Feature Articles

Epidemiology of Clinically Relevant Bleeding in Critically Ill Adolescents*

Pinto, Matthew G. MD¹; Shabanova, Veronika PhD²; Li, Simon MD, MPH¹; Trakas, Erin MD³; Miksa, Michael MD, PhD⁴; Gertz, Shira MD⁵; Polikoff, Lee A. MD⁶; Tala, Joana A. MD⁷; Faustino, Edward Vincent S. MD, MHS²

Author Information

¹Department of Pediatrics, New York Medical College, Valhalla, NY.

²Department of Pediatrics, Yale School of Medicine, New Haven, CT.

³Department of Pediatrics, University of Rochester Golisano Children’s Hospital, Rochester, NY.

⁴Department of Pediatrics, Children’s Hospital at Montefiore, Bronx, NY.

⁵Department of Pediatrics, Saint Barnabas Medical Center, Livingston, NJ.

⁶Department of Pediatrics, The Warren Alpert School of Medicine at Brown University, Providence, RI.

⁷Pediatric Intensive Care Unit, Yale-New Haven Children’s Hospital, New Haven, CT.

*See also p. 986.

Supported, in part, by grant from the American Heart Association Award Number 14CRP20490002 to Dr. Faustino. It was also made possible by Clinical and Translational Science Award grant number UL1 RR024139 from the National Center for Research Resources and the National Center for Advancing Translational Science, components of the National Institutes of Health (NIH), and NIH roadmap for Medical Research to Dr. Shabanova, and an unrestricted grant support from Layla’s Dream to Dr. Polikoff.

Drs. Pinto's, Miksa's, Gertz's, and Faustino’s institutions received funding from the American Heart Association (AHA). Drs. Pinto's and Faustino’s institutions received funding from the National Institutes of Health (NIH). Drs. Pinto, Shabanova, and Faustino received support for article research from the NIH. Dr. Shabanova’a institution received funding from CTSA Grant Number UL1 TR001863 or KL2 TR001862 or TL1 TR001864 from the National Center for Advancing Translational Science. Dr. Trakas’ institution received funding from AHA (#14CRP20490002) and NIH NCRR # UL1 RR024139. Dr. Gertz’s institution received funding from Yale University. Dr. Polikoff’s institution received funding from Layla's Dream; he received funding from Medtronic; and he received support for article research from Layla's Dream. Dr. Tala disclosed work for hire. Dr. Faustino received support for article research from the AHA. Dr. Li has disclosed that he does not have any potential conflicts of interest.

For information regarding this article, E-mail: [email protected]

Pediatric Critical Care Medicine 20(10):p 907-913, October 2019. | DOI: 10.1097/PCC.0000000000002018

Abstract

Objectives:

The epidemiology of clinically relevant bleeding in critically ill adolescents, particularly those who are at high risk of venous thromboembolism, is unclear. In preparation for a randomized clinical trial of pharmacologic prophylaxis against venous thromboembolism, we characterized the epidemiology of clinically relevant bleeding in critically ill adolescents.

Design:

Post hoc analysis of data from a pediatric multicenter observational study of venous thromboembolism.

Setting:

Six PICUs.

Patients:

Adolescents 13–17 years old who received cardiac or pulmonary support for at least 48 hours were eligible. Those admitted with venous thromboembolism or receiving therapeutic anticoagulation were excluded.

Interventions:

None.

Measurements and Main Results:

Adolescents (n = 88) were followed daily for the development of any bleeding event. The severity of the event was categorized based on the definitions by the International Society on Thrombosis and Haemostasis. The frequency of clinically relevant bleeding was 29.5% (95% CI, 20.3–40.2%) or 3.7 events (95% CI, 2.5–5.4 events) per 100 patient-days. Adolescents with venous thromboembolism were more likely to develop clinically relevant bleeding (hazard ratio, 2.06; 95% CI, 1.08–3.94). Age was negatively associated with clinically relevant bleeding (hazard ratio for every 1-year increase in age: 0.68; 95% CI, 0.58–0.79). In contrast, predicted risk of mortality (hazard ratio for every 0.10 increase in risk: 1.35; 95% CI, 1.05–1.74) and admission for trauma or surgery (hazard ratio: 2.04; 95% CI, 1.21–3.44) were positively associated with clinically relevant bleeding. The association of clinically relevant bleeding with medications, interventions, or laboratory tests, including mechanical ventilation and pharmacologic prophylaxis with anticoagulation, did not reach statistical significance. Adolescents with clinically relevant bleeding stayed in the hospital longer than those without clinically relevant bleeding.

Conclusions:

Clinically relevant bleeding is common in critically ill adolescents who are at high risk of venous thromboembolism. Admission for trauma or surgery can be used to stratify the risk of clinically relevant bleeding in these adolescents.

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Epidemiology of Clinically Relevant Bleeding in Critically Ill Adolescents*