Publications by authors named "Sheila J Hanson"

40 Publications

Life-Threatening Bleeding in Children: A Prospective Observational Study.

Crit Care Med 2021 May 12. Epub 2021 May 12.

Division of Emergency Medicine, Department of Pediatrics, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH. Department of Pathology & Laboratory Medicine, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA. Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA. Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Oklahoma College of Medicine, The Children's Hospital at University of Oklahoma Health Sciences Center, Oklahoma City, OK. Department of Anesthesia and Critical Care, ARCO Rome, Bambino Gesù Children's Hospital, Rome, Italy. Division of Pediatric Emergency Medicine, University of Toronto, Hospital for Sick Children, Toronto, ON, Canada. Division of Pediatric Emergency Medicine, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY. Department of Anesthesiology and Critical Care Medicine, Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Children's Hospital of Philadelphia, Philadelphia, PA. Division of Pediatric Surgery, Department of Surgery, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA. Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston Children's Hospital, Boston, MA. Department of Pediatrics, Critical Care Section, Medical College of Wisconsin, Children's Wisconsin, Milwaukee, WI. Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Utah School of Medicine, Primary Children's Medical Center, Salt Lake City, UT. Division of Emergency Medicine, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH. Orange Park Medical Center, Orange Park, Florida. Division of Pediatric Surgery, Akron Children's Hospital, Akron, OH. Division of Critical Care Medicine, Department of Pediatrics, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH. Division of Neonatology, Department of Pediatrics, University of California San Francisco Pritzker School of Medicine, University of California San Francisco Medical Center Parnassus, San Francisco, CA. Division of Pediatric Critical Care Medicine, Department of Child Health, University of Arizona College of Medicine, Phoenix Children's Hospital, Phoenix, AZ. Department of Surgery, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN. Department of Emergency Medicine, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, MI. Department of Pediatrics, Dartmouth Hitchcock Medical Center, Children's Hospital at Dartmouth, Lebanon, NH. Division of Pediatric Hematology and Oncology, Department of Pediatrics, University of Minnesota Medical School, Department of Pediatric Critical Care Medicine, University of Minnesota Masonic Children's Hospital, Minneapolis, MN. Department of Pediatric Surgery, Vanderbilt University College of Medicine, Monroe Carell Jr Children's Hospital Nashville, TN. Keck School of Medicine of University of Southern California, Children's Hospital Los Angeles, Los Angeles, CA. Department of Pediatric Surgery, Baylor College of Medicine, Texas Children's Hospital, Houston, TX. Department of Surgery, Texas A&M University College of Medicine, McLane Children's Hospital, Temple TX. Division of Pediatric Surgery, Alpert Medical School of Brown University, Hasbro Children's Hospital, Providence, RI. Southlake Pediatrics, Birmingham, AL. Department of Pediatrics, University of Alabama School of Medicine, Children's of Alabama, Birmingham, AL. Division of Critical Care, Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis Children's Hospital, St. Louis, MO.

Objectives: The purpose of our study was to describe children with life-threatening bleeding.

Design: We conducted a prospective observational study of children with life-threatening bleeding events.

Setting: Twenty-four childrens hospitals in the United States, Canada, and Italy participated.

Subjects: Children 0-17 years old who received greater than 40 mL/kg total blood products over 6 hours or were transfused under massive transfusion protocol were included.

Interventions: Children were compared according bleeding etiology: trauma, operative, or medical.

Measurements And Main Results: Patient characteristics, therapies administered, and clinical outcomes were analyzed. Among 449 enrolled children, 55.0% were male, and the median age was 7.3 years. Bleeding etiology was 46.1% trauma, 34.1% operative, and 19.8% medical. Prior to the life-threatening bleeding event, most had age-adjusted hypotension (61.2%), and 25% were hypothermic. Children with medical bleeding had higher median Pediatric Risk of Mortality scores (18) compared with children with trauma (11) and operative bleeding (12). Median Glasgow Coma Scale scores were lower for children with trauma (3) compared with operative (14) or medical bleeding (10.5). Median time from bleeding onset to first transfusion was 8 minutes for RBCs, 34 minutes for plasma, and 42 minutes for platelets. Postevent acute respiratory distress syndrome (20.3%) and acute kidney injury (18.5%) were common. Twenty-eight-day mortality was 37.5% and higher among children with medical bleeding (65.2%) compared with trauma (36.1%) and operative (23.8%). There were 82 hemorrhage deaths; 65.8% occurred by 6 hours and 86.5% by 24 hours.

Conclusions: Patient characteristics and outcomes among children with life-threatening bleeding varied by cause of bleeding. Mortality was high, and death from hemorrhage in this population occurred rapidly.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/CCM.0000000000005075DOI Listing
May 2021

Transfusion Practices in a Large Cohort of Hospitalized Children.

Transfusion 2021 May 11. Epub 2021 May 11.

Virginia Commonwealth University School of Medicine, Richmond, Virginia, United States.

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 eleven 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 non-birth inpatient encounters of children 0-18 years of age from 2013-2016 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 (IQR) pre-transfusion laboratory values were: hemoglobin, 7.9 g/dL (7.1-10.4 g/dL); platelet count, 27 x 10 cells/L (14-54 x 10 cells/L); and INR 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 < 0.001) and storage duration of RBC transfusions (median storage duration of 12 [8-17] days in infants and 20 [12-29] days in children, p < 0.001).

Conclusion: Based on a cohort of patients from 2013-2016, 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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/trf.16443DOI Listing
May 2021

Use of Pharmacologic Prophylaxis Against Venous Thromboembolism in Hospitalized Injured Children.

J Pediatr Hematol Oncol 2021 Apr 21. Epub 2021 Apr 21.

Division of Hematology CHOC Children's Hospital, Orange, CA Division of Pediatric Surgery Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, NC Section of Critical Care, Department of Pediatrics Children's Wisconsin/Medical College of Wisconsin, Milwaukee, WI Section of General Pediatrics, Department of Pediatrics Section of Pediatric Critical Care, Department of Pediatrics, Yale School of Medicine, New Haven, CT.

Despite a practice management guideline and risk prediction model for venous thromboembolism (VTE), pediatric-specific evidence on pharmacologic prophylaxis is lacking. In a retrospective study, we characterized receipt of prophylaxis and explored its effectiveness in hospitalized injured patients below 18 years old using data from the Trauma Quality Improvement Program. Concordance of receipt of prophylaxis with guideline and predicted risk of VTE was estimated using κ statistic. Effectiveness was explored using cohorts matched based on the risk prediction model. A total of 11,165 (6.2%) of 180,932 patients received prophylaxis. Those who received prophylaxis were more commonly post-pubertal and more severely injured. Receipt of prophylaxis was fairly concordant with the guideline (κ=0.32) and predicted risk of VTE (κ=0.29). Receipt of prophylaxis was associated with higher rates of VTE likely due to confounding by indication. Low molecular weight heparin seemed more effective against VTE than unfractionated heparin (incidence rate ratio: 0.52; 95% confidence interval: 0.36, 0.75), but less effective when received ≥72 hours after admission to the hospital. We showed that hospitalized injured children did not commonly receive prophylaxis. We also showed that prophylaxis may be effective in hospitalized injured children, but it needs to be proven definitively in a randomized clinical trial.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/MPH.0000000000002167DOI Listing
April 2021

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jpeds.2021.04.002DOI Listing
April 2021

Venovenous Versus Venoarterial Extracorporeal Membranous Oxygenation in Inotrope Dependent Pediatric Patients With Respiratory Failure.

ASAIO J 2021 04;67(4):457-462

From the Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI.

Patients with respiratory failure requiring inotropes or vasopressors are often placed on venoarterial (VA) extracorporeal membrane oxygenation (ECMO), as venovenous (VV) ECMO does not provide direct circulatory support. This retrospective multicenter study compared outcomes for 103 pediatric patients, with hemodynamic compromise, placed on VV ECMO for respiratory failure to those placed on VA ECMO. The primary outcome was survival to hospital discharge. Fifty-seven (55%) study participants were supported on VV ECMO. The two groups had similar PRISM III scores at pediatric intensive care unit (PICU) admission, and vasoactive-inotropic scores at ECMO cannulation. More VV ECMO patients received inhaled nitric oxide (iNO) (54.4 vs. 34.8%; p = 0.04) and had a higher oxygenation index (median 41.5 vs. 19.5; p = 0.04) pre-ECMO. More VA ECMO patients had cardiac dysfunction and cardiac arrest pre-ECMO (50 vs. 14%; p < 0.0001). In univariable analysis, survival to hospital discharge was higher in the VV vs. VA ECMO group (72 vs. 44%; p = 0.005), however, in multivariable models, cannulation type was confounded by cardiopulmonary resuscitation and was not independently associated with survival. VV survivors had longer ECMO duration compared with VA survivors (median, 7 vs. 4.5 days; p = 0.036) but similar PICU and hospital days. No significant difference was noted in functional outcomes or comorbidities at discharge. Cannulation type is not independently associated with survival to hospital discharge in pediatric patients on vasoactive infusions at the time of ECMO cannulation for respiratory indications.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/MAT.0000000000001254DOI Listing
April 2021

Age-Dependent Heterogeneity in the Efficacy of Prophylaxis With Enoxaparin Against Catheter-Associated Thrombosis in Critically Ill Children: A Post Hoc Analysis of a Bayesian Phase 2b Randomized Clinical Trial.

Crit Care Med 2021 04;49(4):e369-e380

Department of Pediatrics, Washington University in St. Louis, St. Louis, MO.

Objectives: We explored the age-dependent heterogeneity in the efficacy of prophylaxis with enoxaparin against central venous catheter-associated deep venous thrombosis in critically ill children.

Design: Post hoc analysis of a Bayesian phase 2b randomized clinical trial.

Setting: Seven PICUs.

Patients: Children less than 18 years old with newly inserted central venous catheter.

Interventions: Enoxaparin started less than 24 hours after insertion of central venous catheter and adjusted to anti-Xa level of 0.2-0.5 international units/mL versus usual care.

Measurements And Main Results: Of 51 children randomized, 24 were infants less than 1 year old. Risk ratios of central venous catheter-associated deep venous thrombosis with prophylaxis with enoxaparin were 0.98 (95% credible interval, 0.37-2.44) in infants and 0.24 (95% credible interval, 0.04-0.82) in older children greater than or equal to 1 year old. Infants and older children achieved anti-Xa level greater than or equal to 0.2 international units/mL at comparable times. While central venous catheter was in situ, endogenous thrombin potential, a measure of thrombin generation, was 223.21 nM.min (95% CI, 8.78-437.64 nM.min) lower in infants. Factor VIII activity, a driver of thrombin generation, was also lower in infants by 45.1% (95% CI, 15.7-74.4%). Median minimum platelet count while central venous catheter was in situ was higher in infants by 39 × 103/mm3 (interquartile range, 17-61 × 103/mm3). Central venous catheter:vein ratio was not statistically different. Prophylaxis with enoxaparin was less efficacious against central venous catheter-associated deep venous thrombosis at lower factor VIII activity and at higher platelet count.

Conclusions: The relatively lesser contribution of thrombin generation on central venous catheter-associated thrombus formation in critically ill infants potentially explains the age-dependent heterogeneity in the efficacy of prophylaxis with enoxaparin.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/CCM.0000000000004848DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7979442PMC
April 2021

Efficacy of Early Prophylaxis Against Catheter-Associated Thrombosis in Critically Ill Children: A Bayesian Phase 2b Randomized Clinical Trial.

Crit Care Med 2021 03;49(3):e235-e246

Department of Pediatrics, Washington University in St. Louis, St. Louis, MO.

Objectives: We obtained preliminary evidence on the efficacy of early prophylaxis on the risk of central venous catheter-associated deep venous thrombosis and its effect on thrombin generation in critically ill children.

Design: Bayesian phase 2b randomized clinical trial.

Setting: Seven PICUs.

Patients: Children less than 18 years old with a newly inserted central venous catheter and at low risk of bleeding.

Intervention: Enoxaparin adjusted to anti-Xa level of 0.2-0.5 international units/mL started at less than 24 hours after insertion of central venous catheter (enoxaparin arm) versus usual care without placebo (usual care arm).

Measurements And Main Results: At the interim analysis, the proportion of central venous catheter-associated deep venous thrombosis on ultrasonography in the usual care arm, which was 54.2% of 24 children, was significantly higher than that previously reported. This resulted in misspecification of the preapproved Bayesian analysis, reversal of direction of treatment effect, and early termination of the randomized clinical trial. Nevertheless, with 30.4% of 23 children with central venous catheter-associated deep venous thrombosis on ultrasonography in the enoxaparin arm, risk ratio of central venous catheter-associated deep venous thrombosis was 0.55 (95% credible interval, 0.24-1.11). Including children without ultrasonography, clinically relevant central venous catheter-associated deep venous thrombosis developed in one of 27 children (3.7%) in the enoxaparin arm and seven of 24 (29.2%) in the usual care arm (p = 0.02). Clinically relevant bleeding developed in one child randomized to the enoxaparin arm. Response profile of endogenous thrombin potential, a measure of thrombin generation, was not statistically different between trial arms.

Conclusions: These findings suggest the efficacy and safety of early prophylaxis that should be validated in a pivotal randomized clinical trial.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/CCM.0000000000004784DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7902342PMC
March 2021

The authors reply.

Crit Care Med 2021 01;49(1):e111-e112

Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/CCM.0000000000004721DOI Listing
January 2021

The Development of a Long Peripheral Catheter Program at a Large Pediatric Academic Center: A Pilot Study.

Hosp Pediatr 2020 10;10(10):897-901

Children's Wisconsin, Milwaukee, Wisconsin; and.

Objectives: The purpose of this study was to evaluate the feasibility of a new long peripheral catheter (LPC) program at a large academic center in an effort to reduce the use of peripherally inserted central catheters (PICCs) and their related complications.

Methods: The pilot participants were hospitalized children, age >2 years, with a need for noncentral intravenous access for 2 to 29 days, or laboratory blood draw >5 times per day. Patients expected to discharge with intravenous access were excluded. Included in the pilot program development were a literature review, 1-year baseline data analysis, and program design and implementation. A multidisciplinary committee developed and implemented the program from December 2018 to September 2019. LPCs were placed from August to September 2019.

Results: Regarding the baseline data, between July 2018 and June 2019, 584 PICCs were placed in 461 patients. Of these, 139 PICCs (24%) did not meet requirements necessitating central access and, potentially, could have been avoided if an LPC alternative were available at the time. For the LPC pilot program, 20 LPCs were placed in 19 patients. The median age was 11 (interquartile range of 7-15). The insertion success rate was 83%. There were no serious complications, such as venous thrombosis or catheter-related bloodstream infection. The total rate of minor complications was 35%: the rate of occlusions was 10% ( = 2), and the rate of dislodgement was 25% ( = 5). The catheter failure rate was 74 per 1000 catheter-days. The mean line duration was 6 days.

Conclusions: There is a role for LPCs in hospitalized children requiring durable vascular access. Multispecialty designed pilot implementation of an LPC program was successful at an academic pediatric hospital.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1542/hpeds.2020-0181DOI Listing
October 2020

Risks of venous thrombosis and bleeding in critically ill adolescents after trauma or major surgery.

J Pediatr Surg 2021 Feb 30;56(2):302-308. Epub 2020 Jun 30.

Section of Critical Care, Department of Pediatrics, Yale School of Medicine, New Haven, CT.

Background: The risks of venous thromboembolism (VTE) and bleeding in critically ill adolescents based on interventions received and anatomic site of trauma or major surgery may identify a cohort eligible for enrollment in a trial of pharmacologic prophylaxis.

Methods: This retrospective cohort study using the Virtual Pediatric Systems database included adolescents admitted to pediatric intensive care units after trauma or major surgery between 2013 and 2017. Mixed effects logistic regression was used to determine the adjusted risks of VTE and bleeding with central venous catheterization (CVC), mechanical ventilation (MV) and anatomic site of trauma or major surgery. The adjusted risks were used to identify the cohort eligible for enrollment.

Measurements And Main Results: VTE developed in 212 (0.8%) of 27,647 adolescents. The adjusted risk of VTE was >2% with CVC and 2 or more of MV and trauma or major surgery to the brain or abdomen. Excluding those with bleeds present on admission or at high risk of bleeding, 375 (1.4%) adolescents would be eligible for enrollment.

Conclusions: VTE is generally uncommon in adolescents after trauma or major surgery. The small proportion of adolescents who are at high risk of VTE and at low risk of bleeding impacts the feasibility of a trial.

Level Of Evidence: Prognostic Study Level II.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jpedsurg.2020.06.037DOI Listing
February 2021

Rates of Venous Thromboembolism and Central Line-Associated Bloodstream Infections Among Types of Central Venous Access Devices in Critically Ill Children.

Crit Care Med 2020 09;48(9):1340-1348

Pediatric Critical Care, Children's Hospital of Wisconsin, Milwaukee, WI.

Objectives: Central venous access devices, including peripherally inserted central catheters and central venous catheters, are often needed in critically ill patients, but also are associated with complications, including central-line associated bloodstream infections and venous thromboembolism. We compared different central venous access device types and these complications in the PICU.

Design: Multicenter, cohort study.

Setting: One hundred forty-eight participating Virtual PICU Systems, LLC, hospital PICU sites.

Patients: Pediatric patients with central venous access placed from January 1, 2010, to December 31, 2015.

Interventions: None.

Measurements And Main Results: Patient and central venous access device variables postulated to be associated with central-line associated bloodstream infection and venous thromboembolism were included. Data were analyzed using Pearson chi-square test or Fisher exact test for categorical variables, Mann-Whitney U test for continuous variables, and logistic regression and classification trees for multivariable analysis that examined significant predictors of venous thromboembolism or central-line associated bloodstream infection. Analysis included 74,196 first lines including 4,493 peripherally inserted central catheters and 66,194 central venous catheters. An increased rate of venous thromboembolism (peripherally inserted central catheter: 0.93%, central venous catheter: 0.52%; p = 0.001) (peripherally inserted central catheter: 8.65/1,000 line days, central venous catheter: 6.29/1,000 line days) and central-line associated bloodstream infection (peripherally inserted central catheter: 0.73%, central venous catheter: 0.24%; p = 0.001) (peripherally inserted central catheter: 10.82/1,000 line days, central venous catheter: 4.97/1,000 line days) occurred in peripherally inserted central catheters. In multivariable analysis, central venous catheters had decreased association with central-line associated bloodstream infection (odds ratio, 0.505; 95% CI, 0.336-0.759; p = 0.001) and venous thromboembolism (odds ratio, 0.569; 95% CI, 0.330-0.982; p = 0.043) compared with peripherally inserted central catheters.

Conclusions: Peripherally inserted central catheters are associated with higher rates of central-line associated bloodstream infection and venous thromboembolism than central venous catheters in children admitted to the PICU.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/CCM.0000000000004461DOI Listing
September 2020

Outcomes of pediatric patients with oncologic disease or following hematopoietic stem cell transplant supported on extracorporeal membrane oxygenation: The PEDECOR experience.

Pediatr Blood Cancer 2020 10 9;67(10):e28403. Epub 2020 Jun 9.

Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Background: Outcomes for patients with oncologic disease and/or after hematopoietic stem cell transplant (HSCT) requiring intensive care unit admission have improved, but indications for and outcomes after extracorporeal membrane oxygenation (ECMO) support in this population are poorly characterized.

Procedure: We analyzed data from consecutive patients < 18 years with oncologic disease and/or after HSCT reported to a pediatric ECMO registry by nine pediatric centers in the United States between 2011 and 2018.

Results: We identified 18 ECMO patients with oncologic disease and/or HSCT, and 415 ECMO controls matched with a propensity score algorithm based on age, gender, race, severity of illness at admission, and reason for ECMO. The primary indication for ECMO was respiratory failure in 66.7% in the oncologic disease and/or HSCT group, and in 70.7% in the matched ECMO control group. Eleven of 18 patients survived to hospital discharge (61.1%), similar to the matched control group (60.8%), P = 0.979. Children with oncologic disease and/or HSCT had lower mean platelet counts during ECMO and received higher volumes of platelets compared with the control group, mean 14.6 mL/kg/day (standard deviations [SD], 9.8) versus mean 9.3 mL/kg/day (SD, 10.4), P = 0.001. Of the 11 surviving children with oncologic disease and/or HSCT, five sustained new neurologic disorders (45.5%) versus 45 of 222 (20.3%) in the control group, P = 0.061. Bleeding complications were similar in the two groups.

Conclusions: Outcomes of patients with oncologic disease and/or HSCT supported on ECMO in the current era are not significantly different compared with matched ECMO controls and are improved from previously published reports.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/pbc.28403DOI Listing
October 2020

Standardized Implementation of Evidence-based Guidelines to Decrease Blood Transfusions in Pediatric Intensive Care Units.

Pediatr Qual Saf 2019 May-Jun;4(3):e165. Epub 2019 Apr 9.

Division of Pediatric Critical Care, Norton Children's Hospital /University of Louisville School of Medicine Louisville, KY.

Introduction: Despite evidence that red blood cell (RBC) transfusions may be associated with more harm than benefit, current transfusion practices vary significantly. This multicenter, quality improvement study aimed to sustainably decrease the rate of RBC transfusions in pediatric intensive care units (PICUs).

Methods: This 16-month prospective study included 5 PICUs. We implemented a standardized project plan including education, bedside tools, real-time reminders, and email feedback. We collected data from consecutive transfusions during pre-implementation (Phase I), postimplementation (Phase II), and post-stabilization phases (Phase III).

Results: Of the 2,064 RBC transfusions, we excluded 35% (N = 729) from analysis in patients undergoing extracorporeal membrane oxygenation. Transfusion/1,000 admissions improved throughout the study periods from a baseline 209.6 -199.8 in Phase II and 195.8 in Phase III ( value < 0.05). There were fewer transfusions outside of the hemoglobin threshold guideline, decreasing from 81% of transfusions outside of guidelines in Phase I to 74% in Phases II and III, < 0.05. Study phase, site, co-management status, service of requesting provider, admit reason, previous transfusion status, and age were associated with transfusion above guideline threshold.

Conclusions: Multicenter collaboration can successfully deploy a standardized plan that adheres to implementation science principles to sustainably decrease the rate of RBC transfusion outside of guideline thresholds. However, we did not decrease the total number of transfusions in our study. The complexity of multiple specialties co-managing patients is common in the contemporary PICU. Educational initiatives aimed at one specialty may have limited effectiveness in a multifaceted system of care.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/pq9.0000000000000165DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6594784PMC
April 2019

The authors reply.

Pediatr Crit Care Med 2019 01;20(1):94-95

Section of Critical Care, Department of Pediatrics, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/PCC.0000000000001785DOI Listing
January 2019

Impact of the Timing of Placement of an Intracranial Pressure Monitor on Outcomes in Children with Severe Traumatic Brain Injury.

Pediatr Neurosurg 2018 7;53(6):379-386. Epub 2018 Nov 7.

Section of Critical Care, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA,

Background: Severe traumatic brain injury (sTBI) is the leading cause of morbidity and mortality from trauma. Brain Trauma Foundation guidelines recommend intracranial pressure (ICP) monitoring in sTBI. We hypothesized that early ICP monitor placement was associated with better outcomes in children.

Methods: This was a retrospective study of children with sTBI admitted to the participating pediatric intensive care units (PICUs) and entered into the Virtual Pediatric Systems (VPS), LLC, database between 1 January 2010 and 31 December 2015. We compared outcomes of patients who had an ICP monitor placed early (≤6 h from PICU admission) to those with later placement (> 6 to < 72 h). We collected demographics, diagnoses, procedure data, illness severity scores, outcomes, and site data. Multivariable regression analysis was used to identify variables independently associated with outcomes.

Results: Twenty-seven percent of 3,608 patients with sTBI underwent ICP monitoring, 355 in the early and 156 in the later ICP monitoring groups, respectively. A higher proportion of patients in the early ICP monitoring group had worse markers of illness/injury severity; unadjusted analysis showed higher mortality in this group (31.3 vs. 21.8%, p = 0.029). Multivariable regression analysis showed that ICP monitoring was not independently associated with any of the outcomes.

Conclusion: Time to ICP monitoring was not associated with outcomes after pediatric sTBI.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1159/000494028DOI Listing
January 2019

Enteral Nutrition Initiation in Children Admitted to Pediatric Intensive Care Units After Traumatic Brain Injury.

Neurocrit Care 2019 02;30(1):193-200

Division of Critical Care, Department of Pediatrics, Children's Hospital of Wisconsin/Medical College of Wisconsin, 9000 W. Wisconsin Avenue, Milwaukee, WI, 53226, USA.

Background: Traumatic brain injury (TBI) is the leading cause of death and long-term disability among injured children. Early feeding has been shown to improve outcomes in adults, with some similar evidence in children with severe TBI. We aimed to examine the current practice of initiation of enteral nutrition in children with TBI and to evaluate the risk factors associated with delayed initiation of enteral nutrition.

Methods: This retrospective, multicenter study used the Pediatric Trauma Assessment and Management Database including all children with head trauma discharged from five pediatric intensive care units (PICU) at pediatric trauma centers between January 1, 2013 and December 31, 2013. We compared demographics, injury and procedure data, time to initiation of nutrition, and injury and illness severity scores between patients who received enteral nutrition early (≤ 48 h) and late (> 48 h). Fisher's exact and Mann-Whitney U tests compared discrete and continuous variables. Univariate and multivariable analyses evaluated variables associated with delayed initiation of feeding. Outcomes of interest included mortality, complications, ventilator days, hospital and ICU length of stay, and functional status at ICU discharge.

Results: In the 416 patients in the study, the overall mortality was 2.6%. The majority of patients (83%; range 69-88% between five sites, p = 0.0008) received enteral nutrition within 48 h of PICU admission. Lower Glasgow Coma Scale scores and higher Injury Severity Score (ISS) were independently associated with delayed initiation of enteral nutrition. Delayed enteral nutrition was independently associated with worse functional status at PICU discharge (p = 0.02) but was not associated with mortality or increased length of stay.

Conclusions: Children with severe TBI and higher ISS were more likely to have delayed initiation of enteral nutrition. Delayed enteral nutrition was an independent risk factor for worse functional status at ICU discharge for the entire cohort, but not for the severe TBI group.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s12028-018-0597-6DOI Listing
February 2019

Comparison of Complication Rates of Central Venous Catheters Versus Peripherally Inserted Central Venous Catheters in Pediatric Patients.

Pediatr Crit Care Med 2018 Dec;19(12):1097-1105

Division of Critical Care Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI.

Objectives: The purpose of our study is to compare the rate of central line-associated blood stream infections and venous thromboembolism in central venous catheters versus peripherally inserted central catheters in hospitalized children. There is a growing body of literature in adults describing an increased rate of venous thromboembolisms and similar rates of central line-associated blood stream infection associated with peripherally inserted central catheters versus central venous catheters. It is not known if the rate of central line-associated blood stream infection and venous thromboembolism differs between peripherally inserted central catheters and central venous catheters in children. Based on current adult literature, we hypothesize that central line-associated blood stream infection rates for peripherally inserted central catheters and central venous catheters will be similar, and the rate of venous thromboembolism will be higher for peripherally inserted central catheters versus central venous catheters.

Design: This is a cohort study using retrospective review of medical records and prospectively collected hospital quality improvement databases.

Setting: Quaternary-care pediatric hospital from October 2012 to March 2016.

Patients: All patients age 1 day to 18 years old with central venous catheters and peripherally inserted central catheters placed during hospital admission over the study dates were included. Central venous catheters that were present upon hospital admission were excluded. The primary outcomes were rate of central line-associated blood stream infection and rate of venous thromboembolism.

Interventions: None.

Measurements And Main Results: Of 2,709 catheters included in the study, 1,126 were peripherally inserted central catheters and 1,583 were central venous catheters. Peripherally inserted central catheters demonstrated a higher rate of both infection and venous thromboembolism than central venous catheters in all reported measures. In multivariable analysis, peripherally inserted central catheters had increased association with central line-associated blood stream infection (odds ratio of 3.15; 95% CI, 1.74-5.71; p = 0.0002) and increased association with venous thromboembolism (odds ratio of 2.71; 95% CI, 1.65-4.45; p < 0.0001) compared with central venous catheters.

Conclusions: Rates of central line-associated blood stream infection and venous thromboembolism were higher in hospitalized pediatric patients with peripherally inserted central catheters as compared to central venous catheters. Our study confirms the need for further investigation into the safety of central access devices to assist in proper catheter selection.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/PCC.0000000000001707DOI Listing
December 2018

Efficacy of surveillance ultrasound for venous thromboembolism diagnosis in critically ill children after trauma.

J Pediatr Surg 2018 Nov 20;53(11):2195-2201. Epub 2018 Jun 20.

Division of Pediatric Surgery, The Children's Hospital of Wisconsin. Electronic address:

Introduction: Venous thromboembolism (VTE) is increasingly prevalent in injured children admitted to the intensive care unit (ICU). Few data exist to support VTE pharmacologic prophylaxis or ultrasound (US) surveillance in children with high bleeding risk. After implementation of screening US guidelines, we sought to describe our experience, hypothesizing that screening US of children at highest risk for VTE results in earlier detection and management.

Study Design: A retrospective analysis was conducted on prospectively collected data of injured children admitted to an American College of Surgeons Verified level 1 Pediatric Trauma Center from 2010 to 2015. In patients at high risk for both VTE and bleeding (HRHR), guidelines recommended deferral of pharmacologic prophylaxis and a screening US at ≥7 ICU days if bleeding risk remained. Outcomes analyzed included VTE rates, guideline compliance, and US timing. The rate of deep vein thrombosis (DVT) detection (number of DVT captured/number of US obtained) was examined.

Results: Of 4061 trauma patients, 588 (14.5%) were critically injured including 112 patients who met HRHR criteria. The rate of VTE in the HRHR group ≥7 ICU days was 25% (14/56). Of 23 VTE diagnosed in the ICU, 17 were detected by 49 US performed (34.7%), with the remaining 6 diagnosed by computed tomography. DVT was detected earlier than the US guideline recommended 7 days, independent of symptoms. Guideline compliance was 86%.

Conclusion: Critically injured children at risk for bleeding frequently develop VTE. Surveillance ultrasound in patients at high risk for both VTE and bleeding allows earlier detection and treatment.

Level Of Evidence: Therapeutic study, level II.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jpedsurg.2018.06.013DOI Listing
November 2018

Multicenter Review of Current Practices Associated With Venous Thromboembolism Prophylaxis in Pediatric Patients After Trauma.

Pediatr Crit Care Med 2018 09;19(9):e448-e454

Division of Critical Care, Department of Pediatrics, Children's Hospital of Wisconsin/Medical College of Wisconsin, Milwaukee, WI.

Objectives: Frequency of venous thromboembolism in pediatric trauma patients admitted to PICUs is not insignificant, ranging up to 6%. Risk factors have been identified in this population. However, there is little consensus of actual venous thromboembolism prophylaxis practice. We examined factors associated with venous thromboembolism prophylaxis in PICUs.

Design: A retrospective study evaluating associations with mechanical venous thromboembolism prophylaxis, pharmacologic venous thromboembolism prophylaxis, or dual therapy (DUAL) prophylaxis compared with no venous thromboembolism prophylaxis. Multivariable logistic regression explored the relationship between prophylaxis type and selected covariates with stepwise selection method to identify the independent predictors of venous thromboembolism prophylaxis utilization.

Setting: Five level I/II pediatric trauma centers in the United States.

Patients: Children less than 18 years from January 1, 2013, to December 31, 2013, admitted to the PICU after a trauma, identified through combined trauma registry and Virtual Pediatric Systems database.

Interventions: None.

Measurements And Main Results: Six hundred ninety-two patients were included in the database, with 55 excluded for missing data. Of the remaining 637 patients, 538 (84.5%) had no venous thromboembolism prophylaxis by 48 hours, 77 (12.1%) had only mechanical venous thromboembolism prophylaxis, 11 (1.7%) had DUAL, and 11 (1.7%) had pharmacologic venous thromboembolism prophylaxis alone. Multivariable analysis showed increased age, and orthopedic procedure was associated with all forms of prophylaxis. Orthopedic procedures were associated with higher utilization of dual prophylaxis use (odds ratio, 5.2; 95% CI, 1.2-21.8), pharmacologic venous thromboembolism prophylaxis (odds ratio, 8.5; 95% CI, 2.3-31.7), and mechanical venous thromboembolism prophylaxis (odds ratio, 2.2; 95% CI, 1.1-4.2) alone. Brain/spinal cord procedures (odds ratio, 3.7; 95% CI, 1.9-7.3) and abdominal procedures (odds ratio, 6.6; 95% CI, 2.5-17.1) were associated with mechanical venous thromboembolism prophylaxis. Head injury was associated with a decreased use of any prophylaxis (odds ratio, 0.5; 95% CI, 0.3-0.9). Patient comorbidities were associated with decreased use of mechanical venous thromboembolism prophylaxis (odds ratio, 0.5; 95% CI, 0.3-1.0).

Conclusions: Pharmacologic venous thromboembolism prophylaxis is not common in critically ill children after trauma. Patient age, orthopedic and vascular procedures, and higher injury severity are associated with pharmacologic venous thromboembolism prophylaxis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/PCC.0000000000001614DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6123256PMC
September 2018

Central Venous Catheter-associated Venous Thromboembolism in Children With Hematologic Malignancy.

J Pediatr Hematol Oncol 2018 11;40(8):e519-e524

Department of Pediatrics, Medical College of Wisconsin.

In pediatric oncology, the diagnosis of a hematologic malignancy and presence of a central venous catheter (CVC) have been identified as significant risk factors for the development of a venous thromboembolism (VTE). There remain little data regarding CVC factors associated with CVC-related VTE. Using the VTE and oncology database in a quaternary care center, a retrospective cohort study was conducted in children below 18 years old with hematologic cancer from November 5, 2012 to April 4, 2016. Patient, CVC factors, and VTE occurrence were analyzed to identify significant patient and CVC factors associated with the development of clinically identified CVC-related VTE. Utilizing the χ, Mann-Whitney, and the Fisher exact tests, patient factors were compared across VTE yes/no groups. Of the 198 study patients, 22 VTE cases were identified. Eighteen VTE events were CVC-associated, occurring in 9% of study population. Peripherally inserted central catheter lines and older ages were associated with VTE. The use of tissue-plasminogen activator for CVC occlusion was associated with decreased VTE rates, suggesting a protective potential.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/MPH.0000000000001229DOI Listing
November 2018

Evaluation of guidelines for injured children at high risk for venous thromboembolism: A prospective observational study.

J Trauma Acute Care Surg 2017 05;82(5):836-844

From the Department of Surgery (R.M.L.), Division of Pediatric Surgery (K.B., D.M.G.), and the Department of Pediatrics (S.J.H., R.C.P.), Division of Critical Care and Division of Hematology/Oncology, The Children's Hospital of Wisconsin; and Institute for Health and Equity (L.D.C.), Medical College of Wisconsin, Milwaukee, Wisconsin.

Background: Pharmacologic prophylaxis for venous thromboembolism (VTE) is a widely accepted practice in adult trauma patients to prevent associated morbidity and mortality. However, VTE prophylaxis has not been standardized in injured pediatric patients. Our institution identified factors potentially associated with a high risk of VTE in critically injured children that led to prospective implementation of VTE prophylaxis guidelines. We hypothesize that the guidelines are accurate in predicting children at risk for VTE.

Methods: Data were prospectively collected on injured children from August 2010 to August 2015. Pharmacologic prophylaxis was indicated for patients identified by the guidelines as high risk for VTE. Prophylaxis was deferred and a screening ultrasound was performed if the high-risk VTE patients were also at high risk for bleeding. To assess the accuracy of predicting confirmed cases of VTE, stepwise logistic regression analysis was used to measure the association of individual risk factors with VTE controlling for age (≥13 years). A receiver operating characteristic curve measured the accuracy of the final model to predict a VTE.

Results: Of 4,061 trauma patients, 588 were admitted to the ICU, with the guidelines identifying 199 as high risk for VTE. VTE occurred in 3.9% (23/588) of the ICU population and 10% (20/199) of the high risk group. The median age of VTE patients in the ICU was 9.7 years. Statistically significant predictors (p < 0.05) of VTE in the multivariate model included presence of a central venous catheter (OR = 5.2), inotropes (OR = 7.7), immobilization (OR = 5.5), and a Glasgow Coma Scale of <9 (OR = 1.3). The area under receiver operating characteristic curve of this model was 0.92, demonstrating its excellent predictive ability.

Conclusion: Specific clinical factors in critically injured children are associated with a high risk for VTE. Incorporating these risk factors in VTE prophylaxis guidelines facilitates more accurate risk stratification and may allow for improved VTE prevention in pediatric trauma.

Level Of Evidence: Prognostic study, level II.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/TA.0000000000001404DOI Listing
May 2017

Venous Thromboembolism in Critical Illness and Trauma: Pediatric Perspectives.

Front Pediatr 2017 13;5:47. Epub 2017 Mar 13.

Medical College of Wisconsin, Children's Hospital of Wisconsin , Milwaukee, WI , USA.

Critically ill children and those sustaining severe traumatic injuries are at higher risk for developing venous thromboembolism (VTE) than other hospitalized children. Multiple factors including the need for central venous catheters, immobility, surgical procedures, malignancy, and dysregulated inflammatory state confer this increased risk. As well as being at higher risk of VTE, this population is frequently at an increased risk of bleeding, making the decision of prophylactic anticoagulation even more nuanced. The use of pharmacologic and mechanical prophylaxis remains variable in this high-risk cohort. VTE pharmacologic prophylaxis is an accepted practice in adult trauma and intensive care to prevent VTE development and associated morbidity, but it is not standardized in critically ill or injured children. Given the lack of pediatric specific guidelines, prevention strategies are variably extrapolated from the successful use of mechanical and pharmacologic prophylaxis in adults, despite the differences in developmental hemostasis and thrombosis risk between children and adults. Whether the burden of VTE can be reduced in the pediatric critically ill or injured population is not known given the lack of robust data. There are no trials in children showing efficacy of mechanical compression devices or prophylactic anticoagulation in reducing the rate of VTE. Risk stratification using clinical factors has been shown to identify those at highest risk for VTE and allows targeted prophylaxis. It remains unproven if such a strategy will mitigate the risk of VTE and its potential sequelae.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3389/fped.2017.00047DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5346591PMC
March 2017

Low near infrared spectroscopic somatic oxygen saturation at admission is associated with need for lifesaving interventions among unplanned admissions to the pediatric intensive care unit.

J Clin Monit Comput 2018 Feb 3;32(1):89-96. Epub 2017 Mar 3.

Section of Critical Care, Children's Hospital of Wisconsin, 9000 W Wisconsin Ave, Milwaukee, WI, 53226-4874, USA.

To investigate the association between low near infrared spectroscopy (NIRS) somatic oxygen saturation (<70%) at admission and the need for lifesaving interventions (LSI) in the initial 24 h of a PICU admission. Retrospective chart review of all unplanned admissions to the pediatric intensive care unit (PICU) with NIRS somatic oxygen saturation data available within 4 h of admission, excluding admissions with a cardiac diagnosis. LSI data were collected for the first 24 h after admission. Hemodynamic parameters, laboratory values, illness severity scores and diagnoses were collected. Included PICU admissions were stratified by lowest NIRS value in the first 4 h after admission: low NIRS (<70%) and normal NIRS (≥70%) groups. Rate of LSI from 4 h to 24 h was compared between the two groups. Association of LSI with NIRS saturation and other clinical and laboratory parameters was measured by univariate and multivariate methods. We reviewed 411 consecutive unplanned admissions to the PICU of which 184 (44%) patients underwent NIRS monitoring. A higher proportion of patients who underwent somatic NIRS monitoring required LSIs compared to those without NIRS monitoring (36.4 vs 5.7% respectively, p < 0.0001). The proportion of patients who required LSI was higher in the group with low NIRS (<70%) within the first 4 h compared to those with normal NIRS (≥70%) (77.1 vs 22.1%, p < 0.0001). Fluid resuscitation, blood products and vasoactive medications were the most common LSIs. Multivariable modeling showed NIRS < 70% and heart rate > 2SD for age to be associated with LSIs. ROC curve analysis of the combination of NIRS < 70% and HR >2SD for age had an area under the curve of 0.79 with 78% sensitivity and 76% specificity for association with LSI. Compared to the normal NIRS group, the low NIRS group had higher mortality (10.4 vs 0.7%, p = 0.005) and longer median hospital length of stay (2.9 vs 1.6 days, p < 0.0001). Low somatic NIRS oxygen saturation (<70%) in the first 4 h of an unplanned PICU admission is associated with need for higher number of subsequent lifesaving interventions up to 24 h after admission. Noninvasive, continuous, somatic NIRS monitoring may identify children at high risk of medical instability.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s10877-017-0007-1DOI Listing
February 2018

Prophylaxis against venous thromboembolism in pediatric trauma: A practice management guideline from the Eastern Association for the Surgery of Trauma and the Pediatric Trauma Society.

J Trauma Acute Care Surg 2017 03;82(3):627-636

Division of Hematology, Department of Pediatrics, University of California Irvine School of Medicine, Orange, California (A.M.); Division of Pediatric Surgery, Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina (J.K.P.); Division of Critical Care, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin (S.J.H.); Department of Pharmacy Services, Medical University of South Carolina, Charleston, South Carolina (A.J.T.); Division of Hematology and Oncology, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio (S.H.O.); Division of Pediatric Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina (C.J.S.); Division of Critical Care, Department of Pediatrics Emory School of Medicine, Atlanta, Georgia (T.M.P.); and Section of Pediatric Critical Care, Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut (E.V.S.F.).

Background: Despite the increasing incidence of venous thromboembolism (VTE) in hospitalized children, the risks and benefits of VTE prophylaxis, particularly for those hospitalized after trauma, are unclear. The Pediatric Trauma Society and the Eastern Association for the Surgery of Trauma convened a writing group to develop a practice management guideline on VTE prophylaxis for this cohort of children using the Grading of Recommendations Assessment, Development, and Evaluation framework.

Methods: A systematic review of MEDLINE using PubMed from January 1946 to July 2015 was performed. The search retrieved English-language articles on VTE prophylaxis in children 0 to 21 years old with trauma. Topics of investigation included pharmacologic and mechanical VTE prophylaxis, active radiologic surveillance for VTE, and risk factors for VTE.

Results: Forty-eight articles were identified and 14 were included in the development of the guideline. The quality of evidence was low to very low because of the observational study design and risks of bias.

Conclusions: In children hospitalized after trauma who are at low risk of bleeding, we conditionally recommend pharmacologic prophylaxis be considered for children older than 15 years old and in younger postpubertal children with Injury Severity Score (ISS) greater than 25. For prepubertal children, even with ISS greater than 25, we conditionally recommend against routine pharmacologic prophylaxis. Second, in children hospitalized after trauma, we conditionally recommend mechanical prophylaxis be considered for children older than 15 years and in younger postpubertal children with ISS greater than 25 versus no prophylaxis or in addition to pharmacologic prophylaxis. Lastly, in children hospitalized after trauma, we conditionally recommend against active surveillance for VTE with ultrasound compared with routine daily physical examination alone for earlier detection of VTE. The limited pediatric data and paucity of high-quality evidence preclude providing more definitive recommendations and highlight the need for clinical trials of prophylaxis.

Level Of Evidence: Systematic review/meta-analysis, level III.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/TA.0000000000001359DOI Listing
March 2017

Screening Guidelines for Venous Thromboembolism Risk in Hospitalized Children Have Low Sensitivity for Central Venous Catheter-Associated Thrombosis.

Hosp Pediatr 2017 01 13;7(1):39-45. Epub 2016 Dec 13.

Critical Care, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin;

Objectives: Local pediatric screening guidelines for venous thromboembolism (VTE) are developed from incomplete pediatric data and extrapolated from adult data in which immobility is a major risk factor. We hypothesized that screening guidelines centered on immobility are inadequate for identifying children at risk of central venous catheter (CVC)-associated VTE.

Methods: This retrospective case-control (4:1) study at an academic, quaternary-level, free-standing children's hospital applied screening guidelines for VTE risk to all cases of VTE from July 2012 to April 2014. Cases and controls were classified as "at risk" or "not at risk" of VTE by guideline criteria. These guidelines assessed VTE risk factors, including CVC, as reported in the pediatric literature.

Results: VTE prevalence was 0.5 per 100 admissions. Sixty-nine of 114 patients with radiographically confirmed VTE were classified as being "at risk" by the guidelines, with a sensitivity of 61%, specificity of 90.8%, a positive predictive value of 2.4%, and negative predictive value of 99.8%. There was no difference in screening guidelines sensitivity for identifying CVC-associated VTE versus non-CVC-associated VTE. Half of the 45 patients with VTE who were not captured as being "at risk" did not have decreased mobility, the entry point to the algorithm, and 80% of these patients had a CVC.

Conclusions: Screening guidelines have low sensitivity for identifying hospitalized children at increased risk of both CVC-associated and other VTE events. Decreased mobility is not a requirement for CVC-associated VTE. Risk factors extrapolated from adult data are insufficient for identifying children at risk of VTE.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1542/hpeds.2016-0078DOI Listing
January 2017

Factors Associated With Continuous Low-Dose Heparin Infusion for Central Venous Catheter Patency in Critically Ill Children Worldwide.

Pediatr Crit Care Med 2016 08;17(8):e352-61

1Medical College of Wisconsin, Milwaukee, WI. 2Department of Pediatrics, Medical College of Wisconsin, WI. 3Critical Care Division, Children's Hospital of Wisconsin, Milwaukee, WI. 4Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI. 5Department of Pediatrics, Yale School of Medicine, New Haven, CT.

Objectives: To identify patient, hospital, and central venous catheter factors that may influence the use of low-dose heparin infusion for central venous catheter patency in critically ill children.

Design: Secondary analysis of an international multicenter observational study.

Setting: Fifty-nine PICUs over four study dates in 2012, involving seven countries.

Patients: Children less than 18 years old with a central venous catheter who were admitted to a participating unit and enrolled in the completed Prophylaxis against Thrombosis Practice study were included. All overflow patients were excluded.

Interventions: None.

Measurements And Main Results: Of the 2,484 patients in the Prophylaxis against Thrombosis Practice study, 1,312 patients had a central venous catheter. Five hundred seven of those patients used low-dose heparin infusion. The frequency of low-dose heparin infusion was compared across various patient, hospital, and central venous catheter factors using chi-square, Mann-Whitney U, and Fisher exact tests. In the multivariate analysis, age was not a significant factor for low-dose heparin infusion use. Patients with pulmonary hypertension had decreased low-dose heparin infusion use, whereas those with active surgical or trauma diagnoses had increased low-dose heparin infusion use. All centrally inserted central venous catheters were more likely to use low-dose heparin infusion when compared with peripherally inserted central venous catheters. The Asia-Pacific region showed increased low-dose heparin infusion use, along with community hospitals and smaller ICUs (< 10 beds).

Conclusions: Patient, central venous catheter, and hospital factors are associated with the use of low-dose heparin infusion in critically ill children. Further study is needed to evaluate the efficacy and persistence of low-dose heparin infusion use.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/PCC.0000000000000854DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4980163PMC
August 2016

The Effects of Pediatric Advanced Life Support Guidelines on Pediatric Trauma Airway Management.

Pediatr Emerg Care 2016 Aug;32(8):499-503

From the *Division of Critical Care, Department of Pediatrics, and †Division of Quantitative Health Sciences Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, WI.

Objective: Recent Pediatric Advanced Life Support (PALS) guidelines have deemphasized the use of advanced airways in short transport. It is unclear if guideline recommendations have altered practice. We sought to determine if a temporal change exists in the number of prehospital pediatric trauma intubations since the 2005 PALS guidelines update.

Methods: This is an institutional review board-approved, retrospective, single-center study. Reviewed all pediatric trauma activations where patients younger than 19 years were intubated at the scene, en route or at the level 1 trauma center during 2006 to 2011. Specific complications collected were esophageal intubations, mainstem intubations and need for re-intubations.

Results: There were 1012 trauma activations, 1009 pediatric patients, 300 (29.7%) intubated during transport to Children's Hospital of Wisconsin Pediatric Trauma Center (PTC) or upon arrival. Mean age of 9.5 ± 5.9 years. Fifty-seven percent (n = 172) were intubated before PTC, 31.7% (n = 95) field intubations, 25.7% (n = 77) outside facility intubations. 44% (n = 132) at PTC. Age was not a significant variable. There was no difference in the proportion of injured children requiring intubation who were intubated before arrival to the PTC. Those intubated in the field versus a facility had significantly increased mortality (P = 0.0002), longer hospital days (P = 0.0004) including intensive care unit days (P = 0.0003) and ventilator days (P = 0.0003) even when adjusted for illness severity.

Conclusions: There was no significant change in the proportion of pretrauma room intubations following the 2005 PALS guidelines even when adjusted for illness or injury severity. Children injured farther from the PTC and more severely injured children were more likely to be intubated before arrival at the PTC.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/PEC.0000000000000759DOI Listing
August 2016

Recommendations for venous thromboembolism prophylaxis in pediatric trauma patients: A national, multidisciplinary consensus study.

J Trauma Acute Care Surg 2016 May;80(5):695-701

From the Division of Critical Care (S.J.H.), Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Critical Care (E.V.S.F.), Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut; Division of Hematology and Oncology (A.M.), Department of Pediatrics, University of California Irvine School of Medicine, Orange, California; Division of Hematology and Oncology (S.H.O.), Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio; Division of Pediatric Surgery (C.J.S.), Department of Surgery, and Department of Pharmacy Services (A.J.T.), Medical University of South Carolina, Charleston, South Carolina; Division of Critical Care (T.M.P.), Department of Pediatrics, Emory School of Medicine, Atlanta, Georgia; and Division of Pediatric Surgery (J.K.P.), Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/TA.0000000000000962DOI Listing
May 2016

Multicenter Analysis of the Factors Associated With Unplanned Extubation in the PICU.

Pediatr Crit Care Med 2015 Sep;16(7):e217-23

1Pediatric Critical Care, Helen De Vos Children's Hospital, Grand Rapids, MI. 2Grand Rapids Medical Education Partners, Milwaukee, WI. 3Critical Care Section, Medical College of Wisconsin, Pediatrics and Children's Hospital of Wisconsin, Milwaukee, WI.

Objective: To identify factors associated with unplanned extubation in PICUs.

Design: A prospective, case-controlled multicenter study.

Setting: Eleven Pediatric Intensive Care Units collaborating through the National Association of Children's Hospitals and Related Institutions PICU focus group.

Patients: Patients with unplanned extubation events and control patients without unplanned extubation.

Interventions: Unplanned extubation events were prospectively tracked for 1 year at 11 centers. When an unplanned extubation occurred, up to four controls were randomly identified of other intubated patients in the unit. For each event and control, data associated with unplanned extubation events, reintubation, and outcomes were collected.

Measurements And Main Results: One hundred eighty-nine unplanned extubation events occurred out of 25,500 endotracheal tube days in the study (0.74 unplanned extubations/100 endotracheal days; 95% CI, 0.64-0.85), with 654 associated controls. Unplanned extubation rates ranged by site from 0.3 to 2.1 unplanned extubations/100 endotracheal days. Children less than 6 years had an increased rate of unplanned extubation (0.83 for < 6 yr vs 0.45 for ≥ 6 yr; p = 0.001). After multivariate analysis, inadequate patient sedation (odds ratio, 9.1; 95% CI, 4.5-18.5), loose or slimy endotracheal tube (odds ratio, 10.4; 95% CI, 5.0-22.2), a planned extubation in the next 12 hours (odds ratio, 2.3; 95% CI, 1.3-4.1), and a nurse pulled from another unit (odds ratio, 3.8; 95% CI, 1.4-9.9) were associated with unplanned extubation. Sixty percent of unplanned extubations required reintubation.

Conclusions: The rate of unplanned extubation is higher in patients aged less than 6 years. Patient factors, such as decreased level of sedation, loose or slimy endotracheal tube, and staffing factors such as floating nurse from another unit, contribute to unplanned extubation in children.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/PCC.0000000000000496DOI Listing
September 2015

Intrapleural alteplase decreases parapneumonic effusion volume in children more than saline irrigation.

Pediatr Pulmonol 2015 Dec 2;50(12):1328-35. Epub 2015 Apr 2.

Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, Wisconsin.

Objective: In this prospective, double-blind, randomized crossover trial, we determined the effect of intrapleural fibrinolysis with alteplase compared to that of normal saline irrigation on the thoracostomy tube output and pleural effusion volume in children with complicated parapneumonic effusion.

Methods: Twenty seven children, median age 3.5 years, referred to the interventional radiology service for thoracostomy tube drainage of a parapneumonic effusion were studied. Seventeen patients with pleural fluid thickness greater than 2 cm or >20% ipsilateral chest volume after 8 hr of thoracostomy tube drainage entered the treatment arm. They were randomized to receive alteplase 0.1 mg/kg twice a day on days 1 and 3, or on days 2 and 4, with normal saline irrigation on the alternate days. Daily pleural fluid volume measured by low dose chest computed tomography (CT) and thoracostomy tube output was compared between the saline and alteplase groups.

Results: Compared to normal saline irrigation, alteplase irrigation resulted in increased thoracostomy tube drainage and to a greater decline in pleural fluid volume. Earlier alteplase administration resulted in increased fluid mobilization compared to administration later in the hospital course. There were no bleeding complications.

Conclusions: Intrapleural fibrinolysis with alteplase safely increases pleural drainage and decreases the volume of pleural inflammatory debris compared to intrapleural administration of normal saline. The benefit of intrapleural alteplase on decreasing the volume of pleural inflammatory debris occurs for up to 72 hr with repeated twice daily dosing.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/ppul.23184DOI Listing
December 2015