Article

Is Transfusion an Independent Predictive Risk Factor of Postoperative Outcome in Pediatric Orthopedic Surgical Patients? A Retrospective Study.

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Abstract

Background: Intraoperative and postoperative morbi-mortality factors are multiple in pediatric patients. Studies in pediatric cardiac surgery and intensive care patients have identified transfusion as one independent factor among others. Objectives: To investigate whether transfusion was an independent risk factor of postoperative outcome in pediatric orthopedic surgical patients. Design: Retrospective observational descriptive pediatric cohort study. Setting: Monocentric pediatric tertiary center, Necker University Sick Children’s Hospital Paris, from 1 January 2014 to 17 May 2017. Patients: 195 patients with a median age of 144 months [106.5- 178.5] were included. Inclusion criteria was the presence or the absence of transfusion in the intraoperative period in orthopedic surgery. Exclusion criterion was transfusion in the postoperative period until discharge from hospital. Main outcome measures: Primary outcome was morbidity in transfused and nontransfused patients. Morbidity was assessed by deaths, complications and repeat surgery occuring intraoperatively or postoperatively during the entire hospitalization. Secondary outcome was assessed by length of stay in the intensive care unit, in the hospitalisation ward, total length of stay in hospital and duration of mechanical ventilation. Statistical analysis: Multiple logistic and log-linear regressions were used to assess for independent predictors of outcome. Results: ASA score [odds ratio 2.73, p-value<0.01 ] and transfusion [odds ratio 1.98, p-value<0.01] were independent predictive risk factors for complications. Emergency surgery [odds ratio 7.62, p-value<0.01] was the independent predictive risk factor for repeat surgery. ASA score, transfusion and emergency surgery [p-value<0.01] were independent predictive risk factors for length of stay in the intensive care unit and length of stay in hospital. ASA score, transfusion and age [p-value<0.01] were independent predictive risk factors for length of mechanical ventilation. There was no mortality in this cohort. Conclusions: Transfusion was an independent predictive risk factor among others for postoperative outcome. Specific measures aiming to reduce exposure to blood products in potential hemorrhagic surgery like scoliosis can improve outcome.

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... All patients were transfused intra-operatively. The median packed red blood cell volume was 2 [1][2][3][4][5][6][7][8][9][10][11][12] units, the median fresh frozen plasma volume was 5[0-16] units and the median concentrated platelet volume was 0[0-6] units. The mean preoperative hemoglobin level was 9.8±1 g/dL, and the mean postoperative hemoglobin level was 10.6±1.5 g/dL. ...
... All patients were transfused intra-operatively with packed red blood cells and or fresh frozen plasma and or platelet units. Transfusion with all sorts of blood product which is a necessary therapeutic in hemorrhagic surgery has been correlated with adverse postoperative outcome in terms of organ dysfunction and length of hospital and intensive care unit stays and length of mechanical ventilation in critically ill patients (1,3,4,5). In children, patient blood management programs with goal directed transfusion guided with point of care viscoelastic devices have been shown to reduce intra-operative fresh frozen plasma and length of hospital stay in hemorrhagic interventions like liver transplantation (6). ...
... Monitoring and optimizing these biomarkers should be part of intra-operative patient management in critically ill patients and major surgery. Postoperative outcome depends on multiple predictors (1,3,4,5). In this study, the rate of postoperative cardio-circulatory, neurologic, multiple organ and respiratory failure was 26.3, 10.5, 5.3 and 5.3 % respectively. ...
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Background: Liver transplantation is a hemorrhagic surgery with high postoperative complication rates in terms of organ dysfunction and infections. We conducted a retrospective observational monocentric study that had the objectives of determining predictors of postoperative outcome in children. In the initial cohort, 19 children underwent liver transplantation. A description of the postoperative outcomes of these patients was undertaken. Objective: To describe intraoperative and postoperative outcomes in children undergoing liver transplantation and to propose intraoperative management implementation measures for postoperative outcome improvement. Methods: Secondary analysis of liver transplanted patients included in the initial study. Results: There were 19 patients who underwent liver transplantation with a median age of 31[2-154] months. Five patients had re-operations (26.3%). Fourteen (73.7%) had intraoperative and/or postoperative complications. Five (26.3%) had intraoperative hemorrhagic shock. One (5.3%) had postoperative respiratory failure, one (5.3%) had postoperative multiple organ failure, two (10.5%) had postoperative neurologic failure and five (26.3%) had cardio-circulatory failure. One (5.3%) had postoperative pulmonary sepsis, five (26.3%) had postoperative abdominal sepsis, and six (31.6%) had postoperative septicemia. Intra-operative transfusion rate was 100%. In-hospital mortality rate was 10.5% (two patients). Conclusion: There were multiple postoperative adverse outcome predictors. Optimal intraoperative patient management with transfusion guided by point-of-care viscoelastic devices and goal-directed fluid and hemodynamic therapy with validated parameters and tools in children is a possible pathway to upgrade postoperative evolution in pediatric liver transplantation.
... A Thesis Project has been undertaken which has the objectives to determine the impact of Goal directed therapies on postoperative outcome in children [1]. The background of this Thesis Project were the results of five retrospective observational studies realized in the pediatric surgical settings [2][3][4][5][6]. These studies had the objectives of determining predictors of adverse postoperative outcomes in the surgical pediatric population. ...
... The ideal hemoglobin level is one that avoids situations where VO 2 is dependent on DO 2 and depends on the clinical context [22]. Since transfusion of all sorts of blood products has been related to postoperative morbidity in terms of organ dysfunction among others, it is important to transfuse the right product at the right time [2][3][4][5]. Using point of care viscoelastic methods can be helpful to guide and transfuse correctly [24][25][26][27][28]. ...
... The important issue is to avoid unnecessary blood product administration which increases morbidity [2][3][4][5] and also avoid unnecessary anemia which can increase mortality [26]. In hemorrhagic settings like surgery, point of care devices can be useful to detect coagulation disorders which can be promptly treated with the appropriate blood products. ...
... It has been evidenced that in pediatric neurosurgery, abdominal and orthopedic surgery, ASA score (American Society of Anesthesiologists score), transfusion, emergency surgery, age, type of surgery were independent predictive factors of postoperative outcomes in terms of organ dysfunction, length of intensive care unit stay (LOSICU), length of mechanical ventilation (LMV), length of hospital stay (LOS) and total length of hospital stay, (TLOS) (LOSICU+LOS) (1,2,3,4). In a study where 594 surgical patients with a mean age of 90.86±71.80 ...
... Preoperative hemoglobin levels were signi cantly correlated to LOSICU, LOS, TLOS and the number of patients with intra-operative and postoperative complications however considering the variability of these outcomes which was between 4 and 9%, other variables also predicted these outcomes as it has been evidenced earlier in the initial studies (1,2,3,4). In these studies, it was demonstrated that complications, re-surgery, LOSICU, LOS, TLOS, LMV were predicted by the ASA status, transfusion, emergency, age and surgery. ...
... It has also been shown that in the general pediatric population anemia was related to mortality and neurodevelopmental disorders (8). In this secondary analysis, there was no correlation between preoperative hemoglobin levels and mortality which is not a surprise since in the initial studies, the independent predictor of mortality in this cohort was the ASA score (1)(2)(3)(4). According to Page 12/32 this analysis, preoperative hemoglobin levels less than 6 g/dL were correlated to high LOSICU, LOS and TLOS. ...
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Background: Postoperative outcome in children is multifactorial. Among the reported predictors of postoperative outcome, preoperative anemia has been related to adverse outcome in children. A secondary analysis was undertaken to determine the correlation between hemoglobin levels and postoperative outcome in children included in a cohort of an observational pediatric study published previously since this analysis has not been done. Objective: To determine the correlation between preoperative, intra-operative, postoperative hemoglobin levels and postoperative outcome in children in neurosurgery, abdominal and orthopedic surgery. Methods: Secondary analysis of a sub-cohort of 252 pediatric surgical patients with a median age of 62 months [12.50-144.00]. Results: Preoperative hemoglobin levels were negatively correlated to length of stay in the intensive care unit (LOSICU) (p=0.002), to length of hospital stay (LOS) (p<0.0001), to the number of patients with intra-operative and/or postoperative complications (p<0.0001) and to re-surgery (p<0001). Low preoperative hemoglobin levels below 6 g/dL were correlated to higher postoperative LOSICU and LOS. Intra-operative hemoglobin levels were negatively correlated to LOS (p<0.0001) and to the number of patients with intra-operative and/or postoperative complications (p=0.004). Low intra-operative hemoglobin levels below 5 g/dL were correlated to higher LOS. Postoperative hemoglobin levels were positively correlated to LMV (p=0.002). Conclusion: Hemoglobin levels are among other multifactorial predictors of postoperative outcome in pediatric surgical patients emphasizing the importance of a global patient blood management implementation program to improve outcome in surgical children.
... All patients were transfused intra-operatively. The median packed red blood cell volume was 2 [1][2][3][4][5][6][7][8][9][10][11][12] units, the median fresh frozen plasma volume was 5[0-16] units and the median concentrated platelet volume was 0[0-6] units. The mean preoperative hemoglobin level was 9.8±1 g/dL, and the mean postoperative hemoglobin level was 10.6±1.5 g/dL. ...
... Transfusion with all sorts of blood products, which is a necessary therapeutic in hemorrhagic surgery, has been correlated with adverse postoperative outcomes in terms of organ dysfunction, length of hospital and intensive care unit stays and length of mechanical ventilation in critically ill patients (1,3,4,5). In children, patient blood management programs with goal-directed transfusion guided with point-of-care viscoelastic devices have been shown to reduce intraoperative fresh frozen plasma and length of hospital stay in hemorrhagic interventions such as liver transplantation (6). ...
... Monitoring and optimizing these biomarkers should be part of intraoperative patient management in critically ill patients and major surgery. Postoperative outcomes depend on multiple predictors (1,3,4,5). In this study, the rates of postoperative cardio-circulatory, neurologic, multiple organ and respiratory failure were 26.3, 10.5, 5.3 and 5.3%, respectively. ...
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Full-text available
Background: Liver transplantation is a hemorrhagic surgery with high postoperative complication rates in terms of organ dysfunction and infections. We conducted a retrospective observational monocentric study that had the objectives of determining predictors of postoperative outcome in children. In the initial cohort, 19 children underwent liver transplantation. A description of the postoperative outcomes of these patients was undertaken. Objective: To describe intraoperative and postoperative outcomes in children undergoing liver transplantation and to propose intraoperative management implementation measures for postoperative outcome improvement. Methods: Secondary analysis of liver transplanted patients included in the initial study. Results: There were 19 patients who underwent liver transplantation with a median age of 31[2-154] months. Five patients had re-operations (26.3%). Fourteen (73.7%) had intraoperative and/or postoperative complications. Five (26.3%) had intraoperative hemorrhagic shock. One (5.3%) had postoperative respiratory failure, one (5.3%) had postoperative multiple organ failure, two (10.5%) had postoperative neurologic failure and five (26.3%) had cardio-circulatory failure. One (5.3%) had postoperative pulmonary sepsis, five (26.3%) had postoperative abdominal sepsis, and six (31.6%) had postoperative septicemia. Intra-operative transfusion rate was 100%. In-hospital mortality rate was 10.5% (two patients). Conclusion: There were multiple postoperative adverse outcome predictors. Optimal intraoperative patient management with transfusion guided by point-of-care viscoelastic devices and goal-directed fluid and hemodynamic therapy with validated parameters and tools in children is a possible pathway to upgrade postoperative evolution in pediatric liver transplantation.
... Postoperative outcome predictors in this study were American Society of Anesthesiologists status (ASA), transfusion, emergency, surgery and age. A similar analysis in different surgical settings was undertaken and conducted to the same conclusions (2,3,4). ...
... To emphasize the importance of postoperative outcome in surgical children, a secondary analysis was conducted with the objective to describe in detail with regard to age, postoperative evolution in children aged between 10 and 18 years included in the initial retrospective study (1). Similar secondary analyses have been conducted in pre-terms, infants less than 1 year old, children aged between 1 and 3 years, children from 3 to 6 years old and children from 6 to 10 years with the objective to describe postoperative outcome with consideration to age since age has been revealed to be an independent predictor of postoperative outcome (1,2,3,4). ...
... A recent meta-analysis in children aged less than 18 years old in hemorrhagic settings revealed that transfusion guided with point care tests reduced fresh frozen plasma administration and length of hospital stay (5). Since transfusion is one of the predictors of postoperative outcome (1,2,3,4) it is mandatory to have patient blood management protocols in hemorrhagic surgery since these protocols are not yet a routine generalized practice in our Hospital. Length of hospital stay as well as hospital costs were signi cantly higher in transfused patients than in non-transfused patients (8). ...
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Background In a previously conducted monocentric retrospective study, predictors of postoperative outcome in children included American Society of Anesthesiologists score, transfusion, emergency interventions, surgery and age. A study has been undertaken to describe postoperative outcome in patients aged between 10 and 18 years included in the initial study in abdominal surgery, neurosurgery and orthopedics. Aims To describe postoperative outcome in children aged between 10 and 18 years. Methods Secondary analysis of postoperative outcome in children aged between 10 and 18 years included retrospectively in the initial study of 594 patients. The study was approved by the Ethics Committee. Results There were 221 children with a mean age of 165.5±24.3 months in abdominal surgery, neurosurgery and orthopedics.16.3% patients had intra-operative or postoperative complications. Intra-operatively, 3.2%had hemorrhagic shock, 0.45% anaphylaxis and 0.45% respiratory failure. Postoperatively,3.2% had neurologic failure, 2.3% respiratory failure, 0.45% cardio-circulatory failure, 0.45%endocrinal failure, 0.45% had hepatic failure, 0.45% multiple organ failure, and 0.45% had renal failure. In-hospital mortality rate was 0.45%. Conclusion These results emphasize the importance of optimizing intra-operative management in critically ill patients in major surgery with goal directed therapies in order to improve postoperative outcome.
... A similar analysis in different surgical settings was undertaken and conducted to the same conclusions. [2][3][4] Postoperative outcome was defined as organ failure, infections, re-operations, length of stay in the intensive care unit, length of hospital stay, total length of hospital stay and length of mechanical ventilation. Meta-analyses in patients under 18 years revealed that intra-operative goal directed fluid and hemodynamic therapy is not a routine generalized practice, that non optimal intra-operative hemodynamic parameters were predictors of adverse postoperative outcome in terms of morbidity and mortality, that transfusion goal directed therapy with point of care tests reduced fresh frozen plasma transfusion and length of hospital stay and that enhanced recovery after surgery applied in surgical settings reduced postoperative complications. ...
... [5][6][7] To emphasize the importance of postoperative outcome in surgical children, a secondary analysis was conducted with the objective to describe in detail with regard to age, postoperative evolution in children aged between 10 and 18 years included in the initial retrospective study. 1 Similar secondary analyses have been conducted in pre-terms, infants less than 1 year old, children aged between 1 and 3 years, children from 3 to 6 years old and children from 6 to 10 years with the objective to describe postoperative outcome with consideration to age since age has been revealed to be an independent predictor of postoperative outcome. [1][2][3][4] ...
... A recent meta-analysis in children aged less than 18 years old in hemorrhagic settings revealed that transfusion guided with point care tests reduced fresh frozen plasma administration and length of hospital stay. 5 Since transfusion is one of the predictors of postoperative outcome [1][2][3][4] it is mandatory to have patient blood management protocols in hemorrhagic surgery since these protocols are not yet a routine generalized practice in our Hospital. Length of hospital stay as well as hospital costs were significantly higher in transfused patients than in non-transfused patients. ...
Article
Background: In a previously conducted monocentric retrospective study, predictors of postoperative outcome in children included American Society of Anesthesiologists score, transfusion, emergency interventions, surgery and age. A study has been undertaken to describe postoperative outcome in patients aged between 10 and 18 years included in the initial study in abdominal surgery, neurosurgery and orthopedics. Aims: To describe postoperative outcome in children aged between 10 and 18 years. Methods: Secondary analysis of postoperative outcome in children aged between 10 and 18 years included retrospectively in the initial study of 594 patients. The study was approved by the Ethics Committee. Results: There were 221 children with a mean age of 165.5±24.3 months in abdominal surgery, neurosurgery and orthopedics. 16.3% patients had intra-operative or postoperative complications. Intra-operatively, 3.2% had hemorrhagic shock, 0.45% anaphylaxis and 0.45% respiratory failure. Postoperatively, 3.2% had neurologic failure, 2.3% respiratory failure, 0.45% cardio-circulatory failure, 0.45% endocrinal failure, 0.45% had hepatic failure, 0.45% multiple organ failure, and 0.45% had renal failure. In-hospital mortality rate was 0.45%. Conclusion: These results emphasize the importance of optimizing intra-operative management in critically ill patients in major surgery with goal directed therapies in order to improve postoperative outcome.
... It has been evidenced that in pediatric neurosurgery, abdominal and orthopedic surgery, ASA score (American Society of Anesthesiologists score), transfusion, emergency surgery, age, type of surgery were independent predictive factors of postoperative outcomes in terms of organ dysfunction, length of intensive care unit stay (LOSICU), length of mechanical ventilation (LMV), length of hospital stay (LOS) and total length of hospital stay, (TLOS) (LOSICU + LOS) (1,2,3,4). In a study where 594 surgical patients with a mean age of 90.86±71.80 ...
... Preoperative hemoglobin levels were signi cantly correlated to LOSICU, LOS, TLOS and the number of patients with intra-operative and postoperative complications however considering the variability of these outcomes which was between 4 and 9%, other variables also predicted these outcomes as it has been evidenced earlier in the initial studies (1,2,3,4). In these studies, it was demonstrated that complications, re-surgery, LOSICU, LOS, TLOS, LMV were predicted by the ASA status, transfusion, emergency, age and surgery. ...
... It has also been shown that in the general pediatric population anemia was related to mortality and neurodevelopmental disorders (8). In this secondary analysis, there was no correlation between preoperative hemoglobin levels and mortality which is not a surprise since in the initial studies, the independent predictor of mortality in this cohort was the ASA score (1)(2)(3)(4). According to this analysis, preoperative hemoglobin levels less than 6 g/dL were correlated to high LOSICU, LOS and TLOS. ...
Preprint
Full-text available
Background: Postoperative outcome in children is multifactorial. Among the reported predictors of postoperative outcome, preoperative anemia has been related to adverse outcome in children. A secondary analysis was undertaken to determine the correlation between hemoglobin levels and postoperative outcome in children included in a cohort of an observational pediatric study published previously since this analysis has not been done. Objective: To determine the correlation between preoperative, intra-operative, postoperative hemoglobin levels and postoperative outcome in children in neurosurgery, abdominal and orthopedic surgery. Methods: Secondary analysis of a sub-cohort of 252 pediatric surgical patients with a median age of 62 months [12.50-144.00]. Results: Preoperative hemoglobin levels were negatively correlated to length of stay in the intensive care unit (LOSICU) (p=0.002), to length of hospital stay (LOS) (p<0.0001), to the number of patients with intra-operative and/or postoperative complications (p<0.0001) and to re-surgery (p<0001). Low preoperative hemoglobin levels below 6 g/dL were correlated to higher postoperative LOSICU and LOS. Intra-operative hemoglobin levels were negatively correlated to LOS (p<0.0001) and to the number of patients with intra-operative and/or postoperative complications (p=0.004). Low intra-operative hemoglobin levels below 5 g/dL were correlated to higher LOS. Postoperative hemoglobin levels were positively correlated to LMV (p=0.002). Conclusion: Hemoglobin levels are among other multifactorial predictors of postoperative outcome in pediatric surgical patients emphasizing the importance of a global patient blood management implementation program to improve outcome in surgical children.
... Intraoperative and postoperative outcomes in children have been reported to be multifactorial [1] [2] [3] [4]. Reported independent predictors of intraoperative and postoperative complications were age, American Society of Anesthesiologists Score (ASA), emergency situations, surgery and transfusion [1] [2] [3] [4]. ...
... Intraoperative and postoperative outcomes in children have been reported to be multifactorial [1] [2] [3] [4]. Reported independent predictors of intraoperative and postoperative complications were age, American Society of Anesthesiologists Score (ASA), emergency situations, surgery and transfusion [1] [2] [3] [4]. ...
... An observational study was undertaken in 2017 to determine predictive factors of postoperative outcome in 594 pediatric surgical patients in neurosurgery, abdominal and orthopedic surgery [1][2][3][4]. Among other predictive factors of postoperative outcome, transfusion was identified as an independent predictive factor of morbidity in terms of organ dysfunction, infections, length of intensive care unit stay (LOSICU), length of mechanical ventilation (LMV) and length of hospital stay (LOS). ...
... Intuitively, taking into account the results of the previous studies [1][2][3][4][5]7], transfused patients have high hospitalization costs which are related to the critical illness and the increased LOSICU, LMV and LOS [1]. ...
... With regards to the rate of patients with intraoperative and or postoperative complications, including transfusion guided protocols with point of care tests, goal directed uid and hemodynamic therapy with validated tools and parameters in children and integrating enhanced recovery after surgery protocols to optimize intraoperative management in scoliosis surgery could improve postoperative outcome in this surgical setting (3,4,5,6,7,8,9,10,11,12,13,14,15). ...
... Enhanced recovery after surgery protocols have been shown to decrease postoperative complications in scoliosis surgery in children, integrating these pathways in this surgical setting can improve postoperative evolution (3). Predictors of postoperative outcomes include patient's global status, type of surgery, emergency age and transfusion (14). Goal directed therapies are possible solutions for postoperative outcome improvement in critical ill children and in major pediatric surgery. ...
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Background: Scoliosis is among interventions with high postoperative complication rates due to the characteristics of the surgery, where blood loss, transfusion and fluid requirements can be increased. A monocentric retrospective observational study was undertaken earlier to determine predictors of intraoperative and postoperative outcomes in surgical patients. In this initial cohort, there were patients who underwent scoliosis surgery, and a secondary analysis to describe outcomes in these patients was realized and is presented here. Objective: To describe intraoperative and postoperative outcomes in patients under 18 years old in scoliosis surgery included in the initial study and to propose improvement implementation measures. Methods: Secondary analysis of patients undergoing scoliosis surgery. The study was approved by the Ethics Committee. Results: There were 116 patients with a mean age of 147.5 ± 40.2 months. Twenty-eight patients (24.1%) presented intraoperative and/or postoperative complications. The most common intraoperative complication was hemorrhagic shock in 3 patients (2.6%). The most common postoperative organ failure was neurologic in seven patients (6%), respiratory in 3 patients (2.6%), cardio-circulatory in 2 patients (1.7%) and renal failure in one patient (0.9%). The most common postoperative infection was surgical wound sepsis in 8 patients (6.9%), urinary sepsis in three patients (2.6%), and abdominal sepsis and septicemia in two patients (1.7%). twelve patients (10.3%) had reoperations. Fifty-six patients (48.3%) had intraoperative transfusion. There was no in-hospital mortality. Conclusion: Integrating goal-directed therapies in this surgical setting could improve postoperative outcomes.
... A retrospective observational study was undertaken to determine predictors of adverse intraoperative and postoperative outcome in patients in neurosurgery, abdominal and orthopedic surgery in our hospital Necker Enfants Malades University Hospital (8). Age, American Society of Anesthesiologists Score (ASA), emergency situations, surgery and transfusion were independent predictors of intraoperative and postoperative outcome in terms of morbidity, re-operations, length of stay in the intensive care unit (LOSICU), length of stay in hospital in the conventional hospitalization ward (LOS), total length of stay in hospital (LOSICU + LOS) and length of mechanical ventilation (LMV) (8,9). ...
... As described in previous studies these goal-directed therapies have the objectives of improving postoperative outcome (10,11,12,13,14,15,16,17,18,19). Transfusion and intraoperative non-optimal hemodynamic parameters have been associated with adverse postoperative outcomes in surgical patients (8,9,19). Non-optimal preoperative, intraoperative and postoperative hemoglobin levels have been correlated to adverse postoperative outcomes in surgical patients (20). ...
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Background Femoral and pelvic osteotomies are potential hemorrhagic interventions where transfusion requirements can be necessary. Objective We undertook a secondary analysis of patients who underwent femoral and pelvic osteotomy in the initial cohort. The objective of this secondary analysis was to describe intraoperative, postoperative outcomes and to describe intraoperative management in these patients in terms of blood product management, fluid and hemodynamic therapy with the aims to implement optimization management protocols for postoperative outcome improvement. Methods Secondary analysis of patients who underwent femoral and pelvic osteotomy surgery included in the initial retrospective study. Results There were eighteen patients with a mean age of 104± 47.1 months. Four (22.2%) patients had intraoperative and or postoperative complications. One patient (5.6%) had intraoperative hemorrhagic shock, two patients (11.1%) had postoperative neurologic failure and one patient (5.6%) had postoperative wound sepsis. Transfusion rate was 50% in nine patients. Conclusion Femoral and pelvic osteotomies are interventions where blood, transfusion and fluid requirements can be increased thus this implies the necessity of global patient blood management protocol with point of care tests, with fluid and hemodynamic guided protocols with validated tools in children for intraoperative and postoperative outcome optimization.
... Intraoperative and postoperative outcomes in children have been reported to be multifactorial (1,2,3,4). Reported independent predictors of intraoperative and postoperative complications were age, American Society of Anesthesiologists Score (ASA), emergency situations, surgery and transfusion (1,2,3,4). ASA was the independent predictor of mortality (1). ...
... Intraoperative and postoperative outcomes in children have been reported to be multifactorial (1,2,3,4). Reported independent predictors of intraoperative and postoperative complications were age, American Society of Anesthesiologists Score (ASA), emergency situations, surgery and transfusion (1,2,3,4). ASA was the independent predictor of mortality (1). ...
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Background: Reported independent predictors of intraoperative and postoperative complications were age, American Society of Anesthesiologists Score (ASA), emergency situations, surgery and transfusion. ASA was the independent predictor of mortality. We conducted a secondary analysis of the initial retrospective study in patients who underwent exploratory laparotomy and intestinal resection. Objectives: To describe intraoperative and postoperative outcomes in patients who underwent exploratory laparotomy and intestinal resection in the initial study and to implement improvement protocols for intraoperative and postoperative optimization. Methods: Secondary analysis of the initial study. The Ethics Committee approved the study. Results: There were 54 patients with a median age of 15.5[0-172] months. Thirty-seven (68.5%) patients underwent intestinal resection, nine (16.7%) underwent exploratory laparotomy, and eight (16.8%) underwent laparotomy for volvulus. Fourteen (25.9%) patients had intraoperative and/or postoperative complications. Two (3.7%) patients had intraoperative hemorrhagic shock. Two (3.7%) patients had postoperative cardio-circulatory failure. Three (5.6%) had postoperative respiratory failure. One (1.8%) patient had postoperative multiple organ failure and neurologic failure. Three (5.6%) patients had postoperative abdominal sepsis. One (1.8%) patient had postoperative multiple organ sepsis and neuromeningeal sepsis. Four (7.4%) patients had postoperative pulmonary sepsis. Two (3.7%) had postoperative septicemia. Six (11.1%) patients had reoperations. Seventeen (31.5%) patients had intraoperative transfusion. The in-hospital mortality rate was 3.7% in two patients. Conclusion: Intraoperative goal-directed therapies need to be developed and included in these surgical settings for intraoperative and postoperative optimization.
... Intraoperative and postoperative outcomes in children have been reported to be multifactorial (1,2,3,4). Reported independent predictors of intraoperative and postoperative complications were Age, American Society of Anesthesiologists Score (ASA), emergency situations, surgery and transfusion (1,2,3,4). ASA was the independent predictor of mortality (1). ...
... Intraoperative and postoperative outcomes in children have been reported to be multifactorial (1,2,3,4). Reported independent predictors of intraoperative and postoperative complications were Age, American Society of Anesthesiologists Score (ASA), emergency situations, surgery and transfusion (1,2,3,4). ASA was the independent predictor of mortality (1). ...
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Background Reported independent predictors of intraoperative and postoperative complications were Age, American Society of Anesthesiologists Score (ASA), emergency situations, surgery and transfusion. ASA was the independent predictor of mortality. We conducted a secondary analysis of the initial retrospective study in patients who underwent exploratory laparotomy and intestinal resection. Objectives To describe intraoperative and postoperative outcomes in patients who underwent exploratory laparotomy and intestinal resection in the initial study and to implement improvement protocols for intraoperative and postoperative optimization. Methods Secondary analysis of the initial study. The Ethics Committee approved the study. Results There were 54 patients with a median age of 15.5[0–172] months. Thirty-seven (68.5%) patients had an intestinal resection, nine (16.7%) had an exploratory laparotomy and eight (16.8%) patients had a laparotomy for volvulus.
... Predictors of postoperative outcome are multifactorial, among which American Society of Anesthesiologists status (ASA), transfusion, emergency, surgery and age were identi ed in previous studies (1,2,3,4). Predictors of postoperative outcome in this study were not exhaustive, which means that other nonidenti ed factors may contribute to how patients evolve after surgery. ...
... These patients were in majority ASA grade 3 or more. As revealed in the initial studies (1,2,3,4), postoperative outcome depends on multiple factors, precisely ASA status, transfusion, age, emergency and surgery. Integrating goal-directed therapies for intraoperative management in these patients is necessary to improve postoperative outcomes in pediatric surgical patients. ...
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Background Anticipating postoperative evolution in surgical patients is an important issue in our daily practice. We demonstrated in a previous study that there were multiple predictors of postoperative outcome, including American Society of Anesthesiologists status (ASA), transfusion, emergency, surgery and age. A detailed description of postoperative outcome was undertaken in children aged between 6 and 10 years old included in the initial study. Objective To describe postoperative outcomes in children aged between 6 and 10 years old included in the initial cohort in abdominal surgery, neurosurgery and orthopedics. Methods The secondary analysis of postoperative outcomes in children aged between 6 and 10 years old was retrospectively included in the initial study of 594 patients. The study was approved by the Ethics Committee. Results There were 88 patients with a mean age of 98.7±13.8 months. The most common surgical interventions were scoliosis in 23 patients (26.1%), limb tumor resection in 8 patients (9.1%), femoral osteotomy in 6 patients (6.8%), intracerebral tumor resection in 6 patients (6.8%), intestinal resection in 5 patients (5.6%), Chiari’s malformation in 4 patients (4.5%), pelvic osteotomy in 4 patients (4.5%) and renal transplantation in 4 patients (4.5%). Most patients (45%) were American Society of Anesthesiologists grade 3 (ASA 3), and 13 (14.8%) were ASA grade 4. Twenty-two (25%) patients had intraoperative and/or postoperative complications (organ dysfunction or sepsis). Two patients (2.3%) had intraoperative hemorrhage, 1 patient (1.1%) had intraoperative difficult intubation, and 1 patient experienced intraoperative anaphylaxis. Nine patients (10.2%) had postoperative neurologic failure, and 2 (2.3%) had postoperative cardio-circulatory failure. Three patients (3.4%) had postoperative septicemia, 2 patients (2.3%) had postoperative pulmonary and urinary sepsis, and 1 patient (1.1%) had postoperative abdominal sepsis. 3 patients (3.4%) had re-operations. 42(47.7%) patients had intra-operative transfusion. There was 1 in-hospital death (1.1%). The median total length of hospital stay was 9 days [5-16]. Conclusion Twenty-five percent of the patients had intraoperative and/or postoperative complications, and most of them were ASA grade ³3. Integrating goal-directed therapies to optimize intraoperative management in these patients is necessary to improve postoperative outcomes in surgical pediatric patients.
... A retrospective observational study was undertaken to determine predictors of adverse intraoperative and postoperative outcomes in patients undergoing neurosurgery, abdominal and orthopedic surgery at our hospital Necker Enfants Malades University Hospital (8). Age, American Society of Anesthesiologists Score (ASA), emergency situations, surgery and transfusion were independent predictors of intraoperative and postoperative outcomes in terms of morbidity, reoperations, length of stay in the intensive care unit (LOSICU), length of stay in hospital in the conventional hospitalization ward (LOS), total length of stay in hospital (LOSICU+LOS) and length of mechanical ventilation (LMV) (8,9). We undertook a secondary analysis of patients who underwent femoral and pelvic osteotomy in the initial cohort. ...
... As described in previous studies, these goal-directed therapies have the objectives of improving postoperative outcomes (10,11,12,13,14,15,16,17,18,19). Transfusion and intraoperative nonoptimal hemodynamic parameters have been associated with adverse postoperative outcomes in surgical patients (8,9,19). Non-optimal preoperative, intraoperative and postoperative hemoglobin levels have been correlated with adverse postoperative outcomes in surgical patients (20). ...
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Background: Femoral and pelvic osteotomies are potential hemorrhagic interventions where transfusion requirements can be necessary. Objective: We undertook a secondary analysis of patients who underwent femoral and pelvic osteotomy in the initial cohort. The objective of this secondary analysis was to describe intraoperative and postoperative outcomes and to describe intraoperative management in these patients in terms of blood product management, fluid and hemodynamic therapy with the aim of implementing optimization management protocols for postoperative outcome improvement. Methods: A secondary analysis of patients who underwent femoral and pelvic osteotomy surgery was included in the initial retrospective study. Results: There were eighteen patients with a mean age of 104± 47.1 months. Four (22.2%) patients had intraoperative and/or postoperative complications. One patient (5.6%) had intraoperative hemorrhagic shock, two patients (11.1%) had postoperative neurologic failure, and one patient (5.6%) had postoperative wound sepsis. Transfusion rate was 50% in nine patients. Conclusion: Femoral and pelvic osteotomies are interventions where blood, transfusion and fluid requirements can be increased; thus, this implies the necessity of a global patient blood management protocol with point-of-care tests and fluid- and hemodynamic-guided protocols with validated tools in children for intraoperative and postoperative outcome optimization.
... The first phase of this Thesis Project consisted in conducting 5 retrospective pediatric studies in three different pediatric surgical population [5][6][7][8][9] to determine predictors of postoperative outcome. Several risk factors were identified. ...
... Four retrospective studies concerning more than 500 children less than 18 years in orthopedics, in abdominal surgery and neurosurgery evidenced that transfusion, emergency surgery, age and ASA (American Society of Anesthesiologists) score status were predictors of adverse postoperative outcome (complications, length of hospital stay, repeated surgery) [5][6][7][8]. These studies showed that ASA score status was the predictor of mortality. ...
... These patients were in the majority ASA grade 3 or more. As revealed in the initial studies [1] [2] [3] [4], the postoperative outcome depends on multiple factors, precisely ASA status, transfusion, age, emergency and surgery. Integrating goal-directed therapies for intraoperative management in these patients could be necessary to improve postoperative outcomes in pediatric surgical patients. ...
... Predictors of postoperative outcome are multifactorial among which American Society of Anesthesiologists status (ASA), transfusion, emergency, surgery and age were identi ed in previous studies (1,2,3,4). Predictors of postoperative outcome in this study were not exhaustive which means that other non-identi ed factors may contribute in how patients evolve after surgery. ...
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Background Anticipating postoperative evolution in surgical patients is an important issue in our daily practice. We have demonstrated in a previous study that predictors of postoperative outcome are multiple including American Society of Anesthesiologists status (ASA), transfusion, emergency, surgery and age. A detailed description of postoperative outcome was undertaken in children aged between 6 and 10 years included in the initial study. Objective To describe postoperative outcome in children aged between 6 and 10 years included in the initial cohort in abdominal surgery, neurosurgery and orthopedics. Methods Secondary analysis of postoperative outcome in children aged between 6 and 10 years included retrospectively in the initial study of 594 patients. The study was approved by the Ethics Committee. Results There were 88 patients with a mean age of 98.7±13.8 months. The most common surgical interventions were scoliosis in 23 patients (26.1%), femoral osteotomy 7 patients (7.9%), limb tumor resection 7 patients (7.9%), intracerebral tumor resection 6 patients (6.8%), intestinal resection 5 patients (5.6%), Chiari’s malformation 4 patients (4.5%), pelvic osteotomy 4 patients (4.5%) and renal transplantation 4 patients (4.5%). Most patients (45%) were American Society of Anesthesiologists grade 3 (ASA 3) and 13 (14.8%) were ASA grade 4. 22(25%) patients had intra-operative and or postoperative complications (organ dysfunction or sepsis). 2 patients (2.3%) had intra-operative hemorrhagic, 1 patient (1.1%) had an intra-operative difficult intubation and 1 patient experienced intra-operative anaphylaxis. 9 patients (10.2%) had postoperative neurologic failure and 2 (2.3%) postoperative cardio-circulatory failure. 3 patients (3.4%) had postoperative septicemia, 2 patients (2.3%) had postoperative pulmonary and urinary sepsis and 1 patient (1.1%) had postoperative abdominal sepsis. 3 patients (3.4%) had re-operations. 42(47.7%) patients had intra-operative transfusion. There was 1 in-hospital death (1.1%). Median total length of hospital stay was 9 days [5-16]. Conclusion 25% of the patients had intra-operative and or postoperative complications and most of them were ASA grade ³3. Integrating goal directed therapies to optimize intra-operative management in these patients is a necessary implementation to improve postoperative outcome in surgical pediatric patients.
... Predictors of postoperative outcomes include the patient's global status, type of surgery, emergency age and transfusion [14]. Goal-directed therapies are possible solutions for postoperative outcome improvement in critically ill children and in major pediatric surgery. ...
... Randomized controlled trials are not always easy to realize in children especially in a setting of hemorrhage. The recent systematic review and meta-analysis on transfusion goal directed protocols in children [2,3] is part of a vast and extended Thesis Project concerning the impact of Goal Directed Therapies on postoperative outcome in the pediatric population [4][5][6][7][8][9][10][11][12][13][14][15][16]. This Thesis in development is registered at ...
... Why is it important to realize this study? As precised in earlier publications, postoperative outcome is multifactorial [2][3][4][5]. Among these multiple risk factors, patient's general state (ASA score, American Society of Anesthesiologists score) and surgery were identified as independent predictors [2-5]. ...
... A lot of trials in this population are prospective, observational and retrospective. The recent systematic review and meta-analysis on GDFHT in children [2] is part of a vast and extended Thesis Project concerning the impact of Goal Directed therapies on postoperative outcome in the pediatric population [3][4][5][6][7][8][9]. ...
Article
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Background: The aim of this study was to evaluate postoperative complications in patients having major elective surgery using oesophageal Doppler monitor-guided goal-directed haemodynamic therapy (GDHT), in which administration of fluids, inotropes, and vasopressors was guided by stroke volume, mean arterial pressure, and cardiac index. Methods: The FEDORA trial was a prospective, multicentre, randomised, parallel-group, controlled patient- and observerblind trial conducted in adults scheduled for major elective surgery. Randomization and allocation were carried out by a central computer system. In the control group, intraoperative fluids were given based on traditional principles. In the GDHT group, the intraoperative goals were to maintain a maximal stroke volume, with mean arterial pressure >70 mm Hg, and cardiac index �2.5 litres min�1 m�2. The primary outcome was percentage of patients with moderate or severe postoperative complications during the first 180 days after surgery. Results: In total, 450 patients were randomized to the GDHT group (n¼224) or control group (n¼226). Data from 420 subjects were analysed. There were significantly fewer with complications in the GDHT group (8.6% vs 16.6%, P¼0.018). There were also fewer complications (acute kidney disease, pulmonary oedema, respiratory distress syndrome, wound infections, etc.), and length of hospital stay was shorter in the GDHT group. There was no significant difference in mortality between groups. Conclusions: Oesophageal Doppler monitor-guided GDHT reduced postoperative complications and hospital length of stay in lowemoderate risk patients undergoing intermediate risk surgery, with no difference in mortality at 180 days. Clinical trial registration: ISRCTN93543537.
Article
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Background: The surgical treatment of adolescent idiopathic scoliosis can be associated with substantial blood loss, requiring allogeneic red blood cell (RBC) transfusion. This study describes the use of RBC and the effect of a standardized perioperative patient blood management program. Study design and methods: Patients treated with posterior instrumented fusion were consecutively enrolled over a 6-year period. Patient blood management strategies were implemented in 2011, including prophylactic tranexamic acid, intraoperative permissive hypotension, restrictive fluid therapy (including avoidance of synthetic colloids), restrictive RBC trigger according to institutional standardized protocol, the use of cell savage, and goal-directed therapy according to thrombelastography. Results: In total, 210 patients were included. 64 patients (31%) received RBC transfusions. A decline in the intraoperative rate of RBC transfusion was observed, from 77% in 2011 to 13% in 2016 (p < 0.001). Patients in the transfusion group had a significantly larger major curve, lower preoperative hemoglobin, higher estimated blood loss, and an increased use of crystalloid volume resuscitation. Multiple logistic regression showed that significant predictors for RBC transfusion were preoperative hemoglobin level (odds ratio [OR], 0.40; 95% confidence interval [CI], 0.27-0.57), estimated blood loss (OR, 1.26; 95% CI, 1.15-1.42), and year of surgery (indicating the effect of patient blood management) (OR per year, 0.76; 95% CI, 0.58-0.99). Conclusion: A perioperative patient blood management program substantially reduced the need for RBC transfusion. A preoperative evaluation of anemia is essential to further minimize transfusion rates.
Article
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AIM To investigate whether autologous blood transfusion (ABT) drains and intra-operative cell salvage reduced donor blood transfusion requirements during scoliosis surgery. METHODS Retrospective data collection on transfusion requirements of patients undergoing scoliosis surgery is between January 2006 and March 2010. There were three distinct phases of transfusion practice over this time: Group A received “traditional treatment” with allogeneic red cell transfusion (ARCT) in response to an intra- or post-operative anaemia (Hb < 8 g/dL or a symptomatic anaemia); Group B received intra-operative cell salvage in addition to “traditional treatment”. In group C, ABT wound drains were used together with both intra-operative cell salvage and “traditional treatment”. RESULTS Data from 97 procedures on 77 patients, there was no difference in mean preoperative haemoglobin levels between the groups (A: 13.1 g/dL; B: 13.49 g/dL; C: 13.66 g/dL). Allogeneic red cell transfusion was required for 22 of the 37 procedures (59%) in group A, 17 of 30 (57%) in group B and 16 of 30 (53%) in group C. There was an overall 6% reduction in the proportion of patients requiring an ARCT between groups A and C but this was not statistically significant (χ² = 0.398). Patients in group C received fewer units (mean 2.19) than group B (mean 2.94) (P = 0.984) and significantly fewer than those in group A (mean 3.82) (P = 0.0322). Mean length of inpatient stay was lower in group C (8.65 d) than in groups B (12.83) or A (12.62). CONCLUSION When used alongside measures to minimise blood loss during surgery, ABT drains and intra-operative cell salvage leads to a reduced need for donor blood transfusion in patients undergoing scoliosis surgery.
Article
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Background Adolescent idiopathic scoliosis (AIS) surgery usually require prolonged operative times with extensive soft tissue dissection and significant perioperative blood loss, and allogeneic blood products are frequently needed. Methods to reduce the requirement for transfusion would have a beneficial effect on these patients. Although many previous studies have revealed the efficacy of tranexamic acid (TXA) in spinal surgery, there is still a lack of agreement concerning the reduction of both blood loss and transfusion requirements of large dose tranexamic acid (TXA) in surgery for adolescent idiopathic scoliosis (AIS). The objective of this study was to elevate the efficacy and safety of a large dose tranexamic acid (TXA) in reducing transfusion requirements of allogeneic blood products in adolescent idiopathic scoliosis (AIS) surgery using a retrospective study designed with historical control group. Methods One hundred thirty seven consecutive AIS patients who underwent surgery treatment with posterior spinal pedicle systems from August 2011 to March 2015 in our scoliosis center were retrospectively reviewed. Patients were divided into two groups, the TXA group and the historical recruited no TXA group (NTXA). Preoperative demographics, radiographic parameters, operative parameters, estimated blood loss (EBL), total irrigation fluid, number of patients requiring blood transfusion, mean drop of Hb (Pre-op Hb-Post-op Hb), haematocrit pre and post-surgery, mean volume of blood transfusion, hospitalization time, and adverse effect were recorded and compared. Results All the patients were successfully treated with satisfied clinical and radiographic outcomes. There were 71 patients in the TXA group and 66 patients in the NTXA group. The preoperative demographics were homogeneity between two groups (P > 0.05). There were no significant difference in average operative time between two groups (209 min vs 215 min, p >0.05). Number of patients in the TXA group showed a significant decrease in transfusion requirements with an associated reduced intraoperative blood loss of nearly 45% compared with those in NTXA group (8 vs37, 619 ml vs 1125 ml, P < 0.05). There were no significant difference in total irrigation fluid between two groups (540 vs 550, p >0.05). Additional, patients in NTXA group showed significant decrease of Hb compared with patients in TXA group (5.2 g/dL vs 3.3 g/dL, P < 0.05), No significant difference were found in hospitalization time between two groups (6.3vs7.2 days, P > 0.05). No minor adverse effects associated with use of TXA were noted. Conclusions Use of large dose tranexamic acid routinely seems to be effective and safe in reducing allogenic blood transfusion and blood loss in adolescent idiopathic scoliosis surgery.
Article
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Severity of illness is an important consideration in making the decision to transfuse as it is the sicker patient that often needs a red cell transfusion. Red blood cell (RBC) transfusions could potentially have direct effects and interact with presenting illness by contributing to pathologies such as multi-organ dysfunction and acute lung injury thus exerting a considerable impact on overall morbidity and mortality. In this study, we examine if transfusion is an independent predictor of mortality, or if outcomes are merely a result of the initial severity as predicted by Pediatric Risk of Mortality (PRISM) III, Pediatric Index of Mortality (PIM2), and day 1 Pediatric Logistic Organ Dysfunction (PELOD) scores. A single center retrospective study was conducted using data from a prospectively maintained transfusion database and center-specific data at our pediatric ICU between January 2009 and December 2012. Multivariate regression was used to control for the effects of clinical findings, therapy, and severity scores, with mortality as the dependent variable. Likelihood ratios and area under the curve were used to test the fidelity of severity scores by comparing transfused vs. non-transfused patients. There were 4975 admissions that met entry criteria. In multivariate analysis, PRISM III scores and serum hemoglobin were significant predictors of transfusion (p < 0.05). Transfused and non-transfused subjects were distinctly disparate, so multivariate regression was used to control for differences. Severity scores, age, volume transfused, and vasoactive agents were significantly associated with mortality whereas hemoglobin was not. A substantial number of transfusions (45 %) occurred in the first 24 h, and patients transfused later (24–48 h) were more likely to die compared to this earlier time point. Likelihood ratio testing revealed statistically significant differences in severity scoring systems to predict mortality in transfused vs. non-transfused patients. This study suggests that RBC transfusion is an important risk factor that is statistically independent of severity. The timing of transfusions that related strongest to mortality remained outside the purview of severity scoring, as these happened beyond the timing of data collection for most scoring systems.
Article
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Haemorrhage is a leading cause of death in paediatric trauma patients. Predefined massive transfusion protocols (MTP) have the potential to significantly reduce mortality by treating haemorrhagic shock and coagulopathy, in adhering to the principles of haemostatic resuscitation with rapid administration of balanced ratios of packed red blood cells (RBC), fresh frozen plasma (FFP) and platelets (PLT). Because of their substantial physiological reserve, initial vital signs may not be good predictors of early haemorrhage in paediatric patients. Determining the triggers for MTP activation in paediatric trauma patients is challenging, and the optimal blood product ratio that will increase survival in massively bleeding paediatric trauma patients has yet to be determined. To date, only a few small descriptive studies and case reports have investigated the use of predefined MTP in paediatric trauma patients. MTP with increased FFP or PLT to RBC ratios combined with viscoelastic haemostatic assay (VHA) guided haemostatic resuscitation have not yet been tested in paediatric populations but based on results from adult trauma patients, this therapeutic approach seems promising. Considering the high prevalence of early coagulopathy in paediatric trauma patients, immediate identification and implementation of VHA-directed treatment of traumatic coagulopathy could ensure faster haemostasis and thereby, potentially, reduce bleeding as well as the total transfusion requirements and further improve outcome in paediatric trauma patients. Prospective randomized trials investigating this therapeutic approach in paediatric trauma patients are highly warranted.
Article
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In paediatric cardiac surgery, red blood cell (RBC) transfusions are given to treat haemorrhage or to increase oxygen delivery (therapeutic transfusion). Sometimes, RBCs are added to the prime solution to avoid a too low haematocrit on bypass (CPB-driven transfusion). Our study investigated whether the reason for RBC transfusion might affect severe postoperative morbidity or mortality. This retrospective cohort study was conducted in a tertiary care level, children's hospital. The charts of all patients admitted between 2006 and 2009 were reviewed. Among transfused patients, children receiving a therapeutic transfusion were compared with those receiving a CPB-driven transfusion. The primary outcome was severe postoperative morbidity or mortality. Statistically significant variables founded with univariate analysis were incorporated in the multivariable logistic regression analysis to build a model that predicts severe postoperative morbidity or mortality. This model was then adjusted for clinically relevant variables that may interfere with 'indication for transfusion'. One hundred and one (48%) patients in the therapeutic and 92 (26%) patients in the CPB-driven transfusion group developed severe postoperative morbidity or died (P < 0.001). A multivariable logistic regression showed that weight, ASA, calculated blood loss, intraoperative fluid balance, duration of CPB time and the indication group for transfusion [1.64 (1.03-2.62); P = 0.039] were independent risk factors for severe postoperative morbidity or mortality. The indication group for transfusion remained significant [2.0 (1.16-3.45); P = 0.013] after adjustment for significant predictors of indication for transfusion. Number of patients with infections, or neurological deficit, and length of mechanical ventilation, PICU and hospital length of stay, were significantly higher in the therapeutic compared with the CPB-driven transfusion group one. The indication group for transfusion has an impact on the occurrence of severe postoperative morbidity or mortality in children undergoing cardiac surgery.
Article
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The optimal hemoglobin threshold for erythrocyte transfusions in critically ill children is unknown. We hypothesized that a restrictive transfusion strategy of using packed red cells that were leukocyte-reduced before storage would be as safe as a liberal transfusion strategy, as judged by the outcome of multiple-organ dysfunction. In this noninferiority trial, we enrolled 637 stable, critically ill children who had hemoglobin concentrations below 9.5 g per deciliter within 7 days after admission to an intensive care unit. We randomly assigned 320 patients to a hemoglobin threshold of 7 g per deciliter for red-cell transfusion (restrictive-strategy group) and 317 patients to a threshold of 9.5 g per deciliter (liberal-strategy group). Hemoglobin concentrations were maintained at a mean (+/-SD) level that was 2.1+/-0.2 g per deciliter lower in the restrictive-strategy group than in the liberal-strategy group (lowest average levels, 8.7+/-0.4 and 10.8+/-0.5 g per deciliter, respectively; P<0.001). Patients in the restrictive-strategy group received 44% fewer transfusions; 174 patients (54%) in that group did not receive any transfusions, as compared with 7 patients (2%) in the liberal-strategy group (P<0.001). New or progressive multiple-organ dysfunction syndrome (the primary outcome) developed in 38 patients in the restrictive-strategy group, as compared with 39 in the liberal-strategy group (12% in both groups) (absolute risk reduction with the restrictive strategy, 0.4%; 95% confidence interval, -4.6 to 5.4). There were 14 deaths in each group within 28 days after randomization. No significant differences were found in other outcomes, including adverse events. In stable, critically ill children a hemoglobin threshold of 7 g per deciliter for red-cell transfusion can decrease transfusion requirements without increasing adverse outcomes. (Controlled-trials.com number, ISRCTN37246456 [controlled-trials.com].).
Article
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To test the hypothesis that RBC transfusion in critically ill children is independently associated with increased mortality and morbidity. Retrospective, descriptive epidemiologic cohort study. Single-center experience of a nine-bed pediatric intensive care unit (PICU) facility. Critically ill children without ongoing active blood loss aged 0[Symbol: see text]months to 18[Symbol: see text]years, excluding prematurely born infants or patients after cardiothoracic surgery, and patients with chronic anemia. None. Data of 295 consecutive patients was studied. Of these patients, 13.4% had a Hb concentration less than 9.6 g/dl. Sixty-seven (22.7%) of all patients were transfused, 39 only once. Transfused patients had a higher mortality (16.4 vs. 2.6%, p < 0.001). Mortality seemed related to the number of transfusion (p = 0.002) rather than the pre-transfusion Hb concentration (p = 0.10). Transfused patients required prolonged ventilatory support (11.1 +/- 1.8 vs. +/- 0.3 days, p < 0.001), infusion of vaso-active agents (8.2 +/- 1.8 vs. 2.8 +/- 0.6 days, p < 0.001) and PICU stay (13.0 +/- 1.8 vs. 3.2 +/- 0.2 days, p < 0.001). After multivariate analysis adjusting for age, PIM probability of death, mean TISS-28 score during the first 48 h, post-operative admission, diagnosis of sepsis or trauma or malignancy, pre-transfusion Hb concentration, and RBC transfusion remained independently associated with mortality and morbidity. RBC transfusion in critically ill children is independently associated with increased mortality and prolonged duration of mechanical ventilation, prolonged infusion of vaso-active agents and prolonged PICU stay.
Article
Enhanced recovery after surgery (ERAS) is a multimodal approach to the care of the surgical patient focused on reducing the stress response and associated physiologic changes that accompany surgery. Over the past 20 years, ERAS programs have been found to result in reduced LOS and complications in adult patients. Despite abundant adult literature describing implementation and outcomes of enhanced recovery programs, pediatric data in this area is sparse. This educational review describes the history and elements of ERAS protocols, reviews the available evidence in adult and pediatric populations, compares and contrasts ERAS with the PSH, and offers strategies for implementation and ideas for future directions of ERAS in children.
Article
Background: Up to 40% of combat casualties with a truncal injury die of massive hemorrhage before reaching a surgeon. This hemorrhage can be prevented with damage control resuscitation (DCR) methods, which are focused on replacing shed whole blood (WB) by empirically transfusing blood components in a 1:1:1:1 ratio of platelets:plasma:erythrocytes:cryoprecipitate (PLT:FFP:RBC:CRYO). Measurement of hemostatic function with thromboelastometry (ROTEM) may allow optimization of the type and quantity of blood products transfused. Our hypothesis was that incorporating ROTEM measurements into DCR methods at the US Role 3 hospital at Bagram Airfield, Afghanistan (BAF) would change the standard transfusion ratios of 1:1:1:1 to a product mix tailored specifically for the combat causality. Methods: This retrospective study collected data from the Department of Defense (DOD) Trauma Registry to compare transfusion practices and outcomes before and after ROTEM deployment to BAF. Over the course of six months, 134 trauma patients received a transfusion (pre-ROTEM) and 85 received a transfusion and underwent ROTEM testing (post-ROTEM). Trauma teams received instruction on ROTEM use and interpretation, with no provision of a specific transfusion protocol, to supplement their clinical judgment and practice. Results: The pre and post groups were not significantly different in terms of mortality, massive transfusion protocol activation, mean injury severity score, or coagulation measurements. Despite the difference in size, each group received an equal total number of transfusions. However, the post-ROTEM group received a significant increase in platelets and cryoprecipitate transfusions ratios, 4x and 2x, respectively. Conclusions: The introduction of ROTEM significantly improved adherence to DCR practices. The transfusion differences suggest that aggressive DCR without thromboelastometry data may result in reduced hemostatic support and underestimate the need for platelets and cryoprecipitate. Thus, future controlled trials should include ROTEM-guided coagulation management in trauma resuscitation. Level of evidence: Diagnostic Test Level 3.
Article
Background: Severe bleeding and coagulopathy are serious clinical conditions that are associated with high mortality. Thromboelastography (TEG) and thromboelastometry (ROTEM) are increasingly used to guide transfusion strategy but their roles remain disputed. This review was first published in 2011 and updated in January 2016. Objectives: We assessed the benefits and harms of thromboelastography (TEG)-guided or thromboelastometry (ROTEM)-guided transfusion in adults and children with bleeding. We looked at various outcomes, such as overall mortality and bleeding events, conducted subgroup and sensitivity analyses, examined the role of bias, and applied trial sequential analyses (TSAs) to examine the amount of evidence gathered so far. Search methods: In this updated review we identified randomized controlled trials (RCTs) from the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 1); MEDLINE; Embase; Science Citation Index Expanded; International Web of Science; CINAHL; LILACS; and the Chinese Biomedical Literature Database (up to 5 January 2016). We contacted trial authors, authors of previous reviews, and manufacturers in the field. The original search was run in October 2010. Selection criteria: We included all RCTs, irrespective of blinding or language, that compared transfusion guided by TEG or ROTEM to transfusion guided by clinical judgement, guided by standard laboratory tests, or a combination. We also included interventional algorithms including both TEG or ROTEM in combination with standard laboratory tests or other devices. The primary analysis included trials on TEG or ROTEM versus any comparator. Data collection and analysis: Two review authors independently abstracted data; we resolved any disagreements by discussion. We presented pooled estimates of the intervention effects on dichotomous outcomes as risk ratio (RR) with 95% confidence intervals (CIs). Due to skewed data, meta-analysis was not provided for continuous outcome data. Our primary outcome measure was all-cause mortality. We performed subgroup and sensitivity analyses to assess the effect based on the presence of coagulopathy of a TEG- or ROTEM-guided algorithm, and in adults and children on various clinical and physiological outcomes. We assessed the risk of bias through assessment of trial methodological components and the risk of random error through TSA. Main results: We included eight new studies (617 participants) in this updated review. In total we included 17 studies (1493 participants). A total of 15 trials provided data for the meta-analyses. We judged only two trials as low risk of bias. The majority of studies included participants undergoing cardiac surgery.We found six ongoing trials but were unable to retrieve any data from them. Compared with transfusion guided by any method, TEG or ROTEM seemed to reduce overall mortality (7.4% versus 3.9%; risk ratio (RR) 0.52, 95% CI 0.28 to 0.95; I(2) = 0%, 8 studies, 717 participants, low quality of evidence) but only eight trials provided data on mortality, and two were zero event trials. Our analyses demonstrated a statistically significant effect of TEG or ROTEM compared to any comparison on the proportion of participants transfused with pooled red blood cells (PRBCs) (RR 0.86, 95% CI 0.79 to 0.94; I(2) = 0%, 10 studies, 832 participants, low quality of evidence), fresh frozen plasma (FFP) (RR 0.57, 95% CI 0.33 to 0.96; I(2) = 86%, 8 studies, 761 participants, low quality of evidence), platelets (RR 0.73, 95% CI 0.60 to 0.88; I(2) = 0%, 10 studies, 832 participants, low quality of evidence), and overall haemostatic transfusion with FFP or platelets (low quality of evidence). Meta-analyses also showed fewer participants with dialysis-dependent renal failure.We found no difference in the proportion needing surgical reinterventions (RR 0.75, 95% CI 0.50 to 1.10; I(2) = 0%, 9 studies, 887 participants, low quality of evidence) and excessive bleeding events or massive transfusion (RR 0.38, 95% CI 0.38 to 1.77; I(2) = 34%, 2 studies, 280 participants, low quality of evidence). The planned subgroup analyses failed to show any significant differences.We graded the quality of evidence as low based on the high risk of bias in the studies, large heterogeneity, low number of events, imprecision, and indirectness. TSA indicates that only 54% of required information size has been reached so far in regards to mortality, while there may be evidence of benefit for transfusion outcomes. Overall, evaluated outcomes were consistent with a benefit in favour of a TEG- or ROTEM-guided transfusion in bleeding patients. Authors' conclusions: There is growing evidence that application of TEG- or ROTEM-guided transfusion strategies may reduce the need for blood products, and improve morbidity in patients with bleeding. However, these results are primarily based on trials of elective cardiac surgery involving cardiopulmonary bypass, and the level of evidence remains low. Further evaluation of TEG- or ROTEM-guided transfusion in acute settings and other patient categories in low risk of bias studies is needed.
Article
Background: Posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) is associated with significant pain and prolonged hospitalization. There is evidence that early mobilization and multimodal analgesia can accelerate functional recovery and reduced length of stay (LOS). Using these principles, we implemented a quality improvement initiative to enable earlier functional recovery in our AIS-PSF population. Methods: We designed and implemented a standardized rapid recovery pathway (RRP) with evidence-based management recommendations for children aged 10 to 21 years undergoing PSF for AIS. Our primary outcome, functional recovery, was assessed using statistical process control charts for LOS and average daily pain scores. Our process measures were medication adherence and order set utilization. The balancing measure was 30-day readmission rate. Results: We included 322 patients from January 1, 2011 to June 30, 2015 with 134 (42%) serving as historical controls, 104 (32%) representing our transition population, and 84 (26%) serving as our RRP population. Baseline average LOS was 5.7 days and decreased to 4 days after RRP implementation. Average daily pain scores remained stable with improvement on postoperative day 0 (3.8 vs 4.9 days) and 1 (3.8 vs 5 days) after RRP implementation. In the second quarter of 2015, gabapentin (91%) and ketorolac (95%) use became routine and order set utilization was 100%. Readmission rates did not increase as a result of this pathway. Conclusions: Implementation of a standardized RRP with multimodal pain management and early mobilization strategies resulted in reduced LOS without an increase in reported pain scores or readmissions.
Article
Acute lung injury (ALI) that develops within 6hours after transfusion (TRALI) is the leading cause of transfusion-related morbidity and mortality. Both incidence and patient and transfusion-related risk factors are well studied in the adult critically ill patient population. Clinical data on TRALI in the pediatric population are sparse and are mainly limited to case reports and hemovigilance reporting systems. The objective of this study was to determine incidence, risk factors, and outcome of TRALI in critically ill children. In a retrospective cohort study, all first-time admissions to the pediatric intensive care unit from January 1, 2009, until December 31, 2012, were screened for onset of TRALI using the consensus criteria. Of 2294 admitted patients, 304 were transfused, of whom 21 (6.9%) developed TRALI. Compared with transfused control subjects, risk factors for TRALI were mechanical ventilation (odds ratio, 18.94 [2.38-2452.56]), sepsis (odds ratio, 7.20 [2.69-19.69]), and high Pediatric Risk of Mortality III score (odds ratio, 1.05 [1.01-1.10]). Patients with TRALI had a higher mortality and a longer duration of mechanical ventilation when compared with transfused control subjects. Transfusion-related ALI is relatively common in critically ill children. The incidence in the pediatric intensive care unit population is similar to that in adult intensive care unit patients. High PRISM score on admission, mechanical ventilation and sepsis were identified as independent risk factors, which may help to assess the risks and benefits of transfusion in critically ill patients. Copyright © 2014 Elsevier Inc. All rights reserved.
Article
Transfusion-related acute lung injury (TRALI) is defined as the onset or the worsening of respiratory distress within 6 h of the transfusion of a plasma-containing blood component. It is currently considered to be one of the leading causes of severe posttransfusion morbidity and acute mortality in countries with a high development index. Understanding of the pathogenesis of TRALI has resulted in the development of preventive measures that have contributed to reducing its incidence. Early recognition of the clinical symptoms allow the clinician to identify the syndrome and to undertake therapeutic measures that may reduce the morbidity and mortality associated with this complication.
Article
Pediatric scoliosis surgery is associated with considerable blood loss and allogenic transfusions. Transfusions contribute to morbidities and cost. A perioperative pediatric blood management program was implemented at our institution. Patients received preoperative evaluation, cell salvage, topical hemostasis, antifibrinolytics, and hypotensive anesthesia. The study was a 2-year retrospective cohort review of the program's population from September 2007 through August 2009. A total of 110 scoliosis surgeries were performed with only 34 and 12% of the patients requiring preoperative oral iron and erythropoietin, respectively. Neuromuscular scoliosis patients had more repaired segments and a larger transfusion rate than idiopathic scoliosis patients (36% vs. 1.7%, p = 0.001). Transfused patients had more blood loss relative to their blood volume (p = 0.001) and blood loss was associated with higher Cobb angles (p = 0.04). Logistic regression revealed that blood loss (p = 0.001), number of segments fused (p = 0.004), and lower patient weight (p = 0.007) are associated with increased odds for transfusion. Twelve patients (10.9%) were identified with low von Willebrand activity with a trend toward higher blood losses (p = 0.07) with lower activity levels. Transfusion requirements in scoliosis patients are dependent on blood loss as determined by Cobb angles and number of segments fused relative to the patients' blood volume as determined by weight. Implementation of a blood management protocol resulted in a low transfusion rate and unexpectedly led to the preoperative diagnosis of a number of patients with low levels of von Willebrand activity.
Multivariable analyzes: biostatistical note
  • C Mélot
Mélot C (2005) Multivariable analyzes: biostatistical note. Respir Dis J 22: 687-690.
Enhanced recovery after surgey protocol versus conventional perioperative care in colorectal surgey. A single center cohort study
  • J Ripollés-Melchor
  • Mlf Varela
  • S C Camargo
  • P J Fernández
  • Á C Barrio
Ripollés-Melchor J, Varela MLF, Camargo SC, Fernández PJ, Barrio ÁC, et al. (2018) Enhanced recovery after surgey protocol versus conventional perioperative care in colorectal surgey. A single center cohort study. Rev Bras Anestesiol S0034-7094: 30389-30396.
Anesthesia-related critical incidents in the perioperative period
  • J C De Graaff
  • M C Sarfo
  • L Van Wolfswinkel
  • D B Van Der Werff
  • A N Schouten
de Graaff JC, Sarfo MC, van Wolfswinkel L, van der Werff DB, Schouten AN (2015) Anesthesia-related critical incidents in the perioperative period