Blood Transfusion Thresholds Research Articles

Hemoglobin Threshold for Blood Transfusion in a Pediatric Intensive Care Unit

Objective: To evaluate the hemoglobin threshold for red cell transfusion in children admitted to a pediatric intensive care unit (PICU). Methods: Retrospective chart review study. Tertiary care PICU. Critically ill pediatric patients requiring blood transfusion. No intervention. Results: We analyzed the charts of all children between 1 month and 21 years of age who received packed red blood cell (PRBC) transfusions during a 2-year period. The target patients were identified from our blood bank database. For analysis, the patients were subdivided into four groups: acute blood loss (postsurgically, trauma, or acute gastrointestinal bleeding from other causes), hematologic (hematologic malignancies, bone marrow suppression, hemolytic anemia, or sickle cell disease), unstable (FiO₂ > 0.6 and/or on inotropic support), and stable groups. We also compared the pre-transfusion hemoglobin threshold in all unstable patients with that of all stable patients. A total of 571 transfusion episodes in 284 patients were analyzed. 28% (n = 160) of transfusions were administered to patients in the acute blood loss group, 36% (n = 206) to hematologic patients, 17% (n = 99) to unstable patients, and 18% (n = 106) to stable patients. The mean pre-transfusion hemoglobin (± SD) in all children as well as in the acute blood loss, hematologic, unstable and stable groups was 7.3 ± 1.20, 7.83 ± 1.32, 6.97 ± 1.31, 7.96 ± 1.37, 7.31 ± 1.09 g/dl, respectively. The transfusion threshold for acute blood loss and unstable groups was higher compared to hematologic and stable groups (p < 0.001; ANOVA with multiple comparisons). The mean pre-transfusion hemoglobin threshold for stable and unstable patients among all groups was 7.3 ± 1.3 and 7.9 ± 1.3 (p < 0.0001), respectively. The observed mortality rate was higher among children who received transfusion compared to other children admitted to PICU. Conclusion: The hemoglobin threshold for transfusion varied according to clinical conditions. Overall, the hemoglobin threshold for transfusion was 7.3 ± 1.20 g/dl.

Predictors of neurological outcomes after successful extracorporeal cardiopulmonary resuscitation.

BackgroundExtracorporeal cardiopulmonary resuscitation (ECPR) refers to use of extracorporeal membrane oxygenation (ECMO) in cardiopulmonary arrest. Although ECPR can increase survival rates after cardiac arrest, it can also result in poor post-resuscitation neurological status. Thus, we investigated predictors of good neurological outcomes after successful ECPR.MethodsA total of 227 patients underwent ECPR from May 2004 to June 2013 at Samsung Medical Center. Successful ECPR was defined as survival more than 24 hours after ECPR. Neurological outcomes were assessed at discharge using the Glasgow-Pittsburgh Cerebral Performance Categories scale (CPC). CPC 1 and 2 were classified as good and CPC 3 to 5 were classified as poor neurological outcomes. Excluded were 22 patients who did not survive more than 24 hours after ECPR and 90 patients who died from unknown causes or causes other than brain death or whose neurological status could not be assessed at discharge. Multiple logistic regression analysis was used to identify independent predictors of neurological outcomes.ResultsIncluded were 115 patients with a mean age of 58 (range 45–66) years and 80 men (70%). Cardiopulmonary resuscitation (CPR) was performed at non-hospital sites for 19 (17%) patients and bystander CPR was performed in 9 of 19 cases (47%). Cardiac etiology was verified in 74 (64%) patients and therapeutic hypothermia was performed in 9 patients (8%); 68 (59%) had good neurological outcomes and 47 (41%) did not and 24 patients died from brain death. Neurological outcomes were affected by hemoglobin levels before ECMO (P = 0.02), serum lactic acid (P < 0.001) before ECMO insertion, and interval from cardiac arrest to ECMO (P = 0.04).ConclusionsLow hemoglobin or high serum lactic acid levels before ECMO, and prolonged interval from cardiac arrest to ECMO predicted poor neurological outcomes after successful ECPR. Early institution of ECMO and a low threshold for blood transfusion might improve neurological outcomes for patients who survive ECPR.

Management of Hip Fractures in the Elderly

The purpose of this clinical practice guideline is to help improve treatment and management of hip fractures in the elderly based on current best evidence. The guideline contains twenty-five recommendations, including both diagnosis and treatment. Of those recommendations, strong evidence supports regional analgesia to improve preoperative pain control, similar outcomes for general or spinal anesthesia, arthroplasty for patients with unstable (displaced) femoral neck fractures, the use of a cephalomedullary device for the treatment of patients with subtrochanteric or reverse obliquity fractures, a blood transfusion threshold of no higher than 8 g/dL in asymptomatic postoperative patients, intensive physical therapy postdischarge, use of an interdisciplinary care program in patients with mild to moderate dementia, and multimodal pain management after hip fracture surgery. In addition to the recommendations, the work group highlighted the need for better research in the treatment of hip fractures.

Open and robot‐assisted radical retropubic prostatectomy in men receiving ongoing low‐dose aspirin medication: revisiting an old paradigm?

To assess blood loss, transfusion rates and 90-day complication rates in patients receiving ongoing 100 mg/day aspirin medication and undergoing open radical prostatectomy (RP) or robot-assisted RP (RARP). Between February 2010 and August 2011, 2061 open RPs and 400 RARPs were performed. All patients received low-molecular-weight heparin for thrombembolism prophylaxis. Aspirin intake during surgery was recorded in 137 patients (5.5%). Descriptive statistics and multivariable analyses after propensity-score matching for balancing potential differences in patients with and without aspirin medication were used to assess the risk of blood loss above the median in patients undergoing open RP or RARP. The median blood loss in the open RP cohort with and without aspirin medication was 750 and 700 mL, respectively, and in the RARP cohort it was 200 and 150 mL, respectively. Within the same cohorts, transfusions were administered in 21 and 8% and 0 and 1% of patients, respectively. The 90-day complication rates in patients with ongoing aspirin medication were 5.8, 4.4, 7.3 and 0% for Clavien grades I, II, III and IV complications, respectively. In multivariable analyses and after propensity-score matching, prostate volume (odds ratio 1.03; 95% CI 1.02-1.04; P < 0.01) but not ongoing aspirin medication achieved independent predictor status for the risk of blood loss above the median. Major surgery such as open RP and RARP can be safely performed in patients with ongoing aspirin medication without greater blood loss. Higher 90-day complication rates were not detected in such patients. Differences in transfusion rates between the groups receiving and not receiving ongoing aspirin medication may be explained by a higher proportion of patients with coronary artery disease in the group receiving ongoing aspirin medication. This comorbidity may result in a higher peri-operative threshold for allogenic blood transfusion.

Delirium Outcomes in a Randomized Trial of Blood Transfusion Thresholds in Hospitalized Older Adults with Hip Fracture

To determine whether a higher blood transfusion threshold would prevent new or worsening delirium symptoms in the hospital after hip fracture surgery. Ancillary study to a randomized clinical trial. Thirteen hospitals in the United States and Canada. One hundred thirty-nine individuals hospitalized with hip fracture aged 50 and older (mean age 81.5 ± 9.1) with cardiovascular disease or risk factors and hemoglobin concentrations of less than 10 g/dL within 3 days of surgery recruited in an ancillary study of the Transfusion Trigger Trial for Functional Outcomes in Cardiovascular Patients Undergoing Surgical Hip Fracture Repair. Individuals in the liberal treatment group received one unit of packed red blood cells and as much blood as needed to maintain hemoglobin concentrations at greater than 10 g/dL; those in the restrictive treatment group received transfusions if they developed symptoms of anemia or their hemoglobin fell below 8 g/dL. Delirium assessments were performed before randomization and up to three times after randomization. The primary outcome was severity of delirium according to the Memorial Delirium Assessment Scale (MDAS). The secondary outcome was the presence or absence of delirium defined according to the Confusion Assessment Method (CAM). The liberal group received a median two units of blood and the restrictive group zero units of blood. Hemoglobin concentration on Day 1 after randomization was 1.4 g/dL higher in the liberal group. Treatment groups did not differ significantly at any time point or over time on MDAS delirium severity (P = .28) or CAM delirium presence (P = .83). Blood transfusion to maintain hemoglobin concentrations greater than 10 g/dL alone is unlikely to influence delirium severity or rate in individuals with hip fracture after surgery with a hemoglobin concentration less than 10 g/dL.

Applicability of the WHO Maternal Near Miss Criteria in a Low-Resource Setting

BackgroundMaternal near misses are increasingly used to study quality of obstetric care. Inclusion criteria for the identification of near misses are diverse and studies not comparable. WHO developed universal near miss inclusion criteria in 2009 and these criteria have been validated in Brazil and Canada.ObjectivesTo validate and refine the WHO near miss criteria in a low-resource setting.MethodsA prospective cross-sectional study was performed in a rural referral hospital in Tanzania. From November 2009 until November 2011, all cases of maternal death (MD) and maternal near miss (MNM) were included. For identification of MNM, a local modification of the WHO near miss criteria was used, because most laboratory-based and some management-based criteria could not be applied in this setting. Disease-based criteria were added as they reflect severe maternal morbidity. In the absence of a gold standard for identification of MNM, the clinical WHO criteria were validated for identification of MD.Results32 MD and 216 MNM were identified using the locally adapted near miss criteria; case fatality rate (CFR) was 12.9%. WHO near miss criteria identified only 60 MNM (CFR 35.6%). All clinical criteria, 25% of the laboratory-based criteria and 50% of the management-based criteria could be applied. The threshold of five units of blood for identification of MNM led to underreporting of MNM. Clinical criteria showed specificity of 99.5% (95%CI: 99.4%–99.7%) and sensitivity of 100% (95%CI: 91.1%–100%). Some inclusion criteria did not contribute to the identification of cases and therefore may be eligible for removal.ConclusionThe applicability of the WHO near miss criteria depends on the local context, e.g. level of health care. The clinical criteria showed good validity. Lowering the threshold for blood transfusion from five to two units in settings without blood bank and addition of disease-based criteria in low-resource settings is recommended.

Liberal or Restrictive Transfusion in High-Risk Patients after Hip Surgery

The hemoglobin threshold at which postoperative red-cell transfusion is warranted is controversial. We conducted a randomized trial to determine whether a higher threshold for blood transfusion would improve recovery in patients who had undergone surgery for hip fracture. We enrolled 2016 patients who were 50 years of age or older, who had either a history of or risk factors for cardiovascular disease, and whose hemoglobin level was below 10 g per deciliter after hip-fracture surgery. We randomly assigned patients to a liberal transfusion strategy (a hemoglobin threshold of 10 g per deciliter) or a restrictive transfusion strategy (symptoms of anemia or at physician discretion for a hemoglobin level of <8 g per deciliter). The primary outcome was death or an inability to walk across a room without human assistance on 60-day follow-up. A median of 2 units of red cells were transfused in the liberal-strategy group and none in the restrictive-strategy group. The rates of the primary outcome were 35.2% in the liberal-strategy group and 34.7% in the restrictive-strategy group (odds ratio in the liberal-strategy group, 1.01; 95% confidence interval [CI], 0.84 to 1.22), for an absolute risk difference of 0.5 percentage points (95% CI, -3.7 to 4.7). The rates of in-hospital acute coronary syndrome or death were 4.3% and 5.2%, respectively (absolute risk difference, -0.9%; 99% CI, -3.3 to 1.6), and rates of death on 60-day follow-up were 7.6% and 6.6%, respectively (absolute risk difference, 1.0%; 99% CI, -1.9 to 4.0). The rates of other complications were similar in the two groups. A liberal transfusion strategy, as compared with a restrictive strategy, did not reduce rates of death or inability to walk independently on 60-day follow-up or reduce in-hospital morbidity in elderly patients at high cardiovascular risk. (Funded by the National Heart, Lung, and Blood Institute; FOCUS ClinicalTrials.gov number, NCT00071032.).

Low versus high haemoglobin concentration threshold for blood transfusion for preventing morbidity and mortality in very low birth weight infants

Infants of very low birth weight often receive multiple transfusions of red blood cells, usually in response to predetermined haemoglobin or haematocrit thresholds. In the absence of better indices, haemoglobin levels are imperfect but necessary guides to the need for transfusion. Chronic anaemia in premature infants may, if severe, cause apnoea, poor neurodevelopmental outcomes or poor weight gain.On the other hand, red blood cell transfusion may result in transmission of infections, circulatory or iron overload, or dysfunctional oxygen carriage and delivery. To determine if erythrocyte transfusion administered to maintain low as compared to high haemoglobin thresholds reduces mortality or morbidity in very low birth weight infants enrolled within three days of birth. Two review authors independently searched the Cochrane Central Register of Controlled Trials (The Cochrane Library) , MEDLINE,EMBASE, and conference proceedings through June 2010. We selected randomised controlled trials (RCTs) comparing the effects of early versus late, or restrictive versus liberal erythrocyte transfusion regimes in low birth weight infants applied within three days of birth, with mortality or major morbidity as outcomes.

A survey of blood transfusion practice in French‐speaking pediatric anesthesiologists

There are so far no existing consensus guidelines regarding red blood cell transfusion during pediatric surgery, and there is a little information regarding red blood cell transfusion policy among pediatric anesthesiologists. To determine the transfusion threshold and the volumes of packed red blood cell (PRBC) transfusion among French-speaking pediatric anesthesiologists. A questionnaire of case scenarios was sent to active members of the French Language Society of Pediatrics Anesthesiologists (ADARPEF). Of the 324 active members of the ADARPEF, 175 (54%) completed the questionnaire. The threshold for blood transfusion varied from 6 to 12 g·dl(-1) depending on the scenario. The hemoglobin threshold for blood transfusion and the volume of blood transfused vary among ADARPEF physicians, for the same class of patients. The median [95% CI] hemoglobin threshold for starting blood transfusion was 7.9 [6.9-8.9], 7.3 [6.4-8.2], and 8.1 [7.0-9.2] g·dl(-1) in the pre-, intra-, and postoperative phase, respectively. The median [95% CI] PRBC volume transfused was 11.7 [6.6-16.8] ml·kg(-1), and the median hemoglobin target was 11.3 [9.8-12.8] g·dl(-1). Physicians ranked age (79%), clinical tolerance of anemia (99%), underlying medical conditions (95%), hemodynamic instability (89%), hemostasis disorder (86%), and sepsis (79%) as the most significant factors affecting their transfusion decisions. Most pediatric anesthesiologists (89%) measure the hemoglobin level before PRBC transfusion. This survey identifies significant differences in transfusion practice patterns among pediatric anesthesiologists with a median transfusion threshold of 7.6 [6.6-8.6] g·dl(-1) and a median PRBC volume transfusion of 11.7 [16.8-6.6] ml·kg(-1).

Tissue oxygen monitoring leads to lower rates of blood transfusions

Evidence exists that blood transfusions may be more harmful for patients than once suspected [1]. Optimal goals for transfusion therapy remain elusive. Lower rates of blood transfusion seem to lead to better patient outcomes. Tissue oxygenation monitoring may offer a novel insight into blood transfusion requirements as it represents an indication of oxygen content further down the oxygen cascade than the blood oxygen content defined by pulse oximetry and hematocrit. Our hypothesis is that the use of this monitor may define a safer, lower threshold for blood transfusion that may lead to decreased transfusion rates.

833 The Effects of Erythropoeitin-Beta on Ferritin, Reticulocyte, Haemoglobin Levels and Blood Transfusion Requirements in Vlbw Infants with Anaemia of Prematurity

Aim: To study the effects of erythropoietin-beta in VLBW infants with anaemia of prematurity on their ferritin, reticulocyte, haemoglobin levels and transfusional requirements during the first month of treatment. Methods: Routine blood sampling for ferritin, haemoglobin and reticulocyte counts were done weekly for VLBW infants receiving 750U/kg of erythropoietin in 3 divided doses per week and daily oral iron of 6mg/kg according to our unit policy. Results: Over a 9-month period, 35 infants (17 males,18 females) received erythropoeitin. Their mean gestation was 29±2 weeks and mean birthweight was 1.08±0.24 kg. The median haemoglobin level pre-erythropoietin was 10.9g/dL; ferritin, 222mcgl/L; and reticulocyte count, 2.9%. Erythropoietin was commenced after the first three weeks of life (mean, 23+5 days; range,13 to 33 days). The earliest response observed was a 2.5- fold increase in reticulocytes (median, 7.2%; p< 0.01) after one week of therapy (3 doses). After 3 weeks of treatment (9 doses), the average ferritin level decreased by 50% (median, 104mcg/dL; p=0.011), but the haemoglobin maintained stable at 10.4g/dL vs the initial 10.8g/dL, p = 0.25. All but ten infants (29%) required blood transfusion because of concomitant illnesses or poor weight gain. Conclusion: The use of erythropoietin-beta was associated with an early rapid increase in reticulocytes and a significant fall in ferritin levels. Monitoring and ensuring iron adequacy is vital to prevent iron-deficiency during erythropoietin therapy. Nine doses of erythropoeitin-beta commenced at 3-4 weeks postnatal age maintained haemoglobin levels above the blood transfusion threshold in the majority of our VLBW infants before hospital discharge.

Transfusion Trigger Trial for Functional Outcomes in Cardiovascular Patients Undergoing Surgical Hip Fracture Repair (FOCUS): The Principal Results

Abstract LBA-6▪▪This icon denotes an abstract that is clinically relevant. Introduction:Red blood cell transfusion is commonly administered after surgery. It has been suggested that patients with underlying cardiovascular disease are especially vulnerable to anemia and may benefit from transfusion to higher hemoglobin levels. However, red blood cell transfusion is costly and associated with uncommon but clinically important adverse effects. Thus, the indications for red blood cell transfusion are controversial. The aim of this NHLBI-sponsored randomized clinical trial was to determine whether higher blood transfusion thresholds improve functional recovery and reduce mortality and morbidity in patients with underlying cardiovascular disease or cardiovascular risk factors. Patients and Methods:We enrolled patients who were 50 years of age or older, underwent surgery for hip fracture, had a history of or risk factors for cardiovascular disease, and had postoperative hemoglobin < 10 g/dL. We randomly allocated patients to a transfusion threshold of 10 g/dL, or to receive transfusion when anemia symptoms occurred; transfusion was permitted if hemoglobin was < 8 /g dL. The primary outcome was death or the inability to walk across a room without human assistance at 60-Day follow-up. Secondary outcomes included 60-Day follow-up mortality, fatigue, falls, readmission to the hospital, and function. Results:We enrolled 2016 patients from 47 medical centers in North America. The age of the subjects varied from 51-103; mean age was 81.6 and 24% were male. 82% had hypertension, 40% had coronary artery disease, 25% had diabetes mellitus and 18% had history of cancer. The mean hemoglobin concentration prior to randomization was 9.0 g/dL (standard deviation +/‐ 0.8). The hemoglobin concentration prior to transfusion in 10 /g dL group was 9.2 g/dL (standard deviation +/‐ 0.5) and in symptomatic group 7.9 g/dL (standard deviation +/‐ 0.5). 10g/dL arm was transfused median 2 units (interquartile range 1,2), while the symptomatic group was transfused median 0 units (interquartile range 0,1). In the 10 g/dL group 35% (40% men, 33% women) were dead or unable to walk without human assistance and for symptomatic group 35% (32% men, 35% women); odds ratio = 1.03, 95% confidence interval 0.85 to 1.23; difference = 0.6%, 95% confidence interval = -3.6 to 4.8%. In the 10 g/dL group 7.6% were dead on 60-Day follow-up and for symptomatic group 6.5%; odds ratio = 1.19, 99% confidence interval 0.76 to 1.86; difference = 1.1%, 99% confidence interval = -1.8 to 4.1%. The frequency of readmission to the hospital, falls, and the fatigue score were similar between the transfusion groups. Conclusions:Symptomatic transfusion conserved blood and had no adverse effects on ability to walk, 60-Day follow-up mortality, falls, readmission rates, or fatigue in this high-risk group of elderly patients with underlying cardiovascular disease or cardiovascular risk factors. Disclosures:Magaziner: Merck: Research Funding; Novartis: Research Funding; Amgen: Consultancy; Lilly: Consultancy.

Extreme Anemia in an Injured Jehovah's Witness: A Test of Our Understanding of the Physiology of Severe Anemia and the Threshold for Blood Transfusion

Extreme Anemia in an Injured Jehovah's Witness: A Test of Our Understanding of the Physiology of Severe Anemia and the Threshold for Blood Transfusion

Current status of blood component therapy in surgical critical care.

The use of blood component therapy, with transfusion of red cells, plasma, and platelets, is common in critical care. New evidence has emerged documenting the risks associated and lack of efficacy or improvement in clinical outcome with blood transfusion for the treatment of anemia in critically ill patients who are hemodynamically stable. The safety of a restrictive transfusion strategy (transfuse only if hemoglobin < 7 g/dL) was reported in 1999. Despite compelling evidence from this prospective randomized clinical trial, clinicians have not substantially changed practice regarding blood transfusion in critical care. The recently published CRIT trial reported that the mean pre-transfusion hemoglobin was 8.6 g/dL in this large multicenter trial that examined transfusion practices in critical care in the US. Furthermore, only 19% of hospitals had an institutional blood transfusion protocol. The Surviving Sepsis Campaign guidelines have also recommended blood transfusion only when hemoglobin falls to 7.0 g/dL, following resolution of tissue hypoperfusion and in the absence of significant coronary artery disease or acute hemorrhage. We have an increased understanding of the pathophysiology of the anemia associated with critical care, related to the inflammatory response, downregulation of erythropoietin, and lack of iron availability due to macrophage sequestration. Clinical trials are underway to confirm the efficacy of recombinant erythropoietin in the treatment of critically ill patients with anemia. Current data regarding blood transfusion thresholds and risks of blood transfusion have not as yet significantly altered practice patterns. Efforts to reduce blood transfusion rates in critically ill patients are required. These strategies will require education, unit and institutional protocols, and reduction of phlebotomy for diagnostic laboratory testing in the intensive care unit. Further investigations regarding anemia in critical care and new treatment and prevention strategies are required.

Treatment patterns in patients with heart failure and anemia: is there a bias?

Anemia in heart failure (HF) patients (pts), defined as hemoglobin (Hb)<12 g/dL, is often sub-optimally evaluated and inconsistently treated. In an effort to define Health Care Providers (HCP) awareness and quantitate perceived thresholds for anemia treatment in HF pts, approximately 300 surveys that addressed the treatment patterns for patients with heart failure, anemia and other conditions were distributed during the 7th Annual Scientific Meeting of the Heart Failure Society of America in September 2003. A total of 155 surveys were completed, with a response rate 52%. HCP consisted of 102 physicians (66%) and 53 advanced practice professionals (34%). The survey contained 21 questions of which 10 were specific to the importance of anemia in HF pts. The survey queried the threshold of blood transfusion as well as the initiation and comfort level of utilizing an erythropoietic agent (EPO). As anemia may be associated with cancer and its treatment, the survey also addressed the extent of the HCP willingness to provide cardiovascular intervention to cancer pts. Results: Anemia was perceived as important or very important in 137 (88%) of respondents. With regard to prescribing an EPO agent, 117 (78%) were comfortable or very comfortable. The blood transfusion threshold was Hb≤8 g/dL in 102 (67%) and the EPO agent threshold was Hb≤10 g/dL in 88 (57%) of respondents. The majority of HCP were comfortable prescribing transfusions (n=89, 57%), EPO agent (n=109, 70%) and/or iron therapy (n=133, 85%). HCP believed anemia occurred in HF pts more than 11% of the time (n=123,79%), and 124 (80%) perceived anemia was important for prognosis. However, only 101 (65%) of HCP check Hb routinely. HPC who perceived anemia as very important and were comfortable prescribing an EPO agent were more likely to check Hb and initiate an EPO agent at higher Hb levels (p<0.01). Surprisingly, HCP are reluctant to utilize cardiac intervention according to treatment guidelines in eligible cancer pts. Furthermore HPC who are comfortable prescribing an EPO agent were more likely to adhere to these guidelines (p<0.01). Conclusions: The majority of HCP perceived anemia in heart failure as important, and were comfortable prescribing an EPO agent. However, greater than 30% seldom or never check hemoglobin. HPC who are comfortable prescribing an EPO agent were more likely to check hemoglobin and initiate EPO therapy. Patients with cancer as a comorbidity may not be treated with cardiac intervention using the same rigor as the guidelines suggest.

Blood transfusion in burns: what do we do?

Over 11 million units of blood are transfused yearly in the United States. Although blood transfusion is common in burns, data are lacking on appropriate transfusion thresholds. The purpose of the study was to identify current burn center physician blood transfusion practices. A 30-question survey of blood transfusion practices was developed and sent to burn center directors. The survey assessed demographics, burn experience, and blood transfusion thresholds. Physicians were asked to list factors affecting their blood transfusion thresholds and then to give their blood transfusion threshold for patients based on age and percent burn. The final section presents three case scenarios with alterations in one physiological parameter to assess the effect on transfusion thresholds. A total of 55 of the 180 surveys (31%) were returned. Mean number of burn beds was 15.7 +/- 1.4, with 264 +/- 25 burn admissions per year. The respondents had been in burn care for 15.9 +/- 1.4 years. Their mean hemoglobin transfusion threshold was 8.12 +/- 1.7 g/dl. The most frequent reasons for transfusion were ongoing blood loss (22%), anemia (20%), hypoxia (13%), and cardiac disease (12%). Inhalation injury influenced the decision to transfuse blood in 34%. The hemoglobin level below which respondents would transfuse blood increased with increasing TBSA burn, history of cardiac disease, acute respiratory distress syndrome, and age. Blood transfusion thresholds in burns vary based on burn percentage, age, and presence of cardiac disease. To date, no standard of care exists for blood transfusions in burns. Future prospective studies are needed to determine the appropriate use of blood in burns.

Blood transfusion policy among European pediatric intensive care physicians.

The objective of this study was to define current blood transfusion practices among European pediatric intensive care physicians treating critically ill children. A questionnaire of case scenarios was administered to members of the European Society of Pediatric and Neonatal Intensive Care (ESPNIC). Of the 258 members of the ESPNIC, 134 (51.9%) pediatric intensive care physicians completed the questionnaire. The suggested blood transfusion thresholds for case scenario 1 (post-orthopedic surgery child) ranged from <7.0 g/dl to 11 g/dl. A total of 57.3% suggested 7 g/dl, 33.6% suggested 8 g/dl, and 6.9% suggested 9 g/dl as a hemoglobin threshold for transfusion (mean, 7.54 +/- 0.75). For case scenarios 2 to 4, the suggested hemoglobin thresholds were 7 g/dl to 12 g/dl. For case scenario 2 (a child with acute respiratory distress syndrome), 22.4% suggested 8 g/dl, 15.7% suggested 9 g/dl, and 41% suggested 10 g/dl as a hemoglobin threshold for transfusion (mean, 9.40 +/- 1.27 g/dl). For case scenario 3 (a post-cardiac surgery infant), 20.1% suggested 7 g/dl, 24.6% suggested 8 g/dl, 21.6% suggested 9 g/dl, and 23.9% suggested 10 g/dl as a hemoglobin threshold for transfusion (mean, 8.72 +/- 1.24 g/dl). For case scenario 4 (a child with septic shock), 23.1% suggested 8 g/dl, 16.4% suggested 9 g/dl, and 41% suggested 10 g/dl as a hemoglobin threshold for transfusion (mean, 9.45 +/- 1.24 g/dl). The threshold for transfusion was not statistically different (P >.05) between the physicians according to their subspecialty, years of experience, or country of origin. The suggested volume of transfused blood was 10 to 15 ml/kg in 427 responses (82.6%) and 20 ml/kg in 89 responses (17.2%). Most physicians, 78/128 (60.9%), did not consider the age of the transfused blood an important factor in their decision to transfuse. Of the 106 (79.1%) physicians who detailed their considerations for elevating the threshold for transfusion, 82 (77.3%) gave a general nonspecific indication, 47 (44.3%) stated hemodynamic instability and shock, and 40 (37.7%) an ongoing bleeding. The hemoglobin threshold for blood transfusion and transfusion volume varies among European pediatric intensive care physicians, for the same patient.

Use of a screen log to audit patient recruitment into multiple randomized trials in the intensive care unit. Canadian Critical Care Trials Group.

To develop and evaluate a screen log for monitoring enrollment in multiple randomized clinical trials conducted in a single center. University-affiliated 20-bed tertiary care medical-surgical intensive care unit (ICU). Consecutive ICU patients admitted between April 1995 and March 1997. We developed a screen log for multicentered studies conducted in our ICU. Using a multiple-project, unicenter perspective, we evaluated the screen log as a tool for monitoring eligibility and enrollment of patients in four multicentered randomized trials focused on stress ulcer prophylaxis, blood transfusion thresholds, immunotherapy for sepsis and mechanical ventilation strategies. The screen log was used as an instrument to monitor trial execution. We recorded all aspects of study enrollment and created a taxonomy of reasons for nonenrollment into each trial. We calculated enrollment efficiency rates and used these data to develop strategies to maximize accrual. The screen log became a communication tool that fostered research-oriented continuous quality improvement initiatives for the management of concurrently conducted randomized trials in our ICU. Intensivists participating in several clinical trials may be interested in monitoring and maximizing enrollment when conducting multiple studies and understanding the influence of each trial on enrollment into the others. The unicenter, multiple-project screen log is one tool that may help to achieve these goals.