Bayesian analysis of the epidemiology of bleeding in critically ill children

Greenway, Tyler; Eysenbach, Lindsay; Shabanova, Veronika; Faustino, E. Vincent S.

doi:10.1016/j.jcrc.2020.09.028

Cited by 8 publications

(9 citation statements)

References 14 publications

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“…Pinto et al ( 2 ) showed that in critically ill adolescents, this incidence was 30%, and when studying specifically critically ill children, White et al ( 3 ) estimated the bleeding incidence to be 37%, with clinically significant bleeds only occurring in 9% of patients. Greenway et al ( 14 ) identified a similar incidence of clinically relevant bleeds in critically ill children; 10% using the ISTH definition. It should be noted that White et al excluded patients bleeding at admission, which eliminated a large number of surgical patients from the bleeding cohort, and was likely contributory to the subsequently decreased risk of bleeding associated with surgery when compared to our cohort.…”

Section: Discussionmentioning

confidence: 97%

Epidemiology of Bleeding in Critically Ill Children

2021

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Objective: Bleeding can be a severe complication of critical illness, but its true epidemiologic impact on children has seldom been studied. Our objective is to describe the epidemiology of bleeding in critically ill children, using a validated clinical tool, as well as the hemostatic interventions and clinical outcomes associated with bleeding.Design: Prospective observational cohort study.Setting: Tertiary pediatric critical care unitPatients: All consecutive patients (1 month to 18 years of age) admitted to a tertiary pediatric critical care unitMeasurements and Main Results: Bleeding events were categorized as minimal, moderate, severe, or fatal, according to the Bleeding Assessment Scale in Critically Ill Children. We collected demographics and severity at admission, as evaluated by the Pediatric Index of Mortality. We used regression models to compare the severity of bleeding with outcomes adjusting for age, surgery, and severity. Over 12 months, 902 critically ill patients were enrolled. The median age was 64 months (IQR 17; 159), the median admission predicted risk of mortality was 0.5% (IQR 0.2; 1.4), and 24% were post-surgical. Eighteen percent of patients experienced at least one bleeding event. The highest severity of bleeding was minimal for 7.9% of patients, moderate for 5.8%, severe for 3.8%, and fatal for 0.1%. Adjusting for age, severity at admission, medical diagnosis, type of surgery, and duration of surgery, bleeding severity was independently associated with fewer ventilator-free days (p < 0.001) and fewer PICU-free days (p < 0.001). Adjusting for the same variables, bleeding severity was independently associated with an increased risk of mortality (adjusted odds ratio for each bleeding category 2.4, 95% CI 1.5; 3.7, p < 0.001).Conclusion: Our data indicate bleeding occurs in nearly one-fifth of all critically ill children, and that higher severity of bleeding was independently associated with worse clinical outcome. Further multicenter studies are required to better understand the impact of bleeding in critically ill children.

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Section: Discussionmentioning

confidence: 97%

Epidemiology of Bleeding in Critically Ill Children

2021

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“…Critically ill children have a significant risk of developing clinically significant bleeding due to underlying organ dysfunction and possible bone marrow suppression and/or consumptive coagulopathies ( 1 ). Children supported by extracorporeal membrane oxygenation (ECMO) are substantially more likely to bleed from a variety of factors, including initial hemodilution upon cannulation, required anticoagulation, circuit-induced consumptive coagulopathy and platelet dysfunction ( 2 , 3 ).…”

Section: Introductionmentioning

confidence: 99%

Epidemiology of the Use of Hemostatic Agents in Children Supported by Extracorporeal Membrane Oxygenation: A Pediatric Health Information System Database Study

et al. 2021

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Objectives: Children supported by extracorporeal membrane oxygenation (ECMO) are at high risk of bleeding. Though practitioners often prescribe blood components and/or medications to prevent or treat bleeding, the utilization of these hemostatic measures in children is not well-understood. We sought to evaluate the use of hemostatic blood products (platelet, plasma and cryoprecipitate transfusions) and medications [aminocaproic acid, tranexamic acid (TXA) and Factor VIIa] in children supported by ECMO.Design: Retrospective observational study using the Pediatric Health Information System (PHIS) database from 2011-2017.Setting: Fifty-one U.S. children's hospitals.Patients: Children (aged 0–18 years) supported by ECMO.Interventions: None.Measurements and Main Results: ECMO was employed in the care of 7,910 children for a total of 56,079 ECMO days. Fifty-five percent of the patients were male with a median (IQR) age of 0 (0–2) years. The median (IQR) length of ECMO was 5 (2–9) days with a hospital mortality rate of 34%. Platelets were transfused on 49% of ECMO days, plasma on 33% of ECMO days and cryoprecipitate on 17% of ECMO days. Twenty-two percent of children received TXA with the majority receiving it on the first day of ECMO and the use of TXA increased during the 6-year period studied (p < 0.001). Seven percent of children received aminocaproic acid and 3% received Factor VIIa.Conclusions: Children supported by ECMO are exposed to a significant number of hemostatic blood products. Antifibrinolytics, in particular TXA, are being used more frequently. Given the known morbidity and mortality associated with hemostatic blood products, studies are warranted to evaluate the effectiveness of hemostatic strategies.

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“…The aim is to reduce the risk of clinically significant upper gastrointestinal bleeding (6), which is a complication of critical illness (7,8). However, the contemporary prevalence of upper gastrointestinal bleeding is probably low (8)(9)(10)(11). In this context, the efficacy of stress ulcer prophylaxis in the PICU is uncertain (2,12,13).…”

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confidence: 99%