Criteria for Clinically Relevant Bleeding in Critically Ill Children: An International Survey

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. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (https://ift.tt/2gIrZ5Y). Supported, in part, by research funds from Weill Cornell Medicine and Virginia Commonwealth University, as well as the Clinical and Translational Science Award No. UL1TR000058 from the National Center for Advancing Translational Sciences (for access to Research Electronic Data Capture). Dr. Zantek’ institution received funding from Octapharma, Terumo BCT, and Bayer Healthcare, and she disclosed that she is on the Executive Board of the North American Specialized Coagulation Laboratory Association and her spouse is an employee of Boston Scientific and has stock/financial interest in ENDO International PLC. The remaining authors have disclosed that he does not have any potential conflicts of interest. For information regarding this article, E-mail: oliver.karam@vcuhealth.org ©2018The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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