Editorials 8. Harenberg J, Haaf B, Dempfle CE, et al: Monitoring of heparins in haemodialysis using an anti-factor-Xa-specific whole-blood clotting assay. Nephrol Dial Transplant 1995; 10:217–222 9. Schmid P, Fischer AG, Wuillemin WA: Low-molecular-weight heparin in patients with renal insufficiency. Swiss Med Wkly 2009; 139:438–452 10. Stratta P, Karvela E, Canavese C, et al: Structure-activity relationships of low molecular weight heparins expose to the risk of achieving inappropriate targets in patients with renal failure. Curr Med Chem 2009; 16:3028–3040 11. Jeffrey RF, Khan AA, Douglas JT, et al: Anticoagulation with low molecular weight heparin (Fragmin) during continuous hemodialysis in the intensive care unit. Artif Organs 1993; 17:717–720 12. Dörffler-Melly J, de Jonge E, Pont AC, et al: Bioavailability of subcutaneous low-molecular-weight heparin to patients on vasopressors. Lancet 2002; 359:849–850 13. Cruickshank MK, Levine MN, Hirsh J, et al: A standard heparin nomogram for the management of heparin therapy. Arch Intern Med 1991; 151:333–337 14. Holm HA, Ly B, Handeland GF, et al: Subcutaneous heparin treatment of deep venous thrombosis: A comparison of unfractionated and low molecular weight heparin. Haemostasis 1986; 16(Suppl 2):30–37 15. Erkens PM, Prins MH: Fixed dose subcutaneous low molecular weight heparins versus adjusted dose unfractionated heparin for venous thromboembolism. Cochrane Database Syst Rev 2010; 9:CD001100 16. Aki EA, Vasireddi SR, Gunukula S, et al: Anticoagulation for the initial treatment of venous thromboembolism in patients with cancer. Cochrane Database Syst Rev 2011; 4:CD006649 17. Rothberg MB, Pekow PS, Lahti M, et al: Comparative effectiveness of low-molecular-weight heparin versus unfractionated heparin for thromboembolism prophylaxis for medical patients. J Hosp Med 2012; 7:457–463
18. Cook D, Crowther M, Meade M, et al: Deep venous thrombosis in medical-surgical critically ill patients: Prevalence, incidence, and risk factors. Crit Care Med 2005; 33:1565–1571 19. Raffini L, Huang YS, Witmer C, et al: Dramatic increase in venous thromboembolism in children’s hospitals in the United States from 2001 to 2007. Pediatrics 2009; 124:1001–1008 20. Ockelford PA, Carter CJ, Mitchell L, et al: Discordance between the anti-Xa activity and the antithrombotic activity in an ultra-low molecular weight heparin fraction. Thromb Res 1982; 28:401–409 21. Ofosu FA, Blajchman MA, Modi GJ, et al: The importance of thrombin inhibition for the expression of the anticoagulant activities of heparin, dermatan sulphate, low molecular weight heparin and pentosan polysulphate. Br J Haematol 1985; 60:695–704 22. Mauray S, de Raucourt E, Talbot JC, et al: Mechanism of factor IXa inhibition by antithrombin in the presence of unfractionated and low molecular weight heparins and fucoidan. Biochim Biophys Acta 1998; 1387:184–194 23. Amar J, Caranobe C, Sie P, et al: Antithrombotic potencies of heparins in relation to their antifactor Xa and antithrombin activities: An experimental study in two models of thrombosis in the rabbit. Br J Haematol 1990; 76:94–100 24. Buyue Y, Misenheimer TM, Sheehan JP: Low molecular weight heparin inhibits plasma thrombin generation via direct targeting of factor IXa: Contribution of the serpin-independent mechanism. J Thromb Haemost 2012; 10:2086–2098 25. Barrowcliffe TW, Mulloy B, Johnson EA, et al: The anticoagulant activity of heparin: Measurement and relationship to chemical structure. J Pharm Biomed Anal 1989; 7:217–226 2 6. Carter CA, Skoutakis VA, Spiro TE, et al: Enoxaparin: The lowmolecular-weight heparin for prevention of postoperative thromboembolic complications. Ann Pharmacother 1993; 27: 1223–1230
High-Volume Hemofiltration for Critically Ill Children With Acute Liver Failure: A Standard Treatment?* Aicha Merouani, MD Pediatric Nephrology Unit Sainte-Justine Hospital Université de Montréal Montréal, Canada Philippe Jouvet, MD, PhD Pediatric Critical Care Unit Department of Pediatrics Sainte-Justine Hospital Université de Montréal Montréal, Canada
*See also p. e300. Key Words: child; critical care; hemofiltration; intensive care; liver failure Dr. Jouvet received support from Philips Medical and Maquet (lent medical devices). Dr. Merouani has disclosed that she does not have any potential conflicts of interest. Copyright © 2014 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies DOI: 10.1097/PCC.0000000000000187
Pediatric Critical Care Medicine
A
cute liver failure (ALF) in children is a rare but a lifethreatening condition resulting in a multisystemic disorder that includes coagulopathy, severe hypoglycemia, encephalopathy with cerebral edema, hemodynamic instability, pulmonary edema, infection, and acute kidney injury ultimately leading to multiple organ failure and death (1). In neonates and infants, metabolic diseases are the main cause of ALF, and in older children, the most common identified causes are viruses, drug-induced hepatotoxicity, and autoimmune hepatitis, but the cause for ALF still remains undetermined in a large proportion of children (1). Orthotopic liver transplantation remains the only effective treatment in many children with ALF (2). Enhanced by persistent shortage of donor organs, extracorporeal strategies to support the liver function were developed to bridge patients with ALF to either transplantation or recovery (3). An ideal liver-assist device should support the three main liver functions: synthesis, detoxification, and excretion. During the last decades, progress in the management of liver failure patients has mainly focused on the removal of toxins by the development of extracorporeal methods using albumin dialysis (Table 1), such as the Molecular Adsorbent Recirculating www.pccmjournal.org
681
Editorials
Table 1. Comparison of Six Extracorporeal Methods Used in Children to Remove Toxics Accumulated in Acute Liver Failure High-Volume Continuous Continuous Venovenous Venovenous Molecular Hemofiltration Hemofiltration Absorbent (Ultrafiltrate (Ultrafiltrate Recirculating Rate < 80 mL/kg/hr) Rate ≥ 80 mL/kg/hr) System
Variable
Solute exchange mechanism(s) Molecular cutoff (kDa) Advantages
Disadvantages
Convection
Convection
≈ 50
≈ 50
Low complexity
Low complexity
Prometheus Dialysis
Diffusion/ Plasma adsorption separation/ adsorption/ diffusion ≈ 50
≈ 900
RPBS RPBS without without exogenous exogenous protein protein
Plasmapheresis Combined With Hemodialysis
Plasma separation/ diffusion
Diffusion
≈ 900/nonea
≈ 50
RPBS Nitrogen-neutral balance of plasma protein
Low complexity RPBS without exogenous protein
All methods increase the risk of bleeding because of mechanical platelet sequestration and coagulation factor consumption Complexity+ Complexity++
Complexity+ Fresh-frozen plasma exposition risks
Pediatric randomized control trial (n)
Single-Pass Albumin Dialysis
0
0
0
0
0
Albumin use+++
0
RPBS = removal of protein bound substances. a Depending on the plasmapheresis method used.
System (Gambro, Lund, Sweden), fractionated plasma separation and adsorption (Prometheus; Fresenius Medical Care, Bad Homburg, Germany), and single-pass albumin dialysis which were added to previous known methods such as plasma exchanges, hemodialysis, and continuous hemofiltration (4). The concept of albumin dialysis was developed to treat patients with ALF because some endogenous toxins accumulated in the blood leading to organ failure are protein bound to albumin (bile acids, aromatic amino acids, and medium-chain fatty acids) (5). But, neurotoxins accumulated in liver failure are mainly small (ex: ammonia) and middle-sized molecules easily cleared by conventional extracorporeal support, such as hemodialysis and continuous venovenous hemofiltration (CVVH). In this issue of Pediatric Critical Care Medicine, Chevret et al (6) take an important step forward by applying the rationale of high-volume hemofiltration (HVHF) used in sepsis to the ALF situation. Considering the fact that patients with liver failure share common pathophysiological similarities with sepsis, 22 children admitted in ICU for ALF requiring emergency liver transplantation were treated with HVHF, defined as an ultrafiltrate flow more than or equal to 80 mL/kg/hr. Chevret et al (6) report a significant increase in mean arterial pressure and decrease in grade of hepatic encephalopathy in the first 2 days of treatment. Twelve patients survived at day 28 including seven of eight transplanted patients and five patients with 682
www.pccmjournal.org
spontaneous recovery of liver function. They conclude that HVHF therapy significantly improves hemodynamic stability and neurological status in children with ALF awaiting for emergency liver transplantation. The cohort of patients is interesting as this study was targeting infants with a median age of 18 months and a median weight of 10 kg. All patients need vasopressor infusion. In this young population, the use of more complex extracorporeal methods have not demonstrated any clinical positive impact (7) and even some side effects (8), suggesting that HVHF is the extracorporeal method to use nowadays until more convincing data support another strategy. The most important impact of HVHF was a decrease in hepatic encephalopathy grade and hemodynamic stability. The factors resulting in hemodynamic and neurological improvement are unclear, but the team experience in the management of CVVH was probably one of these factors. In PICUs, the multidisciplinary team is trained to manage CVVH, and the increase in ultrafiltrate flow with HVHF is a minor practice change. The training in extracorporeal therapies is a key component in the appropriate management of infants. The prevalence of extracorporeal methods used in PICU is 0.7% to 2.4% of PICU admissions (9–11). With such a low prevalence, it is difficult for a PICU to maintain a staff trained in several extracorporeal therapies including September 2014 • Volume 15 • Number 7
Editorials
new complex ones (Table 1). This suggests that in addition to HVHF positive effect, the team experience in CVVH use can have contributed to the clinical improvement observed by Chevret et al (6). For these reasons, in the absence of randomized clinical trial on the clinical impact of extracorporeal devices, the experience reported by Chevret et al (6) supports the use of HVHF, a therapy derived from an extracorporeal method used for decades in pediatric intensive care, in children with acute renal failure.
REFERENCES
1. Devictor D, Tissieres P, Afanetti M, et al: Acute liver failure in children. Clin Res Hepatol Gastroenterol 2011; 35:430–437 2. Gotthardt D, Riediger C, Weiss KH, et al: Fulminant hepatic failure: Etiology and indications for liver transplantation. Nephrol Dial Transplant 2007; 22(Suppl 8):viii5–viii8 3. Rademacher S, Oppert M, Jörres A: Artificial extracorporeal liver support therapy in patients with severe liver failure. Expert Rev Gastroenterol Hepatol 2011; 5:591–599
4. Schmitt C, Schaefer F: Extracorporeal liver replacement therapy for pediatric patients. In: Pediatric Dialysis. Warady B, Schaefer F, Alexander S (Eds). Second Edition. London, Springer, 2012, pp 755–764 5. Wittebole X, Hantson P: Use of the Molecular Adsorbent Recirculating System (MARS™) for the management of acute poisoning with or without liver failure. Clin Toxicol (Phila) 2011; 49:782–793 6. Chevret L, Durand P, Lambert J, et al: High-Volume Hemofiltration in Children With Acute Liver Failure. Pediatr Crit Care Med 2014; 15:e300–e305 7. Schaefer B, Schaefer F, Engelmann G, et al: Comparison of Molecular Adsorbents Recirculating System (MARS) dialysis with combined plasma exchange and haemodialysis in children with acute liver failure. Nephrol Dial Transplant 2011; 26:3633–3639 8. Bourgoin P, Merouani A, Phan V, et al: Molecular Absorbent Recirculating System therapy (MARS®) in pediatric acute liver failure: A single center experience. Pediatr Nephrol 2014; 29:901–908 9. Gong WK, Tan TH, Foong PP, et al: Eighteen years experience in pediatric acute dialysis: Analysis of predictors of outcome. Pediatr Nephrol 2001; 16:212–215 10. Bunchman TE, McBryde KD, Mottes TE, et al: Pediatric acute renal failure: Outcome by modality and disease. Pediatr Nephrol 2001; 16:1067–1071 11. Lowrie LH: Renal replacement therapies in pediatric multiorgan dysfunction syndrome. Pediatr Nephrol 2000; 14:6–12
RBC Transfusion in Pediatric Trauma: Do We Need the Eye of Horus?* James Lin, MD Division of Pediatric Critical Care Medicine Department of Pediatrics Mattel Children’s Hospital UCLA University of California, Los Angeles (UCLA) Los Angeles, CA
T
he icon of the all-seeing eye appears in many religions and even on the great seal of the United States. One of the earliest icon, the Egyptian Eye of Horus, has been the object of diverse philosophic contemplation. In addition to illuminating the world, the Eye was thought to have healing and protective powers. The Eye’s representative hieroglyphic Wedjat is subdivided into six components, each representing a mathematical fraction or one of the six senses. In the increasingly evidence-based practice of pediatric trauma resuscitation, could it be that we need an illuminating, protective sixth sense to determine when to transfuse RBC? In this issue of Pediatric Critical Care Medicine, Hassan et al (1) compare the characteristics and outcomes of children
*See also p. e306. Key Words: noninvasive clinical monitoring; pediatric trauma; red blood cell transfusion; transfusion-related complications The author has disclosed that he does not have any potential conflicts of interest. Copyright © 2014 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies DOI: 10.1097/PCC.0000000000000215
Pediatric Critical Care Medicine
admitted to an ICU after traumatic injury, who did or did not receive packed RBC (PRBC) transfusions. Originally conceived as a quality improvement project, the study retrospectively reviewed 389 pediatric patients who have undergone trauma, who have been admitted over a 3-year period. Patients with burns and patients who had undergone massive transfusion were excluded. Eight-one patients were transfused with PRBCs. The timing of PRBC transfusion was available for 73 patients, with a quarter transfused earlier to PICU admission, one tenth transfused before and after PICU admission, and two thirds transfused after PICU admission. Demographics including the mechanism of injury were similar between transfused versus nontransfused patients, but transfused patients had greater Injury Severity Score (ISS), PICU length of stay (LOS), hospital LOS, and mortality. PRBC-transfused patients had a significantly greater need for mechanical ventilation, a longer duration of mechanical ventilation, and more pneumonia. After stratification by ISS ≥ 25 or < 25 and Glasgow Coma Scale (GCS) > 7 or ≤ 7, transfused patients in the high- and low-acuity groups had significantly longer PICU LOS, longer hospital LOS, higher mortality, and lower discharge GCS (DCGCS). Increased infections were also observed in transfused patients in the low-acuity group. When controlling for ISS and GCS, the volume of PRBC transfused was associated with longer hospital LOS in survivors. The number of transfusions was associated with the prevalence of pneumonia and longer LOS in the hospital. Multivariate logistic regression of patient’s age, storage age, of PRBC, ISS, volume transfused, and the number www.pccmjournal.org
683
18. Cook D, Crowther M, Meade M, et al: Deep venous thrombosis in medical-surgical critically ill patients: Prevalence, incidence, and risk factors. Crit Care Med 2005; 33:1565–1571 19. Raffini L, Huang YS, Witmer C, et al: Dramatic increase in venous thromboembolism in children’s hospitals in the United States from 2001 to 2007. Pediatrics 2009; 124:1001–1008 20. Ockelford PA, Carter CJ, Mitchell L, et al: Discordance between the anti-Xa activity and the antithrombotic activity in an ultra-low molecular weight heparin fraction. Thromb Res 1982; 28:401–409 21. Ofosu FA, Blajchman MA, Modi GJ, et al: The importance of thrombin inhibition for the expression of the anticoagulant activities of heparin, dermatan sulphate, low molecular weight heparin and pentosan polysulphate. Br J Haematol 1985; 60:695–704 22. Mauray S, de Raucourt E, Talbot JC, et al: Mechanism of factor IXa inhibition by antithrombin in the presence of unfractionated and low molecular weight heparins and fucoidan. Biochim Biophys Acta 1998; 1387:184–194 23. Amar J, Caranobe C, Sie P, et al: Antithrombotic potencies of heparins in relation to their antifactor Xa and antithrombin activities: An experimental study in two models of thrombosis in the rabbit. Br J Haematol 1990; 76:94–100 24. Buyue Y, Misenheimer TM, Sheehan JP: Low molecular weight heparin inhibits plasma thrombin generation via direct targeting of factor IXa: Contribution of the serpin-independent mechanism. J Thromb Haemost 2012; 10:2086–2098 25. Barrowcliffe TW, Mulloy B, Johnson EA, et al: The anticoagulant activity of heparin: Measurement and relationship to chemical structure. J Pharm Biomed Anal 1989; 7:217–226 2 6. Carter CA, Skoutakis VA, Spiro TE, et al: Enoxaparin: The lowmolecular-weight heparin for prevention of postoperative thromboembolic complications. Ann Pharmacother 1993; 27: 1223–1230
High-Volume Hemofiltration for Critically Ill Children With Acute Liver Failure: A Standard Treatment?* Aicha Merouani, MD Pediatric Nephrology Unit Sainte-Justine Hospital Université de Montréal Montréal, Canada Philippe Jouvet, MD, PhD Pediatric Critical Care Unit Department of Pediatrics Sainte-Justine Hospital Université de Montréal Montréal, Canada
*See also p. e300. Key Words: child; critical care; hemofiltration; intensive care; liver failure Dr. Jouvet received support from Philips Medical and Maquet (lent medical devices). Dr. Merouani has disclosed that she does not have any potential conflicts of interest. Copyright © 2014 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies DOI: 10.1097/PCC.0000000000000187
Pediatric Critical Care Medicine
A
cute liver failure (ALF) in children is a rare but a lifethreatening condition resulting in a multisystemic disorder that includes coagulopathy, severe hypoglycemia, encephalopathy with cerebral edema, hemodynamic instability, pulmonary edema, infection, and acute kidney injury ultimately leading to multiple organ failure and death (1). In neonates and infants, metabolic diseases are the main cause of ALF, and in older children, the most common identified causes are viruses, drug-induced hepatotoxicity, and autoimmune hepatitis, but the cause for ALF still remains undetermined in a large proportion of children (1). Orthotopic liver transplantation remains the only effective treatment in many children with ALF (2). Enhanced by persistent shortage of donor organs, extracorporeal strategies to support the liver function were developed to bridge patients with ALF to either transplantation or recovery (3). An ideal liver-assist device should support the three main liver functions: synthesis, detoxification, and excretion. During the last decades, progress in the management of liver failure patients has mainly focused on the removal of toxins by the development of extracorporeal methods using albumin dialysis (Table 1), such as the Molecular Adsorbent Recirculating www.pccmjournal.org
681
Editorials
Table 1. Comparison of Six Extracorporeal Methods Used in Children to Remove Toxics Accumulated in Acute Liver Failure High-Volume Continuous Continuous Venovenous Venovenous Molecular Hemofiltration Hemofiltration Absorbent (Ultrafiltrate (Ultrafiltrate Recirculating Rate < 80 mL/kg/hr) Rate ≥ 80 mL/kg/hr) System
Variable
Solute exchange mechanism(s) Molecular cutoff (kDa) Advantages
Disadvantages
Convection
Convection
≈ 50
≈ 50
Low complexity
Low complexity
Prometheus Dialysis
Diffusion/ Plasma adsorption separation/ adsorption/ diffusion ≈ 50
≈ 900
RPBS RPBS without without exogenous exogenous protein protein
Plasmapheresis Combined With Hemodialysis
Plasma separation/ diffusion
Diffusion
≈ 900/nonea
≈ 50
RPBS Nitrogen-neutral balance of plasma protein
Low complexity RPBS without exogenous protein
All methods increase the risk of bleeding because of mechanical platelet sequestration and coagulation factor consumption Complexity+ Complexity++
Complexity+ Fresh-frozen plasma exposition risks
Pediatric randomized control trial (n)
Single-Pass Albumin Dialysis
0
0
0
0
0
Albumin use+++
0
RPBS = removal of protein bound substances. a Depending on the plasmapheresis method used.
System (Gambro, Lund, Sweden), fractionated plasma separation and adsorption (Prometheus; Fresenius Medical Care, Bad Homburg, Germany), and single-pass albumin dialysis which were added to previous known methods such as plasma exchanges, hemodialysis, and continuous hemofiltration (4). The concept of albumin dialysis was developed to treat patients with ALF because some endogenous toxins accumulated in the blood leading to organ failure are protein bound to albumin (bile acids, aromatic amino acids, and medium-chain fatty acids) (5). But, neurotoxins accumulated in liver failure are mainly small (ex: ammonia) and middle-sized molecules easily cleared by conventional extracorporeal support, such as hemodialysis and continuous venovenous hemofiltration (CVVH). In this issue of Pediatric Critical Care Medicine, Chevret et al (6) take an important step forward by applying the rationale of high-volume hemofiltration (HVHF) used in sepsis to the ALF situation. Considering the fact that patients with liver failure share common pathophysiological similarities with sepsis, 22 children admitted in ICU for ALF requiring emergency liver transplantation were treated with HVHF, defined as an ultrafiltrate flow more than or equal to 80 mL/kg/hr. Chevret et al (6) report a significant increase in mean arterial pressure and decrease in grade of hepatic encephalopathy in the first 2 days of treatment. Twelve patients survived at day 28 including seven of eight transplanted patients and five patients with 682
www.pccmjournal.org
spontaneous recovery of liver function. They conclude that HVHF therapy significantly improves hemodynamic stability and neurological status in children with ALF awaiting for emergency liver transplantation. The cohort of patients is interesting as this study was targeting infants with a median age of 18 months and a median weight of 10 kg. All patients need vasopressor infusion. In this young population, the use of more complex extracorporeal methods have not demonstrated any clinical positive impact (7) and even some side effects (8), suggesting that HVHF is the extracorporeal method to use nowadays until more convincing data support another strategy. The most important impact of HVHF was a decrease in hepatic encephalopathy grade and hemodynamic stability. The factors resulting in hemodynamic and neurological improvement are unclear, but the team experience in the management of CVVH was probably one of these factors. In PICUs, the multidisciplinary team is trained to manage CVVH, and the increase in ultrafiltrate flow with HVHF is a minor practice change. The training in extracorporeal therapies is a key component in the appropriate management of infants. The prevalence of extracorporeal methods used in PICU is 0.7% to 2.4% of PICU admissions (9–11). With such a low prevalence, it is difficult for a PICU to maintain a staff trained in several extracorporeal therapies including September 2014 • Volume 15 • Number 7
Editorials
new complex ones (Table 1). This suggests that in addition to HVHF positive effect, the team experience in CVVH use can have contributed to the clinical improvement observed by Chevret et al (6). For these reasons, in the absence of randomized clinical trial on the clinical impact of extracorporeal devices, the experience reported by Chevret et al (6) supports the use of HVHF, a therapy derived from an extracorporeal method used for decades in pediatric intensive care, in children with acute renal failure.
REFERENCES
1. Devictor D, Tissieres P, Afanetti M, et al: Acute liver failure in children. Clin Res Hepatol Gastroenterol 2011; 35:430–437 2. Gotthardt D, Riediger C, Weiss KH, et al: Fulminant hepatic failure: Etiology and indications for liver transplantation. Nephrol Dial Transplant 2007; 22(Suppl 8):viii5–viii8 3. Rademacher S, Oppert M, Jörres A: Artificial extracorporeal liver support therapy in patients with severe liver failure. Expert Rev Gastroenterol Hepatol 2011; 5:591–599
4. Schmitt C, Schaefer F: Extracorporeal liver replacement therapy for pediatric patients. In: Pediatric Dialysis. Warady B, Schaefer F, Alexander S (Eds). Second Edition. London, Springer, 2012, pp 755–764 5. Wittebole X, Hantson P: Use of the Molecular Adsorbent Recirculating System (MARS™) for the management of acute poisoning with or without liver failure. Clin Toxicol (Phila) 2011; 49:782–793 6. Chevret L, Durand P, Lambert J, et al: High-Volume Hemofiltration in Children With Acute Liver Failure. Pediatr Crit Care Med 2014; 15:e300–e305 7. Schaefer B, Schaefer F, Engelmann G, et al: Comparison of Molecular Adsorbents Recirculating System (MARS) dialysis with combined plasma exchange and haemodialysis in children with acute liver failure. Nephrol Dial Transplant 2011; 26:3633–3639 8. Bourgoin P, Merouani A, Phan V, et al: Molecular Absorbent Recirculating System therapy (MARS®) in pediatric acute liver failure: A single center experience. Pediatr Nephrol 2014; 29:901–908 9. Gong WK, Tan TH, Foong PP, et al: Eighteen years experience in pediatric acute dialysis: Analysis of predictors of outcome. Pediatr Nephrol 2001; 16:212–215 10. Bunchman TE, McBryde KD, Mottes TE, et al: Pediatric acute renal failure: Outcome by modality and disease. Pediatr Nephrol 2001; 16:1067–1071 11. Lowrie LH: Renal replacement therapies in pediatric multiorgan dysfunction syndrome. Pediatr Nephrol 2000; 14:6–12
RBC Transfusion in Pediatric Trauma: Do We Need the Eye of Horus?* James Lin, MD Division of Pediatric Critical Care Medicine Department of Pediatrics Mattel Children’s Hospital UCLA University of California, Los Angeles (UCLA) Los Angeles, CA
T
he icon of the all-seeing eye appears in many religions and even on the great seal of the United States. One of the earliest icon, the Egyptian Eye of Horus, has been the object of diverse philosophic contemplation. In addition to illuminating the world, the Eye was thought to have healing and protective powers. The Eye’s representative hieroglyphic Wedjat is subdivided into six components, each representing a mathematical fraction or one of the six senses. In the increasingly evidence-based practice of pediatric trauma resuscitation, could it be that we need an illuminating, protective sixth sense to determine when to transfuse RBC? In this issue of Pediatric Critical Care Medicine, Hassan et al (1) compare the characteristics and outcomes of children
*See also p. e306. Key Words: noninvasive clinical monitoring; pediatric trauma; red blood cell transfusion; transfusion-related complications The author has disclosed that he does not have any potential conflicts of interest. Copyright © 2014 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies DOI: 10.1097/PCC.0000000000000215
Pediatric Critical Care Medicine
admitted to an ICU after traumatic injury, who did or did not receive packed RBC (PRBC) transfusions. Originally conceived as a quality improvement project, the study retrospectively reviewed 389 pediatric patients who have undergone trauma, who have been admitted over a 3-year period. Patients with burns and patients who had undergone massive transfusion were excluded. Eight-one patients were transfused with PRBCs. The timing of PRBC transfusion was available for 73 patients, with a quarter transfused earlier to PICU admission, one tenth transfused before and after PICU admission, and two thirds transfused after PICU admission. Demographics including the mechanism of injury were similar between transfused versus nontransfused patients, but transfused patients had greater Injury Severity Score (ISS), PICU length of stay (LOS), hospital LOS, and mortality. PRBC-transfused patients had a significantly greater need for mechanical ventilation, a longer duration of mechanical ventilation, and more pneumonia. After stratification by ISS ≥ 25 or < 25 and Glasgow Coma Scale (GCS) > 7 or ≤ 7, transfused patients in the high- and low-acuity groups had significantly longer PICU LOS, longer hospital LOS, higher mortality, and lower discharge GCS (DCGCS). Increased infections were also observed in transfused patients in the low-acuity group. When controlling for ISS and GCS, the volume of PRBC transfused was associated with longer hospital LOS in survivors. The number of transfusions was associated with the prevalence of pneumonia and longer LOS in the hospital. Multivariate logistic regression of patient’s age, storage age, of PRBC, ISS, volume transfused, and the number www.pccmjournal.org
683
