How 217 Pediatric Intensivists Manage Anemia at PICU Discharge: Online Responses to an International Survey*

Abstract

Objective: To describe the management of anemia at PICU discharge by pediatric intensivists. Design: Self-administered, online, scenario-based survey. Setting: PICUs in Australia/New Zealand, Europe, and North America. Subjects: Pediatric intensivists. Interventions: None. Measurements and Main Results: Respondents were asked to report their decisions regarding RBC transfusions, iron, and erythropoietin prescription to children ready to be discharged from PICU, who had been admitted for hemorrhagic shock, cardiac surgery, craniofacial surgery, and polytrauma. Clinical and biological variables were altered separately in order to assess their effect on the management of anemia. Two-hundred seventeen responses were analyzed. They reported that the mean (± sem) transfusion threshold was a hemoglobin level of 6.9 ± 0.09 g/dL after hemorrhagic shock, 7.6 ± 0.10 g/dL after cardiac surgery, 7.0 ± 0.10 g/dL after craniofacial surgery, and 7.0 ± 0.10 g/dL after polytrauma (p < 0.001). The most important increase in transfusion threshold was observed in the presence of a cyanotic heart disease (mean increase ranging from 1.80 to 2.30 g/dL when compared with baseline scenario) or left ventricular dysfunction (mean increase, 1.41–2.15 g/dL). One third of respondents stated that they would not prescribe iron at PICU discharge, regardless of the hemoglobin level or the baseline scenario. Most respondents (69.4–75.0%, depending on the scenario) did not prescribe erythropoietin. Conclusions: Pediatric intensivists state that they use restrictive transfusion strategies at PICU discharge similar to those they use during the acute phase of critical illness. Supplemental iron is less frequently prescribed than RBCs, and prescription of erythropoietin is uncommon. Optimal management of post-PICU anemia is currently unknown. Further studies are required to highlight the consequences of this anemia and to determine appropriate management.

Iron Deficiency in Anemic Children Surviving Critical Illness: Post Hoc Analysis of a Single-Center Prospective Cohort in Canada, 2019–2022

“…The recent shift toward a more conservative transfusion strategy in ICUs, supported by robust clinical trial data, has led to a significant reduction in blood transfusions and a greater tolerance for anemia in the PICU (21,22). Consequently, a large proportion of pediatric patients leave the PICU with untreated anemia, often without proper follow-up (2). Despite this, our understanding of the pathophysiology and recovery patterns related to this ICUinduced complication is still limited.…”

“…In our previous PICU cohort study from 2013 to 2018 (1), we found that the prevalence of anemia at discharge was over 50%. More recently, in an international survey of 217 pediatric intensivists in 2018–2019, we also found that most of these discharged children likely leave the hospital without any follow-up or management plan for their anemia (2). Anemia of critical illness is thought to be primarily caused by inflammation and functional iron depletion (ID).…”

“…any follow-up or management plan for their anemia (2). Anemia of critical illness is thought to be primarily caused by inflammation and functional iron depletion (ID).…”

Editor’s Choice Articles for January

“…Finally, we have the topic of anemia from blood sampling during PICU admission. We know from an online survey of 217 pediatric intensivists from around the world that there is considerable uncertainty about how to manage anemia at PICU discharge (18). We also know from a prospective, single-center cohort study in Canada (published in PCCM , June 2022) that there remains a major impact of diagnostic blood sampling on anemia during PICU admission (19).…”

Pediatric Acute Lung Injury and Sepsis Investigators (PALISI): Evolution of an Investigator-Initiated Research Network

“…This group is mainly comprised of hematologists, transfusion medicine, and pediatric critical care specialists. To date, the BloodNet investigators have conducted a range of studies and outputs for the field, including surveys (30, 31), point-prevalence studies (32), prospective observational studies (33, 34), RCTs (15), development of assessment scales for bleeding (19), and consensus conferences in the areas of transfusion medicine (20, 35). The key lesson learned here is that there are some areas in pediatric critical care in which research development requires cross-discipline interactions and working together, and the transfusion and blood product subgroup is an exemplar of this approach.…”