Pediatric Interfacility Transport Curriculum: Its Impact on the Pediatric Intensive Care and Emergency Medicine Fellows' Performance and Confidence.

OBJECTIVE: Pediatric interfacility transports are frequent. Despite the absence of a formal pediatric transport curriculum in eastern Canada, directly managing patients during transport and medical direction of the referring center and transport team are part of the pediatric critical care medicine (PCCM) and pediatric emergency medicine (PEM) program requirements. The authors developed a pediatric interfacility transport curriculum and measured its impact on fellows' confidence and performance. METHODS: This was a pilot interventional prospective study in Montreal, Canada. Postcurriculum surveys were used to measure confidence, and high-fidelity simulations were used to measure performance. A target threshold for confidence was defined before implementation, and pre- and post values were compared. The simulation scenario and assessment checklist were locally developed. RESULTS: The participants were 11 PCCM and 3 PEM fellows. The content of the curriculum and educational methods were selected based on the literature and a needs assessment survey. All participants rated themselves as confident at the end of the curriculum. Eighty-three percent of the participants were deemed proficient with a perfect interrater agreement. CONCLUSION: The pediatric transport curriculum had a positive impact on PEM and PCCM fellows' confidence and performance in transport. Further studies should look at the impact of such a curriculum on participants' real-life performance and patient care.

Transfusion-Associated Circulatory Overload in ICUs: A Scoping Review of Incidence, Risk Factors, and Outcomes.

Transfusion-associated circulatory overload is the most frequent serious adverse transfusion reaction, with an incidence close to 1% of transfused patients in the general adult population. Patients in ICUs are probably more at risk of transfusion-associated circulatory overload as they are more frequently transfused and associated with more comorbidities. However, the epidemiology of transfusion-associated circulatory overload in ICU is not well characterized, leading to a risk of underdiagnosis. OBJECTIVES: We conducted a scoping review to describe the incidence, risk factors, and outcomes of transfusion-associated circulatory overload in PICU and adult ICU. DATA SOURCES: PubMed, Ovid Medline, Ovid All EBM Reviews, Ovid Embase, and EBSCO CINAHL COMPLETE. STUDY SELECTION: Two reviewers independently screened each article for inclusion criteria. Studies were eligible if they reported data on incidence, risk factors, or outcomes of transfusion-associated circulatory overload in at least 10 ICU patients. DATA SYNTHESIS: Among 5,926 studies identified, nine were included. Five studies were prospective, and four were retrospective. The definition of transfusion-associated circulatory overload varied among studies. The pooled incidence of transfusion-associated circulatory overload was of 5.5% (95% CI, 2.6-9.4%) in adult ICUs (four studies, 2,252 patients, high heterogeneity). In PICUs, two studies (345 patients) reported 0 cases, and a third study (136 patients) reported variable incidences between 1.5% and 76%, depending on diagnostic criteria. Risk factors for transfusion-associated circulatory overload included positive fluid balance, the number and type of products transfused, rate of transfusion, and cardiovascular and renal comorbidities. Transfusion-associated circulatory overload was associated with increased ICU and hospital lengths of stay, whereas the association with mortality was not consistent. CONCLUSIONS: Transfusion-associated circulatory overload is frequent in ICU patients and is associated with adverse outcomes. The lack of a pediatric-adjusted definition of transfusion-associated circulatory overload may lead to a risk of underdiagnosis of this condition in PICUs. Further research is warranted to improve the knowledge of transfusion-associated circulatory overload and the safety of transfusion in ICU patients.

Transfusion-associated circulatory overload in a pediatric intensive care unit: different incidences with different diagnostic criteria.

BACKGROUND: The incidence of transfusion-associated circulatory overload (TACO) is not well known in children, especially in pediatric intensive care unit (PICU) patients. STUDY DESIGN AND METHODS: All consecutive patients admitted over 1 year to the PICU of CHU Sainte-Justine were included after they received their first red blood cell transfusion. TACO was diagnosed using the criteria of the International Society of Blood Transfusion, with two different ways of defining abnormal values: 1) using normal pediatric values published in the Nelson Textbook of Pediatrics and 2) by using the patient as its own control and comparing pre- and posttransfusion values with either 10 or 20% difference threshold. We monitored for TACO up to 24 hours posttransfusion. RESULTS: A total of 136 patients were included. Using the "normal pediatric values" definition, we diagnosed 63, 88, and 104 patients with TACO at 6, 12, and 24 hours posttransfusion, respectively. Using the "10% threshold" definition we detected 4, 15, and 27 TACO cases in the same periods, respectively; using the "20% threshold" definition, the number of TACO cases was 2, 6, and 17, respectively. Chest radiograph was the most frequent missing item, especially at 6 and 12 hours posttransfusion. Overall, the incidence of TACO varied from 1.5% to 76% depending on the definition. CONCLUSION: A more operational definition of TACO is needed in PICU patients. Using a threshold could be more optimal but more studies are needed to confirm the best threshold.