The Effect of Hemoglobin Levels on Mortality in Pediatric Patients with Severe Traumatic Brain Injury

Objective. There is increasing evidence of adverse outcomes associated with blood transfusions for adult traumatic brain injury patients. However, current evidence suggests that pediatric traumatic brain injury patients may respond to blood transfusions differently on a vascular level. This study examined the influence of blood transfusions and anemia on the outcome of pediatric traumatic brain injury patients. Design. A retrospective cohort analysis of severe pediatric traumatic brain injury (TBI) patients was undertaken to investigate the association between blood transfusions and anemia on patient outcomes. Measurements and Main Results. One hundred and twenty patients with severe traumatic brain injury were identified and included in the analysis. The median Glasgow Coma Scale (GCS) was 6 and the mean hemoglobin (Hgb) on admission was 115.8 g/L. Forty-three percent of patients (43%) received at least one blood transfusion and the mean hemoglobin before transfusion was 80.1 g/L. Multivariable regression analysis revealed that anemia and the administration of packed red blood cells were not associated with adverse outcomes. Factors that were significantly associated with mortality were presence of abusive head trauma, increasing PRISM score, and low GCS after admission. Conclusion. In this single centre retrospective cohort study, there was no association found between anemia, blood transfusions, and hospital mortality in a pediatric traumatic brain injury patient population. Background Traumatic brain injury (TBI) is a leading cause of pediatric morbidity and mortality, accounting for approximately 60,000 hospitalizations and 7,400 deaths per year While the current adult literature is gaining increasing evidence that there may be an adverse effect of transfusion on TBI patients, these results may not be generalizable to pediatric patients. Significant differences exist between pediatric and adult cerebral blood flow (CBF) in both normal and traumatic-injured states Further, pediatric TBI patients may respond to blood transfusions differently compared to adults. Figaji et al. reported that 79% of their pediatric TBI patients demonstrated an improvement in brain oxygenation after a transfusion The Transfusion Requirements in Pediatric Intensive Care Unit (TRIPICU) trial demonstrated that adopting a restrictive blood transfusion threshold of a hemoglobin (Hgb) level of 70 g/L in stable critically ill children results in no difference in mortality, but they did not look at TBI patients specifically Materials and Methods Approval from the Conjoint Health Research Ethics Board at the University of Calgary was obtained (Study ID REB13-0095) and informed consent was waived. Patients with a diagnosis of TBI admitted to the Alberta Children's Hospital (ACH) PICU between January 2001 and December 2012 had their charts analyzed by the study investigators. Inclusion criteria were <18 years of age, admission to ACH PICU with diagnosis of TBI or skull fracture, and initial Glasgow Coma Scale (GCS) of ≤8. Exclusion criteria included patient obeying commands within 12 hours of admission, patient death within 12 hours of admission (with injuries likely so severe that blood transfusions would be unlikely to alter their course), nontraumatic etiology to explain decreased level of consciousness (e.g., alcohol or drugs), and concomitant traumatic quadriparesis (unable to assess GCS). These criteria were modelled after a similar study in adult TBI patients Data was collected on standardized case report forms. Aside from standard demographic information, additional data collected included patient initial hemoglobin and mean hemoglobin for up to the next 7 days after admission; type and severity of the injury characterized by initial vital signs and GCS scores; mechanism of injury; surgical procedures performed; and the presence of signs indicative of raised intracranial pressure (ICP) on CT scans, as reported by a radiologist. At our institution, all patients with severe TBI receive radiologic studies as part of their workup, but not all patients receive invasive ICP monitoring. Presence of intracranial hemorrhage and other injuries was also collected. Recording of patient management data included transfusions in the first 14 days, use of mannitol or hypertonic saline, therapeutic hypothermia, and administration of neuromuscular blockade. Length of hospital and ICU stay along with allcause mortality within 30 days was used as our primary endpoints. A database containing all previously admitted pediatric patients diagnosed from the desired time period was created. All patients with diagnosis codes of brain injury, traumatic cerebral edema, skull fractures, wounds to head, face, or scalp, and intracranial bleeding admitted to the PICU for more than 24 hours were included in the initial screening. Presented patient demographic and clinical data are expressed as the mean ± SD or median with interquartile range (IQR) dependent on data normality as assessed using the Shapiro-Wilk test ( < 0.05). Given the potential practice change of the publication of the landmark transfusion threshold study in critically ill children by Lacroix et al., we stratified the patients according to whether they were admitted prior to or after ( < 0.05) in continuous demographic and clinical variables between those transfused and not transfused were assessed using the independent samples -test or Mann Whitneytest upon failure of data normality. Significant differences ( < 0.05) in categorical variables were assessed using the chisquare test for association or Fisher's exact test. An exploratory model to predict the probability of mortality was developed using logistic regression. Seven independent variables (age, presence of suspected nonaccidental trauma (NAT), PRISM III score, RBC transnfusion, admission GCS score, admission Hgb, and 7-day mean Hgb) were initially considered as possible covariates. Prior to model construction, a correlation of = 0.65 was found between admission Hgb and 7-day mean Hgb using Spearman's rank coefficient. Univariate logistic regression was used to assess the strength of admission and 7-day mean Hgb in predicting the probability of mortality. Nagelkerke 2 values were 0.1 and 0.02 for admission and 7-day mean Hgb, respectively, supporting the consideration of admission Hgb as a covariate in our predictive logistic regression model. Additionally, an interaction term of RBC infusion * admission Hgb was also considered as a possible covariate. The criteria of variable selection for model inclusion followed that of Hosmer Jr. et al. Results A total of 466 patients with TBI were screened for possible study inclusion Canadian Respiratory Journal 3 The reduced covariate logistic regression model suspected NAT and PRISM III score as significant ( < 0.05) covariates: Log odds (mortality) = −5.294 + (2.198 * presence of suspected NAT) Odds ratios were 9.01 (95% CI: 2.16-37.68) and 1.32 (95% CI: 1.17-1.48) for presence of suspected NAT and PRISM III score, respectively. The model explained 55.2% of the variance in mortality (Nagelkerke 2 ) and correctly classified 89.1% of patients. Sensitivity and specificity were 50% and 97%, respectively. The likelihood ratio chi-square test was not significant ( 2 = 3.70; = 0.594). Discussion In this retrospective cohort study of 120 pediatric patients with severe TBI admitted to our PICU, it was found that hemoglobin at time of admission, administration of blood transfusions, and 7-day average hemoglobin after admission were not associated with adverse outcomes. Significant variables that were associated with increased mortality were the presence of suspected NAT and increasing PRISM score. It should be noted that there was a significant difference in the patients that were transfused and those that were not. The patients receiving blood transfusions tended to be younger and less well. Despite these differences, there was no clinical outcome difference associated with hemoglobin levels and transfusions. The goals of TBI management are to prevent secondary insults to the brain after the initial injury, including injury caused by hypoxia and hypotension In a large retrospective study of adult TBI patients, Salim and colleagues demonstrated that anemia and correction of it by blood transfusion are associated with increased mortality Similar to Sekhon and colleagues, we chose to study measured exposure to hemoglobin levels by looking at the initial and average hemoglobin for up to 7 days after admission. A variety of methods have been used to observe hemoglobin Canadian Respiratory Journal 5 levels, but 7 days is thought to capture the occurrence of peak ICP Other limitations of this study include the retrospective nature and the long period of time during which patient information was gathered. During this period of data collection, management strategies may have changed over time, which may have also affected our results. Having said that, our multivariate logistic regression analysis did not show an association between other management strategies and outcomes. All patients reviewed were admitted to a single centre suggesting that our results may not be entirely generalizable to other hospitals. However, the fact that our study found associations between NAT, GCS, and PRISM scores suggests that our study population is similar to other pediatric TBI studies that identified these as factors as well In conclusion, initial admission Hgb and mean Hgb values averaged over seven days after admission to PICU were not found to be strong predictors of mortality in children with severe TBI. No difference in outcome can be demonstrated when patients are transfused. Based on our study, we cannot advocate for deviation from the widely accepted transfusion threshold of 7 g per deciliter in critically ill pediatric patients presenting with TB

Education, implementation, and teams : 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with treatment recommendations

For this 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, the Education, Implementation, and Teams Task Force applied the population, intervention, comparator, outcome, study design, time frame format and performed 15 systematic reviews, applying the Grading of Recommendations, Assessment, Development, and Evaluation guidance. Furthermore, 4 scoping reviews and 7 evidence updates assessed any new evidence to determine if a change in any existing treatment recommendation was required. The topics covered included training for the treatment of opioid overdose; basic life support, including automated external defibrillator training; measuring implementation and performance in communities, and cardiac arrest centers; advanced life support training, including team and leadership training and rapid response teams; measuring cardiopulmonary resuscitation performance, feedback devices, and debriefing; and the use of social media to improve cardiopulmonary resuscitation application

2019 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

The International Liaison Committee on Resuscitation has initiated a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation science. This is the third annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. It addresses the most recent published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. This summary addresses the role of cardiac arrest centers and dispatcher-assisted cardiopulmonary resuscitation, the role of extracorporeal cardiopulmonary resuscitation in adults and children, vasopressors in adults, advanced airway interventions in adults and children, targeted temperature management in children after cardiac arrest, initial oxygen concentration during resuscitation of newborns, and interventions for presyncope by first aid providers. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the certainty of the evidence on the basis of the Grading of Recommendations, Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence to Decision Framework Highlights sections. The task forces also listed priority knowledge gaps for further research

The Effect of Hemoglobin Levels on Mortality in Pediatric Patients with Severe Traumatic Brain Injury

Objective. There is increasing evidence of adverse outcomes associated with blood transfusions for adult traumatic brain injury patients. However, current evidence suggests that pediatric traumatic brain injury patients may respond to blood transfusions differently on a vascular level. This study examined the influence of blood transfusions and anemia on the outcome of pediatric traumatic brain injury patients. Design. A retrospective cohort analysis of severe pediatric traumatic brain injury (TBI) patients was undertaken to investigate the association between blood transfusions and anemia on patient outcomes. Measurements and Main Results. One hundred and twenty patients with severe traumatic brain injury were identified and included in the analysis. The median Glasgow Coma Scale (GCS) was 6 and the mean hemoglobin (Hgb) on admission was 115.8 g/L. Forty-three percent of patients (43%) received at least one blood transfusion and the mean hemoglobin before transfusion was 80.1 g/L. Multivariable regression analysis revealed that anemia and the administration of packed red blood cells were not associated with adverse outcomes. Factors that were significantly associated with mortality were presence of abusive head trauma, increasing PRISM score, and low GCS after admission. Conclusion. In this single centre retrospective cohort study, there was no association found between anemia, blood transfusions, and hospital mortality in a pediatric traumatic brain injury patient population.Peer Reviewe

The Effect of Hemoglobin Levels on Mortality in Pediatric Patients with Severe Traumatic Brain Injury

Objective. There is increasing evidence of adverse outcomes associated with blood transfusions for adult traumatic brain injury patients. However, current evidence suggests that pediatric traumatic brain injury patients may respond to blood transfusions differently on a vascular level. This study examined the influence of blood transfusions and anemia on the outcome of pediatric traumatic brain injury patients. Design. A retrospective cohort analysis of severe pediatric traumatic brain injury (TBI) patients was undertaken to investigate the association between blood transfusions and anemia on patient outcomes. Measurements and Main Results. One hundred and twenty patients with severe traumatic brain injury were identified and included in the analysis. The median Glasgow Coma Scale (GCS) was 6 and the mean hemoglobin (Hgb) on admission was 115.8 g/L. Forty-three percent of patients (43%) received at least one blood transfusion and the mean hemoglobin before transfusion was 80.1 g/L. Multivariable regression analysis revealed that anemia and the administration of packed red blood cells were not associated with adverse outcomes. Factors that were significantly associated with mortality were presence of abusive head trauma, increasing PRISM score, and low GCS after admission. Conclusion. In this single centre retrospective cohort study, there was no association found between anemia, blood transfusions, and hospital mortality in a pediatric traumatic brain injury patient population

A taxonomy and rating system to measure situation awareness in resuscitation teams.

Team SA involves a common perspective between two or more individuals regarding current environmental events, their meaning, and projected future status. Team SA has been theorized to be important for resuscitation team effectiveness. Accordingly, multidimensional frameworks of observable behaviors relevant to resuscitation teams are needed to understand more deeply the nature of team SA, its implications for team effectiveness, and whether it can be trained. A seven-dimension team resuscitation SA framework was developed following a literature review and consensus process using a modified Delphi approach with a group of content experts. We applied a pre-post design within a day-long team training program involving four video-recorded simulated resuscitation events and 42 teams across Canada. The first and fourth events represented "pre" and "post" training events, respectively. Teams were scored on SA five times within each 15-minute event. Distractions were introduced to investigate whether SA scores would be affected. The current study provides initial construct validity evidence for a new measure of SA and explicates SA's role in resuscitation teams

Need for a Randomized Controlled Trial of Stress Ulcer Prophylaxis in Critically Ill Children: A Canadian Survey

ABSTRACTBackground: Stress ulcer prophylaxis is commonly used in pediatric critical care, to prevent upper gastrointestinal bleeding. The most frequently used agents are histamine-2 receptor antagonists (H2RAs) and proton pump inhibitors (PPIs). The risk–benefit ratio for stress ulcer prophylaxis is uncertain, because data from randomized clinical trials (RCTs) on the effectiveness and harms of prophylaxis in children are limited.Objective: To describe the views of Canadian pediatric intensivists about a future RCT of stress ulcer prophylaxis.Methods: We conducted an online survey of Canadian pediatric critical care physicians. We e-mailed information about the study and a link to a 10-item survey to 111 potential respondents, with 2 reminders for nonrespondents. We assessed the relationship between respondents’ characteristics and their views about the need for and potential participation in a trial using logistic regression and assessed regional differences using the 2 test.Results: The 68 physicians who replied (61% of potential respondents) had a median of 12 (interquartile range 5–20) years of experience. Fortyfour (65%) of the respondents stated that a large, rigorous RCT of stress ulcer prophylaxis in children is needed, and 94% (62 of 66) indicated that it should include a placebo group. The 3 most common designs suggested were a 3-arm trial comparing PPI, H2RA, and placebo (56% [37 of 66 respondents to this question]) and 2-arm trials comparing PPI with placebo (15% [n = 10]) and H2RA with placebo (8% [n = 5]). The 5 patient groups that respondents most commonly stated should be excluded (because they should not receive placebo) were children receiving acid suppression at home (66% [42 of 64 respondents to this question]) or corticosteroids (59% [n = 38]), those with severe coagulopathy or receiving extracorporeal membrane oxygenation (both 36% [n = 23]), and those with burns (31% [n = 20]). Most respondents indicated a willingness to participate in an RCT (64% [42 of 66 respondents to this question]), whereas some (29% [n = 19]) indicated that participation would depend on trial design or funding; only 8% (n = 5) were disinclined to participate.Conclusions: There is considerable interest in a placebo-controlled RCT of stress ulcer prophylaxis among pediatric critical care physicians in Canada, but consensus on key elements of the trial design is needed.RÉSUMÉContexte : La prophylaxie de l’ulcère de stress est fréquemment employée en soins intensifs pédiatriques afin de prévenir les saignements du tractus gastro-intestinal supérieur. Les agents les plus souvent employés sont les antagonistes des récepteurs H2 de l’histamine (anti-H2) et les inhibiteurs de la pompe à protons (IPP). Le rapport bénéfice-risque pour la prophylaxie de l’ulcère de stress est incertain, car les données provenant d’essais cliniques à répartition aléatoire (ECRA) sur l’efficacité et les dangers de la prophylaxie chez l’enfant sont peu nombreuses.Objectif : Décrire les points de vue des pédiatres intensivistes canadiens à propos d’un futur ECRA sur la prophylaxie de l’ulcère de stress.Méthodes : Nous avons réalisé un sondage en ligne auprès de médecins canadiens en soins intensifs pédiatriques. Nous avons envoyé par courriel de l’information sur l’étude, dont un lien menant au sondage en dix points, à 111 répondants potentiels et deux rappels à ceux n’ayant pas répondu d’emblée. Nous avons évalué, au moyen d’un modèle de régression logistique, les points de vue des répondants à propos de la nécessité d’un essai et de leur participation potentielle à celui-ci en fonction de leurs caractéristiques individuelles et, à l’aide d’un test de 2, les différences régionales.Résultats : Les 68 médecins (61 % des répondants potentiels) qui ont répondu avaient une médiane de 12 (écart interquartile de 5 à 20) années d’expérience. Quarante-quatre (65 %) des répondants indiquaient qu’il serait nécessaire de procéder à un important et rigoureux ECRA sur la prophylaxie de l’ulcère de stress chez l’enfant et 94 % (62 des 66 répondants) indiquaient que l’étude devrait comprendre un groupe placebo. Les trois plans expérimentaux les plus souvent suggérés étaient : un essai à trois groupes comparant les IPP, les anti-H2 et le placebo (56 % [37 des 66 répondants à cette question]), un essai à deux groupes comparant les IPP au placebo (15 % [n = 10]) et un essai à deux groupes comparant les anti-H2 au placebo (8 % [n = 5]). Les cinq groupes de patients que les répondants indiquaient le plus souvent comme ceux devant être exclus (parce qu’ils ne devraient pas recevoir de placebo) étaient : les enfants recevant un traitement de suppression de la sécrétion d’acide à la maison (66% [42 des 64 répondants à cette question]), ceux traités à l’aide de corticoïdes (59 % [n = 38]), ceux atteints d’une coagulopathie grave ou ceux traités par oxygénation extracorporelle sur oxygénateur à membrane (36 % chacun [n = 23]) et ceux souffrant de brûlures (31% [n = 20]). La plupart des répondants ont indiqué être prêts à participer à un ECRA (64% [42 des 66 répondants à cette question]), alors que certains (29 % [n = 19]) ont indiqué que leur participation dépendrait du plan de l’étude ou de son financement; seulement 8% (n = 5) n’étaient pas enclins à participer.Conclusions : On constate parmi les médecins canadiens en soins intensifs pédiatriques un intérêt marqué pour la tenue d’un ECRA comparatif contre placebo sur la prophylaxie de l’ulcère de stress, mais il est d’abord nécessaire d’obtenir un consensus sur les éléments clés du plan expérimental

A mixed-methods needs assessment for an antimicrobial stewardship curriculum in pediatrics

Abstract Objective: Antimicrobial stewardship (AS) education initiatives for multidisciplinary teams are most successful when addressing psychosocial factors driving antimicrobial prescribing (AP) and when they address the needs of the team to allow for a tailored approach to their education. Design: We conducted a mixed-methods embedded study as a needs assessment, involving quantitative analysis of AS concerns observed by pharmacists through an audit while attending clinical team rounds, as well as qualitative semi-structured interviews based on the Theoretical Domain Framework (TDF) to identify psychosocial barriers and facilitators for antimicrobial prescribing for an inpatient general pediatric service. We analyzed the data using deductive and inductive methods by mapping the TDF to a model for social determinants of antimicrobial prescribing (SDAP) in pediatric inpatient health care teams. Setting: The Clinical Teaching Unit (CTU) and Pediatric Intensive Care Unit (PICU), at a tertiary care pediatric hospital in Canada. Participants: Interviews (n = 23) with staff and resident physicians, nurse practitioners, and pharmacists. Results: Psychosocial facilitators and barriers for AS practice in the PICU and CTU which were identified included: collaboration, shared decision-making, locally accessible guidelines, and an overarching goal of doing right by the patient and feeling empowered as a prescriber. Some of the barriers identified included the norm of noninterference, professional comparisons, limited resources, feeling inadequately trained in AS, emotional prescribing, and a pejorative monitoring system. Conclusions: Our findings identified barriers and facilitators to AS decisions on pediatric inpatient teams as well as actionable needs in psychosocial-based AS education