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Criteria for Clinically Relevant Bleeding in Critically Ill Children: An International Survey
Oliver Karam1, Marianne E Nellis2, Nicole D Zantek3
1Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Hospital of Richmond at VCU, Richmond, VA.
Insights
Clinically relevant bleeding in critically ill children is poorly defined. This survey identified factors like location and severity that pediatric intensivists consider significant for defining bleeding relevance.
Area of Science:
- Pediatric Critical Care Medicine
- Hemorrhagic Complications
- Clinical Significance Assessment
Background:
- Bleeding is a common and serious complication in critically ill children, yet a clear definition of clinically relevant bleeding is lacking for this population.
- Existing bleeding criteria are primarily for adults, highlighting a critical gap in pediatric critical care research and practice.
- Understanding pediatric intensivists' perceptions is crucial for developing standardized definitions.
Purpose of the Study:
- To identify factors influencing pediatric intensivists' perception of clinically relevant bleeding in critically ill children.
- To lay the groundwork for a validated diagnostic definition of clinically relevant bleeding in pediatric intensive care settings.
Main Methods:
- An international, web-based survey administered to pediatric critical care physicians and nurse practitioners.
- Utilized 9-point Likert scales to assess the clinical significance of 103 distinct bleeding characteristics.
- Collected data from 225 respondents across 16 countries.
Main Results:
- Bleeding in critical locations (CNS, lungs, etc.), requiring interventions, causing organ failure, or prolonged duration were deemed most clinically relevant.
- Quantifiable bleeding exceeding 5 mL/kg/hr for over an hour was frequently considered significant.
- Minor bleeding indicators like blood-tinged urine or streaks in tubes were generally considered irrelevant.
Conclusions:
- This international survey offers valuable insights into how pediatric intensivists assess bleeding relevance.
- The findings provide a foundation for developing a standardized, validated definition of clinically relevant bleeding in critically ill children.
- Establishing clear criteria will improve the diagnosis and management of bleeding complications in pediatric intensive care units.
Objectives:
Bleeding, a feared complication of critical illness, is frequent in critically ill children. However, the concept of clinically relevant bleeding is ill-defined in this population. There are many established diagnostic criteria for bleeding, but only one estimates bleeding in critically ill adults, and none exist for critically ill children. Our objective was to identify the factors that influence pediatric intensivists' perception of clinically relevant bleeding.
Design:
Self-administered, web-based survey with 9-point Likert scales, to qualify the clinical significance of 103 bleeding characteristics in critically ill children.
Setting:
Online survey.
Subjects:
Pediatric critical care physicians and nurse practitioners.
Interventions:
None.
Measurements And Main Results:
The response rate was 40%, with 225 respondents from 16 countries. Characteristics most frequently identified as clinically relevant were bleeding in critical locations (e.g., pericardium, pleural space, CNS, and lungs); requiring interventions; leading to physiologic repercussions, including organ failure; and of prolonged duration. Quantifiable bleeding greater than 5 mL/kg/hr for more than 1 hour was frequently considered clinically relevant. Respondents identified the following characteristics as clinically irrelevant: dressings required to be changed no less frequently than every 6 hours, streaks of blood in gastric tubes, streaks of blood in endotracheal tubes or blood in endotracheal tubes only during suctioning, lightly blood-tinged urine, quantifiable bleeding less than 1 mL/kg/hr, and noncoalescing petechiae. Perception of the clinical relevance of bleeding was not associated with the respondent's geographical location of clinical practice or years of experience.
Conclusions:
This international survey provides a better understanding of the factors that influence the pediatric intensivists' assessment of the clinical relevance of bleeding in critically ill children. It provides the foundation for the development of a validated, diagnostic definition of clinically relevant bleeding in this population.
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