The Relationship Between Remoteness and Outcomes in Critically Ill Children.

OBJECTIVE: A significant number of children live in remote geographic areas without direct access to tertiary care PICU. Our objective was to explore the relationship between remoteness and outcomes of critically ill children in Canada. DESIGN: Retrospective cohort study of patients admitted to the PICU from February 1, 2015, to January 31, 2016. SETTING: Pediatric tertiary care PICU in Canada. PATIENTS: All children admitted to PICU during the study period. INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS:: Four hundred fifty-five unique PICU admissions were included. One hundred sixty-nine patients were transported from another center of whom 28 lived in remote areas. For transported patients, remoteness (hazard ratio, 2.76, p < 0.001; hazard ratio, 2.22, p = 0.006), admission Pediatric Risk of Mortality (hazard ratio, 1.11; p = 0.001; hazard ratio, 1.05, p = 0.016), and transport by a noncritical care trained team (hazard ratio, 0.61, p = 0.021; hazard ratio, 0.66, p = 0.045) were associated with increased PICU and hospital lengths of stay, respectively. PICU mortality increased with duration of transport (odds ratio, 1.46; 95% CI, 1.09-1.97; p = 0.012). The odds of a remote-area patient being refused admission during the winter were significantly higher (odds ratio, 8.2; 95% CI, 3.0-22.3; p < 0.001) than a patient not requiring transport. Admission Pediatric Risk of Mortality score (4, interquartile range, 1-8 vs 2, interquartile range, 0-5; p = 0.001) and mortality rate (7.1%, 12/169 vs 0%, 0/286; p < 0.001) were significantly higher for transported than for nontransported patients. CONCLUSIONS: Remoteness was associated with increased PICU and hospital length of stay, and duration of transport was associated with higher admission Pediatric Risk of Mortality (PRISM) scores and mortality rates. Patients requiring transport had a significantly higher PICU mortality rate than those presenting directly to a tertiary care center. Further studies are needed to explore potential policy and healthcare resource implications of these findings.

Minimizing blood loss and the need for transfusions in very premature infants.

Reducing blood loss and the need for blood transfusions in extremely preterm infants is part of effective care. Delayed cord clamping is well supported by the evidence and is recommended for infants who do not immediately require resuscitation. Cord milking may be an alternative to delayed cord clamping; however, more research is needed to support its use. In view of concerns regarding the increased risk for cognitive delay, clinicians should avoid using hemoglobin transfusion thresholds lower than those tested in clinical trials. Higher transfusion volumes (15 mL/kg to 20 mL/kg) may decrease exposure to multiple donors. Erythropoietin is not recommended for routine use due to concerns about retinopathy of prematurity. Elemental iron supplementation (2 mg/kg/day to 3 mg/kg/day once full oral feeds are achieved) is recommended to prevent later iron deficiency anemia. Noninvasive monitoring (eg, for carbon dioxide, bilirubin) and point-of-care testing reduce the need for blood sampling. Clinicians should strive to order the minimal amount of blood sampling required for safe patient care, and cluster samplings to avoid unnecessary skin breaks.

Dans le cadre des soins efficaces aux très grands prématurés, il est important de limiter les pertes de sang et les transfusions. Le report du clampage du cordon, bien soutenu par les données probantes, est recommandé pour les nouveau-nés qui n'ont pas besoin d'une réanimation immédiate. La traite du cordon peut le remplacer, mais plus de recherches s'imposent pour en confirmer l'intérêt. Lorsqu'ils transfusent, les cliniciens doivent éviter de recourir à des seuils d'hémoglobine inférieurs à ceux qui sont utilisés lors des essais cliniques, en raison des craintes quant à l'augmentation du risque de retard cognitif. De plus gros volumes de transfusion (15 mL/kg à 20 mL/kg) peuvent réduire l'exposition à de multiples donneurs. L'utilisation systématique d'érythropoïétine n'est pas recommandée à cause du risque connexe de rétinopathie des prématurés. Les suppléments de fer élémentaire (de 2 mg/kg/jour à 3 mg/kg/jour une fois l'alimentation orale établie) sont recommandés pour prévenir une anémie ferriprive plus tard. Le monitorage non invasif (p. ex., dioxyde de carbone, bilirubine) et les tests au point de service réduisent les prélèvements de sang. Les cliniciens devraient demander le moins de prélèvements nécessaires pour prodiguer des soins sécuritaires aux patients et les regrouper pour éviter de transpercer la peau inutilement.