a best practice statement. In addition, "in our practice" statements were included when evidence was inconclusive to issue a recommendation, but the panel felt that some guidance based on practice patterns may be appropriate.

Results: The panel provided 77 statements on the management and resuscitation of children with septic shock and other sepsis-associated organ dysfunction. Overall, six were strong recommendations, 52 were weak recommendations, and nine were best-practice statements. For 13 questions, no recommendations could be made; but, for 10 of these, "in our practice" statements were provided. In addition, 49 research priorities were identified.

Conclusions: A large cohort of international experts was able to achieve consensus regarding many recommendations for the best care of children with sepsis, acknowledging that most aspects of care had relatively low quality of evidence resulting in the frequent issuance of weak recommendations. Despite this challenge, these recommendations regarding the management of children with septic shock and other sepsis-associated organ dysfunction provide a foundation for consistent care to improve outcomes and inform future research.
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http://dx.doi.org/10.1097/PCC.0000000000002198DOI Listing
February 2020

Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children.

Intensive Care Med 2020 02;46(Suppl 1):10-67

Radboud University Medical Centre, Nijmegen, The Netherlands.

Objectives: To develop evidence-based recommendations for clinicians caring for children (including infants, school-aged children, and adolescents) with septic shock and other sepsis-associated organ dysfunction.

Design: A panel of 49 international experts, representing 12 international organizations, as well as three methodologists and three public members was convened. Panel members assembled at key international meetings (for those panel members attending the conference), and a stand-alone meeting was held for all panel members in November 2018. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. Teleconferences and electronic-based discussion among the chairs, co-chairs, methodologists, and group heads, as well as within subgroups, served as an integral part of the guideline development process.

Methods: The panel consisted of six subgroups: recognition and management of infection, hemodynamics and resuscitation, ventilation, endocrine and metabolic therapies, adjunctive therapies, and research priorities. We conducted a systematic review for each Population, Intervention, Control, and Outcomes question to identify the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak, or as a best practice statement. In addition, "in our practice" statements were included when evidence was inconclusive to issue a recommendation, but the panel felt that some guidance based on practice patterns may be appropriate.

Results: The panel provided 77 statements on the management and resuscitation of children with septic shock and other sepsis-associated organ dysfunction. Overall, six were strong recommendations, 49 were weak recommendations, and nine were best-practice statements. For 13 questions, no recommendations could be made; but, for 10 of these, "in our practice" statements were provided. In addition, 52 research priorities were identified.

Conclusions: A large cohort of international experts was able to achieve consensus regarding many recommendations for the best care of children with sepsis, acknowledging that most aspects of care had relatively low quality of evidence resulting in the frequent issuance of weak recommendations. Despite this challenge, these recommendations regarding the management of children with septic shock and other sepsis-associated organ dysfunction provide a foundation for consistent care to improve outcomes and inform future research.
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http://dx.doi.org/10.1007/s00134-019-05878-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7095013PMC
February 2020

Transfusion in children with acute respiratory distress syndrome.

Ann Transl Med 2019 Oct;7(19):511

Department of Pediatrics, Division of Pediatric Critical Care Medicine, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, Québec, Canada.

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 (DO). Additionally, appropriate indications for prophylactic transfusion of hemostatic products (plasma or platelets) in children with PARDS are lacking.
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http://dx.doi.org/10.21037/atm.2019.08.28DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6828792PMC
October 2019

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 03;21(3):267-275

Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Hospital of Richmond at VCU, Richmond, VA.

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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http://dx.doi.org/10.1097/PCC.0000000000002160DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7060816PMC
March 2020

Bleeding Assessment Scale in Critically Ill Children (BASIC): Physician-Driven Diagnostic Criteria for Bleeding Severity.

Crit Care Med 2019 12;47(12):1766-1772

Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Hospital of Richmond at VCU, Richmond, VA.

Objective: Although bleeding frequently occurs in critical illness, no published definition to date describes the severity of bleeding accurately in critically ill children. We sought to develop diagnostic criteria for bleeding severity in critically ill children.

Design: Delphi consensus process of multidisciplinary experts in bleeding/hemostasis in critically ill children, followed by prospective cohort study to test internal validity.

Setting: PICU.

Patients: Children at risk of bleeding in PICUs.

Interventions: None.

Measurements And Main Results: Twenty-four physicians worldwide (10 on a steering committee and 14 on an expert committee) from disciplines related to bleeding participated in development of a definition for clinically relevant bleeding. A provisional definition was created from 35 descriptors of bleeding. Using a modified online Delphi process and conference calls, the final definition resulted after seven rounds of voting. The Bleeding Assessment Scale in Critically Ill Children definition categorizes bleeding into severe, moderate, and minimal, using organ dysfunction, proportional changes in vital signs, anemia, and quantifiable bleeding. The criteria do not include treatments such as red cell transfusion or surgical interventions performed in response to the bleed. The definition was prospectively applied to 40 critically ill children with 46 distinct bleeding episodes. The kappa statistic between the two observers was 0.74 (95% CI, 0.57-0.91) representing substantial inter-rater reliability.

Conclusions: The Bleeding Assessment Scale in Critically Ill Children definition of clinically relevant bleeding severity is the first physician-driven definition applicable for bleeding in critically ill children derived via international expert consensus. The Bleeding Assessment Scale in Critically Ill Children definition includes clear criteria for bleeding severity in critically ill children. We anticipate that it will facilitate clinical communication among pediatric intensivists pertaining to bleeding and serve in the design of future epidemiologic studies if it is validated with patient outcomes.
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http://dx.doi.org/10.1097/CCM.0000000000004025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6861687PMC
December 2019

Transfusion Management in Pediatric Oncology Patients.

Hematol Oncol Clin North Am 2019 10 5;33(5):903-913. Epub 2019 Jul 5.

Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Hospital of Richmond at VCU, 1250 East Marshall Street, Richmond, VA 23298, USA. Electronic address: https://twitter.com/DrOliverKaram.

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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http://dx.doi.org/10.1016/j.hoc.2019.05.011DOI Listing
October 2019

Quantifiable Bleeding in Children Supported by Extracorporeal Membrane Oxygenation and Outcome.

Crit Care Med 2019 11;47(11):e886-e892

Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Hospital of Richmond at VCU, Richmond, VA.

Objectives: To evaluate the association between bleeding from chest tubes and clinical outcomes 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: Daily chest tube bleeding, results from hemostatic assays, transfusion volumes, 90-day PICU-free days, and mortality were collected prospectively by trained bedside extracorporeal membrane oxygenation specialists and research coordinators. Extracorporeal membrane oxygenation was employed in the care of 514 consecutive patients. Sixty percent of patients had at least one episode of chest tube bleeding (median chest tube blood volume over the entire extracorporeal membrane oxygenation course was 123 mL/kg [interquartile range, 47-319 mL/kg]). Twenty-six percent had at least 1 day of bleeding from the chest tube greater than 100 mL/kg/d. The number of days with chest tube bleeding greater than 60 mL/kg/d was independently associated with increased in-hospital mortality (adjusted odds ratio, 1.43; 95% CI, 1.05-1.97; p = 0.02) and decreased PICU-free days (beta coefficient, -4.2; 95% CI, -7.7 to -0.6; p = 0.02). The total amount of bleeding from chest tube were independently associated with increased mortality (per mL/kg/extracorporeal membrane oxygenation run; adjusted odds ratio, 1.002; 95% CI, 1.000-1.003; p = 0.04). Fibrinogen, weight, indication for extracorporeal membrane oxygenation, and need for hemodialysis were independently associated with chest tube bleeding, whereas platelet count, coagulation tests, heparin dose, and thrombotic events were not.

Conclusions: In children supported by extracorporeal membrane oxygenation, chest tube bleeding above 60 mL/kg/d was independently associated with worse clinical outcome. Low fibrinogen was independently associated with chest tube bleeding, whereas platelet count and hemostatic tests were not. Further research is needed to evaluate if interventions to prevent or stop chest tube bleeding influence the clinical outcome.
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http://dx.doi.org/10.1097/CCM.0000000000003968DOI Listing
November 2019

Reply to: Prognostic Evaluation of Mortality after Pediatric Resuscitation Assisted by Extracorporeal Life Support.

J Pediatr Intensive Care 2019 Sep 9;8(3):193-194. Epub 2019 Jul 9.

Department of Intensive Care Medicine and Neonatology, University Children's Hospital of Zurich, Zurich, Switzerland.

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http://dx.doi.org/10.1055/s-0039-1692969DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6687445PMC
September 2019

Anemia at Discharge From the PICU: A Bicenter Descriptive Study.

Pediatr Crit Care Med 2019 09;20(9):e400-e409

Université de Lille, CHU Lille, EA 2694 - Santé publique: épidémiologie et qualité des soins, F-59000 Lille, France.

Objective: To determine the prevalence and risk markers of anemia at PICU discharge.

Design: Bicenter retrospective cohort study.

Setting: Two multidisciplinary French PICUs.

Patients: All children admitted during a 5-year period, staying in the PICU for at least 2 days, and for whom a hemoglobin was available at PICU discharge.

Interventions: None.

Measurements And Main Results: Patient, admission, and PICU stay characteristics were retrospectively collected in the electronic medical records of each participating PICU. Anemia was defined according to the World Health Organization criteria. Among the 3,170 patients included for analysis, 1,868 (58.9%) were anemic at discharge from PICU. The proportion of anemic children differed between age categories, whereas the median hemoglobin level did not exhibit significant variations according to age. After multivariate adjustment, anemia at PICU admission was the strongest predictor of anemia at PICU discharge, and the strength of this association varied according to age (interaction). Children anemic at PICU admission had a reduced risk of anemia at PICU discharge if transfused with RBCs during the PICU stay, if less than 6 months old, or if creatinine level at PICU admission was low. Children not anemic at PICU admission had an increased risk of anemia at PICU discharge if they were thrombocytopenic at PICU admission, if they had higher C-reactive protein levels, and if they received plasma transfusion, inotropic/vasopressor support, or mechanical ventilation during the PICU stay.

Conclusions: Anemia is frequent after pediatric critical illness. Anemia status at PICU admission defines different subgroups of critically ill children with specific prevalence and risk markers of anemia at PICU discharge. Further studies are required to confirm our results, to better define anemia during pediatric critical illness, and to highlight the causes of post-PICU stay anemia, its course, and its association with post-PICU outcomes.
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http://dx.doi.org/10.1097/PCC.0000000000002015DOI Listing
September 2019

International Study of the Epidemiology of Platelet Transfusions in Critically Ill Children With an Underlying Oncologic Diagnosis.

Pediatr Crit Care Med 2019 07;20(7):e342-e351

Division of Pediatric Critical Care, Department of Pediatrics, Washington University in St Louis, St Louis, MO.

Objectives: To describe the epidemiology of platelet transfusions in critically ill children with an underlying oncologic diagnosis and to examine effects of prophylactic versus therapeutic transfusions.

Design: Subgroup analysis of a prospective, observational study.

Setting: Eighty-two PICUs in 16 countries.

Patients: All children (3 d to 16 yr old) who received a platelet transfusion during one of the six predefined screening weeks and had received chemotherapy in the previous 6 months or had undergone hematopoietic stem cell transplantation in the last year.

Interventions: None.

Measurements And Main Results: Of the 548 patients enrolled in the parent study, 237 (43%) had an underlying oncologic diagnosis. In this population, 71% (168/237) of transfusions were given prophylactically, and 59% (139/237) of transfusions were given at a total platelet count greater than 20 × 10/L, higher than the current recommendations. Those with an underlying oncologic diagnosis were significantly older, and received less support including less mechanical ventilation, fewer medications that affect platelet function, and less use of extracorporeal life support than those without an underlying oncologic diagnosis. In this subpopulation, there were no statistically significant differences in median (interquartile range) platelet transfusion thresholds when comparing bleeding or nonbleeding patients (50 × 10/L [10-50 × 10/L] and 30 × 10/L [10-50 × 10/L], respectively [p = 0.166]). The median (interquartile range) interval transfusion increment in children with an underlying oncologic diagnosis was 17 × 10/L (6-52 × 10/L). The presence of an underlying oncologic diagnosis was associated with a poor platelet increment response to platelet transfusion in this cohort (adjusted odds ratio, 0.46; 95% CI, 0.22-0.95; p = 0.035).

Conclusions: Children with an underlying oncologic diagnosis receive nearly half of platelet transfusions prescribed by pediatric intensivists. Over half of these transfusions are prescribed at total platelet count greater than current recommendations. Studies must be done to clarify appropriate indications for platelet transfusions in this vulnerable population.
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http://dx.doi.org/10.1097/PCC.0000000000001987DOI Listing
July 2019

Prognostic Evaluation of Mortality after Pediatric Resuscitation Assisted by Extracorporeal Life Support.

J Pediatr Intensive Care 2019 Jun 11;8(2):57-63. Epub 2018 Jul 11.

Pediatric Intensive Care Unit, Geneva University Hospital, Geneva, Switzerland.

To improve survival rates during cardiopulmonary resuscitation (CPR), some patients are put on extracorporeal life support (ECLS) during active resuscitation (ECPR). Our objective was to assess the clinical outcomes after pediatric ECPR in Switzerland and to determine pre-ECPR prognostic factors for mortality. The present study is a retrospective analysis. The study setting included three pediatric intensive care units in Switzerland that use ECPR. All patients (<16 years old) undergoing ECPR from 2008 to 2016 were included in the study. There were no interventions. Data before ECLS initiation and clinical outcomes were collected. An ECPR score was designed to predict mortality, based on variables significantly different between survivors and non-survivors. Fifty-five patients were included, with a median age of 13.5 months. Eighty percent were cardiac patients. The mortality rate was 75%. Mortality was significantly associated with CPR duration (  = 0.02), last lactate (  = 0.05), and last pH (  = 0.01) before ECLS initiation. Based on these three variables, an ECPR score was designed as follows: CPR duration (in minutes): 1 point if < 40; 2 points if ≥ 40; 3 points if ≥ 60; 6 points if ≥ 105. Lactate (in mmol/L): 1 point if < 8; 2 points if ≥ 8; 3 points if ≥ 14; 6 points if ≥ 18. pH: 1 point if > 7.00; 2 points if ≤ 7.00; 3 points if ≤ 6.85; 6 points if ≤ 6.60. The area under the receiver-operating characteristic curve was 0.74. The positive predictive value of a score ≥ 9 was 94%. In our population, a score based on three variables easily available prior to ECLS initiation had good discrimination and could appropriately predict mortality. This score now needs validation in a larger population.
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http://dx.doi.org/10.1055/s-0038-1667012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6517051PMC
June 2019