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Competing Interests: Conflicts of Interest: See Disclosures at the end of the article.

Purpose of Review: Tranexamic acid is routinely used as part of the management of traumatic bleeding. The dose recommendation in trauma was extrapolated from other clinical settings and the results of pragmatic randomized trials rather than pharmaco-kinetic and -dynamic evaluations. The review addresses current evidence on dosing of tranexamic acid in traumatized patients with a focus on efficacy, safety and risk-benefit profile., Recent Findings: A majority, but not all, of existing randomized clinical trials reports a reduction in mortality and/or blood loss with tranexamic acid administration. Increasing dose above the general recommendation (1 g bolus + 1 g infusion/8 h intravenously) has not been shown to further increase efficacy and could potentially increase side effects., Summary: The benefit of tranexamic acid as adjuvant therapy in the management of bleeding trauma patients on mortality and transfusion requirements is clear and well documented, being most effective if given early and to patients with clinical signs of hemorrhagic shock. Recent reports suggest that in some patients presenting with a shutdown of their fibrinolytic pathway the administration of tranexamic acid could be associated with an increased risk of thromboembolic events and poor outcomes. A more personalized approach based on bedside assessment of fibrinolytic activation and pharmacokinetic-based dose regimen should be developed moving forward., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Inherited and acquired coagulopathy are frequently associated with major bleeding in severe trauma, cardiac surgery with cardiopulmonary bypass, and postpartum hemorrhage. Perioperative management is multifactorial and includes preoperative optimization and discontinuation of anticoagulants and antiplatelet therapy in elective procedures. Prophylactic or therapeutic use of antifibrinolytic agents is strongly recommended in guidelines and has been shown to reduce bleeding and need for allogeneic blood administration. In the context of bleeding induced by anticoagulants and/or antiplatelet therapy, reversal strategies should be considered when available. Targeted goal-directed therapy using viscoelastic point-of-care monitoring is increasingly used to guide the administration of coagulation factors and allogenic blood products. In addition, damage control surgery, which includes tamponade of large wound areas, leaving surgical fields open, and other temporary maneuvers, should be considered when bleeding is refractory to hemostatic measures., (Copyright © 2023, the American Society of Anesthesiologists. All Rights Reserved.)

Background: Although the rate of pediatric postoperative mortality is low, the development and validation of perioperative risk assessment models have allowed for the stratification of those at highest risk, including the Pediatric Risk Assessment (PRAm) score. The clinical application of such tools requires manual data entry, which may be inaccurate or incomplete, compromise efficiency, and increase physicians' clerical obligations. We aimed to create an electronically derived, automated PRAm score and to evaluate its agreement with the original American College of Surgery National Surgical Quality Improvement Program (ACS NSQIP)-derived and validated score., Methods: We performed a retrospective observational study of children <18 years who underwent noncardiac surgery from 2017 through 2021 at Boston Children's Hospital (BCH). An automated PRAm score was developed via electronic derivation of International Classification of Disease (ICD) -9 and -10 codes. The primary outcome was agreement and correlation among PRAm scores obtained via automation, NSQIP data, and manual physician entry from the same BCH cohort. The secondary outcome was discriminatory ability of the 3 PRAm versions. Fleiss Kappa, Spearman correlation (rho), and intraclass correlation coefficient (ICC) and receiver operating characteristic (ROC) curve analyses with area under the curve (AUC) were applied accordingly., Results: Of the 6014 patients with NSQIP and automated PRAm scores (manual scores: n = 5267), the rate of 30-day mortality was 0.18% (n = 11). Agreement and correlation were greater between the NSQIP and automated scores (rho = 0.78; 95% confidence interval [CI], 0.76-0.79; P <.001; ICC = 0.80; 95% CI, 0.79-0.81; Fleiss kappa = 0.66; 95% CI, 0.65-0.67) versus the NSQIP and manual scores (rho = 0.73; 95% CI, 0.71-0.74; P < .001; ICC = 0.78; 95% CI, 0.77-0.79; Fleiss kappa = 0.56; 95% CI, 0.54-0.57). ROC analysis with AUC showed the manual score to have the greatest discrimination (AUC = 0.976; 95% CI, 0.959,0.993) compared to the NSQIP (AUC = 0.904; 95% CI, 0.792-0.999) and automated (AUC = 0.880; 95% CI, 0.769-0.999) scores., Conclusions: Development of an electronically derived, automated PRAm score that maintains good discrimination for 30-day mortality in neonates, infants, and children after noncardiac surgery is feasible. The automated PRAm score may reduce the preoperative clerical workload and provide an efficient and accurate means by which to risk stratify neonatal and pediatric surgical patients with the goal of improving clinical outcomes and resource utilization., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2020 International Anesthesia Research Society.)

Background: Perioperative anemia has been associated with increased risk of red blood cell transfusion and increased morbidity and mortality after surgery. The optimal approach to the diagnosis and management of perioperative anemia is not fully established., Objective: To develop consensus recommendations for anemia management in surgical patients., Methods: An international expert panel reviewed the current evidence and developed recommendations using modified RAND Delphi methodology., Results: The panel recommends that all patients except those undergoing minor procedures be screened for anemia before surgery. Appropriate therapy for anemia should be guided by an accurate diagnosis of the etiology. The need to proceed with surgery in some patients with anemia is expected to persist. However, early identification and effective treatment of anemia has the potential to reduce the risks associated with surgery and improve clinical outcomes. As with preoperative anemia, postoperative anemia should be treated in the perioperative period., Conclusions: Early identification and effective treatment of anemia has the potential to improve clinical outcomes in surgical patients., Competing Interests: M.A. has received research funding for data management from Covis Pharmaceuticals (formerly AMAG) and has participated in educational, nonpromotional programs for Pfizer and Pharmacosmos. E.B. has received honoraria from Vifor Pharma and Sysmex for giving lectures. H.L.C. has received honoraria from American Regent. J.E. has received payment from Vifor Pharma for giving lectures. S.F. has received honoraria from Ethicon Biosurgery for giving lectures, and funding from National Blood Authority (Australia) for traveling to and attending meetings. S.M.F. has received honoraria from Haemonetics for scientific advisory board participation. D.G. has received honoraria from Vifor Pharma, for advisory board participation. A.H. received fees, honoraria, or travel costs for consultancy or lecturing from Celgene, G1 Therapeutics, International Foundation for Patient Blood Management, PBMe Solutions, South African National Blood Service, Takeda, TEM and Vifor. J.F.H. has received honoraria from Pharmacosmos for consultancy and scientific presentations, and from Nordic Pharma for consultancy. J.M. received a project-linked scientific grant from Vifor Pharma. M.M. has received honoraria for lectures and/or consultancy from Pharmacosmos, Vifor Pharma, and PharmaNutra. S.O. has received honoraria from Baxter Healthcare for consultancy. A.S. has received honoraria for consultancy and/or serving as a speaker for Merck, AMAG, Masimo Corp, CSL Behring, Vifor Pharma, Pharmacosmos, Pharmaniaga, Accumen and I-SEP, and has received research grants from Masimo Corp, CSL Behring, HbO2 Therapeutics and Werfen. D.R.S. has received honoraria/travel support for consulting or lecturing from Danube University of Krems (Austria), US Department of Defense, European Society of Anaesthesiology, Korean Society for Patient Blood Management, Korean Society of Anesthesiologists, Network for the Advancement of Patient Blood Management, Alexion Pharmaceuticals, Baxalta Switzerland, Bayer, B. Braun Melsungen, Boehringer Ingelheim, Bristol-Myers-Squibb, CSL Behring, Celgene International, Daiichi Sankyo, Haemonetics, Instrumentation Laboratory (Werfen), LFB Biomédicaments, Merck Sharp & Dohme, Novo Nordisk Health Care, PAION Deutschland, Pharmacosmos, Pfizer, Pierre Fabre Pharma, Portola Schweiz, Roche Diagnostics International, Sarstedt, Shire, Tem International, Vifor Pharma, Vifor International and Zuellig Pharma. R.T. has received honoraria from Zuellig Pharma for giving lectures. M.A.W. receives research support through the National Heart, Lung, and Blood Institute of the National Institutes of Health (K23HL153310). The remaining authors report no conflicts of interest., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.)

Competing Interests: Conflicts of Interest: See Disclosures at the end of the article.

Continuous advances in pediatric cardiology, surgery, and critical care have significantly improved survival rates for children and adults with congenital heart disease. Paradoxically, the resulting increase in longevity has expanded the prevalence of both repaired and unrepaired congenital heart disease and has escalated the need for diagnostic and interventional procedures. Because of this expansion in prevalence, anesthesiologists, pediatricians, and other health care professionals increasingly encounter patients with congenital heart disease or other pediatric cardiac diseases who are presenting for surgical treatment of unrelated, noncardiac disease. Patients with congenital heart disease are at high risk for mortality, complications, and reoperation after noncardiac procedures. Rigorous study of risk factors and outcomes has identified subsets of patients with minor, major, and severe congenital heart disease who may have higher-than-baseline risk when undergoing noncardiac procedures, and this has led to the development of risk prediction scores specific to this population. This scientific statement reviews contemporary data on risk from noncardiac procedures, focusing on pediatric patients with congenital heart disease and describing current knowledge on the subject. This scientific statement also addresses preoperative evaluation and testing, perioperative considerations, and postoperative care in this unique patient population and highlights relevant aspects of the pathophysiology of selected conditions that can influence perioperative care and patient management.

Objectives: To determine the effect of intraoperative antifibrinolytics, including tranexamic acid (TXA), aminocaproic acid (EACA), or aprotinin, on bleeding in children undergoing cardiac surgery with cardiopulmonary bypass (CPB)., Data Sources: Relevant articles were systematically searched from Ovid MEDLINE, Ovid EMBASE, CINAHL, Cochrane Library, and Web of Science to November 15, 2021., Study Selection: Abstracts were screened, and full texts were reviewed using predetermined inclusion and exclusion criteria using the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline., Data Extraction: A standardized data extraction tool was used., Data Synthesis: Sixty-eight studies including 28,735 patients were analyzed. TXA compared with placebo resulted in a mean decrease in chest tube output of 9.1 mL/kg (95% CI, 6.0-12.3 mL/kg), I2 equals to 65.2%, p value of less than 0.001, platelet requirement of 2.9 mL/kg (95% CI, 0.1-5.8 mL/kg), I2 =72.5%, p value less than 0.001 and plasma requirement of 4.0 mL/kg (95% CI, 0.6-7.2 mL/kg), I2 equals to 94.5%, p value less than0.001. Aprotinin compared with placebo resulted in a mean decrease in chest tube output of 4.3 mL/kg (2.4-6.2 mL/kg), I2 equals to 66.3%, p value of less than 0.001, platelet transfusion of 4.6 mL/kg (95% CI, 0.6-8.6 mL/kg), I2 equals to 93.6%, p value of less than 0.001, and plasma transfusion of 7.7 mL/kg (95% CI, 2.1-13.2 mL/kg), I2 equals to 95.3%, p value of less than 0.001. EACA compared with placebo resulted in a mean decrease in chest tube output of 9.2 mL/kg (2.3-21.0 mL/kg), I2 equals to 96.4%, p value of less than 0.001, RBC transfusion of 7.2 mL/kg (95% CI, 2.4-12.1 mL/kg), I2 equals to 94.5%, p value equals to 0.002, and platelet transfusion of 10.7 mL/kg (95% CI, 2.9-18.5 mL/kg), I2 equals to 0%, p value of less than 0.001. No statistical difference was observed in chest tube output when TXA was compared with aprotinin. Subgroup analysis of cyanotic patients showed a significant decrease in chest tube output, platelet requirement, and plasma requirement for patients receiving aprotinin. Overall, the quality of evidence was moderate., Conclusions: Antifibrinolytics are effective at decreasing blood loss and blood product requirement in children undergoing cardiac surgery with CPB although the quality of evidence is only moderate., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2022 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

While patient blood management (PBM) initiatives are increasingly adopted across the globe as part of standard of care, there is need for a clear and widely accepted definition of PBM. To address this, an expert group representing PBM organizations from the International Foundation for Patient Blood Management (IFPBM), the Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis (NATA), the Society for the Advancement of Patient Blood Management (SABM), the Western Australia Patient Blood Management (WAPBM) Group, and OnTrac (Ontario Nurse Transfusion Coordinators) convened and developed this definition: "Patient blood management is a patient-centered, systematic, evidence-based approach to improve patient outcomes by managing and preserving a patient's own blood, while promoting patient safety and empowerment." The definition emphasizes the critical role of informed choice. PBM involves the timely, multidisciplinary application of evidence-based medical and surgical concepts aimed at (1) screening for, diagnosing, and appropriately treating anemia; (2) minimizing surgical, procedural, and iatrogenic blood losses and managing coagulopathic bleeding throughout the care; and (3) supporting the patient while appropriate treatment is initiated. We believe that having a common definition for PBM will assist all those involved including PBM organizations, hospital administrators, individual clinicians, and policy makers to focus on the appropriate issues when discussing and implementing PBM. The proposed definition is expected to continue to evolve, making this endeavor a work in progress., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2022 International Anesthesia Research Society.)

Disclaimer: These guidelines for adult and pediatric anticoagulation for extracorporeal membrane oxygenation are intended for educational use to build the knowledge of physicians and other health professionals in assessing the conditions and managing the treatment of patients undergoing ECLS / ECMO and describe what are believed to be useful and safe practice for extracorporeal life support (ECLS, ECMO) but these are not necessarily consensus recommendations. The aim of clinical guidelines are to help clinicians to make informed decisions about their patients. However, adherence to a guideline does not guarantee a successful outcome. Ultimately, healthcare professionals must make their own treatment decisions about care on a case-by-case basis, after consultation with their patients, using their clinical judgment, knowledge and expertise. These guidelines do not take the place of physicians' and other health professionals' judgment in diagnosing and treatment of particular patients. These guidelines are not intended to and should not be interpreted as setting a standard of care or be deemed inclusive of all proper methods of care nor exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgment must be made by the physician and other health professionals and the patient in light of all the circumstances presented by the individual patient, and the known variability and biological behavior of the clinical condition. These guidelines reflect the data at the time the guidelines were prepared; the results of subsequent studies or other information may cause revisions to the recommendations in these guidelines to be prudent to reflect new data, but ELSO is under no obligation to provide updates. In no event will ELSO be liable for any decision made or action taken in reliance upon the information provided through these guidelines., Competing Interests: Disclosure: The authors have no conflicts of interest to report., (Copyright © ELSO 2022.)

Background: The association between race and perioperative outcomes has been evaluated in adult cardiac surgical and in healthy pediatric patients but has not been evaluated in children with congenital heart disease (CHD) presenting for noncardiac procedures. This study compares the incidence of the primary outcome of 30-day mortality and adverse postoperative outcomes following noncardiac surgery between Black and White children with CHD, stratified by severity., Methods: This is a retrospective study. Comparison of outcomes between Black and White children was performed using the 2012-2018 American College of Surgeons National Surgical Quality Improvement Program Pediatric database and after stratification for severity of CHD and propensity score matching., Results: A total of 55,859 patients were included, and divided into 28,601 minor, 23,839 major, and 3419 severe CHD. Black and White children in each category were matched and compared. Following matching in the overall CHD cohort, there were significantly higher rates of the following adverse postoperative outcomes among Black patients as compared to White patients: 30-day mortality (1.84% vs 1.49%; odds ratio [OR], 1.25; 95% confidence interval [CI], 1.05-1.48; P = .014), composite secondary outcomes (19.90% vs 17.88%; OR, 1.14; 95% CI, 1.08-1.21; P < .001), cardiac arrest (1.42% vs 0.98%; OR, 1.46; 95% CI, 1.19-1.79; P < .001), 30-day reoperation (7.59% vs 6.67%; OR, 1.15; 95% CI, 1.05-1.25; P = .002), and reintubation (3.9% vs 2.95%; OR, 1.34; 95% CI, 1.19-1.52; P < .001). No significant statistical interaction between race and CHD severity was found. Following matching and within the minor CHD cohort, Black children had significantly higher rates of composite secondary outcome (17.44% vs 15.60%; OR, 1.15; 95% CI, 1.05-1.25; P = .002), cardiac arrest (1.02% vs 0.53%; OR, 1.94; 95% CI, 1.37-2.76; P < .001), 30-day reoperation (7.19% vs 5.77%; OR, 1.26; 95% CI, 1.11-1.43; P < .001), and thromboembolic complications (0.49% vs 0.23%; OR, 2.17; 95% CI, 1.29-3.63; P = .003) compared to White children. In the major CHD cohort, Black children had significantly higher rates of 30-day mortality (2.75% vs 2.05%; OR, 1.35; 95% CI, 1.08-1.69; P = .008) and reintubation (4.82% vs 3.72%; OR, 1.32; 95% CI, 1.11-1.56; P = .002). There were no statistically significant differences in outcomes in the severe CHD category for 30-day mortality (3.36% vs 3.3%; OR, 1.02; 95% CI, 0.60-1.73; P = .946), composite secondary outcome (22.65% vs 21.36%; OR, 1.08; 95% CI, 0.86-1.36; P = .517) nor the components of the composite secondary outcomes., Conclusions: Race is associated with postoperative mortality and complications in children with minor and major CHD undergoing noncardiac surgery. No significant association was observed between race and postoperative outcomes in patients with severe CHD. This is consistent with previous findings wherein in patients with severe CHD, residual lesion burden and functional status is the leading predictor of outcomes following noncardiac surgery. Nevertheless, there is no evidence that the relationship between race and outcomes differs across the CHD severity categories. Future studies to understand the mechanisms leading to the racial difference, including institutional, clinical, and individual factors are needed., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 International Anesthesia Research Society.)

Background: Adolescent idiopathic scoliosis (AIS) surgery is associated with significant postoperative pain. Remifentanil is a short-acting opioid that is often used as a component of total intravenous anesthesia. Remifentanil has been implicated in acute opioid tolerance and opioid-induced hyperalgesia, resulting in increased postoperative pain and opioid consumption. This retrospective study sought to investigate the relationship between the dose of intraoperative remifentanil and cumulative postoperative opioid consumption through 72 hours following surgery for pediatric AIS patients., Methods: We performed a retrospective chart review of adolescent patients undergoing posterior spine instrumentation under total intravenous general anesthesia at a single major pediatric center between January 2015 and October 2017. The relationship between intraoperative cumulative weight-adjusted remifentanil dose and logarithmic transformation of cumulative weight-adjusted opioid consumption through 72 hours following surgery was examined by regression analysis. A priori determined potential confounding variables were collected, including demographic data, perioperative analgesic agents (ie, ketamine, dexmedetomidine, and acetaminophen), surgical duration, vertebrae instrumented, and blood transfusion. Multivariable linear regression analysis was used to adjust for these possible confounding variables., Results: Eighty-nine patients met inclusion criteria, of which 78 had complete data for analysis. Univariable linear regression analysis revealed no association between remifentanil dose and opioid consumption through 72 hours following surgery (slope = 0.79 [95% confidence interval [CI], 0.61-0.98; R2 = 0.0039; P = .588]). After adjustment for possible confounding factors, no relationship between remifentanil dose (regression coefficient (coeff.) -0.08; 95% CI, -1.59 to 1.43; P = .912) and opioid consumption through 72 hours was found (slope =0.90 [95% CI, -0.65 to 2.46]; R2 = 0.1634). Similar results were obtained when the model was repeated for opioid consumption in postanesthesia care unit (PACU)., Conclusions: In this study examining adolescent patients undergoing surgery for idiopathic scoliosis, no association was found between the dose of intraoperative remifentanil and postoperative opioid consumption in the context of a propofol-based total intravenous anesthetic and multimodal analgesia. These results provide direction for future prospective controlled studies to further evaluate this relationship., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 International Anesthesia Research Society.)

Background: No evidence currently exists to quantify the risk and incidence of perioperative respiratory adverse events (PRAEs) in children with sleep-disordered breathing (SDB) undergoing all procedures requiring general anesthesia. Our objective was to determine the incidence of PRAEs and the risk factors in children with polysomnography-confirmed SDB undergoing procedures requiring general anesthesia., Methods: Retrospective review of all patients with polysomnography-confirmed SDB undergoing general anesthesia from January 2009 to December 2013. Demographic and perioperative outcome variables were compared between children who experienced PRAEs and those who did not. Generalized estimating equations were used to build a predictive model of PRAEs., Results: In a cohort of 393 patients, 51 PRAEs occurred during 43 (5.6%) of 771 anesthesia encounters. Using generalized estimating equations, treatment with continuous positive airway pressure or bilevel positive airway pressure (odds ratio, 1.63; 95% confidence interval [CI], 1.05-2.54; P = .031), outpatient (odds ratio, 1.37; 95% CI, 1.03-1.91; P = .047), presence of severe obstructive sleep apnea (odds ratio, 1.63; 95% CI, 1.09-2.42; P = .016), use of preoperative oxygen (odds ratio 1.82; 95% CI, 1.11-2.97; P = .017), history of prematurity (odds ratio, 2.31; 95% CI, 1.33-4.01; P = .003), and intraoperative airway management with endotracheal intubation (odds ratio, 3.03; 95% CI, 1.79-5.14; P < .001) were associated with PRAEs., Conclusions: We propose the risk factors identified within this cohort of SDB patients could be incorporated into a preoperative risk assessment tool that might better to identify the risk of PRAE during general anesthesia. Further investigation and validation of this model could contribute to improved preoperative risk stratification, decision-making (postoperative admission and level of monitoring), and health care resource allocation., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2020 International Anesthesia Research Society.)

Background: Utilizing the intrinsic surgical risk (ISR) and the patient's chronic and acute conditions, this study aims to develop and validate a comprehensive predictive model of perioperative morbidity in children undergoing noncardiac surgery., Methods: Following institutional review board (IRB) approval at a tertiary care children's hospital, data for all noncardiac surgical encounters for a derivation dataset from July 2017 to December 2018 including 16,724 cases and for a validation dataset from January 2019 to December 2019 including 9043 cases were collected retrospectively. The primary outcome was a composite morbidity score defined by unplanned transfer to an intensive care unit (ICU), acute respiratory failure requiring intubation, postoperative need for noninvasive or invasive positive pressure ventilation, or cardiac arrest. Internal model validation was performed using 1000 bootstrap resamples, and external validation was performed using the 2019 validation cohort., Results: A total of 1519 surgical cases (9.1%) experienced the defined composite morbidity. Using multivariable logistic regression, the Risk Assessment of Morbidity in Pediatric Surgery (RAMPS) score was developed with very good predictive ability in the derivation cohort (area under the curve [AUC] = 0.805; 95% confidence interval [CI], 0.795-0.816), very good internal validity using 1000 bootstrap resamples (bias-corrected Nagelkerke R = 0.21 and Brier score = 0.07), and good external validity (AUC = 0.783; 95% CI, 0.770-0.797). The included variables are age <5 years, critically ill, chronic condition indicator (CCI) ≥3, significant CCI ≥2, and ISR quartile ≥3. The RAMPS score ranges from 0 to 10, with the risk of composite morbidity ranging from 1.8% to 42.7%., Conclusions: The RAMPS score provides the ability to identify a high-risk cohort of pediatric patients using a 5-component tool, and it demonstrated good internal and external validity and generalizability. It also provides an opportunity to improve perioperative planning with the intent of improving both individual-patient outcomes and the appropriate allocation of health care resources.

Background: The objective of this study is to estimate the surgical risk of noncardiac procedures on the incidence of 30-day mortality in children with congenital heart disease., Methods: Children with congenital heart disease undergoing noncardiac surgery from 2012 to 2016 and included in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Pediatric database were included in the derivation cohort, while the 2017 database was used as a validation cohort. Intrinsic surgical risk quartiles were built utilizing 30-day mortality rates for each Current Procedural Terminology code and relative value units to create 2 groups defined as low surgical risk (quartiles 1-3) and high surgical risk procedures (quartile 4). We used multivariable logistic regression to determine the predictors for 30-day mortality including patient comorbidities and intrinsic surgical risk. A partially external validation of the model was performed using the 2017 version of the database., Results: We included 37,658 children with congenital heart disease undergoing noncardiac surgery with an incidence of overall 30-day mortality of 1.7% in the derivation cohort and 1.5% in the validation cohort (n = 13,129). Intrinsic surgical risk of procedures represented by Current Procedural Terminology procedural codes and relative value units risk quartiles was significantly associated with 30-day mortality (unadjusted P < .001). Predicted probability of 30-day mortality ranges from 0.2% (95% confidence interval [CI], 0.2-0.2) with no comorbidities to 39.6% (95% CI, 23.2-56.0) when all comorbidities were present among high surgical risk procedures and from 0.3% (95% CI, 0.3-0.3) to 54.8% (95% CI, 39.4-70.1) among low surgical risk procedures. An excellent discrimination was reported for the multivariable model with area under the curve (AUC) of 0.86 (95% CI, 0.85-0.88). High surgical risk was not associated with increased odds of 30-day mortality after adjustment for all other predictors (adjusted odds ratio [OR]: 0.75, 95% CI, 0.62-0.91). We also estimated the discriminative ability of a model that does not include the surgical risk (0.86 [95% CI, 0.84-0.88], with P value for the direct comparison of the AUC of the 2 models = 0.831). The multivariable model obtained from an external validation cohort reported an optimism corrected AUC of 0.88 (95% CI, 0.85-0.91)., Conclusions: Our study demonstrates that integration of intrinsic surgical risk to comorbidities and severity of cardiac disease does not improve prediction of 30-day mortality in children undergoing noncardiac surgery. In children with congenital heart disease, patient comorbidities, and severity of the cardiac lesion are the predominant predictors of 30-day mortality.

The World Health Organization (WHO) has declared coronavirus disease 2019 (COVID-19), the disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a pandemic. Global health care now faces unprecedented challenges with widespread and rapid human-to-human transmission of SARS-CoV-2 and high morbidity and mortality with COVID-19 worldwide. Across the world, medical care is hampered by a critical shortage of not only hand sanitizers, personal protective equipment, ventilators, and hospital beds, but also impediments to the blood supply. Blood donation centers in many areas around the globe have mostly closed. Donors, practicing social distancing, some either with illness or undergoing self-quarantine, are quickly diminishing. Drastic public health initiatives have focused on containment and "flattening the curve" while invaluable resources are being depleted. In some countries, the point has been reached at which the demand for such resources, including donor blood, outstrips the supply. Questions as to the safety of blood persist. Although it does not appear very likely that the virus can be transmitted through allogeneic blood transfusion, this still remains to be fully determined. As options dwindle, we must enact regional and national shortage plans worldwide and more vitally disseminate the knowledge of and immediately implement patient blood management (PBM). PBM is an evidence-based bundle of care to optimize medical and surgical patient outcomes by clinically managing and preserving a patient's own blood. This multinational and diverse group of authors issue this "Call to Action" underscoring "The Essential Role of Patient Blood Management in the Management of Pandemics" and urging all stakeholders and providers to implement the practical and commonsense principles of PBM and its multiprofessional and multimodality approaches.

Background: Early identification of children at high risk for perioperative mortality could lead to improved outcomes; however, there is a lack of well-validated risk prediction tools. The Pediatric Risk Assessment (PRAm) score is a new model to prognosticate perioperative risk of mortality in pediatric patients undergoing noncardiac surgery. It was derived from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) Pediatric database. In this study, we aimed to externally validate the PRAm score at 1 large institution., Methods: A PRAm score was prospectively assigned by the primary anesthesia team to children ≤18 years of age undergoing noncardiac surgery between July 2017 and July 2018 at a tertiary care pediatric hospital. The primary outcome was the PRAm score's ability to predict 30-day mortality. The area under the receiver operating characteristic (ROC) curve was utilized to determine discriminative ability. Sensitivity and specificity at varying cutoffs were considered. Youden J index and the gray zone approach were applied to determine the optimal PRAm cutoff for predicting 30-day mortality., Results: Among the 13,530 cases included in the external validation cohort, the incidence of 30-day mortality was 0.21% (29/13,530). The PRAm score was found to predict 30-day mortality with an area under the curve (AUC) of 0.956 (95% confidence interval [CI], 0.938-0.974; P < .001). Youden J index determined the optimal PRAm score threshold to be ≥5 with a sensitivity of 86% and a specificity of 91%. The gray zone identified an inconclusive risk of mortality in 6.93% (938/13,530) of patients who had PRAm scores of 4 or 5 (sensitivity or specificity <90%, respectively), therefore refining the optimal cutoff point to be a PRAm score of ≥6. The incidence of mortality for patients with an American Society of Anesthesiologists Physical Status (ASA PS) ≤3 (0.06%, 8/13,530) increased 8-fold for those with an ASA PS of ≤3 and a PRAm score of ≥6., Conclusions: The PRAm score is a simple and objective tool that has excellent ability to predict perioperative risk of mortality in pediatric patients undergoing noncardiac surgery and can be easily used by clinicians. The application of the PRAm score could have important implications on the safety and quality of care delivered to infants and children and on the resource utilization in the pediatric health care system.

Purpose of Review: Perioperative bleeding and blood product transfusion are associated with significant morbidity and mortality. Prevention and optimal management of bleeding decreases risk and lowers costs. Tranexamic acid (TXA) is an antifibrinolytic agent that reduces bleeding and transfusion in a broad number of adult and pediatric surgeries, as well as in trauma and obstetrics. This review highlights the current pediatric indications and contraindications of TXA. The efficacy and safety profile, given current and evolving research, will be covered., Recent Findings: Based on the published evidence, prophylactic or therapeutic TXA administration is a well-tolerated and effective strategy to reduce bleeding, decrease allogeneic blood product transfusion, and improve pediatric patients' outcomes. TXA is now recommended in recent guidelines as an important part of pediatric blood management protocols., Summary: Based on TXA pharmacokinetics, the authors recommend a dosing regimen of between 10 to 30 mg/kg loading dose followed by 5 to 10 mg/kg/h maintenance infusion rate for pediatric trauma and surgery. Maximal efficacy and minimal side-effects with this dosage regime will have to be determined in larger prospective trials including high-risk groups. Furthermore, future research should focus on determining the ideal TXA plasma therapeutic concentration for maximum efficacy and minimal side-effects.

What We Already Know About This Topic: Risk stratification models to predict perioperative mortality in pediatric surgical populations are based on patient comorbidities, but do not take into consideration the intrinsic risk of the surgical procedures., What This Article Tells Us That Is New: Surgical procedures identified by specialty are not independent risk factors for perioperative mortality in pediatric patients. However, in multivariable predictive algorithms, the interaction of patient comorbidities with the intrinsic risk of the surgical procedure strongly predicts 30-day mortality., Background: Recently developed risk stratification models for perioperative mortality incorporate patient comorbidities as predictors but fail to consider the intrinsic risk of surgical procedures. In this study, the authors used the American College of Surgeons National Surgical Quality Improvement Program Pediatric database to demonstrate the relationship between the intrinsic surgical risk and 30-day mortality and develop and validate an accessible risk stratification model that includes the surgical procedures in addition to the patient comorbidities and physical status., Methods: A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program Pediatric database was performed. The incidence of 30-day mortality was the primary outcome. Surgical Current Procedural Terminology codes with at least 25 occurrences were included. Multivariable logistic regression model was used to determine the predictors for mortality including patient comorbidities and intrinsic surgical risk. An internal validation using bootstrap resampling, and an external validation of the model were performed., Results: The authors analyzed 367,065 surgical cases encompassing 659 unique Current Procedural Terminology codes with an incidence of overall 30-day mortality of 0.34%. Intrinsic risk of surgical procedures represented by Current Procedural Terminology risk quartiles instead of broad categorization was significantly associated with 30-day mortality (P < 0.001). Predicted risk of 30-day mortality ranges from 0% with no comorbidities to 4.7% when all comorbidities are present among low-risk surgical procedures and from 0.07 to 46.7% among high-risk surgical procedures. Using an external validation cohort of 110,474 observations, the multivariable predictive risk model displayed good calibration and excellent discrimination with area under curve (c-index) equals 0.95 (95% CI, 0.94 to 0.96; P < 0.001)., Conclusions: Understanding and accurately estimating perioperative risk by accounting for the intrinsic risk of surgical procedures and patient comorbidities will lead to a more comprehensive discussion between patients, families, and providers and could potentially be used to conduct cost analysis and allocate resources.

Patient sedation and analgesia on extracorporeal membrane oxygenation (ECMO) is vital for safety and comfort. However, adsorption to the circuit may alter drug pharmacokinetics and remains poorly characterized. This study characterizes drug adsorption of morphine, fentanyl, midazolam, and dexmedetomidine in an ex vivo infant ECMO circuit utilizing polymethylpentene (PMP) membrane oxygenator (MO) with protein-bounded polyvinylchloride (PVC) tubing. Twelve closed-loop ex vivo ECMO circuits were prepared using P.h.i.s.i.o (phosphorylcholine)-coated PVC tubing (Sorin Group USA, Inc.) and a Quadrox-iD pediatric polymethylpentene MO (Maquet Cardiopulmonary AG). Once the circuits were primed and running, a single medication was injected as a bolus into the circuit with three circuits per drug. Drug samples were drawn following injection, at 2, 5, 15, 30, 60, 120 minutes and at 4, 12, 24, 36, and 48 hours and analyzed using ultra high-performance liquid chromatography with mass spectrometry. Compared with morphine, the other drugs are highly sequestered with fentanyl 68.5%, dexmedetomidine 50.8%, and midazolam 26.2% affecting the availability of free drug in the circuit. Sequestration of fentanyl, midazolam, and dexmedetomidine in an ECMO circuit with P.h.i.s.i.o-coated PVC tubing and PMP MO may limit drug delivery to infants. Future in vivo studies are needed to determine the clinical impact of sequestration.

Efforts to reduce blood product transfusions and adopt blood conservation strategies for infants and children undergoing cardiac surgical procedures are ongoing. Children typically receive red blood cell and coagulant blood products perioperatively for many reasons, including developmental alterations of their hemostatic system, and hemodilution and hypothermia with cardiopulmonary bypass that incites inflammation and coagulopathy and requires systemic anticoagulation. The complexity of their surgical procedures, complex cardiopulmonary interactions, and risk for inadequate oxygen delivery and postoperative bleeding further contribute to blood product utilization in this vulnerable population. Despite these challenges, safe conservative blood management practices spanning the pre-, intra-, and postoperative periods are being developed and are associated with reduced blood product transfusions. This review summarizes the available evidence regarding anemia management and blood transfusion practices in the perioperative care of these critically ill children. The evidence suggests that adoption of a comprehensive blood management approach decreases blood transfusions, but the impact on clinical outcomes is less well studied and represents an area that deserves further investigation.

Background: Recombinant factor VIIa (rFVIIa) is routinely used as an off-label hemostatic agent in children undergoing cardiac surgery. Despite evidence that rFVIIa use is associated with an increased incidence of thrombotic complications in adult cardiac surgery, the safety of rFVIIa as a rescue hemostatic agent in the pediatric cardiac surgical population is less definitively delineated. In this retrospective study, we used propensity score matching to compare the incidence of thrombotic complications between children treated with rFVIIa and their matched controls., Methods: We retrospectively reviewed medical records and pharmacy data from all neonates and children who underwent congenital cardiac surgery between May 1, 2011, and October 31, 2013, at Boston Children's Hospital, and identified those who received rFVIIa during the perioperative period. Using existing knowledge, we chose 10 factors associated with bleeding after cardiac surgery to be used in our propensity score: age, sex, body weight, neonates, prematurity, previous sternotomy, cardiopulmonary bypass time, deep hypothermic circulatory arrest time, aortic cross-clamp time, and the operative surgeon. We then used propensity-matched analysis to match children treated with rFVIIa with 2 controls. The primary outcome was thrombotic complications. Secondary outcomes included reexploration for bleeding, length of cardiac intensive care unit stay, length of hospital stay, and 30-day mortality., Results: One hundred forty-nine patients received perioperative rFVIIa during the study period. Propensity matching yielded 143 rFVIIa patients matched to 2 control patients each (n = 286). Three control patients were found to have received rFVIIa during the perioperative course and were removed from the analysis, for a total of 283 control patients. The administration of rFVIIa was associated with an increased incidence of thrombotic complications (20% vs 8%; odds ratio [OR]: 3.9 [95% confidence interval {CI}: 2.6-5.9], P < .001). Administration of rFVIIa was associated with a prolonged median length of cardiac intensive care unit stay (8 days [interquartile range {IQR}: 4-24] vs 5 days [IQR: 2-10], P < .001) and prolonged length of hospital stay (20 [IQR: 9-44] vs 11 days [IQR: 7-23], P < .001). No difference in reexploration for bleeding (rFVII = 14% vs controls = 9%; OR: 1.7 [95% CI, 0.92-3.1], P = .12) or 30-day mortality was observed (8% vs 6%; OR 1.3 [95% CI, 0.60-2.89], P = .51)., Conclusions: This retrospective analysis confirmed that perioperative administration of rFVIIa is associated with an increased incidence of postoperative thrombotic complications in neonates and children undergoing cardiac surgery, without increase in 30-day mortality. In conclusion, rFVIIa should be used with extreme caution in pediatric patients undergoing cardiac surgery.

Background: Although there have been numerous attempts to predict perioperative mortality in adults, an objective model to predict mortality in children has not been developed. In this study, we aimed to develop a Pediatric Risk Assessment (PRAm) score to predict perioperative mortality in children undergoing noncardiac surgery., Methods: We included all children recorded in the 2012 and 2013 American College of Surgeons National Surgical Quality Improvement Program Pediatric databases in a derivation cohort and those from the 2014 database in a validation cohort. The primary outcome was the incidence of in-hospital mortality. A total of 115,229 (63%) were included in the derivation cohort and 68,194 (37%) in the validation cohort. We used multivariable logistic regression to determine the predictors for mortality and designed the PRAm score., Results: On the basis of the multivariable regression model, we created a simplified risk assessment tool (PRAm score) ranging from 0 to ≥9, including the presence of any comorbidities, factors of critical illness, age <12 months, the requirement for an urgent procedure, and the diagnosis of a neoplasm. The PRAm score showed an excellent discriminative ability with an apparent "optimistic" area under the receiver operating characteristic curve (AUC) of 0.950 (95% confidence interval [CI], 0.942-0.957) in the derivation cohort. In the validation cohort, we observed similar performances with an area under the "naive" receiver operating characteristic curve of 0.950 (95% CI, 0.938-0.961). The AUC was also calculated from a bootstrap procedure and then applied to the original derivation sample to estimate "optimism" for each bootstrap sample with an AUC of 0.943 (95% CI, 0.929-0.9956). The optimism in apparent performance was 0.007, corresponding to an optimism-corrected area of 0.943. Calibration was assessed graphically by plotting the observed outcome against the predicted mortality (Pearson correlation coefficient = 0.995, calibration in the large = 0.001 [P = .974], calibration slope = 0.927)., Conclusions: In this study, we developed a simplified PRAm tool (PRAm score) as a predictor of perioperative mortality in children undergoing noncardiac surgery. The PRAm score has excellent accuracy. In patients assigned American Society of Anesthesiologists physical status classification ≥4, there is wide variability in objectively obtained PRAm scores.

Background: The relationship between preoperative anemia and in-hospital mortality has not been investigated in the pediatric surgical population. We hypothesized that children with preoperative anemia undergoing noncardiac surgery may have an increased risk of in-hospital mortality., Methods: We identified all children between 1 and 18 years of age with a recorded preoperative hematocrit (HCT) in the 2012, 2013, and 2014 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) pediatric databases. The endpoint was defined as the incidence of in-hospital mortality. Children with preoperative anemia were identified based on their preoperative HCT. Demographic and surgical characteristics, as well as comorbidities, were considered potential confounding variables in a multivariable logistic regression analysis. A sensitivity analysis was performed using propensity-matched analysis., Results: Among the 183,833 children included in the 2012, 2013, and 2014 ACS NSQIP database, 74,508 had a preoperative HCT recorded (41%). After exclusion of all children <1 year of age (n = 12,063), those with congenital heart disease (n = 8943), and those who received a preoperative red blood cell (RBC) transfusion (n = 1880), 12,551 (24%) children were anemic, and 39,071 (76%) were nonanemic. The median preoperative HCT was 33% (interquartile range, 31-35) in anemic children, and 39% (interquartile range, 37-42) in nonanemic children (P < .001). Using multivariable logistic regression analysis, and after adjustment for RBC transfusion (OR, 2.13; 95% CI, 1.39-3.26; P < .001), we observed that preoperative anemia was associated with higher odds for in-hospital mortality (OR, 2.17; 95% CI, 1.48-3.19; P < .001). After propensity matching, the presence of anemia was also associated with higher odds of in-hospital mortality (OR, 1.75; 95% CI, 1.15-2.65; P = .004)., Conclusions: Our study demonstrates that children with preoperative anemia are at increased risk for in-hospital mortality. Further studies are needed to assess whether the correction of preoperative HCT, through the development of a patient blood management program, improves patient outcomes or simply reduces the need for transfusions.

Extracorporeal membrane oxygenation (ECMO) has been increasingly used to rescue neonates and children with cardiac or respiratory failure, and critical illnesses including pulmonary artery hypertension (PAH) unresponsive to conventional therapies. This study assesses mortality and outcomes in neonates and children with PAH supported with ECMO. Neonates and children from the 2012 Health Care Cost and Use Project Kids' Database were identified using ICD-9 codes. Children with congenital heart disease were excluded. Univariate logistic regression was applied to assess the relationship between ECMO and outcomes using matched cohorts for age, elective admission, and Elixhauser comorbidity score. We identified 9,355 neonates and children with PAH (0.15%). The incidence of ECMO was 1.4% (132/9,355). After propensity-matched analysis, 130 neonates and children were included in each group. The incidence of mortality was 39% in the group supported with ECMO and 8% in the control group (odds ratio [OR]: 6.98, 95% confidence interval [CI]: 3.43-14.21, p < 0.001). Neonates and children on ECMO had higher odds for acute kidney injury (OR: 2.41, 95% CI: 1.30-4.47, p = 0.005), neurologic complications (OR: 7.11, 95% CI: 1.57-32.18, p = 0.011), sepsis (OR: 2.69, 95% CI: 1.46-4.96, p = 0.002), and thrombotic complications (OR: 2.90, 95% CI: 1.10-7.67, p = 0.032). Neonates and children with PAH supported with ECMO have higher mortality rate and complications compared with matched controls with PAH.

Background: Children with major and severe congenital heart disease (CHD) undergoing noncardiac surgery are at increased risk of mortality. The objective of this study was to identify the predictors for in-hospital mortality, and to develop a risk stratification score that could be used to help decision making and the development of perioperative management guidelines., Methods: We included all children with major (eg, tetralogy of Fallot with wide open pulmonary insufficiency, hypoplastic left heart syndrome including stage 1 repair) or severe CHD (eg, children with uncorrected CHD, children with documented pulmonary hypertension, children with ventricular dysfunction requiring medications, or children listed for heart transplant) recorded in the 2012 and 2013 American College of Surgeons National Surgical Quality Improvement Program Pediatric databases in a derivation cohort, and those recorded in the 2014 database in a validation cohort. The primary outcome variable for our analysis was the incidence of in-hospital mortality. We used univariable and multivariable logistic regression to determine the preoperative predictors for in-hospital mortality and designed the risk stratification score., Results: Among the 183,423 children included in the 2012, 2013, and 2014 American College of Surgeons National Surgical Quality Improvement Program database, we included 4375 children with major or severe CHD in the derivation cohort (mortality: 4.7% [204/4375]) and 2869 in the validation cohort (morality: 4.0% [115/2869]). Eight preoperative predictors were retained in the final multivariable logistic regression model: emergency procedure (odds ratio [OR]: 1.66, 95% confidence interval [CI]: 1.19-2.31, P = .003), severe CHD (OR: 1.65, 95% CI: 1.15-2.39, P = .007), single-ventricle physiology (OR: 1.83, 95% CI: 1.10-3.06, P = .020), previous surgery within 30 days (OR: 2.01, 95% CI: 1.40-2.89, P < .001), inotropic support (OR: 2.05, 95% CI: 1.40-3.01, P < .001), preoperative cardiopulmonary resuscitation (OR: 2.46, 95% CI: 1.32-4.57, P < .004), acute or chronic kidney injury (OR: 4.42, 95% CI: 2.00-9.75, P < .001), and mechanical ventilation (OR: 7.80, 95% CI: 5.42-11.21, P < .001). We created a risk stratification score ranging from 0 to 10 that showed very good calibration and discrimination in the validation cohort (area under the curve: 0.831 [95% CI: 0.787-0.875]), corresponding to an optimism-corrected area of 0.826. Scores ≤ 3 are associated with low risk of mortality (OR: 1.54, 95% CI: 0.78-3.04), scores ranging from 4 to 6 associated with medium risk (OR: 4.19, 95% CI: 2.56-6.87), and scores ≥ 7 associated with high risk (OR: 22.15, 95% CI: 15.06-32.59)., Conclusions: Our study demonstrates that, in addition to preoperative markers of critical illness (eg, inotropic support, mechanical ventilation, preoperative cardiopulmonary resuscitation, and acute or chronic kidney injury), the type of lesion (eg, single-ventricle physiology) and the functional severity of the heart disease (eg, severe CHD) are strong predictors of in-hospital mortality in children undergoing noncardiac surgery.

Objectives: Extracorporeal membrane oxygenation is increasingly utilized to provide cardiopulmonary support to critically ill children. Although life-saving in many instances, extracorporeal membrane oxygenation support is associated with considerable morbidity and mortality. This study evaluates the effect of extracorporeal membrane oxygenation complications and extracorporeal membrane oxygenation hospital characteristics on mortality in neonates and children supported with extracorporeal membrane oxygenation., Design: Retrospective analysis of administrative data., Setting: Data from 31 U.S. states included in 2012 Healthcare Cost and Utilization Project Kids' Inpatient Database., Patients: Children treated with extracorporeal membrane oxygenation., Interventions: None., Measurements and Main Results: Study subject were identified using International Classification of Diseases, 9th Edition Clinical Modification code 39.65 and classified into six diagnostic categories: 1) cardiac surgery, 2) non-surgical heart disease, 3) congenital diaphragmatic hernia, 4) neonatal respiratory failure, 5) pediatric respiratory failure, and 6) sepsis. Demographics, hospital characteristics, and outcome information were used in a multivariate logistic regression analysis to determine factors associated with mortality. We identified 1,465 children treated with extracorporeal membrane oxygenation. Overall mortality was 40% (591/1,465). Mortality was independently associated with diagnosis (heart disease: odds ratio, 1.7; p = 0.01; congenital diaphragmatic hernia: odds ratio, 5.1; p < 0.001; and sepsis odds ratio: 2.4; p = 0.003 compared with neonatal respiratory failure) time from hospital admission to extracorporeal membrane oxygenation of more than 10 days (odds ratio, 4.5; p < 0.001) and extracorporeal membrane oxygenation complications (renal [odds ratio: 5; p < 0.001] and neurologic [odds ratio, 1.4; p = 0.03] injury). In addition, hospitals with bed size less than 400 had higher mortality (odds ratio, 1.4; p = 0.02). In patients with any extracorporeal membrane oxygenation complication, probability of mortality was lower for extracorporeal membrane oxygenation patients in larger hospitals, 38% (95% CI, 37-39) versus 44% (95% CI, 43-46) with p value of less than 0.001., Conclusions: Extracorporeal membrane oxygenation mortality was significantly associated with patient diagnosis, time to extracorporeal membrane oxygenation initiation, extracorporeal membrane oxygenation complications, and extracorporeal membrane oxygenation hospital bed size. Improved survival in larger hospitals supports centralization of extracorporeal membrane oxygenation services to larger centers.

Background: In this pilot study, we hypothesized that velocity parameters obtained from changes in clot amplitude (A) and clot elasticity (E) measured with thromboelastometry (ROTEM, Tem International GmbH, Munich, Germany) could improve detection of fibrinolysis in whole blood obtained from children undergoing surgery for congenital heart disease., Methods: Whole blood samples were obtained after induction of general anesthesia. Seven conditions were studied: native whole blood (baseline) and samples with progressive tissue-type plasminogen activator (t-PA) concentrations (102, 255, 512, 1024, 1535, and 2539 units/mL). We calculated velocity curves based on changes in clot amplitude and elasticity between different time points using ROTEM data. The analysis allowed for the determination of the following parameters: the maximum rate of thrombus formation based on amplitude or elasticity and the maximum rate of thrombus lysis measured based on amplitude (MTL) or maximum rate of thrombus lysis measured based on elasticity (MTLe). We compared these parameters with the lysis in relation to maximal clotting firmness and measured 30 minutes after the clotting time (LI30, in percent)., Results: Concentrations of t-PA ≥ 255 units/mL resulted in a decrease in LI30 (mean difference, 255 units/mL versus baseline, -31.05%, P < 0.0001) and the maximum rate of thrombus formation based on amplitude (mean difference, 255 units/mL versus baseline, -7.5, P = 0.005). Concentrations of t-PA ≥ 512 units/mL resulted in changes in maximum rate of thrombus formation based on elasticity (mean difference, 512 units/mL versus baseline, -10.9, P = 0.010), MTL (mean difference, 255 units/mL versus baseline, -3.2, P = 0.016), and MTLe (mean difference, 255 units/mL versus baseline, -7.8, P = 0.004). For t-PA concentrations ≥ 512 units/mL, clot formation was abolished. The area under the receiver operating characteristics curves did not differ between LI30, MTL, and MTLe for the detection of minimal fibrinolytic activation (102 units/mL; 0.74, 0.75, and 0.72, respectively, P = 0.708), whereas sensitivity and specificity of the cutoff values 97% for LI30, -0.3 for MTL, and -0.5 for MTLe were 52% and 85%, 83% and 45%, and 83% and 45%, respectively., Conclusions: Velocity curves based on the amplitudes or clot elasticity could provide objective measurement of clot growth and clot lysis kinetics, allowing detection of even minor fibrinolysis. Further studies are needed to assess the clinical relevance of these parameters.

Children undergoing major surgery are frequently exposed to a high risk of blood loss often requiring transfusion. Although the risks associated with blood product transfusion have considerably decreased over the last decade, transfusion is still associated with significant morbidity and mortality. Thus, rigorous efforts should be made to decrease surgical bleeding and the need for blood product transfusion. Antifibrinolytic drugs have been shown to be effective when used in both adult and pediatric surgical patients. While there are data in adults to support safety, data remain limited for pediatric patients. Since the restriction of aprotinin use in 2008, the most commonly used antifibrinolytic drugs have been the lysine analogs, tranexamic acid (TXA), and ε-aminocaproic acid, which inhibit the conversion of plasminogen to plasmin and decrease the degree of fibrinolysis. We performed a systematic review of the literature pertaining to the efficacy of antifibrinolytic drugs in children undergoing noncardiac surgery. During spine surgery, both TXA and ε-aminocaproic acid decrease blood loss and transfusion requirements; however, this information comes from small, mainly retrospective trials. Two prospective, randomized, controlled trials have tested the efficacy of TXA in children undergoing craniofacial surgery and have reported that TXA decreases transfusion requirements. Two pharmacokinetic trials were also recently published and are summarized in this review. No data have been published regarding the efficacy of TXA administration in the pediatric trauma population. Further data are still needed in this field of study, and we discuss some perspectives for future research.

Managing patients in the perioperative setting receiving novel oral anticoagulation agents for thromboprophylaxis or stroke prevention with atrial fibrillation is an important consideration for clinicians. The novel oral anticoagulation agents include direct Factor Xa inhibitors rivaroxaban and apixaban, and the direct thrombin inhibitor dabigatran. In elective surgery, discontinuing their use is important, but renal function must also be considered because elimination is highly dependent on renal elimination. If bleeding occurs in patients who have received these agents, common principles of bleeding management as with any anticoagulant (including the known principles for warfarin) should be considered. This review summarizes the available data regarding the management of bleeding with novel oral anticoagulation agents. Hemodialysis is a therapeutic option for dabigatran-related bleeding, while in vitro studies showed that prothrombin complex concentrates are reported to be useful for rivaroxaban-related bleeding. Additional clinical studies are needed to determine the best method for reversal of the novel oral anticoagulation agents when bleeding occurs.

Purpose of Review: Coagulopathy in an ICU setting is multifactorial, but newer anticoagulation agents are the potentially contributing causes. Critically ill patients may suffer from disorders because of surgery or trauma, in addition to acquired causes including antiplatelet agents and the new oral anticoagulants. An understanding of the coagulopathy, hemostatic considerations, and therapeutic approaches is important when managing these patients., Recent Findings: All anticoagulation agents may contribute to coagulopathy in critically ill patients. Options for management include hemodialysis, transfusion of blood products, and prohemostatic drugs. Recombinant and purified coagulation therapies are also now available in most countries that provide clinicians with specific agents to treat targeted deficiencies., Summary: Coagulopathy occurs in ICU patients because of multiple factors including anticoagulants, dilution, fibrinolysis, and factor consumption. Therapeutic prohemostatic pharmacologic approaches, in addition to standard transfusion therapy, need to be considered in managing coagulopathy in the ICU setting.

Purpose of Review: Coagulation management remains a challenge for anesthesiologists involved in cardiovascular surgery as the population undergoing surgery becomes older and presents with more comorbidities. These patients are frequently treated with one or more agents that directly affect coagulation. This review will discuss what is known and the treatments available to manage coagulation in the perioperative setting of cardiac surgery., Recent Findings: New antithrombotics will be discussed as well as their proposed substitution in the preoperative period. The review will also describe the different products available in Europe for the treatment of bleeding and coagulopathy. Finally, the use of new monitoring devices will be discussed., Summary: The introduction of new drugs with different mechanisms of action adds to the complexity of coagulation management during cardiovascular surgery. Monitoring needs to be developed and improved, especially for evaluating platelet function.