The Transfusion and Anemia Expertise Initiative recommendations provide important clinical guidance and applicable tools to avoid unnecessary RBC transfusions. Research recommendations identify areas of focus for future investigation to improve outcomes and safety for RBC transfusion.

In this subgroup analysis of cardiac surgery patients, a restrictive red-cell transfusion strategy, as compared with a liberal one, was not associated with any significant difference in new or progressive multiple organ dysfunction syndrome, but this evidence is not definitive.

We present RBC transfusion management recommendations for the critically ill child with cardiac disease. Clinical recommendations emphasize relevant hemoglobin thresholds, and research recommendations emphasize need for further understanding of physiologic and hemoglobin thresholds and alternatives to RBC transfusion in subpopulations lacking pediatric literature.

Post-CPB plasma fibrinogen concentration significantly influences blood loss in children undergoing cardiac surgery. A fibrinogen concentration of at least 1.5 g l or a MCF of at least 3 mm should accurately predict excessive blood loss in cardiac surgery children. Further prospective trials are needed to assess the effect of fibrinogen supplementation on postoperative blood loss in this population.

The benefit-to-risk ratio of using tranexamic acid (TXA) in paediatric cardiac surgery has not yet been determined. This systematic review evaluated studies that compared TXA to placebo in children undergoing cardiac surgery. A systematic search was conducted in all relevant randomized controlled trials. The following information was extracted from the studies and analysed if relevant: demographic data, TXA dose and regimen of administration, cardiopulmonary bypass time, blood loss and blood product transfusion at 24 h. From the studies screened, only 8 (848 patients) were included in the analysis. Most data were heterogeneously distributed and could not be analysed. Further, transfusion policies were not well defined for each study. TXA reduced the need for red blood cell transfusion by 6.4 ml kg(-1) day(-1) (I(2) = 0%, P = 0.45), platelet transfusion by 3.7 ml kg(-1) day(-1) (I(2) = 0%, P = 0.46) and fresh frozen plasma transfusion by 5.4 ml kg(-1) day(-1) (I(2) = 0%, P = 0.53). The number of children who avoided all blood product transfusions was not reported in most of the studies. Evaluation of the side effects associated with TXA use and the effects of the agent on postoperative morbidity and mortality was not possible from the data. There was marked variability in the dosage and infusion schemes used in different studies. This systematic review showed that in paediatric cardiac surgery, the benefit-to-risk ratio associated with the use of TXA cannot be adequately defined. Evidence supporting the routine use of TXA in paediatric cardiac surgery remains weak.

This study describes an algorithm starting with the detection of abnormal bleeding in which ROTEM could be used to guide haemostatic therapy in bleeding children after CPB. Further studies are needed to test the efficacy of this specific algorithm-based approach.

Although bleeding frequently occurs in critical illness, no published definition to date describes the severity of bleeding accurately in critically ill children. We sought to develop diagnostic criteria for bleeding severity in critically ill children. Design: Delphi consensus process of multidisciplinary experts in bleeding/hemostasis in critically ill children, followed by prospective cohort study to test internal validity. Setting: PICU. Patients: Children at risk of bleeding in PICUs. Interventions: None. Measurements and Main Results: Twenty-four physicians worldwide (10 on a steering committee and 14 on an expert committee) from disciplines related to bleeding participated in development of a definition for clinically relevant bleeding. A provisional definition was created from 35 descriptors of bleeding. Using a modified online Delphi process and conference calls, the final definition resulted after seven rounds of voting. The Bleeding Assessment Scale in Critically Ill Children definition categorizes bleeding into severe, moderate, and minimal, using organ dysfunction, proportional changes in vital signs, anemia, and quantifiable bleeding. The criteria do not include treatments such as red cell transfusion or surgical interventions performed in response to the bleed. The definition was prospectively applied to 40 critically ill children with 46 distinct bleeding episodes. The kappa statistic between the two observers was 0.74 (95% CI, 0.57-0.91) representing substantial inter-rater reliability. Conclusions: The Bleeding Assessment Scale in Critically Ill Children definition of clinically relevant bleeding severity is the first physician-driven definition applicable for bleeding in critically ill children derived via international expert consensus. The Bleeding Assessment Scale in Critically Ill Children definition includes clear criteria for bleeding severity in critically ill children. We anticipate that it will facilitate clinical communication among pediatric intensivists pertaining to bleeding and serve in the design of future epidemiologic studies if it is validated with patient outcomes.

IntroductionSix percent hydroxyethyl starch (HES) 130/0.4 is considered an alternative to human albumin (HA) and crystalloids for volume replacement in children undergoing cardiac surgery. In this large propensity-matched analysis, we aimed to assess the efficacy and safety of replacing HA with HES for intraoperative volume therapy in children undergoing cardiac surgery with cardiopulmonary bypass (CPB).MethodsWe retrospectively reviewed our database, including children who underwent cardiac surgery between January 2002 and December 2010. Four percent HA was used until 2005; it was replaced by HES thereafter. Demographic data, intra- and postoperative blood loss and blood component transfusions were recorded, together with the incidence of postoperative complications and mortality. We performed a propensity-matched analysis using 13 possible confounding factors to compare children who received either HES or HA intraoperatively. The primary objectives included the effects of both fluids on intraoperative fluid balance (difference between fluids in and fluids out (efficacy)) and blood loss and exposure to allogeneic blood products (safety). Secondary safety outcomes were mortality and the incidence of postoperative renal dysfunction.ResultsOf 1,832 children reviewed, 1,495 were included in the analysis. Intraoperative use of HES was associated with a less positive fluid balance. Perioperative blood loss, volume of red blood cells and fresh frozen plasma administered, as well as the number of children who received transfusions, were also significantly lower in the HES group. No difference was observed regarding the incidence of postoperative renal failure requiring renal replacement therapy or of morbidity and mortality.ConclusionsThese results confirm that the use of HES for volume replacement in children during cardiac surgery with CPB is as safe as HA. In addition, its use might be associated with less fluid accumulation. Further large studies are needed to assess whether the reduction in fluid accumulation could have a significant impact on postoperative morbidity and mortality.