723 - Bleeding in critically ill children: a systematic review of risk factors

Poster Number: 723
Publication Number: 723.401

Eesha V. Natarajan, Yale-New Haven Children's Hospital, New Haven, CT, United States; Melissa C. Funaro, Cushing/Whitney Medical Library, Yale University, New Haven, CT, United States; Jodi Forward, Yale-New Haven Children's Hospital, Hamden, CT, United States; Max Tarica, Yale-New Haven Children's Hospital, New Haven, CT, United States; E. Vincent S. Faustino, Yale School of Medicine, New Haven, CT, United States

Background: Understanding the risk factors for clinically relevant bleeding (CRB) in critically ill children may identify preventative measures to reduce morbidity and mortality due to CRB.

Objective: The objective of this systematic review is to characterize the risk factors for CRB in children admitted to the pediatric intensive care unit (PICU).

Design/Methods: We systematically searched the following databases from inception until November 2022: MEDLINE (OvidSP), EMBASE (OvidSP), the Web of Science (Clarivate), Scopus (Elsevier), the Cochrane Central Register for Controlled Trials (Wiley Online). Included were studies of children < 21 years admitted to a mixed medical-surgical or subspecialty PICU who were evaluated for risk factors for CRB as defined by the study authors.

Results: We included 25 studies (12 randomized controlled trials, 9 cohort and 4 case-control), which we divided into 3 groups: general PICU (n=1,460 children), post-operative cardiac (n=591 children), and extracorporeal membrane oxygenation (ECMO; n=410 children). Studies in the general PICU group identified mechanical ventilation, corticosteroid use, stress ulcer prophylaxis, and thrombocytopenia as risk factors for CRB. In the post-operative cardiac group, cyanotic congenital cardiac disease, cardiopulmonary bypass time >90 min, aorta cross-clamp time >60 min, and activated clotting time >140 sec were associated with increased risk of CRB. Conversely, use of intra-operative tranexamic acid, aprotinin, prothrombin complex concentrate, platelet transfusion and modified or zero-balanced ultrafiltration of the blood prime during cardiopulmonary bypass were associated with decreased risk of CRB. In the ECMO group, hypofibrinogenemia, thrombocytopenia, use of activated clotting time (vs. anti-Xa level) to monitor heparin anticoagulation, and use of heparin (vs. bivalirudin) anticoagulation were associated with increased risk of CRB.

Conclusion(s): Studies of critically ill children identified different risk factors for CRB in the general PICU, post-operative cardiac and ECMO groups, which suggest variations in the pathobiology of CRB among groups. Factors related to severity of illness seem to play significant role in the general PICU group, while coagulopathy related to the cardiopulmonary bypass or ECMO seemed more important in the other two groups. Strategies to prevent CRB may be different among these groups.