Pediatric Tube Research Articles

Performance Evaluation of Geometrically Different Pediatric Arterial Cannulae in a Pediatric Cardiopulmonary Bypass Model.

To define a reference chart comparing pressure drop vs. flow generated by a set of arterial cannulae currently utilized in cardiopulmonary bypass conditions in pediatric surgery. Cannulae from two manufacturers were selected considering their design and outer and inner diameters. Cannula performance was evaluated in terms of pressure drop vs. flow during simulated cardiopulmonary bypass conditions. The experimental circuits consisted of a Jostra HL-20 roller pump, a Quadrox-i pediatric oxygenator (Maquet Cardiopulmonary AG, Rastatt, Germany), and a custom pediatric tubing set. The circuit was primed with lactated Ringer's solution only (first condition) and with human packed red blood cells added (second condition) to achieve a hematocrit of 30%. Cannula sizes 8 to 16 Fr were inserted into the cardiopulmonary bypass circuit with a "Y" connector. The flow was adjusted in 100 ml/min increments within typical flow ranges for each cannula. Pre-cannula and post-cannula pressures were measured to calculate the pressure drop. Utilizing a pressure drop limit of 100 mmHg, our results suggest a recommended flow limit of 500, 900, 1400, 2600, and 3100 mL/min for Braile arterial cannulae sizes 8, 10, 12, 14, and 16 Fr, respectively. For Medtronic DLP arterial cannulae sizes 8, 10, 12, 14, and 16 Fr, the recommended flow limit is 600, 1100, 1700, 2700, and 3300 mL/min, respectively. This study reinforces discrepancies in pressure drop between cannulae of the same diameter supplied by different manufacturers and the importance of independent translational research to evaluate components' performance.

Self-sampling of blood using a topper and pediatric tubes; a prospective feasibility study for PSA analysis using 120 prostate cancer patients.

Self-collection of blood for diagnostic purposes by blood collection assist devices (BCAD) has gained a lot ofmomentum. Nonetheless, there are a lack of studies demonstrating the feasibility and reliability of self-collecting capillary blood for routine (immuno)chemistry testing. In this study we describe the topper technology together with pediatric tubes to enable self-collection of blood and investigated its feasibility for PSA testing by prostate cancer patients. A total of 120 prostate cancer patients for which a routine follow-up PSA test was requested, were included in this study. Patients received instruction materials and the blood-collection device consisting of a topper, pediatric tube and base-part, and performed the blood collection procedure themselves. Afterwards a questionnaire was filled-in. Finally, PSA was measured on a Roche Cobas Pro. The overall self-sampling success rate was 86.7 %. Furthermore, when specified per age category, a 94.7 % success rate for patients under 70 years and a 25 % success rate for patients of 80 years and older was observed. Venous and self-collected PSA were highly comparable when analyzed by Passing-Bablok regression with a slope of 0.99 and intercept of 0.00011, Spearmans correlation coefficient (0.998) and average self-collected PSA recovery of 99.8 %. Evidence is presented that self-collected capillary blood by topper and pediatric tube from the finger is feasible, particularly for patients under 70 years. Furthermore, capillary blood self-sampling did not compromise any of the PSA test results. Future validation in a real-world setting, without supervision and including sample stability and logistics, is required.

Two-Year Outcomes After Pediatric In-Office Tympanostomy Using Lidocaine/Epinephrine Iontophoresis and an Automated Tube Delivery System.

Evaluate 2-year outcomes after lidocaine/epinephrine iontophoresis and tympanostomy using an automated tube delivery system for pediatric tube placement in-office. Prospective, single-arm. Eighteen otolaryngology practices. Children age 6 months to 12 years indicated for tympanostomy were enrolled between October 2017 and February 2019. Local anesthesia of the tympanic membrane was achieved via lidocaine/epinephrine iontophoresis and tympanostomy was completed using an automated tube delivery system (the Tula® System). An additional Lead-In cohort of patients underwent tube placement in the operating room (OR) under general anesthesia using only the tube delivery system. Patients were followed for 2 years or until tube extrusion, whichever occurred first. Otoscopy and tympanometry were performed at 3 weeks, and 6, 12, 18, and 24 months. Tube retention, patency, and safety were evaluated. Tubes were placed in-office for 269 patients (449 ears) and in the OR for 68 patients (131 ears) (mean age, 4.5 years). The median and mean times to tube extrusion for the combined OR and In-Office cohorts were 15.82 (95% confidence interval [CI]: 15.41-19.05) and 16.79 (95% CI: 16.16-17.42) months, respectively. Sequelae included ongoing perforation for 1.9% of ears (11/580) and medial tube displacement for 0.2% (1/580) observed at 18 months. Over a mean follow-up of 14.3 months, 30.3% (176/580) of ears had otorrhea and 14.3% (83/580) had occluded tubes. In-office pediatric tympanostomy using lidocaine/epinephrine iontophoresis and automated tube delivery results in tube retention within the ranges described for similar grommet-type tubes and complication rates consistent with traditional tube placement in the OR.

Pediatric Tube Weaning: A Meta-Analysis of Factors Contributing to Success.

Approximately 3-10% of children have severe feeding issues, and some require enteral/tube nutrition to grow and thrive. For many children, tube feeding is temporary, making efficacious interventions for tube weaning essential. We conducted a systematic review and meta-analysis of tube weaning treatments. Outcomes included percentage of participants completely weaned from the tube, and mean percentage of kilocalories consumed orally following treatment. Data were extracted from 42 studies, including cohort studies and single-subject research design studies. We evaluated moderators of treatment success, including treatment setting, use of behavioral approaches, use of hunger provocation, and use of a multidisciplinary approach. Results indicated that, after treatment, children received significantly more calories orally, and 67-69% of children were fully weaned. These analyses suggest that current interventions are generally effective; however, variability within treatments exist. Prospective randomized clinical trials are needed to understand effective components of weaning interventions.

Examination of pediatric tube feeding schedules and oral intake: A retrospective cross-sectional study.

A common treatment goal for children dependent on enteral feeding is to advance oral nutrition intake and decrease enteral feeding dependence. The purpose of this study was to investigate the relationship between tube feeding schedule and oral intake in feeding tube-dependent children diagnosed with avoidant restrictive food intake disorder (ARFID). A retrospective chart review was completed including 76 tube-dependent children with ARFID between the ages of 1 and 14 years who were evaluated by a registered dietitian, in conjunction with a multidisciplinary feeding team, during January 1, 2018, to May 31, 2019. Eligible participants were diagnosed with ARFID and receiving enteral nutrition via nasogastric or gastrostomy tube during the time of evaluation. The participants were categorized into groups according to tube feeding schedule type (bolus vs. overnight continuous) and further stratified by severity of oral motor deficit, as documented by the speech language pathologist or occupational therapist: none/mild and moderate/severe. The exclusion criteria included children aged <1 year, appetite stimulant listed as an active medication, overnight enteral feeding infusion of >12 h, or calculated percentage of calories from oral intake not specified. The primary study outcome was dichotomized percentage of oral intake, >0% vs 0%. Following adjustment for confounders, this retrospective chart review showed statistically higher odds of percentage of oral intake >0% in ARFID patients receiving overnight continuous enteral feeding schedules (odds ratio = 0.20, 95% CI: 0.05-0.83, P = 0.027). A bolus feeding schedule may not promote oral intake in feeding tube-dependent children diagnosed with ARFID.

S1288 Varying and Prevalent Complications Associated With Pediatric Gastrostomy Tubes

S1288 Varying and Prevalent Complications Associated With Pediatric Gastrostomy Tubes

Behavioral Strategies to Minimize Procedural Distress During In-Office Pediatric Tympanostomy Tube Placement Without Sedation or Restraint

The purpose of this study was to evaluate behavioral strategies to minimize procedural distress associated with in-office tympanostomy tube placement for children without general anesthesia, sedation, or papoose-board restraints. 120 6-month- to 4-year-olds and 102 5- to 12-year-olds were treated at 16 otolaryngology practices. Mean age of children was 4.7 years old (SD = 3.18 years), with more boys (58.1%) than girls (41.9%). The cohort included 14% Hispanic or Latinx, 84.2% White, 12.6% Black, 1.8% Asian and 4.1% ‘Other’ race and ethnicity classifications. The in-office tube placement procedure included local anesthesia via lidocaine/epinephrine iontophoresis and tube placement using an integrated and automated myringotomy and tube delivery system. Behavioral strategies were used to minimize procedural distress. Anxiolytics, sedation, or papoose board were not used. Pain was measured via the faces pain scale-revised (FPS-R) self-reported by the children ages 5 through 12 years. Independent coders supervised by a psychologist completed the face, legs, activity, cry, consolability (FLACC) behavior observational rating scale to quantify children’s distress. Mean FPS-R score for tube placement was 3.30, in the “mild’ pain range, and decreased to 1.69 at 5-min post-procedure. Mean tube placement FLACC score was 4.0 (out of a maximum score of 10) for children ages 6 months to 4 years and was 0.4 for children age 5–12 years. Mean FLACC score 3-min post-tube placement was 1.3 for children ages 6 months to 4 years and was 0.2 for children age 5–12 years. FLACC scores were inversely correlated with age, with older children displaying lower distress. The iontophoresis, tube delivery system and behavioral program were associated with generally low behavioral distress. These data suggest that pediatric tympanostomy and tube placement can be achieved in the outpatient setting without anxiolytics, sedatives, or mechanical restraints.

AML-104: Westchester Medical Center (WMC) Approach to Jehovah’s Witness Acute Myeloid Leukemia (AML) Patients

<h3>Objective:</h3> Development of a bloodless therapeutic approach to management of AML in Jehovah's Witness patients <h3>Design:</h3> Our center developed an approach for bloodless management of AML in adult patients in line with the religious beliefs of Jehovah's Witness patients. <h3>Setting:</h3> There are over 8 million Jehovah's Witnesses worldwide. Their world headquarters is located 30 miles from WMC, and the area supports a sizable population of Jehovah's Witnesses. <h3>Eligible Patients:</h3> Eligibility criteria include: >18 years of age, confirmed diagnosis of AML, and refusal to accept transfusion of blood products. <h3>Interventions:</h3> The protocol emphasizes the optimization of hemoglobin and platelet count, practicing conservative measures, such as minimizing blood draws and invasive procedures and using prophylactic measures against potential complications such as gastrointestinal bleeding. Our protocol includes: pediatric tubes, limited blood draws, IV iron, erythropoietin, weekly romiplostim, vitamin B12, folate, and aminocaproic acid. Venetoclax was planned for patients, given its less hematopoietic burden than traditional intensive chemotherapy. <h3>Main Outcomes Measures:</h3> The primary outcome is overall survival. Secondary outcome is progression free survival. Outcome measures include hemoglobin and platelet counts. <h3>Results:</h3> We present our first patient using this approach to evaluate efficacy and safety of this bloodless induction protocol, a 57-year-old gentleman with newly diagnosed AML. We initiated venetoclax and decitabine, along with all supportive interventions outlined above. Unfortunately, the patient felt unwell after the initial doses of chemotherapy and declined further treatment and left against medical advice. The patient's total hospital stay was six days. We saw no qualitative, logistical, or administrative concerns with the bloodless approach. On discharge, the patient's hemoglobin was 3.8 g/dL and his platelet count was 4 k/mm³. He eventually was admitted to another hospital, where he expired without AML treatment. We were unable to measure our primary and secondary outcomes, given our patient did not complete treatment. <h3>Conclusions:</h3> Though our initial patient did not complete his induction chemotherapy, from a qualitative analysis, our supportive care measures to optimize hemoglobin and platelet counts and limit bleeding risk were delivered without issues and may serve as a model for other centers with patients declining blood products in their leukemia care.

Weaning children from prolonged enteral nutrition: A position paper.

Enteral nutrition (EN) allows adequate nutritional intake in children for whom oral intake is impossible, insufficient or unsafe. With maturation and health improvements, most children ameliorate oral skills and become able to eat orally, therefore weaning from EN becomes a therapeutic goal. No recommendations currently exist on tube weaning, and practices vary widely between centres. With this report, the French Network of Rare Digestive Diseases (FIMATHO) and the French-Speaking Group of Paediatric Hepatology, Gastroenterology and Nutrition (GFHGNP) aim to develop uniform clinical practice recommendations for weaning children from EN. A multidisciplinary working group (WG) encompassing paediatricians, paediatric gastroenterologists, speech-language therapists, psychologists, dietitians and occupational therapists, was formed in June 2018. A systematic literature search was performed on those published from January 1, 1998, to April 30, 2020, using MEDLINE. After several rounds of e-discussions, relevant items for paediatric tube weaning were identified, and recommendations were developed, discussed and finalized. The WG members voted on each recommendation using a nominal voting technique. Expert opinion was applied to support the recommendations where no high-quality studies were available.

A33 MEALTIME SUPPORT: A PILOT COHORT STUDY OF AN EFFECTIVE, COST-SAVING OUTPATIENT HUNGER-BASED FEEDING PROGRAM FOR TUBE DEPENDENCY

Abstract Background Tube dependency is an under recognized complication of long-term enteral feeding in young children. Many children struggle to progress to full oral feeds even with sufficient oral motor skills and swallowing ability. Tube dependency greatly impacts the quality of life of children and families and is a significant burden to the health care system. Economic challenges, increased burden of care and psychosocial issues all reinforce the need for timely tube removal. Aims We aimed to examine the efficacy of a multidisciplinary child-led, hunger-based approach called “Mealtime Support” at the Stollery Children’s Hospital in Edmonton. Nutritional outcomes, parental satisfaction and cost implications were evaluated. As a secondary aim we sought to determine the rates of gastrostomy tube insertions in the pediatric age range across Canada as a potential indicator of increasing need for long term tube feeding, hence the need for cost effective tube weaning programs to be developed in Canada. Methods The ambulatory program was delivered 2–3 times a day, for 2 weeks, by an occupational therapist and dietitian, under medical supervision. Hunger was promoted by reducing tube fed calories by 80% prior to commencement. Top-up tube feeds were given immediately after feeding sessions if needed. Caregivers completed 12-question subjective surveys pre and post intervention. Micro-costing methods compared costs between the program and ongoing tube feeding. The number of pediatric hospital admissions and gastrostomy tube insertions from 2008–2019, per province, was collected from the Canadian Institute for Health Information (CIHI). Results From 2016 - 2017, 6 children who had been tube fed from 7 to 21 months in total were enrolled and 5 completed the program. At 1-month post intervention, 4/5 of the children were 100% orally fed. Parents reported improvement in mealtime struggles (p-value = 0.005), reduction in worry about their child’s eating (p-value = 0.005) and improvement in their child’s appetite/variety foods eaten (p-value = 0.004). Over a year the potential cost savings were estimated at $42,471.24. By 6-months, all feeding tubes were removed. Based on the CIHI data, the number of gastrostomy tubes inserted per 100,000 children varied significantly between provinces, but highest in Nova Scotia, Saskatchewan and Alberta with increases seen from 2008–2018. Conclusions The transition from tube feeding to oral feeding is difficult for children who are tube dependent and poses several economic and psychosocial challenges. Mealtime Support was safe and successful in reducing tube dependency and cost-effective compared to no intervention or hospital based programs. There is a need to develop and fund Canadian outpatient feeding programs. Funding Agencies The Stollery Children’s Foundation

IKanEat: protocol for a randomized controlled trial of megestrol as a component of a pediatric tube weaning protocol

BackgroundAlthough tube feeding routinely saves the lives of children who do not eat by mouth, chronic tube feeding can be a burden to patients, caregivers, and families. Very few randomized trials exist regarding the best methods for weaning children from their feeding tubes.MethodsThe current paper describes a randomized controlled trial of an empirically supported outpatient treatment protocol for moving children from tube to oral eating called iKanEat. Specifically, we describe the methods of randomized double-blind, placebo-controlled trial which includes a 4-week course of megestrol, the only medication used in the iKanEat protocol, to determine whether the addition of megestrol results in improved child outcomes. The primary and secondary aims are to assess the safety and efficacy of megestrol as part of the iKanEat protocol. The third aim is to provide critical information about the impact of the transition from tube to oral feeding on parent stress and parent and child quality of life.DiscussionThis trial will provide data regarding whether megestrol is a safe and effective component of the iKanEat tube weaning protocol, as well as important data on how the tube weaning process impacts parent stress and parent and child quality of life.Trial registrationClinicalTrials.gov NCT#03815019. Registered on January 17, 2019

Pediatric size phlebotomy tubes and transfusions in adult critically ill patients: a pilot randomized controlled trial

BackgroundTransfusion of red blood cells (RBC) is common, can have adverse effects, and is a costly and limited resource. Interventions that reduce iatrogenic blood losses could reduce transfusions. The objectives of this pilot trial were to assess the feasibility (acceptability of the intervention and suitability of eligibility criteria) and potential effectiveness of pediatric size phlebotomy tubes in adult critically ill patients.MethodsWe conducted a pilot, randomized controlled trial in the medical intensive care unit (ICU) of a university-affiliated, tertiary care referral hospital from November 2017 to September 2018. A total of 200 patients with hemoglobin of at least 7 g/dL and without bleeding were randomized to pediatric or adult size phlebotomy tubes. Stratification was according to baseline hemoglobin (7–9.49 g/dL, 9.5–11.99 g/dL, and 12 g/dL or greater). Acceptability was measured via the number of blood test recollections and the number of patients that discontinued the use of pediatric tubes. The suitability of patient eligibility criteria was determined by identifying baseline characteristics associated with RBC transfusions. Potential effectiveness was estimated from the time to RBC transfusion or to hemoglobin level below 7 g/dL.ResultsThe use of pediatric tubes was acceptable as patients experienced a low number of tests recollections (on average 1 every 57 days), and none of the participants discontinued their use. The baseline hemoglobin category was the only factor that appeared to be independently associated with RBC transfusions. A total of 6 patients (6%) in the pediatric tube group and 11 patients (11%) in the adult tube group (hazard ratio, 0.69; 95% CI, 0.25 to 1.9) received an RBC transfusion or reached hemoglobin below 7 g/dL. Almost all of these patients (16 of 17 participants) had baseline hemoglobin of 7–9.49 g/dL.ConclusionsThis pilot study suggests that pediatric phlebotomy tubes are acceptable to patients and can therefore be used in adult ICU patients. A future study should focus on patients with hemoglobin levels below 9.5 g/dL, as these patients have a high risk of transfusions. This intervention has the potential of being successful in selected patients. A definitive trial is warranted.Trial registrationClinicalTrials.gov, NCT03286465. Retrospectively registered on September 18, 2017.

Strategies for 'bloodless' surgery: the experience of cytoreductive surgery for peritoneal carcinomatosis in Jehovah's Witnesses.

Cytoreductive surgery (CRS) for the management of peritoneal carcinomatosis (PC) can involve significant blood loss which necessitates the transfusion of blood products. This poses a particular challenge in the Jehovah's Witnesses population whose beliefs do not permit the transfusion of blood products or blood-related derivatives. This report describes the experience of one institution performing CRS with hyperthermic intraperitoneal chemotherapy (HIPEC) for PC in Jehovah's Witnesses and perioperative management strategies employed to avoid blood transfusion. A review of literature and prospectively collated data of Jehovah's Witnesses patients who underwent extensive CRS for PC and HIPEC for PC. Four patients had CRS and HIPEC for PC. The median PC index score was 11 and complete cytoreduction was achieved in all cases. Primary tumours were ovarian (n = 1), colorectal (n = 2) and neuroendocrine tumour of gastrointestinal origin (n = 1). The median difference between preoperative and postoperative haemoglobin was 38 g/L (23-43 g/L). Strategies included acute normovolumaeic haemodilution and autotransfusion within a closed circuit, autotransfusion from cell salvage and provisions for possible use of a haemoglobin based oxygen carrier. Ancillary measures identified and implemented to minimize transfusion dependence included, but were not limited to, preoperative iron infusion, perioperative acute haemodilution and cell salvage, administration of tranexamic acid, prothrombinex and use of paediatric tubes for venepuncture. The review suggests CRS and HIPEC for extensive PC can be done safely in circumstances where transfusion of allogenic blood products is not permitted.

Helping families nurture children: A paediatric tube feed with food-derived ingredients

Helping families nurture children: A paediatric tube feed with food-derived ingredients

Insights into paediatric tube feeding dependence: A Speech-language pathology perspective

Purpose: To explore possible factors contributing to paediatric tube feeding dependency from the speech-language pathology perspective. Tube feeding dependency can have serious repercussions for children and their families with failed or slow weaning/transitioning from tube to oral feeding, more likely after the age of five. Method: A mixed methods approach was conducted. During the first quantitative phase, an online national survey of speech-language pathologists (SLPs) from the health and non-health sectors was carried out followed by interviews with a subset of the respondents. Forty-three SLPs completed the survey. In the second qualitative phase, 10 participants from the survey were interviewed in depth as to their opinions about why tube dependency occurs. Survey data from phase one were analysed using descriptive statistics and chi square comparisons. Interview data were categorised using thematic analysis. Findings from both methodologies were combined to report the results. Result: Two interlinking meta-themes were identified from the combined data sets. These were: (1) Medicalisation of tube fed children in infancy as a root cause of tube feeding dependency and (2) Fragmentation of the tube fed child’s continuity of care. The specific results indicated several possible reasons for tube feeding dependency including medical emphasis on weight gain, prolonged nasogastric tube feeding and waiting too long for transition from tube to oral feeding. A lack of integrated care and clinician confidence in non-health settings also appeared to be a factor contributing to tube feeding dependency. Conclusion: Early and ongoing biomedical focus on weight gain affected long-term goals for transitioning leading, subsequently, to tube feeding becoming normalised by school age.

A comment on - "Lung isolation for lobectomy in elderly, post-radiation fibrosis of a difficult airway - pediatric double-lumen tube and pediatric ureteroscope as rescue devices".

A comment on - "Lung isolation for lobectomy in elderly, post-radiation fibrosis of a difficult airway - pediatric double-lumen tube and pediatric ureteroscope as rescue devices".

Impact of Vacuum-Assisted Venous Drainage on Forward Flow in Simulated Pediatric Cardiopulmonary Bypass Circuits Utilizing a Centrifugal Arterial Pump Head.

ObjectiveTo analyze the impact of vacuum-assisted venous drainage (VAVD) on arterial pump flow in a simulated pediatric cardiopulmonary bypass circuit utilizing a centrifugal pump (CP) with an external arterial filter.MethodsThe simulation circuit consisted of a Quadrox-I Pediatric oxygenator, a Rotaflow CP (Maquet Cardiopulmonary AG, Rastatt, Germany), and a custom pediatric tubing set primed with Lactated Ringer's solution and packed red blood cells. Venous line pressure, reservoir pressure, and arterial flow were measured with VAVD turned off to record baseline values. Four other conditions were tested with progressively higher vacuum pressures (-20, -40, -60, and -80 mmHg) applied to the baseline cardiotomy pressure. An arterial filter was placed into the circuit and arterial flow was measured with the purge line in both open and closed positions. These trials were repeated at set arterial flow rates of 1500, 2000, and 2500 mL/min.ResultsThe use of progressively higher vacuum caused a reduction in effective arterial flow from 1490±0.00 to 590±0.00, from 2020±0.01 to 1220±0.00, and from 2490±0.0 to 1830±0.01 mL/min. Effective forward flow decreased with increased levels of VAVD.ConclusionThe use of VAVD reduces arterial flow when a CP is used as the main arterial pump. The reduction in the forward arterial flow increases as the vacuum level increases. The loss of forward flow is further reduced when the arterial filter purge line is kept in the recommended open position.An independent flow probe is essential to monitor pump flow during cardiopulmonary bypass.

Impact of low volume citrate tubes on results of first-line hemostasis testing.

Pediatric tubes are increasingly used for drawing blood for hemostasis testing. This study has investigated the potential impact of low volume citrate tubes on results of first-line hemostasis testing. The study population comprised 34 patients on warfarin therapy and 17 ostensibly healthy volunteers. Blood was collected into five different evacuated blood tubes from each subject. On right arm, blood was drawn directly into two standard evacuated blood tubes (3-mL Vacuette and 2-mL Vacutest) and one evacuated low volume blood tube (1-mL Vacuette) by straight needle venipuncture. On left arm, blood was drawn using a 5-mL syringe and then transferred within two nonevacuated microtubes (0.5mL MiniCollect and 0.5mL Micro Test). Prothrombin time (PT), activated partial thromboplastin time (APTT), and fibrinogen were assayed on ACL TOP 700. Spearman's correlation of PT, APTT, and fibrinogen values obtained using different tubes was always satisfactory (ie, ≥0.93).A statistically significant bias was frequently found by comparing values obtained in different tubes. Nevertheless, the minimum quality specifications for bias were exceeded only by comparing data of Vacuette 1mL with those of all other blood tubes for PT, by comparing data of Micro Test 0.5mL with those of all other blood tubes for APTT, and by comparing data of Micro Test 0.5-mL blood tubes with those of Vacuette 3mL and Vacuette 1. First-line hemostasis testing using low volume citrate tubes may display differences sometimes exceeding the minimum quality specifications.

Bloodless Autologous Hematopoeitic Stem Cell Transplant: An Alternative for Jehovah's Witnesses and Others Who Prefer to Go Bloodless

Topic Significance & Study Purpose/Background/Rationale Every year people are diagnosed with Non-Hodgkin's Lymphoma (NHL) and Multiple Myeloma (MM). As an alternative treatment modality, they may seek to have a Hematopoietic Stem Cell Transplant (HSCT), which usually requires blood product transfusions. This poses a challenge when treating Jehovah's Witnesses, who normally refuse whole blood products based on religious beliefs; however, many will accept minor blood fractions and recombinant products, such as erythropoietin and granulocyte colony stimulating factors (G-CSF). Methods, Intervention, & Analysis In this study, five Jehovah's Witnesses were enrolled in the Bloodless Care Program and went through a series of pretransplant testing. Testing included an echocardiogram, electrocardiogram, and stress test to evaluate possible underlying coronary artery disease and cardiac amyloidosis. Once they qualified for a transplant, a conditioning regimen was determined and they were prepared for apheresis. Before apheresis, the patient must have hemoglobin of 11.0 g/dL and platelet count of 100 K/mm3; if not, erythropoietin and intravenous iron were given to achieve that goal. Patients were then prepped with G-CSF and Plerixafor for stem cell collection. The goal for collection was a minimum of 4 million CD34+ cells per kilogram. Post collection, there was a two week window given prior to admission for the bloodless autologous HSCT. The conditioning regimen varied on their diagnosis. For the four MM patients, the regimen was Melphalan 140mg/m2; for the one NHL patient, the regimen was Carmustine, Etoposide, and Cytoxan (BECy). When the platelet count fell below 30 K/mm3 post-transplant, Amicar was administered. Minimal phlebotomy and pediatric tubes were recommended to reduce iatrogenic anemia. Findings & Interpretation The Average length of stay was 16.7 days. After transplant, the median nadir hemoglobin was 9.15 g/dL, while the platelets were 5.5 K/mm3. One patient was readmitted within 30 days after transplant for fever during engraftment. One patient relapsed and received a second bloodless autologous HSCT 9 months later. There were no mortalities. Discussion & Implications Utilizing minor fractions, blood conservation modalities, and appropriate pre-transplant workup, resulted in safely performing bloodless autologous HSCT for Jehovah's Witness; therefore, proving this can be an alternative treatment for those who prefer to go bloodless.

Derivation and validation of a formula for paediatric tracheal tube size using bootstrap resampling procedure.

Background and Aims:The accuracy of age-, length- and weight-based formulae to predict optimal size of uncuffed tracheal tubes (TTs) in children varies widely. We determined the accuracy of age, length and weight in predicting the size of TT in Indian children, and derived and validated a formula using the best predictor.Methods:In the derivation phase, 100 children aged 1-8 years undergoing general anaesthesia and tracheal intubation with an uncuffed tube were prospectively studied. The correct size of the TT used was confirmed using the leak test. A bootstrap resampling procedure was used to estimate the accuracy of the predictors (age, weight, or length alone; length and age; length and weight; and length, weight and age). The best predictor was used to derive a formula (Paediatric Tube Size Predictor, PTSP) to calculate the size of TT. The accuracy of PTSP was tested in 150 children of the same age group in the validation phase.Results:Length (L (in meters), R2 = 0.61) was the best single predictor of the size of TT and was used to derive the PTSP as internal diameter = 3L + 2.5. In the validation phase, the PTSP predicted the size of TT correctly in 75% of children. Re-intubation was associated with a higher incidence of respiratory morbidity than one-time tracheal intubation.Conclusion:Length of the child predicts the size of an uncuffed TT better than age and weight. The PTSP formula based on length correctly predicts the size of uncuffed TT in 75% of children.