Pediatric Critical Care Blood Management Guideline Consensus Conference Series

Pediatric Critical Care Blood Management Guideline Consensus Conference Series Stacey Valentine, MD MPH & Scot Bateman, MD UMassMemorial Children s Medical Center University of Massachusetts Medical School on behalf of the Executive Committee, Park City, Utah March 11, 2015

Conflicts of Interest No conflicts of interest to report

What is Blood Management? Timely application of evidence-based medical and surgical strategies designed to: maintain a physiologically relevant hemoglobin concentration optimize hemostasis minimize blood loss improve patient outcomes

Pediatric Critical Care Frequent blood transfusions: 49% of patients in the PICU >48hrs get transfused Higher burden of blood loss from phlebotomy and procedures Despite good evidence for lowering Hgb threshold, practice patterns remain varied Morbidity data related to transfusions in the PICU continues to mount

Why Guidelines? Creation of guidelines in other areas: Sepsis, head trauma, acute lung injury to name a few Particularly helpful when focused on pediatric patients Need enough data in pediatric patients to make them worthwhile

Why guidelines? Ongoing variability of blood management in pediatric patients Taking more blood and transfusing more than probably necessary Practice is changing, but slowly Data is mounting for pediatric patients in the area of blood management Thanks to this group in particular!! Can help move along the field with appropriate guidelines

Blood Net + PALISI ideally suited for this. International Consensus Conference on Pediatric Acute Lung Injury

Pediatric Critical Care Blood Management Consensus Conference Objective: Develop pediatric critical care blood management guidelines to improve outcomes and safety for children at risk for or who require transfusion Disseminated via implementation science principles

Pediatric Critical Care Blood Management Consensus Conference Design: Staged approach: 1 st series focused on red blood cell transfusion

Pediatric Critical Care Blood Management Consensus Conference Objective: Staged approach: 1 st series focused on indications for red blood cell transfusion Subsequent series: Indications for non-prbc transfusions, (i.e. plasma, platelets), management of disorders of hemostasis, reduction of induced blood loss

Pediatric Critical Care Blood Management Consensus Conference Design: Staged approach: 1 st series focused on red blood cell transfusion Conference series takes place over 2-3 years and will follow the Delphi method International multidisciplinary experts on RBC transfusion» pediatric critical care, transfusion medicine, hematology, surgery, and anesthesia» Experts published on their topic in the past five years Experts on guideline development and implementation science invited

Blood Management Consenus Conference Time Preparation 1. Create organizing committee 2. Define methodology 3. Select topics 4. Identify experts October May 2014 March 2015 First Expert Meeting Discuss and finalize: 1. Methodology 2. Specific subtopics Second Expert Meeting Discuss: 1. Short text recommendations 2. Determine agreement (Delphi method) 3. Reword if necessary Third Expert Meeting Present: 1. Short text recommendations 2. Discuss disagreements (Delphi method) 3. Finalize recommendations Montreal October October 2014 2015 March Spring 2015 2015 October Fall 2016 2015 Expert Work between meetings 1. Analyze literature 2. Create short text recommendations Expert Work between meetings 1. Score recommendations 2. Reword if necessary 3. Finalize long text Diffusion Present to March Spring 2017 2016

Blood Management Consenus Conference Time Preparation 1. Create organizing committee 2. Define methodology 3. Select topics 4. Identify experts March May 2014 2015 First Expert Meeting Discuss and finalize: 1. Methodology 2. Specific subtopics Second Expert Meeting Discuss: 1. Short text recommendations 2. Determine agreement (Delphi method) 3. Reword if necessary Third Expert Meeting Present: 1. Short text recommendations 2. Discuss disagreements (Delphi method) 3. Finalize recommendations Montreal October 2014 March 2015 October 2015 Expert Work between meetings 1. Analyze literature 2. Create short text recommendations Expert Work between meetings 1. Score recommendations 2. Reword if necessary 3. Finalize long text Diffusion Present to March 2016

Pediatric Critical Care Blood Management Consensus Conference Revised Topic List Indications for Red Blood Cell Transfusion General critical are population Special Populations Indications for transfusion of alternative processing methods of RBC units

Pediatric Critical Care Blood Management Consensus Conference Revised Topic List Indications for Red Blood Cell Transfusion General critical care population (hemodynamically stable, no cardiac disease) Hemoglobin based threshold Physiologic based threshold

Pediatric Critical Care Blood Management Consensus Conference Revised Topic List Indications for Red Blood Cell Transfusion Special populations (data based on hemoglobin and physiologic thresholds) Traumatic brain injury/stroke Extracorporeal support, dialysis, ventricular assist devices, etc Congenital cardiac disease Sickle cell, Stem cell transplant/oncologic population Hemorrhaging patient (hemorrhagic shock, GI bleed, epistaxis, splenic lac, liver tx) Shock (sepsis, heart failure, etc. (hemorrhagic shock excluded)) Respiratory failure

Revised Topic List Pediatric Critical Care Blood Management Consensus Conference Indications for transfusion of alternative processing methods of RBC units i.e. washed, leukoreduced, irradiated

Pediatric Critical Care Blood Management Consensus Conference Indications for Red Blood Cell Transfusion General critical care population (hemodynamically stable, no cardiac disease) Hemoglobin based threshold Physiologic based threshold Indications for Red Blood Cell Transfusion Special populations (data based on hemoglobin and physiologic thresholds) Traumatic brain injury/stroke Extracorporeal support, dialysis, ventricular assist devices, etc. Congenital cardiac disease Sickle cell, Stem cell transplant/oncologic population Hemorrhaging patient (hemorrhagic shock, GI bleed, epistaxis, splenic lac, liver tx) Shock (sepsis, heart failure, etc. (hemorrhagic shock excluded)) Respiratory failure Indications for transfusion of alternative processing methods of RBC units (washed, leukoreduced, irradiated, etc.)

Progress to date: Topic Experts International multidisciplinary experts on RBC transfusion Pediatric critical care Transfusion medicine Pediatric Hematology Pediatric oncology Pediatric surgery Pediatric anesthesia Epidemiology Experts published on their topic in the past five years, using the expert criteria established by PALICC Goal to have expert representation from each continent

Progress to date: Methodology Guideline expertise: Johns Hopkins University Evidence-based Practice Center Serve as a consultants to the guideline development process Literature search methodology will be clearly defined 2-4 centers will carry out the search Tracking software will be used (i.e. RevMan, Refworks, Distiller) Consulting costs are reasonable

Funding Progress to date Funding updates: Phil is resubmiing the CDI grant Received very posinve feedback Funding opportunity for $50,000/year x 3 years Scot and Stacey will be submiing an R13 to the NICHD and NHLBI

Blood Management Consenus Conference Time Preparation 1. Create organizing committee 2. Define methodology 3. Select topics 4. Identify experts March May 2014 2015 First Expert Meeting Discuss and finalize: 1. Methodology 2. Specific subtopics Second Expert Meeting Discuss: 1. Short text recommendations 2. Determine agreement (Delphi method) 3. Reword if necessary Third Expert Meeting Present: 1. Short text recommendations 2. Discuss disagreements (Delphi method) 3. Finalize recommendations Montreal October October 2015 2014 March 2015 October 2015 Expert Work between meetings 1. Analyze literature 2. Create short text recommendations Expert Work between meetings 1. Score recommendations 2. Reword if necessary 3. Finalize long text Diffusion Present to March 2016

Blood Management Consenus Conference Time Preparation 1. Create organizing committee 2. Define methodology 3. Select topics 4. Identify experts October May 2014 March 2015 First Expert Meeting Discuss and finalize: 1. Methodology 2. Specific subtopics Second Expert Meeting Discuss: 1. Short text recommendations 2. Determine agreement (Delphi method) 3. Reword if necessary Third Expert Meeting Present: 1. Short text recommendations 2. Discuss disagreements (Delphi method) 3. Finalize recommendations Montreal October October 2014 2015 March Spring 2015 2015 October Fall 2016 2015 Expert Work between meetings 1. Analyze literature 2. Create short text recommendations Expert Work between meetings 1. Score recommendations 2. Reword if necessary 3. Finalize long text Diffusion Present to March Spring 2017 2016

ImplementaNon and DisseminaNon Implementation science, medical anthropology, and human factor engineering professionals will assist the expert panel on guideline development and dissemination, to improve acceptance of the guidelines

Blood Management Consensus Conference/ ExecuNve Jacques Lacroix Phil Spinella Allan Doctor Marie Steiner Robert Parker Marisa Tucci CommiXee

Thank You

Methodology First meeting: outlining the process, further define our list of subtopics Subtopics will be extensively researched The GRADE methodology used to grade the level of evidence supporting each recommendation Short text recommendations created Second meeting: Short text recommendations presented, voting process using the Delphi method Recommendations will be scored and refined Long text recommendations will be completed Third meeting: Short text recommendations presented, voting process using the Delphi method Recommendations finalized If the process is not complete after the third meeting a fourth will be held

Why guidelines?