Bleeding is a common complication of extracorporeal membrane oxygenation (ECMO), leading to increased mortality. Since one of its main complications is bleeding, platelet transfusions are frequently ...prescribed for children on ECMO. However, there is currently very little information on the effect of platelet transfusions on the function of the ECMO oxygenator. Our objective was to describe the effect of platelet transfusions on oxygenator function.
In this retrospective study, we included all children (<18 years) who received ECMO support in our pediatric intensive care unit (PICU) between January 2017 and December 2019. Oxygenator function, measured before and after platelet transfusion, was assessed by post-oxygenator P
O
and the gradient in pre- post-oxygenator pressures (Delta Pressure).
Over 3 years, we analyzed 235 platelet transfusions from 55 children who received ECMO support. Thirty-two (80%) of children were on veno-arterial ECMO and majority of them were peripherally cannulated. When looking at all transfusions, the post-transfusion change in delta-pressure was 0.1 mmHg (
= 0.69) and post-membrane P
O
was 6 mmHg (
= 0.49). However, in the subgroup with the lowest quartile of pre-transfusion oxygenator function, the post-transfusion change in delta-pressure was -5.2 ± 2.7 mmHg (
< 0.001) and the post-transfusion change in P
O
was -118 ± 49 (
< 0.001). The area under the ROC curve for the pre-transfusion delta-pressure and P
O
to predict a worsening of the oxygenator function were 0.72 (95%CI 0.63-0.81) and 0.71 (95%CI 0.64-0.78), respectively. Using regression models, pre-transfusion delta-pressure and P
O
were the only independent factors associated with oxygenator function worsening (
< 0.001).
Our study suggests that overall, platelet transfusions do not seem to impact the ECMO oxygenator's function. However, in the subgroup of patients with the lowest pre-transfusion oxygenator function, platelet transfusions were independently associated with a worsening function. Future studies should investigate if this warrants adjustments of the anticoagulation strategy around the platelet transfusion, especially among patients with lower oxygenator function.
Annual incidence of venous thromboembolism (VTE) including postoperative VTE in hospitalized children is rising significantly. A growing body of evidence supports the role of red blood cells (RBCs) ...in pathologic thrombosis. In this study, we examined the association of perioperative RBC transfusion with postoperative VTE in pediatric patients.
The pediatric databases of the American College of Surgeons' National Surgical Quality Improvement Project from 2012 to 2017 were used. Multivariable logistic regression was used to examine the association between perioperative RBC transfusion status and the development of new or progressive VTE within 30 days of surgery. The analyses were age stratified, as follows: neonates (≤28 days), infants (>28 days and <1 year), and children (≥1 year).
In this study, we included 20 492 neonates, 79 744 infants, and 382 862 children. Postoperative development of VTE was reported in 99 (0.48%) neonates, 147 (0.2%) infants, and 374 (0.1%) children. In all age groups, development of VTE was significantly more common among patients with a perioperative RBC transfusion than patients without a perioperative RBC transfusion (neonates: adjusted odds ratio aOR = 4.1, 95% confidence interval CI = 2.5-6.7; infants: aOR = 2.4, 95% CI = 1.7-3.6; children: aOR = 2.2, 95% CI = 1.7-2.9). Among children who received an intra- or postoperative transfusion, the weight-based volume of RBCs (mL/kg) transfused was associated with postoperative VTE in a dose-dependent manner: second tertile (odds ratio = 2.3, 95% CI = 1.3-4.1) and third tertile (odds ratio = 4.1, 95% CI = 2.3-7.4) versus first tertile.
Perioperative RBC transfusions are independently associated with development of new or progressive postoperative VTE in children, infants, and neonates. These findings need further validation in prospective studies and emphasize the need for evidence-based perioperative pediatric blood transfusion decisions.
Veno-arterial Extracorporeal Membrane Oxygenation (VA-ECMO) is a standard procedure for patient with refractory shock in Pediatric Intensive Care Unit (PICU). There is a paucity of data on the time ...relationship between VA-ECMO support, nosocomial infection occurrence, and PICU length of stay (LOS). The aim of this study was to determine the characteristics and impact of ECMO-related infections.
This is a retrospective study from 01/2008 to 12/2014, enrolling children with a VA-ECMO support for > 6 h. We recorded the first PICU infection during the VA-ECMO run, defined as a positive microbiological sample with clinical signs of infection or clinical signs of severe infection without positive sample.
During the study period, 41 patients (25/41 male) were included, with a median age of 41.2 months (IQR 12.9-89.9) and a 53% mortality rate. Median time on VA-ECMO was 4.2 d (IQR 2-7.1), median PICU LOS was 14.7 d (IQR 4,7-26,9). Overall, 34% patients developed an infection, with an incidence of 60/1000 VA-ECMO days. Median time to first infection was 4 d (IQR 3-5), with Pseudomonas spp. being the most commonly detected microorganism (42%). Infected sites were ventilator-associated pneumonia (9/14), sternotomy infection (2/14), bloodstream (2/14) and urinary tract infections (1/14). Longer VA-ECMO support (> 5 d) (OR 5.9 (CI 95% 1.4-24.6; p = 0.01) and longer PICU stay (> 14 d) (OR 12 (95% CI 2.2-65.5; p = 0.004) were associated with infection.
In this single-center study, we underlined the high proportion and early occurrence of infections in patient on VA-ECMO, mostly in the first week. As infection was an early event, it may prolong the duration of VA-ECMO support and PICU LOS. Further research is needed to better understand the impact of infections on VA-ECMO and develop prevention strategies.
Pediatric oncology patients will likely require numerous transfusions of blood products, including red blood cell, platelet, and plasma transfusions, during the course of their treatment. Although ...strong evidence-based guidelines for these products in this patient population do not exist, given the morbidities associated with the receipt of blood products, practitioners should attempt to use restrictive transfusion strategies.
Objective:
Bleeding can be a severe complication of critical illness, but its true epidemiologic impact on children has seldom been studied. Our objective is to describe the epidemiology of bleeding ...in critically ill children, using a validated clinical tool, as well as the hemostatic interventions and clinical outcomes associated with bleeding.
Design:
Prospective observational cohort study.
Setting:
Tertiary pediatric critical care unit
Patients:
All consecutive patients (1 month to 18 years of age) admitted to a tertiary pediatric critical care unit
Measurements and Main Results:
Bleeding events were categorized as minimal, moderate, severe, or fatal, according to the Bleeding Assessment Scale in Critically Ill Children. We collected demographics and severity at admission, as evaluated by the Pediatric Index of Mortality. We used regression models to compare the severity of bleeding with outcomes adjusting for age, surgery, and severity. Over 12 months, 902 critically ill patients were enrolled. The median age was 64 months (IQR 17; 159), the median admission predicted risk of mortality was 0.5% (IQR 0.2; 1.4), and 24% were post-surgical. Eighteen percent of patients experienced at least one bleeding event. The highest severity of bleeding was minimal for 7.9% of patients, moderate for 5.8%, severe for 3.8%, and fatal for 0.1%. Adjusting for age, severity at admission, medical diagnosis, type of surgery, and duration of surgery, bleeding severity was independently associated with fewer ventilator-free days (
p
< 0.001) and fewer PICU-free days (
p
< 0.001). Adjusting for the same variables, bleeding severity was independently associated with an increased risk of mortality (adjusted odds ratio for each bleeding category 2.4, 95% CI 1.5; 3.7,
p
< 0.001).
Conclusion:
Our data indicate bleeding occurs in nearly one-fifth of all critically ill children, and that higher severity of bleeding was independently associated with worse clinical outcome. Further multicenter studies are required to better understand the impact of bleeding in critically ill children.
Objectives:
Children supported by extracorporeal membrane oxygenation (ECMO) are at high risk of bleeding. Though practitioners often prescribe blood components and/or medications to prevent or treat ...bleeding, the utilization of these hemostatic measures in children is not well-understood. We sought to evaluate the use of hemostatic blood products (platelet, plasma and cryoprecipitate transfusions) and medications aminocaproic acid, tranexamic acid (TXA) and Factor VIIa in children supported by ECMO.
Design:
Retrospective observational study using the Pediatric Health Information System (PHIS) database from 2011-2017.
Setting:
Fifty-one U.S. children's hospitals.
Patients:
Children (aged 0–18 years) supported by ECMO.
Interventions:
None.
Measurements and Main Results:
ECMO was employed in the care of 7,910 children for a total of 56,079 ECMO days. Fifty-five percent of the patients were male with a median (IQR) age of 0 (0–2) years. The median (IQR) length of ECMO was 5 (2–9) days with a hospital mortality rate of 34%. Platelets were transfused on 49% of ECMO days, plasma on 33% of ECMO days and cryoprecipitate on 17% of ECMO days. Twenty-two percent of children received TXA with the majority receiving it on the first day of ECMO and the use of TXA increased during the 6-year period studied (
p
< 0.001). Seven percent of children received aminocaproic acid and 3% received Factor VIIa.
Conclusions:
Children supported by ECMO are exposed to a significant number of hemostatic blood products. Antifibrinolytics, in particular TXA, are being used more frequently. Given the known morbidity and mortality associated with hemostatic blood products, studies are warranted to evaluate the effectiveness of hemostatic strategies.
Objective:
To describe light and sound characteristics in the rooms of critically ill children.
Design:
Prospective observational cohort study, with continuously measured light and sound levels.
...Setting:
Tertiary care pediatric intensive care unit (PICU), with a newly constructed expansion and an older, pre-existing section.
Patients:
Critically ill patients 0–18 years old, requiring respiratory or cardiovascular support. Patients with severe cognitive pre-conditions were excluded.
Measurements and Main Results:
One hundred patients were enrolled, totaling 602 patient-days. The twenty-four hour median illuminance was 16 (IQR 5-53) lux (lx). Daytime (07:00–21:00) median light level was 27 lx (IQR 13-82), compared with 4 lx (IQR 1-10) overnight (22:00–06:00). Peak light levels occurred midday between 11:00 and 14:00, with a median of 48 lx (IQR 24-119). Daytime median illuminance trended higher over the course of admission, whereas light levels overnight were consistent. Midday light levels were higher in newly constructed rooms: 78 lx (IQR 30-143) vs. 26 lx (IQR 20-40) in existing rooms. The twenty-four hour median equivalent sound level (LAeq) was 60 (IQR 55-64) decibels (dB). Median daytime LAeq was 62 dB (IQR 58-65) and 56 dB (IQR 52-61) overnight. On average, 35% of patients experienced at least one sound peak >80 dB every hour from 22:00 to 06:00. Overnight peaks, but not median sound levels nor daytime peaks, decreased over the course of admission. There was no difference in sound between new and pre-existing rooms.
Conclusions:
This study describes continuously measured light and sound in PICU rooms. Light levels were low even during daytime hours, while sound levels were consistently higher than World Health Organization hospital room recommendations of <35 dB. Given the relevance of light and sound to sleep/wake patterns, and evidence of post-intensive care syndromes, the clinical effects of light and sound on critically ill children should be further explored as potentially modifiable environmental factors.
Objective:
Lactate is often used as a surrogate marker of inappropriate oxygen delivery. It has been shown that hyperlactatemia is associated with worse clinical outcome in children after cardiac ...surgery. The purpose of this study is to evaluate the association of hyperlactatemia, low systemic oxygen delivery, and hyperglycemia, in children admitted to the pediatric critical care unit after cardiopulmonary bypass.
Design:
Secondary analysis of an observational cohort study.
Setting:
Tertiary pediatric critical care unit (PICU).
Patients:
Ninety-three patients, aged 6 months to 16 years, undergoing cardiac surgery with cardiopulmonary bypass.
Interventions:
None.
Measurements and Main Results:
Metabolic tests (blood glucose, lactate, lactate/pyruvate ratio, and ketones) and oxygen extraction (SaO
2
-SvO
2
) were performed before anesthesia, at the end of cardiopulmonary bypass, at PICU admission, and at 4 and 12 h after PICU admission. Four hours after PICU admission, 62% of the patients had hyperlactatemia (>2 mmol/L), of whom 55% had normal oxygen extraction (SaO
2
-SvO
2
< 30%). There was no correlation between lactate and oxygen extraction (R = −0.09,
p
= 0.41) but there was a moderate correlation between lactate and blood glucose (R = 0.55,
p
< 0.001). Using a logistic regression model, hyperlactatemia at 4 h after PICU admission was independently associated with hyperglycemia (
p
= 0.007) and lactate/pyruvate ratio (
p
= 0.007) at the same timepoint, as well as with lactate at PICU admission (
p
= 0.002), but not with weight (
p
= 0.45), severity of the cardiac lesion (
p
= 0.85), duration of bypass (
p
= 0.16), or oxygen extraction, as evaluated by SaO
2
-SvO
2
(
p
= 0.54). At 12 h after PICU admission, there was a very week correlation between lactate and blood glucose (R = 0.27,
p
= 0.007), but none between lactate and oxygen extraction (R = 0.13,
p
= 0.20).
Conclusion:
In children after cardiopulmonary bypass, lactates are not correlated with higher oxygen extraction, but are correlated with hyperglycemia, at both 4 and 12 h after PICU admission. Future research is warranted to better define this relationship.
Clinically significant bleeding complicates up to 20% of admissions to the intensive care unit in adults and is associated with severe physiologic derangements, requirement for significant ...interventions and worse outcome. There is a paucity of published data on bleeding in critically ill children. In this manuscript, we will provide an overview of the epidemiology and characteristics of bleeding in critically ill children, address the association between bleeding and clinical outcomes, describe the current definitions of bleeding and their respective limitations, and finally provide an overview of current knowledge gaps and suggested areas for future research.
Critically ill children are a unique population who frequently receive plasma and platelet transfusions for both active bleeding and mitigation of bleeding risk. While these products are frequently ...administered, transfusion indications in this population remain unclear, and practice varies across institutions and providers. In this manuscript, we will outline the current evidence regarding plasma and platelet transfusions for hemostasis in the pediatric intensive care setting. For both products, we will describe the product composition, epidemiology, and product indications and discuss the potential risks and benefits involved with the transfusion. We will also discuss knowledge gaps and future areas of research.
PDF
