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
Editorials
of transfusions revealed that the age of transfused PRBCs was independently associated with lengthier mechanical ventilation, fewer complications, and higher mortality. Greater volume of PRBC transfusion was independently associated with hospital LOS more than 7 days, and greater number of transfusions was associated with PICU LOS more than 7 days. Although the study by Hassan et al (1) is retrospective and primarily hypothesis-generating, the authors have made appropriate efforts to isolate the possible effects of PRBC transfusions from other risk factors for worse outcomes. To mitigate the effects of overall worse injury in the transfused population, the authors have performed a variety of analyses that were stratified according to ISS, GCS, and the site and extent of injury. Repeated multiple logistic regression analyses were adjusted for ISS and GCS while evaluating the effects of PRBC transfusion on clinical outcomes. Finally, the third strategy of assessing dose-response relationships for PRBC transfusion number, volume transfused, and age of stored blood all lend consistent support to the assertion that PRBC transfusion may be an independent risk factor for worse clinical outcome in pediatric trauma, rather than a covariate with severity of illness. In other words, this series of analyses leads to the hypothesis that PRBC transfusion was not simply required for sicker pediatric patients who have undergone trauma, but that PRBC transfusion might have led those patients to become sicker. A randomized controlled trial would be necessary to evaluate such causality, but the current state of transfusion guidelines makes such a trial difficult to accomplish. PRBC transfusion is an integral part of trauma resuscitation and the Advanced Trauma Life Support (ATLS) Guidelines (2). As hemorrhage is the main cause of shock in trauma, appropriate resuscitation with blood products is indicated. Moderate-to-severe hemorrhage, or class III and IV hemorrhage (associated with at least 30% blood-volume loss), typically requires PRBC to reverse shock. The ATLS Guidelines further suggest that if more than two boluses of 20 mL/kg are required, then 10 mL/kg PRBCs should be considered in place of the 3rd crystalloid bolus. Significantly increased mortality has been observed with crystalloid:PRBC ratio more than 1.5:1 in patients who have undergone trauma, who require massive PRBC transfusion (> 10 units in the first 24 hr) (3). Clinical response to PRBC transfusion is an essential part of the ATLS pediatric fluid resuscitation algorithm and guides the decision to operate. Thus, excessive restraint when considering PRBC transfusions can be life-threatening in pediatric patients who have undergone trauma. In contrast, accumulating literature on critical care cautions against unnecessary PRBC transfusions. Landmark trials in adult ICU and PICU patients established the safety of a restrictive strategy using a threshold hemoglobin level of less than 7 g/dL (4, 5). Additional studies suggested an independent association between PRBC transfusions and increased ICU LOS, mortality, nosocomial infections, and prolonged mechanical ventilation (6–10). Based on this background, the data presented by Hassan et al (1) are consistent with the 684
www.pccmjournal.org
preceding decade of literature on critically ill adult and pediatric PRBC transfusions. Why might transfusion of PRBCs in trauma worsen clinical outcomes? Although specific research is lacking, one may speculate regarding interactions between the well-recognized clinical progression of inflammation and immunosuppression in patients who have undergone trauma (11) and similar effects associated with PRBC transfusions. A multitude of complications following blood product transfusion have been described: transmission of infectious organisms, hemolytic and nonhemolytic transfusion reactions, allergic or anaphylactic reactions, transfusion-related acute lung injury, transfusion-associated circulatory overload, transfusion-related immunomodulation, transfusion-associated graft-versus-host disease, and microchimerism. Additionally, the duration of PRBC storage has been associated with diminished cellular integrity, defective oxygen transport, and proinflammatory oxidative properties. More detailed discussion and mechanisms can be found in a recent review by Sloniewsky (12). With regard to possible storage defects, the study by Hassan et al (1) was consistent with the general literature on PICU, finding that transfusion with PRBC stored for more than 28 days versus less than 28 days was associated with longer hospital LOS, lower DC-GCS, and higher mortality. In view of the growing recognition of risks versus benefits of PRBC transfusion, clinicians increasingly need to balance the well-established benefits of PRBC transfusion in pediatric trauma versus the more insidious complications that may worsen overall clinical outcomes. A multipronged research approach to this problem may include the development of interventions to mitigate PRBC transfusion complications and storage defects, new oxygen-carrying substances, and strategies to reduce blood loss. The most immediate impact might be achieved by a rational, restrictive approach to transfusion in the pediatric patient who has undergone trauma. However, what current markers can guide our clinical decision to transfuse? Threshold hemoglobin concentration as established in general studies on PICU transfusion may be logically confounded in the trauma situation by ongoing hemorrhage and lack of hemodilution or homeostasis. Other clinical markers contributing to the decisions to transfuse—for instance, respiratory failure, hemodynamic instability, and presence of multiple organ dysfunction syndrome—have not been studied with respect to outcomes after PRBC transfusion (13). Multiple current technologies have the potential to improve assessment of the need for blood in trauma: near-infrared spectrometry (14), measures of heart rate variability (15), ultrasonography (16), noninvasive hemoglobinometry (17), and rapid thromboelastography (18), among others. Perhaps, one of these or a newer technology will be our Eye of Horus. The study by Hassan et al (1) adds to the cumulative literature on pediatric critically ill (and now pediatric patients who have undergone trauma) patients who require great care when weighing whether to transfuse RBCs. Although clinicians may not perhaps need an all-seeing eye to guide and protect patients, September 2014 • Volume 15 • Number 7
Editorials
hopefully future research will provide clearer insight on which to base our transfusion decisions in pediatric trauma intensive care.
REFERENCES
1. Hassan NE, DeCou JM, Reischman D, et al: RBC Transfusions in Children Requiring Intensive Care Admission After Traumatic Injury. Pediatr Crit Care Med 2014; 15:e306–e313 2. American College of Surgeons Committee on Trauma: ATLS Advanced Trauma Life Support for Doctors–Student Course Manual. Ninth Edition. Chicago, IL, American College of Surgeons, 2012 3. Neal MD, Hoffman MK, Cuschieri J, et al: Crystalloid to packed red blood cell transfusion ratio in the massively transfused patient: When a little goes a long way. J Trauma Acute Care Surg 2012; 72:892–898 4. Hebert PC, Wells G, Blajchman MA, et al: A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. N Engl J Med 1999; 340:409–417 5. Lacroix J, Hébert PC, Hutchison JS, et al; TRIPICU Investigators; Canadian Critical Care Trials Group; Pediatric Acute Lung Injury and Sepsis Investigators Network: Transfusion strategies for patients in pediatric intensive care units. N Engl J Med 2007; 356: 1609–1619 6. Vincent JL, Baron JF, Reinhart K, et al; ABC (Anemia and Blood Transfusion in Critical Care) Investigators: Anemia and blood transfusion in critically ill patients. JAMA 2002; 288:1499–1507 7. Corwin HL, Gettinger A, Pearl RG, et al: The CRIT Study: Anemia and blood transfusion in the critically ill–current clinical practice in the United States. Crit Care Med 2004; 32:39–52 8. White M, Barron J, Gornbein J, et al: Are red blood cell transfusions associated with nosocomial infections in pediatric intensive care units? Pediatr Crit Care Med 2010; 11:464–468
Pediatric Critical Care Medicine
9. Kneyber MC, Grotenhuis F, Berger RF, et al: Transfusion of leukocytedepleted RBCs is independently associated with increased morbidity after pediatric cardiac surgery. Pediatr Crit Care Med 2013; 14:298–305 10. Glance LG, Dick AW, Mukamel DB, et al: Association between intraoperative blood transfusion and mortality and morbidity in patients undergoing noncardiac surgery. Anesthesiology 2011; 114:283–292 11. Gentile LF, Cuenca AG, Efron PA, et al: Persistent inflammation and immunosuppression: A common syndrome and new horizon for surgical intensive care. J Trauma Acute Care Surg 2012; 72: 1491–1501 12. Sloniewsky D: Anemia and transfusion in critically ill pediatric patients: A review of etiology, management, and outcomes. Crit Care Clin 2013; 29:301–317 13. Armano R, Gauvin F, Ducruet T, et al: Determinants of red blood cell transfusions in a pediatric critical care unit: A prospective, descriptive epidemiological study. Crit Care Med 2005; 33: 2637–2644 14. Moore FA, Nelson T, McKinley BA, et al; StO2 Study Group: Massive transfusion in trauma patients: Tissue hemoglobin oxygen saturation predicts poor outcome. J Trauma 2008; 64:1010–1023 15. Cooke WH, Convertino VA: Heart rate variability and spontaneous baroreflex sequences: Implications for autonomic monitoring during hemorrhage. J Trauma 2005; 58:798–805 16. Murthi SB, Stansbury LG, Dutton RP, et al: Transfusion medicine in trauma patients: An update. Expert Rev Hematol 2011; 4:527–537 17. Moore LJ, Wade CE, Vincent L, et al: Evaluation of noninvasive hemoglobin measurements in trauma patients. Am J Surg 2013; 206:1041–1047 18. Jeger V, Zimmermann H, Exadaktylos AK: Can RapidTEG accelerate the search for coagulopathies in the patient with multiple injuries? J Trauma 2009; 66:1253–1257
www.pccmjournal.org
685
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
Editorials
of transfusions revealed that the age of transfused PRBCs was independently associated with lengthier mechanical ventilation, fewer complications, and higher mortality. Greater volume of PRBC transfusion was independently associated with hospital LOS more than 7 days, and greater number of transfusions was associated with PICU LOS more than 7 days. Although the study by Hassan et al (1) is retrospective and primarily hypothesis-generating, the authors have made appropriate efforts to isolate the possible effects of PRBC transfusions from other risk factors for worse outcomes. To mitigate the effects of overall worse injury in the transfused population, the authors have performed a variety of analyses that were stratified according to ISS, GCS, and the site and extent of injury. Repeated multiple logistic regression analyses were adjusted for ISS and GCS while evaluating the effects of PRBC transfusion on clinical outcomes. Finally, the third strategy of assessing dose-response relationships for PRBC transfusion number, volume transfused, and age of stored blood all lend consistent support to the assertion that PRBC transfusion may be an independent risk factor for worse clinical outcome in pediatric trauma, rather than a covariate with severity of illness. In other words, this series of analyses leads to the hypothesis that PRBC transfusion was not simply required for sicker pediatric patients who have undergone trauma, but that PRBC transfusion might have led those patients to become sicker. A randomized controlled trial would be necessary to evaluate such causality, but the current state of transfusion guidelines makes such a trial difficult to accomplish. PRBC transfusion is an integral part of trauma resuscitation and the Advanced Trauma Life Support (ATLS) Guidelines (2). As hemorrhage is the main cause of shock in trauma, appropriate resuscitation with blood products is indicated. Moderate-to-severe hemorrhage, or class III and IV hemorrhage (associated with at least 30% blood-volume loss), typically requires PRBC to reverse shock. The ATLS Guidelines further suggest that if more than two boluses of 20 mL/kg are required, then 10 mL/kg PRBCs should be considered in place of the 3rd crystalloid bolus. Significantly increased mortality has been observed with crystalloid:PRBC ratio more than 1.5:1 in patients who have undergone trauma, who require massive PRBC transfusion (> 10 units in the first 24 hr) (3). Clinical response to PRBC transfusion is an essential part of the ATLS pediatric fluid resuscitation algorithm and guides the decision to operate. Thus, excessive restraint when considering PRBC transfusions can be life-threatening in pediatric patients who have undergone trauma. In contrast, accumulating literature on critical care cautions against unnecessary PRBC transfusions. Landmark trials in adult ICU and PICU patients established the safety of a restrictive strategy using a threshold hemoglobin level of less than 7 g/dL (4, 5). Additional studies suggested an independent association between PRBC transfusions and increased ICU LOS, mortality, nosocomial infections, and prolonged mechanical ventilation (6–10). Based on this background, the data presented by Hassan et al (1) are consistent with the 684
www.pccmjournal.org
preceding decade of literature on critically ill adult and pediatric PRBC transfusions. Why might transfusion of PRBCs in trauma worsen clinical outcomes? Although specific research is lacking, one may speculate regarding interactions between the well-recognized clinical progression of inflammation and immunosuppression in patients who have undergone trauma (11) and similar effects associated with PRBC transfusions. A multitude of complications following blood product transfusion have been described: transmission of infectious organisms, hemolytic and nonhemolytic transfusion reactions, allergic or anaphylactic reactions, transfusion-related acute lung injury, transfusion-associated circulatory overload, transfusion-related immunomodulation, transfusion-associated graft-versus-host disease, and microchimerism. Additionally, the duration of PRBC storage has been associated with diminished cellular integrity, defective oxygen transport, and proinflammatory oxidative properties. More detailed discussion and mechanisms can be found in a recent review by Sloniewsky (12). With regard to possible storage defects, the study by Hassan et al (1) was consistent with the general literature on PICU, finding that transfusion with PRBC stored for more than 28 days versus less than 28 days was associated with longer hospital LOS, lower DC-GCS, and higher mortality. In view of the growing recognition of risks versus benefits of PRBC transfusion, clinicians increasingly need to balance the well-established benefits of PRBC transfusion in pediatric trauma versus the more insidious complications that may worsen overall clinical outcomes. A multipronged research approach to this problem may include the development of interventions to mitigate PRBC transfusion complications and storage defects, new oxygen-carrying substances, and strategies to reduce blood loss. The most immediate impact might be achieved by a rational, restrictive approach to transfusion in the pediatric patient who has undergone trauma. However, what current markers can guide our clinical decision to transfuse? Threshold hemoglobin concentration as established in general studies on PICU transfusion may be logically confounded in the trauma situation by ongoing hemorrhage and lack of hemodilution or homeostasis. Other clinical markers contributing to the decisions to transfuse—for instance, respiratory failure, hemodynamic instability, and presence of multiple organ dysfunction syndrome—have not been studied with respect to outcomes after PRBC transfusion (13). Multiple current technologies have the potential to improve assessment of the need for blood in trauma: near-infrared spectrometry (14), measures of heart rate variability (15), ultrasonography (16), noninvasive hemoglobinometry (17), and rapid thromboelastography (18), among others. Perhaps, one of these or a newer technology will be our Eye of Horus. The study by Hassan et al (1) adds to the cumulative literature on pediatric critically ill (and now pediatric patients who have undergone trauma) patients who require great care when weighing whether to transfuse RBCs. Although clinicians may not perhaps need an all-seeing eye to guide and protect patients, September 2014 • Volume 15 • Number 7
Editorials
hopefully future research will provide clearer insight on which to base our transfusion decisions in pediatric trauma intensive care.
REFERENCES
1. Hassan NE, DeCou JM, Reischman D, et al: RBC Transfusions in Children Requiring Intensive Care Admission After Traumatic Injury. Pediatr Crit Care Med 2014; 15:e306–e313 2. American College of Surgeons Committee on Trauma: ATLS Advanced Trauma Life Support for Doctors–Student Course Manual. Ninth Edition. Chicago, IL, American College of Surgeons, 2012 3. Neal MD, Hoffman MK, Cuschieri J, et al: Crystalloid to packed red blood cell transfusion ratio in the massively transfused patient: When a little goes a long way. J Trauma Acute Care Surg 2012; 72:892–898 4. Hebert PC, Wells G, Blajchman MA, et al: A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. N Engl J Med 1999; 340:409–417 5. Lacroix J, Hébert PC, Hutchison JS, et al; TRIPICU Investigators; Canadian Critical Care Trials Group; Pediatric Acute Lung Injury and Sepsis Investigators Network: Transfusion strategies for patients in pediatric intensive care units. N Engl J Med 2007; 356: 1609–1619 6. Vincent JL, Baron JF, Reinhart K, et al; ABC (Anemia and Blood Transfusion in Critical Care) Investigators: Anemia and blood transfusion in critically ill patients. JAMA 2002; 288:1499–1507 7. Corwin HL, Gettinger A, Pearl RG, et al: The CRIT Study: Anemia and blood transfusion in the critically ill–current clinical practice in the United States. Crit Care Med 2004; 32:39–52 8. White M, Barron J, Gornbein J, et al: Are red blood cell transfusions associated with nosocomial infections in pediatric intensive care units? Pediatr Crit Care Med 2010; 11:464–468
Pediatric Critical Care Medicine
9. Kneyber MC, Grotenhuis F, Berger RF, et al: Transfusion of leukocytedepleted RBCs is independently associated with increased morbidity after pediatric cardiac surgery. Pediatr Crit Care Med 2013; 14:298–305 10. Glance LG, Dick AW, Mukamel DB, et al: Association between intraoperative blood transfusion and mortality and morbidity in patients undergoing noncardiac surgery. Anesthesiology 2011; 114:283–292 11. Gentile LF, Cuenca AG, Efron PA, et al: Persistent inflammation and immunosuppression: A common syndrome and new horizon for surgical intensive care. J Trauma Acute Care Surg 2012; 72: 1491–1501 12. Sloniewsky D: Anemia and transfusion in critically ill pediatric patients: A review of etiology, management, and outcomes. Crit Care Clin 2013; 29:301–317 13. Armano R, Gauvin F, Ducruet T, et al: Determinants of red blood cell transfusions in a pediatric critical care unit: A prospective, descriptive epidemiological study. Crit Care Med 2005; 33: 2637–2644 14. Moore FA, Nelson T, McKinley BA, et al; StO2 Study Group: Massive transfusion in trauma patients: Tissue hemoglobin oxygen saturation predicts poor outcome. J Trauma 2008; 64:1010–1023 15. Cooke WH, Convertino VA: Heart rate variability and spontaneous baroreflex sequences: Implications for autonomic monitoring during hemorrhage. J Trauma 2005; 58:798–805 16. Murthi SB, Stansbury LG, Dutton RP, et al: Transfusion medicine in trauma patients: An update. Expert Rev Hematol 2011; 4:527–537 17. Moore LJ, Wade CE, Vincent L, et al: Evaluation of noninvasive hemoglobin measurements in trauma patients. Am J Surg 2013; 206:1041–1047 18. Jeger V, Zimmermann H, Exadaktylos AK: Can RapidTEG accelerate the search for coagulopathies in the patient with multiple injuries? J Trauma 2009; 66:1253–1257
www.pccmjournal.org
685
