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Coagulation Dysfunction Criteria in Critically Ill Children: The PODIUM Consensus Conference
E Vincent S Faustino1, Oliver Karam2, Robert I Parker3
1Section of Pediatric Critical Care Medicine, Department of Pediatrics, School of Medicine, Yale University, New Haven, Connecticut.
Insights
New criteria for diagnosing coagulation dysfunction in critically ill children are proposed, based on platelet count, international normalized ratio, fibrinogen, and D-dimer levels. These evidence-based guidelines aim to improve patient outcomes and require further validation.
Area of Science:
- Pediatric critical care medicine
- Hematology
- Coagulation disorders
Background:
- Existing criteria for coagulation dysfunction in critically ill children lack robust evidence, relying primarily on expert opinion.
- There is a need for evidence-based criteria to accurately identify and manage coagulation dysfunction in pediatric critical illness.
Purpose of the Study:
- To systematically review current evidence linking coagulation tests to adverse outcomes in critically ill children.
- To inform the development of evidence-based criteria for coagulation dysfunction in this population.
Main Methods:
- Conducted comprehensive electronic searches of PubMed and Embase (1992-2020).
- Included studies evaluating critically ill children with coagulation dysfunction, assessing screening tools, and measuring patient-centered outcomes.
- Extracted data and assessed risk of bias for eligible studies.
Main Results:
- Proposed criteria for coagulation dysfunction (in absence of liver dysfunction) include at least two of: platelet count <100,000/μL, international normalized ratio (INR) >1.5, fibrinogen <150 mg/dL, or D-dimer >10x upper limit of normal.
- These criteria are supported by a systematic review of available evidence.
Conclusions:
- The proposed criteria offer a foundation for diagnosing coagulation dysfunction in critically ill children.
- Future validation of these criteria is essential to enhance understanding and management of coagulation disorders in this vulnerable group.
Context:
Previous criteria for coagulation dysfunction in critically ill children were based mainly on expert opinion.
Objective:
To evaluate current evidence regarding coagulation tests associated with adverse outcomes in children to inform criteria for coagulation dysfunction during critical illness.
Data Sources:
Electronic searches of PubMed and Embase were conducted from January 1992 to January 2020 by using a combination of medical subject heading terms and text words to define concepts of coagulation dysfunction, pediatric critical illness, and outcomes of interest.
Study Selection:
Studies were included if critically ill children with coagulation dysfunction were evaluated, if performance characteristics of assessment and/or scoring tools to screen for coagulation dysfunction were evaluated, and if outcomes related to mortality or functional status, organ-specific outcomes, or other patient-centered outcomes were assessed.
Data Extraction:
Data were abstracted from each eligible study into a standard data extraction form, along with risk of bias assessment, by a task force member.
Results:
The systematic review supports the presence of at least 2 of the following criteria reflecting coagulation dysfunction in the absence of liver dysfunction: platelet count <100 000 cells per μL, international normalized ratio >1.5, fibrinogen level <150 mg/dL, and D-dimer value above 10 times the upper limit of normal, or above the assay's upper limit of detection if this limit is below 10 times the upper limit of normal.
Limitations:
The proposed criteria for coagulation dysfunction are limited by the available evidence and will require future validation.
Conclusions:
Validation of the proposed criteria and identified scientific priorities will enhance our understanding of coagulation dysfunction in critically ill children.
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