Intensive Care Medicine set us the task of outlining a global clinical research agenda for paedia... more Intensive Care Medicine set us the task of outlining a global clinical research agenda for paediatric intensive care (PIC). In line with the clinical focus of this journal, we have limited this to research that may directly influence patient care. Clinician researchers from PIC research networks of varying degrees of formality from around the world were invited to answer two main questions: (1) What have been the major recent advances in paediatric critical care research? (2) What are the top 10 studies for the next 10 years? (1) Inclusive databases are well established in many countries. These registries allow detailed observational studies and feasibility testing of clinical trial protocols. Recent trials are larger and more valuable, and (2) most common interventions in PIC are not evidenced-based. Clinical studies for the next 10 years should address this deficit, including: ventilation techniques and interfaces; fluid, transfusion and feeding strategies; optimal targets for vit...
To the Editor: Lacroix et al. (April 19 issue) 1 report that a restrictive transfusion strategy (... more To the Editor: Lacroix et al. (April 19 issue) 1 report that a restrictive transfusion strategy (a hemoglobin threshold of 7 g per deciliter) is as safe as a liberal strategy (a hemoglobin threshold of 9.5 g per deciliter) in pediatric patients in the intensive care unit whose condition is clinically ...
Presently, red blood cell units are stored up to 42 days in France and Canada. Length of storage ... more Presently, red blood cell units are stored up to 42 days in France and Canada. Length of storage of red blood cell units is not based on clinical outcomes: it is rather based on a decision made by some experts in the 1940s that red blood cell units can be stored as long as the average hemolysis is lower than 1% and the proportion of red blood cells still alive 24 hours post-transfusion is higher than 70%. Data reported recently suggest that transfusion with older red blood cell units may jeopardize the outcome of severely ill patients. In this paper, we comment the data already published on this question, and we summarize the randomized clinical trials presently on-going that were undertaken to address the relationship between length of storage of red blood cell units and outcomes of transfused patients.
We performed a retrospective analysis of the charts of 168 patients (1 week to 17 years of age) a... more We performed a retrospective analysis of the charts of 168 patients (1 week to 17 years of age) admitted to a pediatric intensive care unit (PICU) with bacterial meningitis over an 11-year period (1980–1990) to delineate clinical characteristics and outcome. The four major reasons for PICU admission were an altered level of consciousness (70%), hemodynamic instability (33%), seizures (13%), and apnea (7%). Many children had more than one reason for admission to the PICU. The pathogens identified included Haemophilus influenzae type b in 71 (42%) patients, Neisseria meningitidis in 33 (20%), Streptococcus pneumoniae (SP) in 23 (14%), Group B Streptococcus (GBS) in 18 (11%), Escherichia coli in 7 (4%), and others in 7 (4%). Overall mortality was 13% (22 of 168); most deaths (12/22) occurred within 24 hours of admission. The highest mortality rate was associated with GBS meningitis (39%). Average duration of stay in the PICU was 2.9 days. Complications in the PICU included seizures (32...
BACKGROUND: Studies suggest that despite sedation, hospitalized children in Pediatric Intensive C... more BACKGROUND: Studies suggest that despite sedation, hospitalized children in Pediatric Intensive Care Unit (PICU) still experience pain from procedures, with lasting consequences. Parental distracting talk, as opposed to empathic talk, appears to be useful in decreasing the child's distress behaviors, although physiological data were only reported in one study. Parental presence as a source of comfort has not been studied in a PICU setting. Previous studies were conducted with healthy children; we will attempt to apply parental distraction in the PICU setting. OBJECTIVE: Evaluate the effect of Maternal Touch and Talk (T&T) in infants and toddlers, <3 y.o., on physiological response to painful procedures in a PICU setting. Maternal Touch and Talk consisted of mothers touching, singing, reading or talking to the child about something unrelated to the hospitalization. DESIGN/METHODS: Cross-over design with each child serving as his own control; order of condition randomly assigne...
To discuss the tradeoff between permissive anemia and administering red blood cell transfusion to... more To discuss the tradeoff between permissive anemia and administering red blood cell transfusion to children in pediatric ICUs. Postsurgical mortality in adults increases abruptly if their nadir hemoglobin level falls below 5 g/dl. Patients with sepsis, even those in septic shock, and patients with upper gastrointestinal bleeding do not require red blood cell (RBC) transfusion if their hemoglobin level is above 7 g/dl. Anemia is common in critically ill children and is well tolerated most of the time. RBC transfusion is required in cases of hemorrhagic shock and in children with a hemoglobin level below 5 g/dl. Children with sepsis, including septic shock, those with a severe upper gastrointestinal bleeding and all stable critically ill children, including noncyanotic cardiac children older than 28 days, do not require an RBC transfusion if their hemoglobin level is above 7 g/dl. Transfusion threshold in children with univentricular physiology and in critically ill children with a hem...
Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies, Jan 22, 2015
To identify the potential complications associated with RBC transfusions. Prospective observation... more To identify the potential complications associated with RBC transfusions. Prospective observational study. PICU in a tertiary children's hospital. All children consecutively admitted to our PICU during a 1-year period. None. Data were abstracted from medical charts prospectively. Outcomes possibly attributable to RBC transfusions were looked for daily. In transfused cases, it was considered that an outcome was associated with a transfusion only if it was observed after the first RBC transfusion. During the 1-year study period, 913 consecutive admissions were documented, 842 of which were included. Among them, 144 (17%) were transfused at least once. When comparing transfused cases with nontransfused cases, the odds ratio for new or progressive multiple organ dysfunction syndrome was 2.39 (95% CI, 1.58-3.62; p < 0.001). This association remained statistically significant in the multivariable analysis for children with admission Pediatric Risk of Mortality score up to 5 (odds r...
American journal of respiratory and critical care medicine, Jan 10, 2015
Plasma transfusions are frequently prescribed for critically ill children, although their indicat... more Plasma transfusions are frequently prescribed for critically ill children, although their indications lack strong evidence base. Plasma transfusions are largely driven by physician conceptions of need and these are poorly documented in pediatric intensive care patients. To identify patient characteristics and characterize indications leading to plasma transfusions in critically ill children and to assess the effect of plasma transfusions on coagulation tests. Point-prevalence study in 101 pediatric intensive care units in 21 countries, on six pre-defined weeks. All critically ill children admitted to a participating unit were included if they received at least one plasma transfusion. During the six study weeks, 13192 children were eligible among whom 443 (3.4%) receiving at least one plasma transfusion were included. The primary indications for plasma transfusion were critical bleeding in 22.3%, minor bleeding in 21.2%, planned surgery or procedure in 11.7%, and high risk of post-op...
Background / Purpose: Transfusion is a common treatment in pediatric intensive care. Studies cond... more Background / Purpose: Transfusion is a common treatment in pediatric intensive care. Studies conducted in adults suggest that length of storage is associated with worse clinical outcome, but no such studies have yet been prospectively conducted in children.Our hypothesis is that there is an association between more prolonged RBC unit storage time and clinical outcome in critically ill children.We conducted a prospective, multicenter, observational study conducted in 29 North American centers, on consecutive patients aged <18 years with a stay ≥48 hours in a pediatric critical care unit. The primary outcome measure was an increase in multiple organ failure after transfusion. The secondary outcomes were the 28-day mortality and pediatric critical care unit length of stay. Odds ratios were adjusted for gender, weight, number of organ failures at admission, total number of transfusions, and total dose of transfusion, using a multiple logistic regression model. Main conclusion: From a...
Respiratory complications associated with RBC transfusions may be underestimated in PICUs because... more Respiratory complications associated with RBC transfusions may be underestimated in PICUs because current definitions exclude patients with preexisting respiratory dysfunction. This study aims to determine the prevalence and characterize the risk factors and outcomes of new or progressive respiratory dysfunction observed after RBC transfusion in critically ill children. Prospective cohort study of all children admitted over a 1-year period. A multidisciplinary PICU in a tertiary pediatric university hospital. Patients who received a RBC transfusion while in PICU. None. Two independent adjudicators established the diagnosis of respiratory dysfunction. A respiratory dysfunction associated with transfusion was considered new if it appeared after the first RBC transfusion in PICU. A progressive respiratory dysfunction associated with transfusion was diagnosed if the respiratory dysfunction was present before the transfusion and the PaO2/FIO2 or the SpO2/FIO2 ratio dropped by at least 20% thereafter. Among 842 children admitted into the PICU, 136 received at least one RBC transfusion and were analyzed. Fifty-eight cases of respiratory dysfunction associated with transfusion (43% of transfused patients) were detected, including nine new respiratory dysfunction associated with transfusion (7%) and 49 progressive respiratory dysfunction associated with transfusion (36%). Higher severity of illness, multiple organ dysfunction syndrome prior to transfusion, and volume (mL/kg) of RBC transfusion were independently associated with respiratory dysfunction associated with transfusion. A dose-response relationship was observed between transfusion volume (mL/kg) and the prevalence of respiratory dysfunction associated with transfusion. Patients with respiratory dysfunction associated with transfusion had more progressive multiple organ dysfunction and less ventilation-free and PICU-free days at day 28. Development of respiratory dysfunction associated with transfusion is frequent in PICU and occurs mainly in patients with prior respiratory dysfunction, who would not be identified using current definitions for transfusion-associated complications. A cause-effect relationship cannot be confirmed. However, the high prevalence and the serious adverse outcomes associated with respiratory dysfunction associated with transfusion suggest that this complication should be further studied.
Presently, red blood cell units are stored up to 42 days in France and Canada. Length of storage ... more Presently, red blood cell units are stored up to 42 days in France and Canada. Length of storage of red blood cell units is not based on clinical outcomes: it is rather based on a decision made by some experts in the 1940s that red blood cell units can be stored as long as the average hemolysis is lower than 1% and the proportion of red blood cells still alive 24 hours post-transfusion is higher than 70%. Data reported recently suggest that transfusion with older red blood cell units may jeopardize the outcome of severely ill patients. In this paper, we comment the data already published on this question, and we summarize the randomized clinical trials presently on-going that were undertaken to address the relationship between length of storage of red blood cell units and outcomes of transfused patients.
Intensive Care Medicine set us the task of outlining a global clinical research agenda for paedia... more Intensive Care Medicine set us the task of outlining a global clinical research agenda for paediatric intensive care (PIC). In line with the clinical focus of this journal, we have limited this to research that may directly influence patient care. Clinician researchers from PIC research networks of varying degrees of formality from around the world were invited to answer two main questions: (1) What have been the major recent advances in paediatric critical care research? (2) What are the top 10 studies for the next 10 years? (1) Inclusive databases are well established in many countries. These registries allow detailed observational studies and feasibility testing of clinical trial protocols. Recent trials are larger and more valuable, and (2) most common interventions in PIC are not evidenced-based. Clinical studies for the next 10 years should address this deficit, including: ventilation techniques and interfaces; fluid, transfusion and feeding strategies; optimal targets for vit...
To the Editor: Lacroix et al. (April 19 issue) 1 report that a restrictive transfusion strategy (... more To the Editor: Lacroix et al. (April 19 issue) 1 report that a restrictive transfusion strategy (a hemoglobin threshold of 7 g per deciliter) is as safe as a liberal strategy (a hemoglobin threshold of 9.5 g per deciliter) in pediatric patients in the intensive care unit whose condition is clinically ...
Presently, red blood cell units are stored up to 42 days in France and Canada. Length of storage ... more Presently, red blood cell units are stored up to 42 days in France and Canada. Length of storage of red blood cell units is not based on clinical outcomes: it is rather based on a decision made by some experts in the 1940s that red blood cell units can be stored as long as the average hemolysis is lower than 1% and the proportion of red blood cells still alive 24 hours post-transfusion is higher than 70%. Data reported recently suggest that transfusion with older red blood cell units may jeopardize the outcome of severely ill patients. In this paper, we comment the data already published on this question, and we summarize the randomized clinical trials presently on-going that were undertaken to address the relationship between length of storage of red blood cell units and outcomes of transfused patients.
We performed a retrospective analysis of the charts of 168 patients (1 week to 17 years of age) a... more We performed a retrospective analysis of the charts of 168 patients (1 week to 17 years of age) admitted to a pediatric intensive care unit (PICU) with bacterial meningitis over an 11-year period (1980–1990) to delineate clinical characteristics and outcome. The four major reasons for PICU admission were an altered level of consciousness (70%), hemodynamic instability (33%), seizures (13%), and apnea (7%). Many children had more than one reason for admission to the PICU. The pathogens identified included Haemophilus influenzae type b in 71 (42%) patients, Neisseria meningitidis in 33 (20%), Streptococcus pneumoniae (SP) in 23 (14%), Group B Streptococcus (GBS) in 18 (11%), Escherichia coli in 7 (4%), and others in 7 (4%). Overall mortality was 13% (22 of 168); most deaths (12/22) occurred within 24 hours of admission. The highest mortality rate was associated with GBS meningitis (39%). Average duration of stay in the PICU was 2.9 days. Complications in the PICU included seizures (32...
BACKGROUND: Studies suggest that despite sedation, hospitalized children in Pediatric Intensive C... more BACKGROUND: Studies suggest that despite sedation, hospitalized children in Pediatric Intensive Care Unit (PICU) still experience pain from procedures, with lasting consequences. Parental distracting talk, as opposed to empathic talk, appears to be useful in decreasing the child's distress behaviors, although physiological data were only reported in one study. Parental presence as a source of comfort has not been studied in a PICU setting. Previous studies were conducted with healthy children; we will attempt to apply parental distraction in the PICU setting. OBJECTIVE: Evaluate the effect of Maternal Touch and Talk (T&T) in infants and toddlers, <3 y.o., on physiological response to painful procedures in a PICU setting. Maternal Touch and Talk consisted of mothers touching, singing, reading or talking to the child about something unrelated to the hospitalization. DESIGN/METHODS: Cross-over design with each child serving as his own control; order of condition randomly assigne...
To discuss the tradeoff between permissive anemia and administering red blood cell transfusion to... more To discuss the tradeoff between permissive anemia and administering red blood cell transfusion to children in pediatric ICUs. Postsurgical mortality in adults increases abruptly if their nadir hemoglobin level falls below 5 g/dl. Patients with sepsis, even those in septic shock, and patients with upper gastrointestinal bleeding do not require red blood cell (RBC) transfusion if their hemoglobin level is above 7 g/dl. Anemia is common in critically ill children and is well tolerated most of the time. RBC transfusion is required in cases of hemorrhagic shock and in children with a hemoglobin level below 5 g/dl. Children with sepsis, including septic shock, those with a severe upper gastrointestinal bleeding and all stable critically ill children, including noncyanotic cardiac children older than 28 days, do not require an RBC transfusion if their hemoglobin level is above 7 g/dl. Transfusion threshold in children with univentricular physiology and in critically ill children with a hem...
Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies, Jan 22, 2015
To identify the potential complications associated with RBC transfusions. Prospective observation... more To identify the potential complications associated with RBC transfusions. Prospective observational study. PICU in a tertiary children's hospital. All children consecutively admitted to our PICU during a 1-year period. None. Data were abstracted from medical charts prospectively. Outcomes possibly attributable to RBC transfusions were looked for daily. In transfused cases, it was considered that an outcome was associated with a transfusion only if it was observed after the first RBC transfusion. During the 1-year study period, 913 consecutive admissions were documented, 842 of which were included. Among them, 144 (17%) were transfused at least once. When comparing transfused cases with nontransfused cases, the odds ratio for new or progressive multiple organ dysfunction syndrome was 2.39 (95% CI, 1.58-3.62; p < 0.001). This association remained statistically significant in the multivariable analysis for children with admission Pediatric Risk of Mortality score up to 5 (odds r...
American journal of respiratory and critical care medicine, Jan 10, 2015
Plasma transfusions are frequently prescribed for critically ill children, although their indicat... more Plasma transfusions are frequently prescribed for critically ill children, although their indications lack strong evidence base. Plasma transfusions are largely driven by physician conceptions of need and these are poorly documented in pediatric intensive care patients. To identify patient characteristics and characterize indications leading to plasma transfusions in critically ill children and to assess the effect of plasma transfusions on coagulation tests. Point-prevalence study in 101 pediatric intensive care units in 21 countries, on six pre-defined weeks. All critically ill children admitted to a participating unit were included if they received at least one plasma transfusion. During the six study weeks, 13192 children were eligible among whom 443 (3.4%) receiving at least one plasma transfusion were included. The primary indications for plasma transfusion were critical bleeding in 22.3%, minor bleeding in 21.2%, planned surgery or procedure in 11.7%, and high risk of post-op...
Background / Purpose: Transfusion is a common treatment in pediatric intensive care. Studies cond... more Background / Purpose: Transfusion is a common treatment in pediatric intensive care. Studies conducted in adults suggest that length of storage is associated with worse clinical outcome, but no such studies have yet been prospectively conducted in children.Our hypothesis is that there is an association between more prolonged RBC unit storage time and clinical outcome in critically ill children.We conducted a prospective, multicenter, observational study conducted in 29 North American centers, on consecutive patients aged <18 years with a stay ≥48 hours in a pediatric critical care unit. The primary outcome measure was an increase in multiple organ failure after transfusion. The secondary outcomes were the 28-day mortality and pediatric critical care unit length of stay. Odds ratios were adjusted for gender, weight, number of organ failures at admission, total number of transfusions, and total dose of transfusion, using a multiple logistic regression model. Main conclusion: From a...
Respiratory complications associated with RBC transfusions may be underestimated in PICUs because... more Respiratory complications associated with RBC transfusions may be underestimated in PICUs because current definitions exclude patients with preexisting respiratory dysfunction. This study aims to determine the prevalence and characterize the risk factors and outcomes of new or progressive respiratory dysfunction observed after RBC transfusion in critically ill children. Prospective cohort study of all children admitted over a 1-year period. A multidisciplinary PICU in a tertiary pediatric university hospital. Patients who received a RBC transfusion while in PICU. None. Two independent adjudicators established the diagnosis of respiratory dysfunction. A respiratory dysfunction associated with transfusion was considered new if it appeared after the first RBC transfusion in PICU. A progressive respiratory dysfunction associated with transfusion was diagnosed if the respiratory dysfunction was present before the transfusion and the PaO2/FIO2 or the SpO2/FIO2 ratio dropped by at least 20% thereafter. Among 842 children admitted into the PICU, 136 received at least one RBC transfusion and were analyzed. Fifty-eight cases of respiratory dysfunction associated with transfusion (43% of transfused patients) were detected, including nine new respiratory dysfunction associated with transfusion (7%) and 49 progressive respiratory dysfunction associated with transfusion (36%). Higher severity of illness, multiple organ dysfunction syndrome prior to transfusion, and volume (mL/kg) of RBC transfusion were independently associated with respiratory dysfunction associated with transfusion. A dose-response relationship was observed between transfusion volume (mL/kg) and the prevalence of respiratory dysfunction associated with transfusion. Patients with respiratory dysfunction associated with transfusion had more progressive multiple organ dysfunction and less ventilation-free and PICU-free days at day 28. Development of respiratory dysfunction associated with transfusion is frequent in PICU and occurs mainly in patients with prior respiratory dysfunction, who would not be identified using current definitions for transfusion-associated complications. A cause-effect relationship cannot be confirmed. However, the high prevalence and the serious adverse outcomes associated with respiratory dysfunction associated with transfusion suggest that this complication should be further studied.
Presently, red blood cell units are stored up to 42 days in France and Canada. Length of storage ... more Presently, red blood cell units are stored up to 42 days in France and Canada. Length of storage of red blood cell units is not based on clinical outcomes: it is rather based on a decision made by some experts in the 1940s that red blood cell units can be stored as long as the average hemolysis is lower than 1% and the proportion of red blood cells still alive 24 hours post-transfusion is higher than 70%. Data reported recently suggest that transfusion with older red blood cell units may jeopardize the outcome of severely ill patients. In this paper, we comment the data already published on this question, and we summarize the randomized clinical trials presently on-going that were undertaken to address the relationship between length of storage of red blood cell units and outcomes of transfused patients.
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