The Lightning Talks at DFTB19

Cite this article as:
Team DFTB. The Lightning Talks at DFTB19, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.22628

We want to encourage a new generation of educators and so at DFTB19 Henry Goldstein invited a bright and enthusiastic group to the stage. Their challenge? To condense the findings of a key paper, chosen by Henry, into just seven minutes. How did they do? You can be the judge of that as you watch:-

Katie Barnes

Apgar V. A proposal for a new method of evaluation of the newborn. Classic Papers in Critical Care. 1952;32(449):97.

Ruth Bird

Curley A, Stanworth SJ, Willoughby K, Fustolo-Gunnink SF, Venkatesh V, Hudson C, Deary A, Hodge R, Hopkins V, Lopez Santamaria B, Mora A. Randomized trial of platelet-transfusion thresholds in neonates. New England Journal of Medicine. 2019 Jan 17;380(3):242-51.

Carrie Thomas

Kirpalani H, Whyte RK, Andersen C, Asztalos EV, Heddle N, Blajchman MA, Peliowski A, Rios A, LaCorte M, Connelly R, Barrington K. The Premature Infants in Need of Transfusion (PINT) study: a randomized, controlled trial of a restrictive (low) versus liberal (high) transfusion threshold for extremely low birth weight infants. The Journal of pediatrics. 2006 Sep 1;149(3):301-7.

Katie Nash

Kaufman, J., Tosif, S., Fitzpatrick, P., Donath, S., Hopper, S., Bryant, P. and Babl, F., 2016. Quick-Wee: A novel non-invasive urine collection method for infants in the emergency department. Paediatrics & Child Health21(5), p.E95.

Sarah Cave-McMullan

Goldenhar LM, Brady PW, Sutcliffe KM, Muething SE. Huddling for high reliability and situation awareness. BMJ Qual Saf. 2013 Nov 1;22(11):899-906.

Roisin Begley

Hibberd O, Nuttall D, Watson RE, Watkins WJ, Kemp AM, Maguire S. Childhood bruising distribution observed from eight mechanisms of unintentional injury. Archives of disease in childhood. 2017 Dec 1;102(12):1103-9.

Felix Hay

Cronin JJ, McCoy S, Kennedy U, an Fhailí SN, Wakai A, Hayden J, Crispino G, Barrett MJ, Walsh S, O’Sullivan R. A randomized trial of single-dose oral dexamethasone versus multidose prednisolone for acute exacerbations of asthma in children who attend the emergency department. Annals of emergency medicine. 2016 May 1;67(5):593-601.

Rebecca Paxton

Powell CV, Kolamunnage-Dona R, Lowe J, Boland A, Petrou S, Doull I, Hood K, Williamson PR, MAGNETIC study group. MAGNEsium Trial In Children (MAGNETIC): a randomised, placebo-controlled trial and economic evaluation of nebulised magnesium sulphate in acute severe asthma in children. Health Technology Assessment (Winchester, England). 2013 Oct;17(45):v.

Felicity Mitchell

Bradford S, Rickwood D. Young people’s views on electronic mental health assessment: Prefer to type than talk?. Journal of child and family studies. 2015 May 1;24(5):1213-21.

Keir Shiels

Hanahan D, Weinberg RA. The hallmarks of cancer. cell. 2000 Jan 7;100(1):57-70.

©Ian Summers

This talk was recorded live at DFTB19 in London, England. With the theme of  “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal. DFTB20 will be held in Brisbane, Australia.

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Blood products

Cite this article as:
Marc Anders. Blood products, Don't Forget the Bubbles, 2013. Available at:
https://doi.org/10.31440/DFTB.3678

Pump blood

Pump blood is the blood remaining in the bypass circuit on the completion of bypass. It is a mixture of the patient’s own blood, other fluids and any bank blood used to prime the bypass circuit.

Unfiltered pump blood has a low Hct and contains large amounts of heparin and inflammatory cytokines. The use of CUF (continuous ultrafiltration) during bypass or MUF (modified ultrafiltration) after bypass, concentrates the pump blood and removes some heparin and cytokines. If pump blood is used, additional heparin reversal will be needed. It should not be used if there is excessive bleeding or if the Hb is low.

Protamine sulphate is used to reverse the heparin in pump blood. The dose is 1 mg per 25 ml of pump blood. Recheck ACT after 10 ml/kg pump blood. Rapid infusion may cause pulmonary hypertension.


Packed red blood cells (PRBC)

Each unit of pack cells contains ~ 300ml and has an Hct of 0.5-0.7 (Na+ ~20, K+ up to 2 0mmol/l, especially if irradiated)

Warning: Neonates should be transfused with blood which is as fresh as possible, and sufficiently slowly to minimise any adverse effect from hyperkalaemia and citrate toxicity (hypocalcaemia).

Used for treatment of anaemia and the management of active bleeding. Must be compatible with recipients ABO and Rh groups and clinically significant red cell antibodies.

Transfusion of 4 ml/kg increases Hb by approximately 1 g/dl. In rapid transfusion situations alternate red cell units with colloid solutions e.g. FFP.

Store only in a designated blood refrigerator (2 to 6°C). Use within 4 hours of removing from refridgerator and always use a leucocyte filter.

Request irradiated products if suspicion of immunodeficiency (e.gg Di George anomaly) or in any neonate <1 month undergoing cardiac surgery.

Donor blood exposes the patient to risk of infection and transfusion reaction. Pump blood, however is blood to which the patient has already been exposed.


Platelets

Cardiopulmonary bypass frequently leads to both thrombocytopenia (dilutional) and more importantly platelet dysfunction (early onset). Platelet transfusion should be considered for excessive bleeding, irrespective of the absolute platelet count. Transfused platelets have a storage (function) defect lasting 2-4 hrs.

Platelet transfusion should not be used for “routine” volume expansion. Should be ABO compatible to prevent haemolysis caused by donor anti-A and anti-B. Female infants and children (all females <45 years) should receive RhD negative platelets. The dose is 10 ml/kg – repeat platelet count and/or TEG.


Fresh frozen plasma

Plasma separated from one donation of blood. Contains normal levels of stable clotting factors, albumin and immunoglobulin. Factor VIII levels are ~70% normal while plasma proteins (immunoglobulins and clotting factors) are slightly diluted.

It should be ABO compatible to prevent haemolysis by donor anti-A or anti-B.

Should be used for microvascular bleeding following massive transfusion or cardiopulmonary bypass, emergency reversal of warfarin effect (in addition to Vitamin K), bleeding resulting from hepatic failure and proven coagulopathy (factor deficiency or DIC).

Loss of clotting factors may occur as a result of excessive loss of peritoneal, pleural fluid or ascites (via PD catheter). If replaced with NaCl 0.9% alone this may lead to a dilutional coagulopathy.

Dose is 10-20 ml/kg IV. FFP should ideally administered slowly (<40 ml/kg/hr) as rapid administration can result in cardiovascular collapse by several mechanisms including calcium chelation by citrate (check patient iCa if concerned).Infection risk similar to other blood components. Transfusion should not be used for ‘routine’ volume expansion.


Cryoprecipitate

The cold precipitated fraction derived from FFP. Contains factor VIII, fibrinogen, von Willebrand factor and factor XIII.

Should be used for significant fibrinogen deficiency associated with clinical bleeding, DIC, trauma or during invasive procedures. Suitable for haemophilia and von Willebrand disease. Dose is 5 ml/kg IV. One bag is usually 20-30 ml. Infection risk is similar to other blood components.


Human albumin solutions

Albumex 4% Albumex 20%
Protein 40 g/l Protein 200 g/l
Na 140mmol/l Na 48 – 100mmol/l
Volume expansion Hypoproteinaemia
50, 250, 500ml bottle 10, 100ml bottle
5 – 10ml/kg aliquots 5ml/kg aliquots

Albumex 20% is hyperoncotic and in an ideal situation (ie. normal capillary permeability) should expand circulating volume by a factor of 5.


References:

[1] Cochrane Database Syst Rev. 2011 Mar 16;3: Perel et al: Colloids versus crystalloids for fluid resuscitation in critically ill patients

[2] SAFE Study Investigators, Finfer et al: Effect of baseline serum albumin concentration on outcome of resuscitation with albumin or saline in patients in intensive care units: analysis of data from the saline versus albumin fluid evaluation (SAFE) study

[3] Pediatr Crit Care Med. 2007 Sep;8(5):459-64: Jatana et al: Deletion 22q11.2 syndrome–implications for the intensive care physician

[4] Peditar Crit Care Med 2011 Vol.12, No2: Isthaphanous: Red blood cell transfusion in critically ill children: A narrative review


 All Marc’s PICU cardiology FOAM can be found on PICU Doctor and can be downloaded as a handy app for free on iPhone or AndroidA list of contributors can be seen here.

ITP – Idiopathic Thrombocytopenic Purpura

Cite this article as:
Tessa Davis. ITP – Idiopathic Thrombocytopenic Purpura, Don't Forget the Bubbles, 2013. Available at:
https://doi.org/10.31440/DFTB.2865

A 4-year-old girl presents with bruising over her legs, trunk and face.  Mum has noticed them appear over the last week.  She has been completely well with no other symptoms.  There is no history of trauma.  After an anxious 1 hour wait, the bloods are back-Hb 113, WCC 7.3, Plt 8 x 109/L.

 

Bottom Line

  • Uncomplicated idiopathic thrombocytopenic purpura (ITP) is new-onset bruising and bleeding with a platelet count <100 x 109/L in the absence of other symptoms
  • It generally resolves itself in 80% by six months
  • 5% will have a recurrence
  • Only treat if there is active bleeding, not just because of a low platelet count
  • Advise parents to avoid NSAIDS and lookout for signs of bleeding
  • Follow up regularly for the first six weeks or until platelet count stabilises

 

What is it and how did she get it?

Idiopathic thrombocytopenic purpura (ITP) is a reduction in platelet count in the absence of any other cause (<100 × 109/L).  Whilst normal platelets last eight to ten days, in ITP there are autoantibodies that destroy them in the first few hours. It has a peak incidence of two to five years of age (chronic ITP peaks in adolescence).  There is often a recent history (one to six weeks) of a viral illness or immunisation.

What are the commons symptoms and signs?

The most common sign is petechiae (1-5 mm red or purple non-blanching spots) on the skin or mucosa – these indicate capillary haemorrhages.  Some mucocutaneous bleeding is often seen, but it is rare for this to be severe (<5%).

Other symptoms of autoimmune disorders should NOT be present in ITP – e.g. no weight loss, rashes, alopecia, joint swelling. The examination should be normal with no hepatosplenomegaly or lymphadenopathy.

How is it diagnosed?

It is diagnosed by having a low platelet count with a normal haemoglobin (unlike in leukaemia, TTP, HUS and DIC). If there is a history of previous bleeding then consider other diagnoses. Bone marrow aspirate is only recommended if there is persistent bleeding in spite of a platelet count >20 × 109/L.

 

What treatment should we use?

The answer is simple: treat the patient not the platelet count.  Assess if the patient has haematuria, melaena, menorrhagia, epistaxis, mucosal bleeding or tonsillar purpura/petechiae.

Although there is variation between specialists, they will all be more concerned with the signs of wet purpura or haematuria rather than just the petechiae on the skin.

Steroids

Prednisolone 1-2mg/kg OD for at least three weeks then taper

OR

Methylprednisolone 30mg/kg/day for three days, then 20mg/kg /day for four days

 

IVIG (intravenous immunoglobulin)

Consider where there is significant bleeding (0.8-1g/kg) – can rapidly raise the platelet count Effects takes place in one to five days and lasts for two to four weeks

 

Platelets

Only give platelets if there is an intracranial hameorrhage (ICG) or significant bleeding.  Can be effective after IVIG administration and this can prolong platelet survival (otherwise transfused platelets are quickly destroyed)

 

When to admit?

Admit if there is significant bleeding: epistaxis>1 hour; haematemesis; haemoptysis, intracranial haemorrhage, melaena.  Or if there is an unclear diagnosis or problematic social circumstances.

When will it go away?

Most ITP self resolves.  80% will have resolved by six months (with or without treatment).  5% of ITP patients will have a recurrence. Although it seems counterintuitive, the lower the platelet count at the beginning, the better.  Uncomplicated ITP normally has a platelet count of <20 × 109/L. Chronic ITP does not resolve within six months and accounts for 10% of ITP.

Could it be anything else?

Confirmation is based on excluding other differentials such as acute leukaemia, aplastic anaemia, HUS.  A full blood count and film us usually adequate to make the diagnosis.

What do you need to inform the parents to look out for?

While the platelets are low, the patient is at risk of bleeding.  ICH is a serious but rare (1%) side effect.  Parents should watch out for any signs of ICH, urinary bleeding, GI bleeding, excessive mucosal bleeding and menorrhagia (in older patients).

They should avoid NSAIDs while the platelet count is low.

Older children should avoid contact sports.  This is completely impractical for young children so is not helpful advice – will only stress out the parents!

When to follow up?

Patients should be reviewed within two weeks of initial presentation and have a repeat FBC. Aim for weekly GP follow up initially and then PRN until resolution.

Paediatric outpatient review at six weeks three months and six months. Refer to haematology if unclear diagnosis, unresolved after six months or a haematological malignancy is suggested by the blood count.

 

Selected references

Pediatric EM Morsels – Wet purpura and ITP

UMEM Educational Pearls – ITP

Royal Children’s Hospital, Melbourne – Guidelines for ITP

Princess Margaret Hospital for Children – ITP Guideline

BMJ BestPractice – ITP

Grainger JD, Rees, JL, Reeves M, Bolton-Maggs PHB.  Changing trends in the UK management of childhood ITP. Arch. Dis. Child. 2012;97:8-11.[/toggle]