Executive Summary of Recommendations and Expert Consensus for Plasma and Platelet Transfusion Practice in Critically Ill Children: From the Transfusion and Anemia EXpertise Initiative—Control/Avoidance of Bleeding (TAXI-CAB)

Abstract

OBJECTIVES:Critically ill children frequently receive plasma and platelet transfusions. We sought to determine evidence-based recommendations, and when evidence was insufficient, we developed expert-based consensus statements about decision-making for plasma and platelet transfusions in critically ill pediatric patients.DESIGN: Systematic review and consensus conference series involving multidisciplinary international experts in hemostasis, and plasma/platelet transfusion in critically ill infants and children (Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding [TAXI-CAB]). SETTING: Not applicable. PATIENTS:Children admitted to a PICU at risk of bleeding and receipt of plasma and/or platelet transfusions. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS:A panel of 29 experts in methodology, transfusion, and implementation science from five countries and nine pediatric subspecialties completed a systematic review and participated in a virtual consensus conference series to develop recommendations. The search included MEDLINE, EMBASE, and Cochrane Library databases, from inception to December 2020, using a combination of subject heading terms and text words for concepts of plasma and platelet transfusion in critically ill children. Four graded recommendations and 49 consensus expert statements were developed using modified Research and Development/UCLA and Grading of Recommendations, Assessment, Development, and Evaluation methodology. We focused on eight subpopulations of critical illness (1, severe trauma, intracranial hemorrhage, or traumatic brain injury; 2, cardiopulmonary bypass surgery; 3, extracorporeal membrane oxygenation; 4, oncologic diagnosis or hematopoietic stem cell transplantation; 5, acute liver failure or liver transplantation; 6, noncardiac surgery; 7, invasive procedures outside the operating room; 8, sepsis and/ or disseminated intravascular coagulation) as well as laboratory assays and selection/processing of plasma and platelet components. In total, we came to consensus on four recommendations, five good practice statements, and 44 consensus-based statements. These results were further developed into consensus-based clinical decision trees for plasma and platelet transfusion in critically ill pediatric patients. CONCLUSIONS:The TAXI-CAB program provides expert-based consensus for pediatric intensivists for the administration of plasma and/or platelet transfusions in critically ill pediatric patients. There is a pressing need for primary research to provide more evidence to guide practitioners.

Transfusion Strategies for Hemostatic Blood Products in Critically Ill Children: A Narrative Review and Update on Expert Consensus Guidelines

“…Physiological and clinical variables that may influence the decision include the maturation and balance of the patient’s hemostatic system, active bleeding, medications affecting coagulation status, and congenital and acquired bleeding disorders. Special circumstances, such as massive hemorrhage, DIC, liver failure and liver transplantation, ECMO, and CPB, should follow evidence-based, and when evidence is lacking, expert-based consensus recommendations 5 and should be included within quality improvement projects and randomized or observational trials.…”

“…aPTT indicates activated partial thromboplastin time; CVL, central venous line; DIC, disseminated intravascular coagulation; ECMO, extracorporeal membrane oxygenation; Hb, hemoglobin; HSCT, hematopoietic stem cell transplantation; ICH, intracranial hemorrhage; ICP, intracranial pressure; INR, international normalized ratio; OR, operating room; PT, prothrombin time; RBC, red blood cell; TAXI-CAB, Transfusion and Anemia eXxpertise Initiative-Control and Avoidance of Bleeding; TBI, traumatic brain injury. Used with permission from Nellis et al 5 ( Pediatric Critical Care Medicine ).…”

Transfusion therapy of neonatal and paediatric patients: They are not just little adults

“…Another single institutional study mentioned that the median platelet transfusion threshold for paediatric oncology patients with hypoproliferative thrombocytopenia was 16 000/μl 67 . The TAXI‐CAB consortium mentioned that in critically ill child in oncology or HSCT, prophylactic platelet transfusions might be considered for a platelet count less than 10 000/μl whereas therapeutic platelet transfusions might be considered for moderate or severe bleeding 68 . A study conducted by Zumberg et al, had identified graft versus host disease, type of transplant such as autologous, allogenic or matched unrelated donor, and use of Amphotericin B are the predictors of bleeding in children admitted in the Haematology‐Oncology service 69 …”

Pediatric platelet transfusions in critical illness: a narrative review of recent studies

“…To address the need for guidance, particularly in the critically ill child, the Transfusion Anemia eXpertise Initiative – Control/Avoidance of Bleeding (TAXI-CAB) program recently conducted a large systematic review and guideline development for platelet transfusions, to both prevent and treat bleeding [41 ▪▪ ]. There was independent expertise and focus on several patient groups at high risk of platelet transfusion including trauma, intracranial hemorrhage, cardiopulmonary bypass, ECMO, noncardiac surgery, invasive procedures, sepsis, oncologic diagnoses and liver failure [42–45].…”