Patient-tailored platelet transfusion practices for children supported by extracorporeal membrane oxygenation.

BACKGROUND AND OBJECTIVES: Extracorporeal membrane oxygenation (ECMO) serves as cardiopulmonary therapy in critically ill patients with respiratory/heart failure and often necessitates multiple blood product transfusions. The administration of platelet transfusions during ECMO is triggered by the presence or risk of significant bleeding. Most paediatric ECMO programmes follow guidelines that recommend a platelet transfusion threshold of 80-100 × 109/L. To reduce exposure to platelets, we developed a practice to dynamically lower the threshold to ~20 × 109/L. We describe our experience with patient-tailored platelet thresholds and related bleeding outcomes. MATERIALS AND METHODS: We retrospectively evaluated our platelet transfusion policy, bleeding complications and patient outcome in 229 ECMO-supported paediatric patients in our unit. RESULTS: We found that more than 97.4% of patients had a platelet count <100 × 109/L at some point during their ECMO course. Platelets were transfused only on 28.5% of ECMO days; and 19.2% of patients never required a platelet transfusion. The median lowest platelet count in children who had bleeding events was 25 × 109/L as compared to 33 × 109/L in children who did not bleed (p < 0.001). Our patients received fewer platelet transfusions and did not require more red blood cell transfusions, nor did they experience more haemorrhagic complications. CONCLUSION: We have shown that a restrictive, 'patient-tailored' rather than 'goal-directed' platelet transfusion policy is feasible and safe, which can greatly reduce the use of platelet products. Although there was a difference in the lowest platelet counts in children who bled versus those who did not, the median counts were much lower than current recommendations.

The Effect of Medical Clowns on Blood Pressure Measurement in Children Presenting to the Emergency Department.

BACKGROUND: Blood pressure (BP) is routinely measured while triaging children presenting to the pediatric emergency department (PED). OBJECTIVES: To determine whether a medical clown shortens the time to acquire a BP measurement among children undergoing triage in the PED. METHODS: The study comprised 133 children. Patients were assigned to one of two groups: with a medical clown or without a medical clown. RESULTS: The presence of a medical clown led to a significantly shorter time to acquire a blood pressure measurement (60 ± 23 seconds vs. 81 ± 43.5 seconds, P < 0.001. Clowns had a significant effect on shortening total triage length among children of Jewish ethnicity compared to Arab ethnicity (113 ± 353.6 seconds vs. 154 ± 418 seconds, P = 0.012). CONCLUSIONS: Using medical clowns while measuring BP during triage when used in a culturally appropriate manner shortens time.

Circulating mRNA for epidermal growth factor-like domain 7 (EGFL7) in maternal blood and early intrauterine growth restriction. A preliminary analysis.

OBJECTIVE: To evaluate the alteration in epidermal growth factor-like domain 7 (EGFL7) mRNA expression in maternal blood from pregnancies affected by early-onset intrauterine growth restriction (IUGR) at 20-24 weeks. METHOD: Case-control study encompassing six women with pregnancies affected by IUGR (cases) matched in a 1 : 7 ratio for gestational age and fetal gender with 42 controls. We quantified EGFL7 mRNA expression in normal and IUGR patients. Matched rank-sum analysis and multiples of median were used to evaluate differences of the marker of interest between cases and controls. Spearman regression analysis was used to correlate the estimated fetal weight at blood sampling with the EGFL7 mRNA values. RESULTS: The mean observed rank in the IUGR group was significantly higher than that of controls (6.67 vs 4.19, p = 0.01). Pregnancies affected with IUGR exhibited 1.70-fold higher levels of maternal EGFL7 mRNA compared with matched controls (p = 0.014). EGFL7 mRNA values were inversely correlated with estimated fetal weight (Spearman's ρ = -0.429, p = 0.198). CONCLUSION: Early IUGR at 20-24 weeks' gestation is associated with higher values of EGFL7 expression in maternal plasma.

Prospective evaluation of ultrasound and biochemical-based multivariable models for the prediction of late pre-eclampsia.

OBJECTIVE: Prospective assignment at 11 + 0 to 13 + 6 weeks of risk for late pre-eclampsia (PE) using eight logistic regression-based statistical models. METHODS: Five hundred and fifty-four pregnancies. Uterine artery pulsatility index, parity, body mass index, mean arterial pressure, pregnancy-associated plasma protein-A, free ß-human chorionic gonadotrophin and maternal age, were combined to obtain 'a posteriori risk of PE'. RESULTS: We observed 39 cases (7%) of late PE. There were 12 cases of severe PE and 27 of mild PE. According to the models used, the estimated detection rate ranged from 38.5% to 84.6% with a false-positive rate of 10%. The median risk ratio (estimated median risk of PE in affected pregnancies divided by estimated risk of PE in unaffected pregnancies) ranged between 1.66 and 7.61. The most reproducible biochemical-based model was a mixed model encompassing maternal history and pregnancy-associated plasma protein-A. CONCLUSION: Some of the multivariable models drawn from the literature accurately predicted the late PE occurrence. The failure of some models may be because of the population in question not bearing several of the risk factors used to generate the models proposed. An effective combined screening at first trimester for late PE seems possible.