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RBC Transfusions Are Associated With Prolonged Mechanical Ventilation in Pediatric Acute Respiratory Distress Syndrome*

Zubrow, Michael, E., MD1; Thomas, Neal, J., MD, MSc2; Friedman, David, F., MD3; Yehya, Nadir, MD1

Pediatric Critical Care Medicine: February 2018 - Volume 19 - Issue 2 - p e88–e96
doi: 10.1097/PCC.0000000000001399
Online Clinical Investigations
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Objectives: Blood products are often transfused in critically ill children, although recent studies have recognized their potential for harm. Translatability to pediatric acute respiratory distress syndrome is unknown given that hypoxemia has excluded pediatric acute respiratory distress syndrome patients from clinical trials. We aimed to determine whether an association exists between blood product transfusion and survival or duration of ventilation in pediatric acute respiratory distress syndrome.

Design: Retrospective analysis of prospectively enrolled cohort.

Setting: Large, academic PICU.

Patients: Invasively ventilated children meeting Berlin Acute Respiratory Distress Syndrome and Pediatric Acute Lung Injury Consensus Conference Pediatric Acute Respiratory Distress Syndrome criteria from 2011 to 2015.

Interventions: We recorded transfusion of RBC, fresh frozen plasma, and platelets within the first 3 days of pediatric acute respiratory distress syndrome onset. Each product was tested for independent association with survival (Cox) and duration of mechanical ventilation (competing risk regression with extubation as primary outcome and death as competing risk). A sensitivity analysis using 1:1 propensity matching was also performed.

Measurements and Main Results: Of 357 pediatric acute respiratory distress syndrome patients, 155 (43%) received RBC, 82 (23%) received fresh frozen plasma, and 92 (26%) received platelets. Patients who received RBC, fresh frozen plasma, or platelets had higher severity of illness score, lower PaO2/FIO2, and were more often immunocompromised (all p < 0.05). Patients who received RBC, fresh frozen plasma, or platelets had worse survival and longer duration of ventilation by univariate analysis (all p < 0.05). After multivariate adjustment for above confounders, no blood product was associated with survival. After adjustment for the same confounders, RBC were associated with decreased probability of extubation (subdistribution hazard ratio, 0.65; 95% CI, 0.51–0.83). The association between RBC and prolonged ventilation was confirmed in propensity-matched subgroup analysis.

Conclusions: RBC transfusion was independently associated with longer duration of mechanical ventilation in pediatric acute respiratory distress syndrome. Hemoglobin transfusion thresholds should be tested specifically within pediatric acute respiratory distress syndrome to establish whether a more restrictive transfusion strategy would improve outcomes.

1Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA.

2Division of Pediatric Critical Care Medicine, Department of Pediatrics and Public Health Science, Penn State Hershey Children’s Hospital, Hershey, PA.

3Blood Bank and Transfusion Medicine Department, Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA.

*See also p. 174.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/pccmjournal).

Supported, in part, by National Institutes of Health (NIH) K12-HL109009 (NY) and NIH K23-136688 (NY).

Dr. Thomas’ institution received funding from GeneFluidics, and he received funding from Therabron and CareFusion. Dr. Friedman received funding from Cord Blood of America and Kline Theroux law firm. Dr. Yehya’s institution received funding from the National Institutes of Health (NIH)/National Heart, Lung, and Blood Institute, and he received support for article research from the NIH. Dr. Zubrow has disclosed that he does not have any potential conflicts of interest.

For information regarding this article, E-mail: yehyan@email.chop.edu

©2018The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies