Charles D Voigt1, Gabriel Hundeshagen, Ioannis Malagaris, Kaitlin Watson, Ruth N Obiarinze, Houman Hasanpour, Lee C Woodson, Karel D Capek, Jong O Lee, Omar Nunez Lopez, Janos Cambiaso-Daniel, Ludwik K Branski, William B Norbury, Celeste C Finnerty, David N Herndon. 1. From the Department of Surgery (C.D.V., G.H., I.M., R.N.O., H. H., L.C.W., K.D.C., J.O.L., O.A.N.L., J.C.D., L.K.B., W.B.N., C.C.F., D.N.H.), University of Texas Medical Branch; Shriners Hospitals for Children®-Galveston (C.D.V., G.H., I.M., R.N.O., H. H., L.C.W., K.D.C., J.O.L., O.A.N.L., J.C.D., L.K.B., W.B.N., C.C.F., D.N.H.), Galveston, Texas; Department of Surgery (C.D.V.), Creighton University, Omaha, Nebraska; Department of Hand, Plastic and Reconstructive Surgery (G.H.), Burn Trauma Center, BG Trauma Center Ludwigshafen; University of Heidelberg, Ludwigshafen, Germany; School of Allied Health Sciences (K.W.), Baylor College of Medicine, Houston, Texas; Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery (J.C.D., L.K.B., D.N.H.), Medical University of Graz, Austria; and Institute for Translational Sciences (J.O.L.,C.C.F.,), University of Texas Medical Branch, Galveston, Texas.
Abstract
BACKGROUND: Blood transfusion is costly and associated with various medical risks. Studies in critically ill adult and pediatric patients suggest that implementation of more restrictive transfusion protocols based on lower threshold hemoglobin concentrations can be medically and economically advantageous. The purpose of this study was to evaluate the implications of a hemoglobin threshold change in pediatric burn patients. METHODS: We implemented a change in hemoglobin threshold from 10 g/dL to 7 g/dL and compared data from patients before and after this protocol change in a retrospective review. Primary endpoints were hemoglobin concentration at baseline, before transfusion, and after transfusion; amount of blood product administered; and mortality. Secondary endpoints were the incidence of sepsis based on the American Burn Association physiological criteria for sepsis and mean number of septic days per patient. All endpoint analyses were adjusted for relevant clinical covariates via generalized additive models or Cox proportional hazard model. Statistical significance was accepted at p less than 0.05. RESULTS: Patient characteristics and baseline hemoglobin concentrations (pre, 13.5 g/dL; post, 13.3 g/dL; p > 0.05) were comparable between groups. The group transfused based on the more restrictive hemoglobin threshold had lower hemoglobin concentrations before and after transfusion throughout acute hospitalization, received lower volumes of blood during operations (pre, 1012 mL; post, 824 mL; p < 0.001) and on days without surgical procedures (pre, 602 mL; post, 353 mL; p < 0.001), and had a lower mortality (pre, 8.0%; post, 3.9%; mortality hazard decline, 0.55 [45%]; p < 0.05). Both groups had a comparable incidence of physiological sepsis, though the more restrictive threshold group had a lower number of sepsis days per patient. CONCLUSION: More restrictive transfusion protocols are safe and efficacious in pediatric burn patients. The associated reduction of transfused blood may lessen medical risks of blood transfusion and lower economic burden. LEVEL OF EVIDENCE: Therapeutic, level IV.
BACKGROUND: Blood transfusion is costly and associated with various medical risks. Studies in critically ill adult and pediatric patients suggest that implementation of more restrictive transfusion protocols based on lower threshold hemoglobin concentrations can be medically and economically advantageous. The purpose of this study was to evaluate the implications of a hemoglobin threshold change in pediatric burn patients. METHODS: We implemented a change in hemoglobin threshold from 10 g/dL to 7 g/dL and compared data from patients before and after this protocol change in a retrospective review. Primary endpoints were hemoglobin concentration at baseline, before transfusion, and after transfusion; amount of blood product administered; and mortality. Secondary endpoints were the incidence of sepsis based on the American Burn Association physiological criteria for sepsis and mean number of septic days per patient. All endpoint analyses were adjusted for relevant clinical covariates via generalized additive models or Cox proportional hazard model. Statistical significance was accepted at p less than 0.05. RESULTS:Patient characteristics and baseline hemoglobin concentrations (pre, 13.5 g/dL; post, 13.3 g/dL; p > 0.05) were comparable between groups. The group transfused based on the more restrictive hemoglobin threshold had lower hemoglobin concentrations before and after transfusion throughout acute hospitalization, received lower volumes of blood during operations (pre, 1012 mL; post, 824 mL; p < 0.001) and on days without surgical procedures (pre, 602 mL; post, 353 mL; p < 0.001), and had a lower mortality (pre, 8.0%; post, 3.9%; mortality hazard decline, 0.55 [45%]; p < 0.05). Both groups had a comparable incidence of physiological sepsis, though the more restrictive threshold group had a lower number of sepsis days per patient. CONCLUSION: More restrictive transfusion protocols are safe and efficacious in pediatric burn patients. The associated reduction of transfused blood may lessen medical risks of blood transfusion and lower economic burden. LEVEL OF EVIDENCE: Therapeutic, level IV.
Authors: Lars B Holst; Nicolai Haase; Jørn Wetterslev; Jan Wernerman; Anne B Guttormsen; Sari Karlsson; Pär I Johansson; Anders Aneman; Marianne L Vang; Robert Winding; Lars Nebrich; Helle L Nibro; Bodil S Rasmussen; Johnny R M Lauridsen; Jane S Nielsen; Anders Oldner; Ville Pettilä; Maria B Cronhjort; Lasse H Andersen; Ulf G Pedersen; Nanna Reiter; Jørgen Wiis; Jonathan O White; Lene Russell; Klaus J Thornberg; Peter B Hjortrup; Rasmus G Müller; Morten H Møller; Morten Steensen; Inga Tjäder; Kristina Kilsand; Suzanne Odeberg-Wernerman; Brit Sjøbø; Helle Bundgaard; Maria A Thyø; David Lodahl; Rikke Mærkedahl; Carsten Albeck; Dorte Illum; Mary Kruse; Per Winkel; Anders Perner Journal: N Engl J Med Date: 2014-10-01 Impact factor: 91.245
Authors: Tina L Palmieri; Daniel M Caruso; Kevin N Foster; Bruce A Cairns; Michael D Peck; Richard L Gamelli; David W Mozingo; Richard J Kagan; Wendy Wahl; Nathan A Kemalyan; Joel S Fish; Manuel Gomez; Robert L Sheridan; Lee D Faucher; Barbara A Latenser; Nicole S Gibran; Robert L Klein; Lynn D Solem; Jeffrey R Saffle; Stephen E Morris; James C Jeng; David Voigt; Pamela A Howard; Fred Molitor; David G Greenhalgh Journal: Crit Care Med Date: 2006-06 Impact factor: 7.598
Authors: J L Carson; A Duff; J A Berlin; V A Lawrence; R M Poses; E C Huber; D A O'Hara; H Noveck; B L Strom Journal: JAMA Date: 1998-01-21 Impact factor: 56.272
Authors: Howard L Corwin; Andrew Gettinger; Ronald G Pearl; Mitchell P Fink; Mitchell M Levy; Edward Abraham; Neil R MacIntyre; M Michael Shabot; Mei-Sheng Duh; Marc J Shapiro Journal: Crit Care Med Date: 2004-01 Impact factor: 7.598
Authors: Paraskevi C Fragkou; Hew D Torrance; Rupert M Pearse; Gareth L Ackland; John R Prowle; Helen C Owen; Charles J Hinds; Michael J O'Dwyer Journal: Crit Care Date: 2014-10-01 Impact factor: 9.097