Taking One for the Team* David Dries, MSE, MD Department of Surgery HealthPartners Medical Group John F. Perry, Jr. Chair of Trauma Surgery University of Minnesota Minneapolis, MN
T
he American College of Surgeons makes a clear case for the importance of optimal care for pediatric injury. We know that more children die of injury than of all other causes combined. For injured children who survive, severe disability may become a lifelong problem. Effective treatment of childhood injury requires identification of effective strategies for prevention, development of systematic emergency medical care for children, and provision of highest quality pediatric trauma and critical care. The specific need for pediatric critical care resources has been identified by the College. Injured children require special resources in any trauma center devoted to their care. All trauma systems should consider the unique needs of injured children and develop appropriate plans that ensure that these needs are met (1). State and regional trauma systems have evolved in North America in an attempt to improve the outcome of patients with traumatic injuries. Trauma systems are public health efforts of a state or region to direct care of injured patients in a coordinated way. One of the many functions of trauma systems and trauma centers is to refer patients to the most appropriate facility, diverting severely injured patients away from nontrauma centers to trauma centers where survival has been shown to be significantly better. Multiple studies have demonstrated the efficacy of trauma systems in adult patients, and the triage of pediatric patients within trauma systems has evolved based on the assumption that similar benefits are available to children (2–5). Mooney et al in a recent study from New England demonstrated that systematic management of pediatric trauma decreased the rates of childhood injury hospitalization and increased the percentage of severely injured children and brain-injured children admitted to the appropriate trauma centers (6). Pracht et al examined the survival benefit associated with treatment of children with serious injuries in the Florida trauma system. Over 27,000 patients were reviewed between ages 0 and 19 years. Treatment in designated trauma centers was associated with a 3.15% reduction in the probability of mortality. Treatment of over 16,000 children in a designated pediatric trauma center as opposed to a nonpediatric trauma center was associated with
*See also p. 319. Key Words: burn injury; outcome; pediatric; survival; volume The author has disclosed that he does not have any potential conflicts of interest. Copyright © 2015 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies DOI: 10.1097/PCC.0000000000000374
Pediatric Critical Care Medicine
an additional 4.84% reduction in mortality in the 0–19-yearold group and a 4.5% reduction in mortality in the 0–15-yearold group over trauma centers featuring only adult designation (7). In our pediatric trauma center, the pediatric intensivist responds with the trauma team to the emergency department and facilitates resuscitation and stabilization of appropriate children in the pediatric critical care unit. Complex surgical problems are generally most effectively managed in high-volume programs. This volume outcome effect is supported by a growing body of evidence in burn care. Burn care requires personnel and equipment that are best maintained in high-volume programs. In North America, this issue has led to burn center verification, a joint effort of the American Burn Association and the American College of Surgeons. Patients with serious burns should be referred to regional programs designed for their care. Transfer criteria for children with burn injury include the presence of second-degree and thirddegree burns involving more than 10% of the total body surface area in children less than 10 years old, cases involving suspicion of child abuse, and children requiring special social, emotional, or long-term rehabilitation support. The American Burn Association states that hospitals without qualified personnel and equipment to care for the burn-injured child should transfer these patients to centers with these capabilities (8, 9). The burn-injured child is clearly a special needs group. A burn center that treats primarily adults will likely have wound care supplies necessary to care for children but may be lacking in pediatric-specific critical care and rehabilitation support. Age-specific capabilities and competencies should be enhanced by an increasing volume of pediatric patients admitted. Centers with a large pediatric burn volume are likely to invest in age-specific resources, and provision of complex pediatric care is likely to be more cost effective than in smaller centers seeing a limited number of burned children (10). In this issue of Pediatric Critical Care Medicine, Palmieri et al (10) examine the American Burn Association National Burn Registry for outcomes, patient and injury characteristics, and age-related performance using the 2009 release of registry data containing over 285,000 admission records. A striking finding was the negative relationship between mortality and median yearly pediatric burn admissions among the burn centers contributing data. With an increase in median yearly pediatric burn admissions by 100, the odds of mortality declined by approximately 40%. This is remarkable as pediatric burn patients tend to have small injuries and very high overall survival. When mortality of children with less than 10% total body surface area burns was examined, 26 of 32 fatalities reported suffered respiratory injury with smoke inhalation or cardiovascular collapse. These data strongly support the need for appropriate critical care resources even in children with small cutaneous injury. The benefit of higher pediatric burn volume is less with injuries including 25% of the total body surface area, but for the patient with 75% total body surface area injury, the estimated www.pccmjournal.org
379
mortality is reduced from approximately 30% at a facility with median yearly pediatric admissions of 75% to 17% at a facility with 300 median annual pediatric burn admissions. Older children in the 15- to 18-year-old group have mortality on a par with the young adult population (10). In this era, market-based competition between burn centers is common. Palmieri et al demonstrate that not all burn centers have comparable treatment outcomes for burned children and that high-volume burn centers featuring resources specific to the needs of children should be treating the burn-injured child. A “patient first” strategy for pediatric burns mandates the use of the pediatric burn team.
REFERENCES
1. Committee on Trauma American College of Surgeons: Resources for Optimal Care of the Injured Patient. Chicago, IL, American College of Surgeons, 2014 2. Barquist E, Pizzutiello M, Tian L, et al: Effect of trauma system maturation on mortality rates in patients with blunt injuries in the Finger Lakes
Region of New York State. J Trauma 2000; 49:63–69; discussion 69-70 3. Mullins RJ, Veum-Stone J, Helfand M, et al: Outcome of hospitalized injured patients after institution of a trauma system in an urban area. JAMA 1994; 271:1919–1924 4. Mann NC, Cahn RM, Mullins RJ, et al: Survival among injured geriatric patients during construction of a statewide trauma system. J Trauma 2001; 50:1111–1116 5. Mullins RJ, Mann NC, Hedges JR, et al: Preferential benefit of implementation of a statewide trauma system in one of two adjacent states. J Trauma 1998; 44:609–616; discussion 617 6. Mooney DP, Gutierrez IM, Chen Q, et al: Impact of trauma system development on pediatric injury care. Pediatr Surg Int 2013; 29:263–268 7. Pracht EE, Tepas JJ III, Langland-Orban B, et al: Do pediatric patients with trauma in Florida have reduced mortality rates when treated in designated trauma centers? J Pediatr Surg 2008; 43:212–221 8. Birkmeyer JD, Siewers AE, Finlayson EV, et al: Hospital volume and surgical mortality in the United States. N Engl J Med 2002; 346:1128–1137 9. Sheridan RL: Burns: A Practical Approach to Immediate Treatment and Long-Term Care. London, Manson Publishing, 2012 10. Palmieri TL, Taylor S, Lawless M, et al: Burn Center Volume Makes a Difference for Burned Children. Pediatr Crit Care Med 2015; 16:319–324
A New Name for Respiratory Distress Associated With Transfusion* James Lin, MD Division of Pediatric Critical Care Medicine Department of Pediatrics Mattel Children’s Hospital UCLA University of California, Los Angeles Los Angeles, CA
M
edical blood transfusion has been practiced since the 1600s, when whole animal blood was first transfused successfully into humans. Although blood transfusion could be life saving, severe adverse reactions to blood transfusion were quickly recognized. The first account of hemolytic transfusion reaction may have been in 1668 shortly after a calf-to-human transfusion, well before the first described successful human-to-human transfusion in the early 1800s (1). Since the rise of modern blood banks and widespread blood transfusion practices after World War II, numerous adverse effects of blood transfusion have been painstakingly identified and elucidated over the ensuing decades: viral infections, bacterial sepsis, hemolytic transfusion reactions, graft-versus-host *See also p. 325. Key Words: red blood cell transfusion; respiratory distress associated with transfusion; transfusion-related acute lung injury; transfusion-related complications The author has disclosed that he does not have any potential conflicts of interest. Copyright © 2015 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies DOI: 10.1097/PCC.0000000000000379
380
www.pccmjournal.org
disease, and transfusion-related acute lung injury (TRALI), among others (2). Although multiple insults related to blood product transfusion as above can lead to lung injury, perhaps the most precisely characterized is TRALI. The key association of transfused leukoagglutinins in plasma-containing blood products with TRALI was recognized as early as the 1950s and subsequently confirmed in multiple studies (3). Early attempts to define TRALI eventually coalesced in a National Heart, Lung, and Blood Institute working group definition that specified no preexisting acute lung injury (ALI) before transfusion, onset of ALI within 6 hours of transfusion, and the adoption of the 1994 North American-European Consensus Conference (AECC) criteria for ALI (3, 4). Patients with an alternative ALI risk factor or recipients of massive transfusion were included. The NHLBI conference roughly coincided with a Canadian Consensus Conference, which similarly adopted the AECC criteria for ALI and added the term “possible TRALI” to describe new ALI occurring within 6 hours of transfusion but with a clear temporal relationship to an alternative risk factor for ALI (5). Despite the Food and Drug Administration report that TRALI was the leading cause of transfusion-related death in the United States, TRALI remained an uncommon condition. Risk of TRALI was estimated at approximately 1 in 5,000 blood units transfused, with pathophysiological differences in prevalence mainly related to content of plasma in the transfused blood product (3, 5). This low prevalence of TRALI may be surprising to practicing clinicians. In one survey of anesthesiologists and surgeons, 2.9% of physicians estimated that dyspnea May 2015 • Volume 16 • Number 4
T
he American College of Surgeons makes a clear case for the importance of optimal care for pediatric injury. We know that more children die of injury than of all other causes combined. For injured children who survive, severe disability may become a lifelong problem. Effective treatment of childhood injury requires identification of effective strategies for prevention, development of systematic emergency medical care for children, and provision of highest quality pediatric trauma and critical care. The specific need for pediatric critical care resources has been identified by the College. Injured children require special resources in any trauma center devoted to their care. All trauma systems should consider the unique needs of injured children and develop appropriate plans that ensure that these needs are met (1). State and regional trauma systems have evolved in North America in an attempt to improve the outcome of patients with traumatic injuries. Trauma systems are public health efforts of a state or region to direct care of injured patients in a coordinated way. One of the many functions of trauma systems and trauma centers is to refer patients to the most appropriate facility, diverting severely injured patients away from nontrauma centers to trauma centers where survival has been shown to be significantly better. Multiple studies have demonstrated the efficacy of trauma systems in adult patients, and the triage of pediatric patients within trauma systems has evolved based on the assumption that similar benefits are available to children (2–5). Mooney et al in a recent study from New England demonstrated that systematic management of pediatric trauma decreased the rates of childhood injury hospitalization and increased the percentage of severely injured children and brain-injured children admitted to the appropriate trauma centers (6). Pracht et al examined the survival benefit associated with treatment of children with serious injuries in the Florida trauma system. Over 27,000 patients were reviewed between ages 0 and 19 years. Treatment in designated trauma centers was associated with a 3.15% reduction in the probability of mortality. Treatment of over 16,000 children in a designated pediatric trauma center as opposed to a nonpediatric trauma center was associated with
*See also p. 319. Key Words: burn injury; outcome; pediatric; survival; volume The author has disclosed that he does not have any potential conflicts of interest. Copyright © 2015 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies DOI: 10.1097/PCC.0000000000000374
Pediatric Critical Care Medicine
an additional 4.84% reduction in mortality in the 0–19-yearold group and a 4.5% reduction in mortality in the 0–15-yearold group over trauma centers featuring only adult designation (7). In our pediatric trauma center, the pediatric intensivist responds with the trauma team to the emergency department and facilitates resuscitation and stabilization of appropriate children in the pediatric critical care unit. Complex surgical problems are generally most effectively managed in high-volume programs. This volume outcome effect is supported by a growing body of evidence in burn care. Burn care requires personnel and equipment that are best maintained in high-volume programs. In North America, this issue has led to burn center verification, a joint effort of the American Burn Association and the American College of Surgeons. Patients with serious burns should be referred to regional programs designed for their care. Transfer criteria for children with burn injury include the presence of second-degree and thirddegree burns involving more than 10% of the total body surface area in children less than 10 years old, cases involving suspicion of child abuse, and children requiring special social, emotional, or long-term rehabilitation support. The American Burn Association states that hospitals without qualified personnel and equipment to care for the burn-injured child should transfer these patients to centers with these capabilities (8, 9). The burn-injured child is clearly a special needs group. A burn center that treats primarily adults will likely have wound care supplies necessary to care for children but may be lacking in pediatric-specific critical care and rehabilitation support. Age-specific capabilities and competencies should be enhanced by an increasing volume of pediatric patients admitted. Centers with a large pediatric burn volume are likely to invest in age-specific resources, and provision of complex pediatric care is likely to be more cost effective than in smaller centers seeing a limited number of burned children (10). In this issue of Pediatric Critical Care Medicine, Palmieri et al (10) examine the American Burn Association National Burn Registry for outcomes, patient and injury characteristics, and age-related performance using the 2009 release of registry data containing over 285,000 admission records. A striking finding was the negative relationship between mortality and median yearly pediatric burn admissions among the burn centers contributing data. With an increase in median yearly pediatric burn admissions by 100, the odds of mortality declined by approximately 40%. This is remarkable as pediatric burn patients tend to have small injuries and very high overall survival. When mortality of children with less than 10% total body surface area burns was examined, 26 of 32 fatalities reported suffered respiratory injury with smoke inhalation or cardiovascular collapse. These data strongly support the need for appropriate critical care resources even in children with small cutaneous injury. The benefit of higher pediatric burn volume is less with injuries including 25% of the total body surface area, but for the patient with 75% total body surface area injury, the estimated www.pccmjournal.org
379
mortality is reduced from approximately 30% at a facility with median yearly pediatric admissions of 75% to 17% at a facility with 300 median annual pediatric burn admissions. Older children in the 15- to 18-year-old group have mortality on a par with the young adult population (10). In this era, market-based competition between burn centers is common. Palmieri et al demonstrate that not all burn centers have comparable treatment outcomes for burned children and that high-volume burn centers featuring resources specific to the needs of children should be treating the burn-injured child. A “patient first” strategy for pediatric burns mandates the use of the pediatric burn team.
REFERENCES
1. Committee on Trauma American College of Surgeons: Resources for Optimal Care of the Injured Patient. Chicago, IL, American College of Surgeons, 2014 2. Barquist E, Pizzutiello M, Tian L, et al: Effect of trauma system maturation on mortality rates in patients with blunt injuries in the Finger Lakes
Region of New York State. J Trauma 2000; 49:63–69; discussion 69-70 3. Mullins RJ, Veum-Stone J, Helfand M, et al: Outcome of hospitalized injured patients after institution of a trauma system in an urban area. JAMA 1994; 271:1919–1924 4. Mann NC, Cahn RM, Mullins RJ, et al: Survival among injured geriatric patients during construction of a statewide trauma system. J Trauma 2001; 50:1111–1116 5. Mullins RJ, Mann NC, Hedges JR, et al: Preferential benefit of implementation of a statewide trauma system in one of two adjacent states. J Trauma 1998; 44:609–616; discussion 617 6. Mooney DP, Gutierrez IM, Chen Q, et al: Impact of trauma system development on pediatric injury care. Pediatr Surg Int 2013; 29:263–268 7. Pracht EE, Tepas JJ III, Langland-Orban B, et al: Do pediatric patients with trauma in Florida have reduced mortality rates when treated in designated trauma centers? J Pediatr Surg 2008; 43:212–221 8. Birkmeyer JD, Siewers AE, Finlayson EV, et al: Hospital volume and surgical mortality in the United States. N Engl J Med 2002; 346:1128–1137 9. Sheridan RL: Burns: A Practical Approach to Immediate Treatment and Long-Term Care. London, Manson Publishing, 2012 10. Palmieri TL, Taylor S, Lawless M, et al: Burn Center Volume Makes a Difference for Burned Children. Pediatr Crit Care Med 2015; 16:319–324
A New Name for Respiratory Distress Associated With Transfusion* James Lin, MD Division of Pediatric Critical Care Medicine Department of Pediatrics Mattel Children’s Hospital UCLA University of California, Los Angeles Los Angeles, CA
M
edical blood transfusion has been practiced since the 1600s, when whole animal blood was first transfused successfully into humans. Although blood transfusion could be life saving, severe adverse reactions to blood transfusion were quickly recognized. The first account of hemolytic transfusion reaction may have been in 1668 shortly after a calf-to-human transfusion, well before the first described successful human-to-human transfusion in the early 1800s (1). Since the rise of modern blood banks and widespread blood transfusion practices after World War II, numerous adverse effects of blood transfusion have been painstakingly identified and elucidated over the ensuing decades: viral infections, bacterial sepsis, hemolytic transfusion reactions, graft-versus-host *See also p. 325. Key Words: red blood cell transfusion; respiratory distress associated with transfusion; transfusion-related acute lung injury; transfusion-related complications The author has disclosed that he does not have any potential conflicts of interest. Copyright © 2015 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies DOI: 10.1097/PCC.0000000000000379
380
www.pccmjournal.org
disease, and transfusion-related acute lung injury (TRALI), among others (2). Although multiple insults related to blood product transfusion as above can lead to lung injury, perhaps the most precisely characterized is TRALI. The key association of transfused leukoagglutinins in plasma-containing blood products with TRALI was recognized as early as the 1950s and subsequently confirmed in multiple studies (3). Early attempts to define TRALI eventually coalesced in a National Heart, Lung, and Blood Institute working group definition that specified no preexisting acute lung injury (ALI) before transfusion, onset of ALI within 6 hours of transfusion, and the adoption of the 1994 North American-European Consensus Conference (AECC) criteria for ALI (3, 4). Patients with an alternative ALI risk factor or recipients of massive transfusion were included. The NHLBI conference roughly coincided with a Canadian Consensus Conference, which similarly adopted the AECC criteria for ALI and added the term “possible TRALI” to describe new ALI occurring within 6 hours of transfusion but with a clear temporal relationship to an alternative risk factor for ALI (5). Despite the Food and Drug Administration report that TRALI was the leading cause of transfusion-related death in the United States, TRALI remained an uncommon condition. Risk of TRALI was estimated at approximately 1 in 5,000 blood units transfused, with pathophysiological differences in prevalence mainly related to content of plasma in the transfused blood product (3, 5). This low prevalence of TRALI may be surprising to practicing clinicians. In one survey of anesthesiologists and surgeons, 2.9% of physicians estimated that dyspnea May 2015 • Volume 16 • Number 4
