Bleeding Scales Applicable to Critically Ill Children: A Systematic Review

Nellis, Marianne; Levasseur, Julie; Stribling, Judy; Faustino, E. Vincent S.; Zantek, Nicole D.; Sheth, Sujit; Karam, Oliver

doi:10.1097/pcc.0000000000001943

Cited by 11 publications

(11 citation statements)

References 31 publications

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“…The voting data, including the number of voting experts and median score, are provided for each statement and recommendation. Rationale: Over 50% of platelet transfusions in the PICU are given as prophylaxis (12,13). Thus, platelet count alone determines whether a platelet transfusion will be administered.…”

Section: Resultsmentioning

confidence: 99%

What Laboratory Tests and Physiologic Triggers Should Guide the Decision to Administer a Platelet or Plasma Transfusion in Critically Ill Children and What Product Attributes Are Optimal to Guide Specific Product Selection? From the Transfusion and Anemia EXpertise Initiative–Control/Avoidance of Bleeding

Delaney

Karam

Lieberman

et al. 2022

Pediatric Critical Care Medicine

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Objectives: To present consensus statements and supporting literature for plasma and platelet product variables and related laboratory testing for transfusions in general critically ill children from the Transfusion and Anemia EXpertise Initiative–Control/Avoidance of Bleeding. Design: Systematic review and consensus conference of international, multidisciplinary experts in platelet and plasma transfusion management of critically ill children. Setting: Not applicable. Patients: Critically ill pediatric patients at risk of bleeding and receiving plasma and/or platelet transfusions. Interventions: None. Measurements and Main Results: A panel of 10 experts developed evidence-based and, when evidence was insufficient, expert-based statements for laboratory testing and blood product attributes for platelet and plasma transfusions. These statements were reviewed and ratified by the 29 Transfusion and Anemia EXpertise Initiative - Control/Avoidance of Bleeding experts. A systematic review was conducted using MEDLINE, EMBASE, and Cochrane Library databases, from inception to December 2020. Consensus was obtained using the Research and Development/University of California, Los Angeles Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. We developed five expert consensus statements and two recommendations in answer to two questions: what laboratory tests and physiologic triggers should guide the decision to administer a platelet or plasma transfusion in critically ill children; and what product attributes are optimal to guide specific product selection? Conclusions: The Transfusion and Anemia EXpertise Initiative–Control/Avoidance of Bleeding program provides some guidance and expert consensus for the laboratory and blood product attributes used for decision-making for plasma and platelet transfusions in critically ill pediatric patients.

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Section: Resultsmentioning

confidence: 99%

What Laboratory Tests and Physiologic Triggers Should Guide the Decision to Administer a Platelet or Plasma Transfusion in Critically Ill Children and What Product Attributes Are Optimal to Guide Specific Product Selection? From the Transfusion and Anemia EXpertise Initiative–Control/Avoidance of Bleeding

Delaney

Karam

Lieberman

et al. 2022

Pediatric Critical Care Medicine

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“…The BASIC definition represents the first multidisciplinary, international, physician-driven, consensus definition for clinically relevant bleeding applicable to critically ill children (7). It was designed with rigorous methodology that involved a preliminary extensive review of the medical literature (7), the input of 225 surveyed clinicians (10), opinion from a multidisciplinary expert committee, and guidance from a steering committee with substantial expertise in transfusion research. The goal of the process was to create a definition of bleeding severity that would be specifically applicable across populations of critically ill children.…”

Section: Discussionmentioning

confidence: 99%

“…There are numerous definitions pertaining to the clinical significance of bleeding, but none are designed for critically ill children (7). Current definitions contain descriptors that are subjective, lack bleeding typically seen in critically ill children (e.g., in endotracheal tube), include transfusions as criteria despite variability in clinical decision-making, often include vital sign changes pertinent to adults but not children, and are rarely correlated and validated to clinical outcomes.…”

mentioning

confidence: 99%

Bleeding Assessment Scale in Critically Ill Children (BASIC): Physician-Driven Diagnostic Criteria for Bleeding Severity

Nellis

Tucci

Lacroix

et al. 2019

Critical Care Medicine

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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.

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“…Though bleeding frequently occurs in critically ill children, there are few published definitions classifying the severity of bleeding accurately in this patient population. A systematic review on bleeding scales and their validation in critically ill children highlighted the use of subjective descriptors of bleeding, the use of transfusions as a criterion to define bleeding despite significant variability in clinical transfusion decision‐making, the use of vital sign changes pertinent to adults but not to children, and the lack of validation with clinical outcomes 28 . Nellis et al have recently proposed the Bleeding Assessment Scale in Critically Ill Children (BASIC) definition, which categorizes bleeding into severe, moderate, and minimal using organ dysfunction, proportional changes in vital signs, anemia, and quantifiable bleeding 29 .…”

Section: Quantifying the Markers Of Rbc Loss In Ecmomentioning

confidence: 99%

Disentangling the causes of RBC loss and anemia in ECMO patients: Some questions answered?

2023

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Extracorporeal membrane oxygenation (ECMO) is a potentially life-saving intervention for children and adults with severe cardiac or respiratory failure. [1][2][3] The use of veno-venous (VV) and veno-arterial (VA) ECMO as a bridge to cardiopulmonary recovery or to heart or lung transplantation has dramatically increased in the last decade. 4 In this issue of TRANSFUSION, Bilodeau et al. seek to characterize and quantify the various causes of red blood cell (RBC) loss in pediatric patients on ECMO. 5 The authors propose the use of the RBC loss index (RLI), a novel metric based upon changes in hematocrit and the volume of transfused RBCs, calculated as mL of RBCs lost per liter of total (patient + circuit) volume per hour. They also propose using RBC extracellular vesicle (REV) generation as a marker of sublethal injury to RBCs during ECMO. The investigators suggest that sublethal RBC damage may stimulate extravascular clearance and eventual RBC loss. We applaud the authors on their effort to provide objective metrics for blood loss as well as RBC injury in children on ECMO, and believe that this article should be of great interest to the readers of TRANSFUSION.Transfusion of blood products, such as RBCs, plasma, platelets, and cryoprecipitate, while on ECMO occurs for a variety of reasons. Anemia is common with ECMO and typically attributed to a combination of circuit-related hemolysis, frequent blood sampling for laboratory monitoring, and an increased risk of bleeding given the use of anticoagulants, consumptive coagulopathy, and thrombocytopenia/platelet dysfunction. 6,7 While bleeding remains a principal cause of anemia in patients on ECMO, the authors attempt to quantify the contribution of other etiologies. They note that in the "non-bleeding" ECMO patients, diagnostic phlebotomy accounted for almost a quarter of blood loss, followed by intravascular hemolysis at 16%. This calculation suggested that a majority (up to 60%) of RBC loss in patients without evidence of bleeding was due to other etiologies. Studies have shown that patients supported with ECMO may inadvertently be exposed to RBC transfusion for the treatment of otherwise mild anemia resulting from blood loss, particularly phlebotomy. Frequent phlebotomy and laboratory sampling can contribute to transfusion requirements in more than 50% of patients and have been the sole reason for at least one transfusion in 40% of patients. 7

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Bleeding Scales Applicable to Critically Ill Children: A Systematic Review

Cited by 11 publications

References 31 publications

Bleeding Assessment Scale in Critically Ill Children (BASIC): Physician-Driven Diagnostic Criteria for Bleeding Severity

Disentangling the causes of RBC loss and anemia in ECMO patients: Some questions answered?

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