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.
Delphi consensus process of multidisciplinary experts in bleeding/hemostasis in critically ill children, followed by prospective cohort study to test internal validity.
Children at risk of bleeding in PICUs.
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.
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.
1Division of Pediatric Critical Care Medicine, Department of Pediatrics, NY Presbyterian Hospital – Weill Cornell Medicine, New York, NY.
2Division of Pediatric Critical Care Medicine, Department of Pediatrics, Sainte-Justine Hospital, University of Montreal, Montreal, QC, Canada.
3Division of Critical Care Medicine, Department of Pediatrics, Washington University in St Louis, St Louis, MO.
4Division of Pediatric Cardiology, Department of Pediatrics, NY Presbyterian Hospital – Weill Cornell Medicine, New York, NY.
5Divisions of Critical Care and Hematology/Oncology, Department of Pediatrics, University of Minnesota, Minneapolis, MN.
6Section of Pediatric Critical Care Medicine, Department of Pediatrics, Yale School of Medicine, New Haven, CT.
7Division of Transfusion Medicine, Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN.
8Paediatric Intensive Care Unit, Bristol Royal Hospital for Children, Bristol, United Kingdom.
9Transfusion Medicine, NHS Blood and Transplant, Oxford, United Kingdom.
10Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.
11Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom.
12Oxford BRC Haematology Theme, Oxford, United Kingdom.
13Divisions of Critical Care and Cardiology, Department of Pediatrics, University of Rochester, Golisano Children’s Hospital, Rochester, NY.
14Emeritus Department of Pediatrics, Division of Hematology/Oncology, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY.
15Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHC, Liège, Belgium.
16Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children’s Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
17Department of Pediatric Surgery, Children’s Hospital of Alabama, Birmingham, AL.
18General Anesthesiology Division, Department of Anesthesia and Critical Care Medicine, The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
19Department of Pediatric Surgery, Texas Children’s Hospital and Baylor College of Medicine, Houston, TX.
20Division of Pediatric Intensive Care, Department of Intensive Care, Leiden Universitair Medisch Centrum, Leiden, The Netherlands.
21Departments of Pathology and Pediatrics, Emory University School of Medicine and the Center for Transfusion and Cellular Therapies, Atlanta, GA.
22Departments of Pediatrics and Pathology, Children’s National Health System, George Washington University School of Medicine and Health Sciences, Washington, DC.
23Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX.
24Université de Lille, CHU Lille, EA 2694 - Santé publique: épidémiologie et qualité des soins, F-59000 Lille, France.
25Department of Pediatrics, Queensland Children’s Hospital, Brisbane, Australia.
26Department of Anesthesiology, Critical Care & Pain Medicine, Harvard Medical School, Boston Children’s Hospital, Boston, MA.
27Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Richmond at VCU, Richmond, VA.
Supported, in part, by Clinical and Translational Science Award award No. UL1TR000058 from the National Center for Advancing Translational Sciences (for access to Research Electronic Data Capture).
Drs. Nellis and Josephson received support for article research from the National Institutes of Health. Dr. Zantek disclosed that she is an Executive Board member of the North American Specialized Coagulation Laboratory Association, and that her spouse is an employee of Boston Scientific and owns stock in Boston Scientific and ENDO International PLC. The remaining authors have disclosed that they do not have any potential conflicts of interest.
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