Publications by authors named "Susan M Goobie"

48 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.
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http://dx.doi.org/10.1097/CCM.0000000000005075DOI Listing
May 2021

Preoperative Anemia Screening and Treatment: Is It Worth the Return on Investment?

Anesth Analg 2021 02;132(2):341-343

Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.

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http://dx.doi.org/10.1213/ANE.0000000000005313DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8054223PMC
February 2021

A systematic review of outcomes reported inpediatric perioperative research: A report from the Pediatric Perioperative Outcomes Group.

Paediatr Anaesth 2020 Jul 30. Epub 2020 Jul 30.

Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA.

The Pediatric Perioperative Outcomes Group (PPOG) is an international collaborative of clinical investigators and clinicians within the subspecialty of pediatric anesthesiology and perioperative care which aims to use COMET (Core Outcomes Measures in Effectiveness Trials) methodology to develop core outcome setsfor infants, children and young people that are tailored to the priorities of the pediatric surgical population.Focusing on four age-dependent patient subpopulations determined a priori for core outcome set development: i) neonates and former preterm infants (up to 60 weeks postmenstrual age); ii) infants (>60 weeks postmenstrual age - <1 year); iii) toddlers and school age children (>1-<13 years); and iv) adolescents (>13-<18 years), we conducted a systematic review of outcomes reported in perioperative studies that include participants within age-dependent pediatric subpopulations. Our review of pediatric perioperative controlled trials published from 2008 to 2018 identified 724 articles reporting 3192 outcome measures. The proportion of published trials and the most frequently reported outcomes varied across pre-determined age groups. Outcomes related to patient comfort, particularly pain and analgesic requirement, were the most frequent domain for infants, children and adolescents. Clinical indicators, particularly cardiorespiratory or medication-related adverse events, were the most common outcomes for neonates and infants < 60 weeks and were the second most frequent domain at all other ages. Neonates and infants <60 weeks of age were significantly under-represented in perioperative trials. Patient-centered outcomes, heath care utilization, and bleeding/transfusion related outcomes were less often reported. In most studies, outcomes were measured in the immediate perioperative period, with the duration often restricted to the post-anesthesia care unit or the first 24 postoperative hours. The outcomes identified with this systematic review will be combined with patient centered outcomes identified through a subsequent stakeholder engagement study to arrive at a core outcome set for each age-specific group.
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http://dx.doi.org/10.1111/pan.13981DOI Listing
July 2020

Enhanced recovery: The evolution of pediatric spinal fusion care.

Paediatr Anaesth 2020 10;30(10):1066-1067

Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.

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http://dx.doi.org/10.1111/pan.13976DOI Listing
October 2020

One Size Does Not Fit All in Treating Massive Hemorrhage.

Anesth Analg 2020 08;131(2):480-482

Department of Anesthesiology and Critical Care Medicine, Englewood Hospital and Medical Center, Englewood, New Jersey.

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http://dx.doi.org/10.1213/ANE.0000000000004690DOI Listing
August 2020

High-dose versus low-dose tranexamic acid for paediatric craniosynostosis surgery: a double-blind randomised controlled non-inferiority trial.

Br J Anaesth 2020 09 30;125(3):336-345. Epub 2020 Jun 30.

Department of Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy.

Background: Tranexamic acid (TXA) reduces blood loss and transfusion in paediatric craniosynostosis surgery. The hypothesis is that low-dose TXA, determined by pharmacokinetic modelling, is non-inferior to high-dose TXA in decreasing blood loss and transfusion in children.

Methods: Children undergoing craniosynostosis surgery were enrolled in a two-centre, prospective, double-blind, randomised, non-inferiority controlled trial to receive high TXA (50 mg kg followed by 5 mg kg h) or low TXA (10 mg kg followed by 5 mg kg h). Primary outcome was blood loss. Low dose was determined to be non-inferior to high dose if the 95% confidence interval (CI) for the mean difference in blood loss was above the non-inferiority margin of -20 ml kg. Secondary outcomes were transfusion, TXA plasma concentrations, and biological markers of fibrinolysis and inflammation.

Results: Sixty-eight children were included. Values were non-inferior regarding blood loss (39.4 [4.4] vs 40.3 [6.2] ml kg [difference=0.9; 95% CI: -14.2, 15.9]) and blood transfusion (21.3 [1.6] vs 23.6 [1.5] ml kg [difference=2.3; 95% CI: -2.1, 6.7]) between high-dose (n=32) and low-dose (n=34) groups, respectively. The TXA plasma concentrations during surgery averaged 50.2 (8.0) and 29.6 (7.6) μg ml. There was no difference in fibrinolytic and inflammatory biological marker concentrations. No adverse events were observed.

Conclusions: Tranexamic acid 10 mg kg followed by 5 mg kg h is not less effective than a higher dose of 50 mg kg and 5 mg kg h in reducing blood loss and transfusion in paediatric craniosynostosis surgery.

Clinical Trial Registration: NCT02188576.
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http://dx.doi.org/10.1016/j.bja.2020.05.054DOI Listing
September 2020

Balancing Supply and Demand for Blood during the COVID-19 Pandemic.

Anesthesiology 2020 07;133(1):16-18

From the Department of Pathology (Transfusion Medicine) (E.A.G.) the Department of Anesthesiology/Critical Care Medicine, The Armstrong Institute for Patient Safety and Quality (S.M.F.), The Johns Hopkins Medical Institutions, Baltimore, Maryland the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts (S.M.G.).

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http://dx.doi.org/10.1097/ALN.0000000000003341DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7176270PMC
July 2020

Consensus Guidelines for Perioperative Care in Neonatal Intestinal Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations.

World J Surg 2020 08;44(8):2482-2492

Department of Oncology, Cumming School of Medicine, University of Calgary, 1403 29 Street NW, Calgary, AB, T2N 2T9, Canada.

Background: Enhanced Recovery After Surgery (ERAS) Society guidelines integrate evidence-based practices into multimodal care pathways that have improved outcomes in multiple adult surgical specialties. There are currently no pediatric ERAS Society guidelines. We created an ERAS guideline designed to enhance quality of care in neonatal intestinal resection surgery.

Methods: A multidisciplinary guideline generation group defined the scope, population, and guideline topics. Systematic reviews were supplemented by targeted searching and expert identification to identify 3514 publications that were screened to develop and support recommendations. Final recommendations were determined through consensus and were assessed for evidence quality and recommendation strength. Parental input was attained throughout the process.

Results: Final recommendations ranged from communication strategies to antibiotic use. Topics with poor-quality and conflicting evidence were eliminated. Several recommendations were combined. The quality of supporting evidence was variable. Seventeen final recommendations are included in the proposed guideline.

Discussion: We have developed a comprehensive, evidence-based ERAS guideline for neonates undergoing intestinal resection surgery. This guideline, and its creation process, provides a foundation for future ERAS guideline development and can ultimately lead to improved perioperative care across a variety of pediatric surgical specialties.
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http://dx.doi.org/10.1007/s00268-020-05530-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7326795PMC
August 2020

Essential Role of Patient Blood Management in a Pandemic: A Call for Action.

Anesth Analg 2020 07;131(1):74-85

Department of Obstetrics and Gynecology, Soonchunhyang University Hospital, Seoul, Korea.

The World Health Organization (WHO) has declared coronavirus disease 2019 (COVID-19), the disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a pandemic. Global health care now faces unprecedented challenges with widespread and rapid human-to-human transmission of SARS-CoV-2 and high morbidity and mortality with COVID-19 worldwide. Across the world, medical care is hampered by a critical shortage of not only hand sanitizers, personal protective equipment, ventilators, and hospital beds, but also impediments to the blood supply. Blood donation centers in many areas around the globe have mostly closed. Donors, practicing social distancing, some either with illness or undergoing self-quarantine, are quickly diminishing. Drastic public health initiatives have focused on containment and "flattening the curve" while invaluable resources are being depleted. In some countries, the point has been reached at which the demand for such resources, including donor blood, outstrips the supply. Questions as to the safety of blood persist. Although it does not appear very likely that the virus can be transmitted through allogeneic blood transfusion, this still remains to be fully determined. As options dwindle, we must enact regional and national shortage plans worldwide and more vitally disseminate the knowledge of and immediately implement patient blood management (PBM). PBM is an evidence-based bundle of care to optimize medical and surgical patient outcomes by clinically managing and preserving a patient's own blood. This multinational and diverse group of authors issue this "Call to Action" underscoring "The Essential Role of Patient Blood Management in the Management of Pandemics" and urging all stakeholders and providers to implement the practical and commonsense principles of PBM and its multiprofessional and multimodality approaches.
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http://dx.doi.org/10.1213/ANE.0000000000004844DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7173035PMC
July 2020

Pediatric non-red cell blood product transfusion practices: what's the evidence to guide transfusion of the 'yellow' blood products?

Curr Opin Anaesthesiol 2020 Apr;33(2):259-267

Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Purpose Of Review: Research studies pertaining to the management of pediatric non-red cell blood product transfusion is limited. Clinical practices vary within disciplines and regions. Anesthesiologists need evidence-based guidelines to make appropriate and safe decisions regarding transfusion of the 'yellow' blood products for pediatric patients.

Recent Findings: This review outlines clinical indications for transfusion of fresh frozen plasma, cryoprecipitate, platelets, and fibrinogen concentrate in pediatrics. Recent studies of non-red blood cell transfusions in critical, but stable situations are highlighted. Recommendations to guide transfusion of the 'yellow' blood products in operative and non-operative settings are summarized. Special attention is drawn to guidelines in massive hemorrhage and trauma situations.

Summary: Evidence-based guidelines and expert consensus recommendations exist to guide the transfusion of pediatric non-red blood products and should be followed when transfusing the 'yellow' blood components. As high-quality studies in neonates, infants and children are limited, future research should broaden our knowledge in this direction with the goal to use restrictive strategies to improve patient outcomes.
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http://dx.doi.org/10.1097/ACO.0000000000000838DOI Listing
April 2020

Minimally Invasive Endoscopic Surgery for Infantile Craniosynostosis: A Longitudinal Cohort Study.

J Pediatr 2020 01 1;216:142-149.e2. Epub 2019 Nov 1.

Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA. Electronic address:

Objective: To evaluate patient outcomes of minimally invasive endoscopic strip craniectomy (ESC) for craniosynostosis.

Study Design: This is a retrospective cohort analysis (2004-2018) of 500 consecutive infants with craniosynostosis treated by ESC with orthotic therapy at a single center. Operative outcomes included transfusions, complications, and reoperations as well as head circumference change based on World Health Organization percentiles. Multivariable logistic regression was used to identify risk factors associated with blood transfusion. Paired t tests were used for within-patient comparisons and Fisher exact test to compare syndromic and nonsyndromic subgroups.

Results: ESC was associated with low rates of blood transfusion (6.6%), complications (1.4%), and reoperations (3.0%). Risk factors for transfusion included syndromic craniosynostosis (P = .01) and multiple fused sutures (P = .02). Median surgical time was 47 minutes, and hospital length of stay 1 day. Transfusion and reoperation rates were higher among syndromic patients (both P < .001). Head circumference normalized by 12 months of age relative to World Health Organization criteria in infants with sagittal, coronal, and multisuture craniosynostosis (all P < .001).

Conclusions: ESC is a safe, effective, and durable correction of infantile craniosynostosis. ESC can achieve head growth normalization with low risks of blood transfusion, complications, or reoperation. Early identification of craniosynostosis in the newborn period and prompt referral by pediatricians allows families the option of ESC vs larger and riskier open reconstruction procedures.
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http://dx.doi.org/10.1016/j.jpeds.2019.09.037DOI Listing
January 2020

Dosing clonidine for sedation in intensive care.

Paediatr Anaesth 2019 10;29(10):983-984

Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts.

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http://dx.doi.org/10.1111/pan.13719DOI Listing
October 2019

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

Tranexamic acid and perioperative bleeding in children: what do we still need to know?

Curr Opin Anaesthesiol 2019 Jun;32(3):343-352

Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.

Purpose Of Review: Perioperative bleeding and blood product transfusion are associated with significant morbidity and mortality. Prevention and optimal management of bleeding decreases risk and lowers costs. Tranexamic acid (TXA) is an antifibrinolytic agent that reduces bleeding and transfusion in a broad number of adult and pediatric surgeries, as well as in trauma and obstetrics. This review highlights the current pediatric indications and contraindications of TXA. The efficacy and safety profile, given current and evolving research, will be covered.

Recent Findings: Based on the published evidence, prophylactic or therapeutic TXA administration is a well-tolerated and effective strategy to reduce bleeding, decrease allogeneic blood product transfusion, and improve pediatric patients' outcomes. TXA is now recommended in recent guidelines as an important part of pediatric blood management protocols.

Summary: Based on TXA pharmacokinetics, the authors recommend a dosing regimen of between 10 to 30 mg/kg loading dose followed by 5 to 10 mg/kg/h maintenance infusion rate for pediatric trauma and surgery. Maximal efficacy and minimal side-effects with this dosage regime will have to be determined in larger prospective trials including high-risk groups. Furthermore, future research should focus on determining the ideal TXA plasma therapeutic concentration for maximum efficacy and minimal side-effects.
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http://dx.doi.org/10.1097/ACO.0000000000000728DOI Listing
June 2019

Predictors of transfusion outcomes in pediatric complex cranial vault reconstruction: a multicentre observational study from the Pediatric Craniofacial Collaborative Group.

Can J Anaesth 2019 05 14;66(5):512-526. Epub 2019 Feb 14.

The Children's Hospital of Philadelphia, Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.

Purpose: Pediatric patients undergoing complex cranial vault reconstruction (CCVR) are at risk of significant perioperative blood loss requiring blood product transfusion. Minimizing allogeneic blood product transfusion is an important goal because of the associated risks and cost. The impact of patient and surgical variables on transfusion is unknown in this population. Our primary aim was to examine relationships between demographic and perioperative variables and blood product transfusion outcomes in CCVR.

Methods: The multicentre Pediatric Surgery Perioperative Registry was checked for children undergoing CCVR between June 2012 and September 2016. Univariable and multivariable analyses were performed examining patient, procedure, and blood conservation variables and their relationship to three outcomes: intraoperative red blood cell-containing product (RBC-CP) transfusion, total perioperative blood donor exposures, and transfusion-free hospitalization.

Results: The registry search returned data from 1,814 cases. Age and surgical duration were the only variables significantly associated with all three outcomes studied. Predictors of reduced RBC-CP transfusion included lower American Society of Anesthesiologists (ASA) physical status and antifibrinolytic administration. Total cranial vault reconstruction, intraoperative vasoactive infusion, and presence of a tracheostomy predicted increased donor exposures. Increased body weight, higher preoperative hematocrit, and utilization of intraoperative cell saver and transfusion protocols were associated with transfusion-free hospitalization.

Conclusion: Clinical factors associated with increased allogeneic blood product transfusion in pediatric CCVR include: age ≤ 24 months, ASA status ≥ III, preoperative anemia, prolonged surgical duration, lack of intraoperative antifibrinolytic use, lack of intraoperative cell saver use, and the lack of transfusion protocols.
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http://dx.doi.org/10.1007/s12630-019-01307-wDOI Listing
May 2019

Society for the advancement of blood management administrative and clinical standards for patient blood management programs. 4th edition (pediatric version).

Paediatr Anaesth 2019 Mar;29(3):231-236

Department of Anesthesiology and Critical Care Medicine, Director, TeamHealth Research Institute Englewood Health, Englewood, New Jersey.

Patient Blood Management is the timely application of evidence-based medical and surgical concepts designed to maintain hemoglobin concentration, optimize hemostasis, and minimize blood loss to improve patient outcomes. Conceptually similar to a "bundle" strategy, it is designed to improve clinical care using comprehensive evidence-based treatment strategies to manage patients with potential or ongoing critical bleeding, bleeding diathesis, critical anemia, and/ or a coagulopathy. Patient Blood Management includes multimodal strategies to screen, diagnose and properly treat anemia, coagulopathies and minimize bleeding, using goal-directed therapy and leverages a patient's physiologic ability to adapt to anemia while definitive treatment is undertaken. Allogeneic blood component transfusion is one traditional therapeutic modality out of many for managing blood loss and anemia and, while it may be the best choice in certain situations, other effective and more appropriate options are available and should be used in conjunction or alone. Therefore, comprehensive Patient Blood Management is the new standard of care to prevent and manage anemia and optimize hemostasis and has been recommended by the World Health Organization, the American Society of Anesthesiologists, the European Society of Anaesthesiology and the Australian National Blood Authority. While there is a plethora of expert consensus and good practice guidelines published for blood component transfusion from multiple professional organizations and societies, there remains a need for more comprehensive and broader standards of patient medical management to proactively reduce the risk of exposure to allogeneic transfusions. In 2010, the Society for Advancement of Blood Management published the first comprehensive standards to address the administrative and clinical components of an effective, patient-centered Patient Blood Management program. Recognizing the need to reduce inappropriate transfusions, some professional organizations have placed their emphasis on transfusion guidelines. In contrast, the focus of the Society for Advancement of Blood Management Standard is on the centrality of the patient and the full spectrum of therapeutic strategies needed to improve clinical outcomes in patients at risk for blood loss or anemia, thereby reducing avoidable transfusions as well. The Standards are meant not to replace, but to complement transfusion guidelines by more completely addressing the need for a multi-modal clinical approach with the goal to improve patient outcomes. Compared to adult programs, Pediatric Patient Blood Management programs are currently not commonly accepted as standard of care for pediatric patients. This is partly due to the fact that, until recently, there was a paucity of robust evidence-based literature and expert consensus guidelines on pediatric PBM. Managing pediatric bleeding and blood product transfusion presents a unique set of challenges. The main goal of transfusion is to correct or avoid imminent inadequate oxygen carrying capacity caused by inadequate red blood cell mass. Determining when, what, and how much to transfuse can be difficult. Neonates, infants, children, and adolescents each have specific considerations based on age, weight, physiology, and pharmacology. In this edition of Pediatric Anaesthesia we provide, in abbreviated format, the 4th edition of the Administrative and Clinical Standards for Patient Blood Management; Pediatric Version, first published in 2010 with the addition of a new Pediatric section in 2016. These Standards provide guidance for implementing a comprehensive Pediatric Patient Blood Management program at both pediatric and adult medical institutions. While every hospital may not be equipped to have a dedicated Pediatric Patient Blood Management program, this document highlights important universal clinical strategies that can be implemented to optimize pediatric bleeding management and minimize allogeneic blood product exposure through the use of multi-modal therapeutic strategies that have their central emphasis on the patient rather than the transfusion. Important strategies include: treatment of preoperative anemia, standardized transfusion algorithms, the use of restrictive transfusion thresholds, goal-directed therapy based on point of care and viscoelastic testing, antifibrinolytics, and avoidance of hemodilution and hypothermia as supported by evidence. For the full version, please go to https://www.sabm.org/publications.
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http://dx.doi.org/10.1111/pan.13574DOI Listing
March 2019

Tranexamic Acid Is Efficacious at Decreasing the Rate of Blood Loss in Adolescent Scoliosis Surgery: A Randomized Placebo-Controlled Trial.

J Bone Joint Surg Am 2018 Dec;100(23):2024-2032

Department of Anesthesiology, Critical Care, and Pain Medicine (S.M.G., D.Z., M.E.M., R.M.B., and N.F.S.) and Department of Orthopaedic Surgery (M.P.G., D.H., L.I.K., J.B.E., and M.T.H.), Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts.

Background: Tranexamic acid (TXA) is an antifibrinolytic drug that reduces surgical blood loss. Evidence supporting its efficacy in surgery for adolescent idiopathic scoliosis is not robust. This trial was designed to validate the clinical efficacy of TXA in surgery for adolescent idiopathic scoliosis.

Methods: This institutional review board-approved prospective double-blinded trial involved 111 patients with adolescent idiopathic scoliosis who were randomized to receive either a placebo or TXA (50-mg/kg loading dose and 10-mg/kg/h infusion). Power analysis indicated that 50 patients per group would provide power to detect a >20% difference in blood loss. Two-way analysis of variance (ANOVA) was applied to compare blood loss rates (slopes) using the group-by-time interaction F test.

Results: The risk of clinically relevant blood loss (>20 mL/kg) was more than twice as high in the placebo group than in the TXA group (44% versus 21%, relative risk = 2.1, 95% confidence interval = 1.2 to 3.7). Compared with the placebo group, the TXA group had a 27% reduction in intraoperative blood loss, a significantly lower rate of intraoperative bleeding per hour (mean and standard deviation, 190 ± 73 versus 230 ± 80 mL, p = 0.01; F = 9.77, p < 0.001) and per fused spinal level (82 ± 32 versus 110 ± 40 mL, p < 0.001), less intraoperative blood loss (836 ± 373 versus 1,031 ± 484 mL, p = 0.02), and less postoperative bleeding (in the drain) (498 ± 228 versus 645 ± 318 mL, p = 0.009). Six patients who received a placebo and no patient who received TXA required an allogenic blood transfusion. No perioperative adverse events, including thromboembolic events or seizures, were observed. Three independent factors were predictive of blood loss: TXA administration, duration of surgery, and number of levels fused. Greater intraoperative blood loss was the only independent variable predictive of a longer hospital stay.

Conclusions: Use of TXA in patients undergoing surgery for adolescent idiopathic scoliosis significantly reduced blood loss, by 27%, compared with that in the placebo group. The rate of intraoperative blood loss per hour and per level fused and the amount of postoperative blood loss were significantly lower in the TXA group. More placebo-treated patients received allogenic blood. Patients with greater intraoperative blood loss spent a longer time in the hospital.

Level Of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.18.00314DOI Listing
December 2018

Improving venous thromboembolism management in children undergoing surgery.

Paediatr Anaesth 2018 05;28(5):378-379

Department of Anesthesia, Harvard Medical School, Boston, MA, USA.

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http://dx.doi.org/10.1111/pan.13349DOI Listing
May 2018

High-dose Versus Low-dose Tranexamic Acid to Reduce Transfusion Requirements in Pediatric Scoliosis Surgery.

J Pediatr Orthop 2017 Dec;37(8):e552-e557

*Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions§Department of Orthopedic Surgery, Johns Hopkins University, Baltimore, MD†Department of Orthopedic Surgery, Hospital of Special Surgery, New York, NY‡Department of Anesthesiology, Boston Children's Hospital, Boston, MA.

Background: Our objective was to quantify blood loss and transfusion requirements for high-dose and low-dose tranexamic acid (TXA) dosing regimens in pediatric patients undergoing spinal fusion for correction of idiopathic scoliosis. Previous investigators have established the efficacy of TXA in pediatric scoliosis surgery; however, the dosing regimens vary widely and the optimal dose has not been established.

Methods: We retrospectively analyzed electronic medical records for 116 patients who underwent spinal fusion surgery for idiopathic scoliosis by a single surgeon and were treated with TXA. In total, 72 patients received a 10 mg/kg loading dose with a 1 mg/kg/h maintenance dose (low-dose) and 44 patients received 50 mg/kg loading dose with a 5 mg/kg/h maintenance dose (high-dose). Estimated blood loss and transfusion requirements were compared between dosing groups.

Results: Patient characteristics were nearly identical between the 2 groups. Compared with the low-dose TXA group, the high-dose TXA group had decreased estimated blood loss (695 vs. 968 mL, P=0.01), and a decrease in both intraoperative (0.3 vs. 0.9 units, P=0.01) and whole hospitalization (0.4 vs. 1.0 units, P=0.04) red blood cell transfusion requirements. The higher-dose TXA was associated with decreased intraoperative (P=0.01), and whole hospital transfusion (P=0.01) requirements, even after risk-adjustment for potential confounding variables.

Conclusions: High-dose TXA is more effective than low-dose TXA in reducing blood loss and transfusion requirements in pediatric idiopathic scoliosis patients undergoing surgery.

Level Of Evidence: Level-III, retrospective cohort study.
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http://dx.doi.org/10.1097/BPO.0000000000000820DOI Listing
December 2017

Ceftaroline pharmacokinetics and pharmacodynamics in patients with cystic fibrosis.

J Cyst Fibros 2018 05 2;17(3):e25-e31. Epub 2017 Nov 2.

Pharmacometrics Core, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA, United States.

Background: Methicillin-resistant Staphylococcus aureus (MRSA) is a prevalent pathogen in patients with cystic fibrosis (CF) associated with increased morbidity. Ceftaroline fosamil is an intravenous (IV) cephalosporin with activity against MRSA. There are minimal data regarding dosing in the CF population. The objective of this study was to determine the pharmacokinetic and pharmacodynamic profile of IV ceftaroline in patients with CF.

Methods: We conducted a single-center prospective study of children and young adults with CF receiving ceftaroline (15mg/kg IV up to 600mg every 8h) as part of treatment for a CF pulmonary exacerbation between June 2016 and April 2017. Seven patients were enrolled for a total of 10 treatment courses. For each treatment course, up to 8 plasma samples were assayed for ceftaroline using ultra-high performance liquid chromatography with mass spectrometry. Maximum plasma concentration, systemic clearance, and elimination half-life were calculated. The area under the curve (AUC) above the minimum inhibitory concentration (MIC) and the percent time above the MIC (%fT>MIC) were determined for each subject using MICs of 0.5, 1, and 2μg/mL and the measured MIC if available.

Results: The mean (SD) age for the 7 patients was 20.3 (8.0) years. Mean (SD) maximum plasma concentration of ceftaroline was 22.7 (9.6) μg/mL, systemic clearance 7.9 (3.3) L/h, and half-life 1.1 (0.4) hours. Using a MIC of 1 μg/mL, accepted as the MIC 90 of MRSA isolates, AUC above MIC mean (SD) was 53.6 (19.5) μg·h/mL, mean (SD) %fT>MIC was 75.7 (10.4), and all subjects had >60%fT>MIC.

Conclusions: In this cohort of CF patients, mean ceftaroline half-life was 1.1h, which is notably lower than the general population. The dosing regimen studied, which exceeds the recommended dosing in the non-CF population, was adequate to achieve >60% time above the MIC in all patients.
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http://dx.doi.org/10.1016/j.jcf.2017.10.010DOI Listing
May 2018

Patient Blood Management in Pediatric Cardiac Surgery: A Review.

Anesth Analg 2018 10;127(4):1002-1016

Division of Pediatric Critical Care, Children's Hospital of Illinois At OSF St Frances, University of Illinois at Peoria, Peoria, Illinois.

Efforts to reduce blood product transfusions and adopt blood conservation strategies for infants and children undergoing cardiac surgical procedures are ongoing. Children typically receive red blood cell and coagulant blood products perioperatively for many reasons, including developmental alterations of their hemostatic system, and hemodilution and hypothermia with cardiopulmonary bypass that incites inflammation and coagulopathy and requires systemic anticoagulation. The complexity of their surgical procedures, complex cardiopulmonary interactions, and risk for inadequate oxygen delivery and postoperative bleeding further contribute to blood product utilization in this vulnerable population. Despite these challenges, safe conservative blood management practices spanning the pre-, intra-, and postoperative periods are being developed and are associated with reduced blood product transfusions. This review summarizes the available evidence regarding anemia management and blood transfusion practices in the perioperative care of these critically ill children. The evidence suggests that adoption of a comprehensive blood management approach decreases blood transfusions, but the impact on clinical outcomes is less well studied and represents an area that deserves further investigation.
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http://dx.doi.org/10.1213/ANE.0000000000002504DOI Listing
October 2018

Tranexamic Acid: What Is Known and Unknown, and Where Do We Go From Here?

Anesthesiology 2017 09;127(3):405-407

From the Department of Anesthesiology, Perioperative and Pain Medicine, Pharmacokinetics Laboratory, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts (S.M.G.); and Department of Anesthesiology/Critical Care Medicine, Johns Hopkins Health System Blood Management Program, The Johns Hopkins Medical Institutions, Baltimore, Maryland (S.M.F.).

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http://dx.doi.org/10.1097/ALN.0000000000001788DOI Listing
September 2017

Incidence and predictors of massive bleeding in children undergoing liver transplantation: A single-center retrospective analysis.

Paediatr Anaesth 2017 Jul 30;27(7):718-725. Epub 2017 May 30.

Department of Anesthesiology, Critical Care, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.

Background: Liver transplantation represents a major surgery involving a highly vascular organ. Reports defining the scope of bleeding in pediatric liver transplants are few.

Aims: We conducted a retrospective analysis of liver transplants performed at our pediatric tertiary care center to quantify blood loss, blood product utilization, and to determine predictors for massive intraoperative bleeding.

Methods: Pediatric patients who underwent isolated liver transplantation at Boston Children's Hospital between 2011 and 2016 were included. The amount of blood product transfused in the perioperative period and the incidence of postoperative complications were reported. Univariable and multivariable logistic regressions were used to determine predictors for massive bleeding, defined as estimated blood loss exceeding one circulating blood volume within 24 hours.

Results: Sixty-eight children underwent liver transplantation during the study period and were included in the analysis. Multivariable logistic regression analysis identified the following independent predictors of massive bleeding: preoperative hemoglobin level <8.5 g/dL (OR 11.09, 95% CI 1.87-65.76), INR >1.5 (OR 11.62, 95% CI 2.36-57.26), platelet count <100 10 /L (OR 7.92, 95% CI 1.46-43.05), and surgery duration >600 minutes (OR 6.97, 95% CI 0.99-48.92).

Conclusions: Pediatric liver transplantation is associated with substantial blood loss and a significant blood product transfusion burden. A 43% incidence of massive bleeding is reported. Further efforts are needed to improve bleeding management in this high-risk population.
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http://dx.doi.org/10.1111/pan.13162DOI Listing
July 2017

Safety of antifibrinolytics in cranial vault reconstructive surgery: a report from the pediatric craniofacial collaborative group.

Paediatr Anaesth 2017 03 17;27(3):271-281. Epub 2017 Feb 17.

Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.

Background: Antifibrinolytic therapy significantly decreases blood loss and transfusion in pediatric cranial vault reconstructive surgery; however, concern regarding the side effects profile limits clinical use.

Aims: The aim was to utilize the Pediatric Craniofacial Surgery Perioperative Registry database to identify the safety profile of antifibrinolytic therapy for cranial vault reconstructive surgery by reporting the incidence of adverse events as they relate to exposure to tranexamic acid and aminocaproic acid compared to no exposure to antifibrinolytics.

Methods: The database was queried for cases of open cranial vault reconstructive surgery. Less invasive procedures such as neuro-endoscopic and spring-mediated cranioplasties were excluded. The outcomes evaluated included any perioperative neurological adverse event including seizures or seizure-like movements and thromboembolic events.

Results: Thirty-one institutions reported a total of 1638 cases from 2010 to 2015. Total antifibrinolytic administration accounted for 59.5% (tranexamic acid, 36.1% and aminocaproic acid, 23.4%), with 40.5% not receiving any antifibrinolytic. The overall incidence of postoperative seizures or seizure-like movements was 0.6%. No significant difference was detected in the incidence of postoperative seizures between patients receiving tranexamic acid and those receiving aminocaproic acid [the odds ratio for seizures being 0.34 (95% confidence interval: 0.07-1.85) controlling for American Society of Anesthesia (ASA) physical class] nor in patients receiving antifibrinolytics compared to those not administered antifibrinolytics (the odds ratio for seizures being 1.02 (confidence interval 0.29-3.63) controlling for ASA physical class). One complicated patient in the antifibrinolytic group with a femoral venous catheter had a postoperative deep venous thrombosis.

Conclusions: This is the first report of an incidence of postoperative seizures of 0.6% in pediatric cranial vault reconstructive surgery. There was no significant difference in postoperative seizures or seizure-like events in those patients who received the tranexamic acid or aminocaproic acid vs those that did not. This report provides evidence of the safety profile of antifibrinolytic in children having noncardiac major surgery. Caution should prevail however in using antifibrinolytic in high-risk patients. Antifibrinolytic dosage regimes should be based on pharmacokinetic data avoiding high doses.
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http://dx.doi.org/10.1111/pan.13076DOI Listing
March 2017

Association of Preoperative Anemia With Postoperative Mortality in Neonates-Reply.

JAMA Pediatr 2017 02;171(2):196-197

Department of Anesthesiology, Peri-operative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jamapediatrics.2016.2965DOI Listing
February 2017

Perioperative Outcomes and Management in Pediatric Complex Cranial Vault Reconstruction: A Multicenter Study from the Pediatric Craniofacial Collaborative Group.

Anesthesiology 2017 02;126(2):276-287

From the Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (P.A.S.); Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts (S.M.G., P.M.M.); Department of Anesthesiology, The Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (F.P.C.); Departments of Anesthesiology and Pain Medicine and Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington, D.C. (C.M.H.); Children's National Health System, Division of Anesthesiology, The George Washington University School of Medicine and Health Sciences, Washington, DC (S.K.R.); Department of Anesthesiology, Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee (T.T.N.); Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania (L.C., M.P.); and Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical School, Children's Medical Center Dallas, Texas and Outcome Research Consortium, Cleveland, Ohio (P.S.).

Background: The Pediatric Craniofacial Collaborative Group established the Pediatric Craniofacial Surgery Perioperative Registry to elucidate practices and outcomes in children with craniosynostosis undergoing complex cranial vault reconstruction and inform quality improvement efforts. The aim of this study is to determine perioperative management, outcomes, and complications in children undergoing complex cranial vault reconstruction across North America and to delineate salient features of current practices.

Methods: Thirty-one institutions contributed data from June 2012 to September 2015. Data extracted included demographics, perioperative management, length of stay, laboratory results, and blood management techniques employed. Complications and outlier events were described. Outcomes analyzed included total blood donor exposures, intraoperative and perioperative transfusion volumes, and length of stay outcomes.

Results: One thousand two hundred twenty-three cases were analyzed: 935 children aged less than or equal to 24 months and 288 children aged more than 24 months. Ninety-five percent of children aged less than or equal to 24 months and 79% of children aged more than 24 months received at least one transfusion. There were no deaths. Notable complications included cardiac arrest, postoperative seizures, unplanned postoperative mechanical ventilation, large-volume transfusion, and unplanned second surgeries. Utilization of blood conservation techniques was highly variable.

Conclusions: The authors present a comprehensive description of perioperative management, outcomes, and complications from a large group of North American children undergoing complex cranial vault reconstruction. Transfusion remains the rule for the vast majority of patients. The occurrence of numerous significant complications together with large variability in perioperative management and outcomes suggest targets for improvement.
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http://dx.doi.org/10.1097/ALN.0000000000001481DOI Listing
February 2017

Relationship Between Preoperative Anemia and In-Hospital Mortality in Children Undergoing Noncardiac Surgery.

Anesth Analg 2016 12;123(6):1582-1587

From the Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.

Background: The relationship between preoperative anemia and in-hospital mortality has not been investigated in the pediatric surgical population. We hypothesized that children with preoperative anemia undergoing noncardiac surgery may have an increased risk of in-hospital mortality.

Methods: We identified all children between 1 and 18 years of age with a recorded preoperative hematocrit (HCT) in the 2012, 2013, and 2014 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) pediatric databases. The endpoint was defined as the incidence of in-hospital mortality. Children with preoperative anemia were identified based on their preoperative HCT. Demographic and surgical characteristics, as well as comorbidities, were considered potential confounding variables in a multivariable logistic regression analysis. A sensitivity analysis was performed using propensity-matched analysis.

Results: Among the 183,833 children included in the 2012, 2013, and 2014 ACS NSQIP database, 74,508 had a preoperative HCT recorded (41%). After exclusion of all children <1 year of age (n = 12,063), those with congenital heart disease (n = 8943), and those who received a preoperative red blood cell (RBC) transfusion (n = 1880), 12,551 (24%) children were anemic, and 39,071 (76%) were nonanemic. The median preoperative HCT was 33% (interquartile range, 31-35) in anemic children, and 39% (interquartile range, 37-42) in nonanemic children (P < .001). Using multivariable logistic regression analysis, and after adjustment for RBC transfusion (OR, 2.13; 95% CI, 1.39-3.26; P < .001), we observed that preoperative anemia was associated with higher odds for in-hospital mortality (OR, 2.17; 95% CI, 1.48-3.19; P < .001). After propensity matching, the presence of anemia was also associated with higher odds of in-hospital mortality (OR, 1.75; 95% CI, 1.15-2.65; P = .004).

Conclusions: Our study demonstrates that children with preoperative anemia are at increased risk for in-hospital mortality. Further studies are needed to assess whether the correction of preoperative HCT, through the development of a patient blood management program, improves patient outcomes or simply reduces the need for transfusions.
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http://dx.doi.org/10.1213/ANE.0000000000001499DOI Listing
December 2016

Multivariable predictors of substantial blood loss in children undergoing craniosynostosis repair: implications for risk stratification.

Paediatr Anaesth 2016 Oct 11;26(10):960-9. Epub 2016 Aug 11.

Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.

Background: Operative treatment of craniosynostosis is associated with substantial blood loss, often requiring transfusion of packed red blood cells (PRBC) and coagulation products.

Aims: The aim of this prospective study was to analyze thromboelastographic (TEG) parameters and platelet fibrinogen product to determine predictors of substantial blood loss, and the need for PRBC transfusion and coagulation products.

Methods: With IRB approval, we enrolled 120 children undergoing craniosynostosis repair with a standardized anesthetic, fluid management, and TEG measurements at predefined times. Outcomes of interest were intraoperative blood loss, and need for PRBC transfusion and coagulation products. Multivariable logistic regression and receiver operating characteristic (ROC) curve analysis was applied to determine independent predictors of substantial blood loss and need for coagulation products.

Results: One hundred and eighteen children were included in the analysis. Forty-four required PRBC transfusion (median 26 ml·kg(-1) ; IQR: 22-42) with median blood loss of 56 ml·kg(-1) (IQR: 43-83). Factors associated with the PRBC transfusion included type of surgery, duration of surgery, and three TEG parameters, α-angle, MA, and K-time (all P < 0.001). A predictive algorithm was developed by subgroup analysis of cranial vault reconstruction (CVR) patients for substantial intraoperative blood loss (defined as ≥60 ml·kg(-1) ) and need for coagulation products with ROC-derived cut-off values: platelet fibrinogen product, <343; α-angle, <62°; MA, <55 mm; K-time, >2.1 min. The best prognostic combination included at least two of these four predictors (sensitivity 89%, specificity 90%). Multivariable regression identified MA as the only independent predictor of coagulation product administration (P < 0.001) and ROC analysis identified MA <46 mm as the optimal cut-off (sensitivity 86%, specificity 94%).

Conclusions: Risk for substantial intraoperative blood loss can be assessed using TEG parameters and platelet fibrinogen product, whereas the need for coagulation products is strongly related to low MA. Patients susceptible to substantial blood loss can be risk stratified based on their TEG/platelet fibrinogen product profile.
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http://dx.doi.org/10.1111/pan.12980DOI Listing
October 2016

The translational value of chart reviews and the need for trials.

Paediatr Anaesth 2016 Sep;26(9):864-5

Department of Anesthesiology, Peri-operative & Pain Medicine, Boston Children's Hospital, Boston, MA, USA.

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http://dx.doi.org/10.1111/pan.12976DOI Listing
September 2016

Association of Preoperative Anemia With Postoperative Mortality in Neonates.

JAMA Pediatr 2016 09;170(9):855-62

Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.

Importance: Neonates undergoing noncardiac surgery are at risk for adverse outcomes. Preoperative anemia is a strong independent risk factor for postoperative mortality in adults. To our knowledge, this association has not been investigated in the neonatal population.

Objective: To assess the association between preoperative anemia and postoperative mortality in neonates undergoing noncardiac surgery in a large sample of US hospitals.

Design, Setting, And Participants: Using data from the 2012 and 2013 pediatric databases of the American College of Surgeons National Surgical Quality Improvement Program, we conducted a retrospective study of neonates undergoing noncardiac surgery. Analysis of the data took place between June 2015 and December 2015. All neonates (0-30 days old) with a recorded preoperative hematocrit value were included.

Exposures: Anemia defined as hematocrit level of less than 40%.

Main Outcomes And Measures: Receiver operating characteristics analysis was used to assess the association between preoperative hematocrit and mortality, and the Youden J Index was used to determine the specific hematocrit cutoff point to define anemia in the neonatal population. Demographic and postoperative outcomes variables were compared between anemic and nonanemic neonates. Univariate and multivariable logistic regression analyses were used to determine factors associated with postoperative neonatal mortality. An external validation was performed using the 2014 American College of Surgeons National Surgical Quality Improvement Program database.

Results: Neonates accounted for 2764 children (6%) in the 2012-2013 American College of Surgeons National Surgical Quality Improvement Program databases. Neonates inlcuded in the study were predominately male (64.5%), white (66.3%), and term (69.9% greater than 36 weeks' gestation) and weighed more than 2 kg (85.0%). Postoperative in-hospital mortality was 3.4% in neonates and 0.6% in all age groups (0-18 years). A preoperative hematocrit level of less than 40% was the optimal cutoff (Youden) to predict in-hospital mortality. Multivariable regression analysis demonstrated that preoperative anemia is an independent risk factor for mortality (OR, 2.62; 95% CI, 1.51-4.57) in neonates. The prevalence of postoperative in-hospital mortality was significantly higher in neonates with a preoperative hematocrit level less than 40%; being 7.5% (95% CI, 1%-10%) vs 1.4% (95% CI, 0%-4%) for preoperative hematocrit levels 40%, or greater. The relationship between anemia and in-hospital mortality was confirmed in our validation cohort (National Surgical Quality Improvement Program 2014).

Conclusions And Relevance: To our knowledge, this is the first study to define the incidence of preoperative anemia in neonates, the incidence of postoperative in-hospital mortality in neonates, and the association between preoperative anemia and postoperative mortality in US hospitals. Timely diagnosis, prevention, and appropriate treatment of preoperative anemia in neonates might improve survival.
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http://dx.doi.org/10.1001/jamapediatrics.2016.1032DOI Listing
September 2016