Peri-operative red blood cell transfusion in neonates and infants: NEonate and Children audiT of Anaesthesia pRactice IN Europe: A prospective European multicentre observational study

BACKGROUND: Little is known about current clinical practice concerning peri-operative red blood cell transfusion in neonates and small infants. Guidelines suggest transfusions based on haemoglobin thresholds ranging from 8.5 to 12 g dl-1, distinguishing between children from birth to day 7 (week 1), from day 8 to day 14 (week 2) or from day 15 (≥week 3) onwards. OBJECTIVE: To observe peri-operative red blood cell transfusion practice according to guidelines in relation to patient outcome. DESIGN: A multicentre observational study. SETTING: The NEonate-Children sTudy of Anaesthesia pRactice IN Europe (NECTARINE) trial recruited patients up to 60 weeks' postmenstrual age undergoing anaesthesia for surgical or diagnostic procedures from 165 centres in 31 European countries between March 2016 and January 2017. PATIENTS: The data included 5609 patients undergoing 6542 procedures. Inclusion criteria was a peri-operative red blood cell transfusion. MAIN OUTCOME MEASURES: The primary endpoint was the haemoglobin level triggering a transfusion for neonates in week 1, week 2 and week 3. Secondary endpoints were transfusion volumes, 'delta haemoglobin' (preprocedure - transfusion-triggering) and 30-day and 90-day morbidity and mortality. RESULTS: Peri-operative red blood cell transfusions were recorded during 447 procedures (6.9%). The median haemoglobin levels triggering a transfusion were 9.6 [IQR 8.7 to 10.9] g dl-1 for neonates in week 1, 9.6 [7.7 to 10.4] g dl-1 in week 2 and 8.0 [7.3 to 9.0] g dl-1 in week 3. The median transfusion volume was 17.1 [11.1 to 26.4] ml kg-1 with a median delta haemoglobin of 1.8 [0.0 to 3.6] g dl-1. Thirty-day morbidity was 47.8% with an overall mortality of 11.3%. CONCLUSIONS: Results indicate lower transfusion-triggering haemoglobin thresholds in clinical practice than suggested by current guidelines. The high morbidity and mortality of this NECTARINE sub-cohort calls for investigative action and evidence-based guidelines addressing peri-operative red blood cell transfusions strategies. TRIAL REGISTRATION: ClinicalTrials.gov, identifier: NCT02350348

End-systolic and end-diastolic frame selection of the right ventricle compared to the left ventricle.

<p>LV = left ventricle, RV = right ventricle, ToF = tetralogy of Fallot.</p

Change in right ventricular volumes and function.

<p>Scatterplots of the change in RV end-systolic volume (<b>A</b>), end-diastolic volume (<b>B</b>) and ejection fraction (<b>C</b>) when using the end-systolic and end-diastolic frame of the RV instead of the LV. EDV = end-diastolic volume, EF = ejection fraction, ESV = end-systolic volume, LV = left ventricular, RBBB = right bundle branch block, RV = right ventricular, ToF = tetralogy of Fallot.</p

Right ventricular volumes measured in the end-systolic and end-diastolic frame of the left and right ventricle.

<p>EDV = end-diastolic volume, EF = ejection fraction, ESV = end-systolic volume, IQR = interquartile range, LV = left ventricle, RV = right ventricle, SD = standard deviation, SV = stroke volume, ToF = tetralogy of Fallot.</p

Example of the left and right end-systolic frame and the corresponding time-volume curve.

<p>Two short axis images of the end-systolic frame of the LV (<b>A</b>) and RV (<b>B</b>), and the corresponding time-volume curve (<b>C</b>) in a patient with ToF and a complete RBBB. Timing of the RV end-systolic frame is 106 ms (3 frames) delayed compared to LV end-systolic frame. Measuring the RV end-systolic volume in the LV instead of the RV end-systolic frame results in a difference of 9 ml/m². This is visible in the short-axis image of the RV end-systolic frame (<b>B</b>) in which the larger blue contour corresponds to the RV contour of the LV end-systolic frame (<b>A</b>) and the yellow contour to the RV contour of the RV end-systolic frame. Timing of the end-diastolic frame is the same for the RV and LV. LV = left ventricle, Max. = maximum volume, Min. = minimal volume, RBBB = right bundle branch block, RV = right ventricle.</p

Incidence of severe critical events in paediatric anaesthesia (APRICOT) : a prospective multicentre observational study in 261 hospitals in Europe

BACKGROUND: Little is known about the incidence of severe critical events in children undergoing general anaesthesia in Europe. We aimed to identify the incidence, nature, and outcome of severe critical events in children undergoing anaesthesia, and the associated potential risk factors. METHODS: The APRICOT study was a prospective observational multicentre cohort study of children from birth to 15 years of age undergoing elective or urgent anaesthesia for diagnostic or surgical procedures. Children were eligible for inclusion during a 2-week period determined prospectively by each centre. There were 261 participating centres across 33 European countries. The primary endpoint was the occurence of perioperative severe critical events requiring immediate intervention. A severe critical event was defined as the occurrence of respiratory, cardiac, allergic, or neurological complications requiring immediate intervention and that led (or could have led) to major disability or death. This study is registered with ClinicalTrials.gov, number NCT01878760. FINDINGS: Between April 1, 2014, and Jan 31, 2015, 31 127 anaesthetic procedures in 30 874 children with a mean age of 6·35 years (SD 4·50) were included. The incidence of perioperative severe critical events was 5·2% (95% CI 5·0-5·5) with an incidence of respiratory critical events of 3·1% (2·9-3·3). Cardiovascular instability occurred in 1·9% (1·7-2·1), with an immediate poor outcome in 5·4% (3·7-7·5) of these cases. The all-cause 30-day in-hospital mortality rate was 10 in 10 000. This was independent of type of anaesthesia. Age (relative risk 0·88, 95% CI 0·86-0·90; p<0·0001), medical history, and physical condition (1·60, 1·40-1·82; p<0·0001) were the major risk factors for a serious critical event. Multivariate analysis revealed evidence for the beneficial effect of years of experience of the most senior anaesthesia team member (0·99, 0·981-0·997; p<0·0048 for respiratory critical events, and 0·98, 0·97-0·99; p=0·0039 for cardiovascular critical events), rather than the type of health institution or providers. INTERPRETATION: This study highlights a relatively high rate of severe critical events during the anaesthesia management of children for surgical or diagnostic procedures in Europe, and a large variability in the practice of paediatric anaesthesia. These findings are substantial enough to warrant attention from national, regional, and specialist societies to target education of anaesthesiologists and their teams and implement strategies for quality improvement in paediatric anaesthesia. FUNDING: European Society of Anaesthesiology

Impact of right ventricular endocardial trabeculae on volumes and function assessed by CMR in patients with tetralogy of Fallot

<p>The objective of this study was to assess the impact of right ventricular (RV) trabeculae and papillary muscles on measured volumes and function assessed by cardiovascular magnetic resonance imaging in patients with repaired tetralogy of Fallot. Sixty-five patients with repaired tetralogy of Fallot underwent routine cardiovascular magnetic resonance imaging. Endocardial and epicardial contours were drawn manually and included trabeculae and papillary muscles in the blood volume. Semi-automatic threshold-based segmentation software excluded these structures. Both methods were compared in terms of end-diastolic, end-systolic and stroke volume, ejection fraction and mass. Observer agreement was determined for all measures. Exclusion of trabeculae and papillary muscle in the RV blood volume decreased measured RV end-diastolic volume by 15 % (from 140 +/- A 35 to 120 +/- A 32 ml/m(2)) compared to inclusion, end-systolic volume by 21 % (from 74 +/- A 23 to 59 +/- A 20 ml/m(2)), stroke volume by 9 % (from 66 +/- A 16 to 60 +/- A 16 ml/m(2)) and relatively increased ejection fraction by 7 % (from 48 +/- A 7 to 51 +/- A 8 %) and end-diastolic mass by 79 % (from 28 +/- A 7 to 51 +/- A 10 g/m(2)), p <.01. Excluding trabeculae and papillary muscle resulted in an improved interobserver agreement of RV mass compared to including these structures (coefficient of agreement of 87 versus 78 %, p <.01). Trabeculae and papillary muscle significantly affect measured RV volumes, function and mass. Semi-automatic threshold-based segmentation software can reliably exclude trabeculae and papillary muscles from the RV blood volume.</p>

Improved Cardiac MRI Volume Measurements in Patients with Tetralogy of Fallot by Independent End-Systolic and End-Diastolic Phase Selection

<p>Objectives: To investigate to what extent cardiac MRI derived measurements of right ventricular (RV) volumes using the left ventricular (LV) end-systolic and end-diastolic frame misrepresent RV end-systolic and end-diastolic volumes in patients with tetralogy of Fallot (ToF) and a right bundle branch block.</p><p>Methods: Sixty-five cardiac MRI scans of patients with ToF and a right bundle branch block, and 50 cardiac MRI scans of control subjects were analyzed. RV volumes and function using the end-systolic and end-diastolic frame of the RV were compared to using the end-systolic and end-diastolic frame of the LV.</p><p>Results: Timing of the RV end-systolic frame was delayed compared to the LV end-systolic frame in 94% of patients with ToF and in 50% of control subjects. RV end-systolic volume using the RV end-systolic instead of LV end-systolic frame was smaller in ToF (median -3.3 ml/m(2), interquartile range -1.9 to 25.6 ml/m(2); p</p><p>Conclusion: For clinical decision making in ToF patients RV volumes derived from cardiac MRI should be measured in the end-systolic frame of the RV instead of the LV.</p>