A Prospective Study of the Association Between Clinically Significant Bleeding in PICU Patients and Thrombocytopenia or Prolonged Coagulation Times.

OBJECTIVE: There are no proven methods to predict the risk of clinically significant bleeding in the PICU. A retrospective study identified platelet count as a risk marker for clinically significant bleeding. We conducted a study to examine any association of platelet count, international normalized ratio, and activated partial thromboplastin time with bleeding risk in PICU patients. DESIGN: Prospective observational cohort study. SETTING: The PICU at the Children's Hospital of Eastern Ontario, a university-affiliated tertiary care pediatric center. PATIENTS: Consecutive patients admitted to the PICU. Exclusion criteria were prior inclusion, admission with bleeding, inherited bleeding disorders, weight less than 3 kg, and age less than 60 days or 18 years or more. INTERVENTIONS: There were no interventions in this observational study. MEASUREMENTS AND MAIN RESULTS: Patients were monitored in real time for clinically significant bleeding, using a broadly inclusive definition of clinically significant bleeding, for up to 72 hours after admission to the PICU, or until death or discharge. All measurements of platelet count, international normalized ratio, and activated partial thromboplastin time obtained during the study period were included as time-varying covariates in Cox proportional hazard models. Two hundred thirty-four patients were eligible, and 25 (11%) had one or more episodes of clinically significant bleeding. Platelet count was associated with increased hazard of clinically significant bleeding (hazard ratio, 0.96 per 10 × 10/L increase in platelet count; 95% CI (0.93-0.997; p = 0.03). Increasing hazard for clinically significant bleeding was seen with decreasing platelet count. Neither international normalized ratio nor activated partial thromboplastin time was significantly associated with clinically significant bleeding. CONCLUSIONS: There is a statistically significant association in PICU patients between decrease in platelet count and clinically significant bleeding, and this association is stronger with lower platelet counts. Further study is required to determine whether platelet transfusion can reduce bleeding risk. International normalized ratio and activated partial thromboplastin time do not predict clinically significant bleeding, and these tests should not be used for this purpose in a general PICU patient population.

A survey of the management of newborns with severe hemophilia in Canada.

OBJECTIVE: To determine the practice patterns of Canadian hematologists and neonatologists/paediatricians who care for newborns with hemophilia, with regard to vitamin K administration, use of empirical clotting factor replacement therapy, neuroimaging and timing of hematology consultation. METHODS: Hematologists and neonatologists/paediatricians, identified from membership lists of Canadian professional organizations, were provided electronic and/or paper versions of the survey instrument. Questions were posed in the context of specific clinical scenarios. Differences in response proportions between groups were compared for selected questions. RESULTS: There were 171 respondents among 616 eligible persons who were sent the survey; 58 respondents had recent experience managing a newborn with hemophilia. There was a consensus not to provide empirical treatment to well newborns after uncomplicated deliveries, to provide empirical treatment to symptomatic newborns and to obtain neuroimaging for symptomatic newborns. Systematic differences between hematologists and neonatologists/paediatricians existed with regard to the timing of hematology consultation when the diagnosis of hemophilia had not been confirmed antenatally, the route of vitamin K administration for newborns with hemophilia and the choice of product to use for empirical treatment of a symptomatic newborn. CONCLUSIONS: The observed lack of consensus regarding important management decisions indicates a need for ongoing research in the care of newborns with hemophilia. Systematic differences between hematologists and neonatologists/paediatricians suggest a role for improved communication and collaboration between these two groups of practitioners.

OBJECTIF: Déterminer les profils de pratique des hématologues et des néonatologistes/pédiatres canadiens qui soignent des nouveau-nés hémophiles à l'égard de l'administration de vitamine K, de l'utilisation empirique du traitement par le facteur de remplacement de coagulation, de la neuro-imagerie et du moment de la consultation en hématologie. MÉTHODOLOGIE: Les hématologues et les néonatologistes/pédiatres, repérés grâce aux listes de membres d'organismes professionnels canadiens, ont reçu une version virtuelle, une version papier ou les deux versions du sondage. Les questions étaient posées dans le contexte de scénarios cliniques précis. Les différences dans les proportions de réponses entre les groupes étaient comparées à l'égard de questions sélectionnées. RÉSULTATS: Sur les 616 personnes admissibles, 171 ont répondu au sondage. De ce nombre, 58 avaient eu une expérience récente de prise en charge d'un nouveau-né hémophile. On observait un consensus de ne pas administrer de traitement empirique aux nouveau-nés en santé après un accouchement sans complication, d'administrer un traitement empirique aux nouveau-nés symptomatiques et d'obtenir une neuroimagerie chez ces nouveau-nés symptomatiques. Il y avait des différences systématiques entre les hématologues et les néonatologistes/pédiatres pour ce qui est du moment de la consultation en hématologie lorsque le diagnostic n'avait pas été confirmé pendant la période anténatale, de la voie d'administration de la vitamine K aux nouveau-nés hémophiles et du choix de produit à utiliser pour administrer un traitement empirique à un nouveau-né symptomatique. CONCLUSIONS: L'absence de consensus observé au sujet d'importantes décisions de prise en charge démontre la nécessité de poursuivre les recherches sur les soins aux nouveau-nés hémophiles. En raison des différences systématiques entre les hématologues et les néonatologistes/pédiatres, il y aurait lieu d'améliorer les communications et la collaboration entre ces deux groupes de praticiens.