Restrictive Transfusion Protocols: Practice Gap discussion at Update Course 2018

All right, and we are back. Uh, we're gonna try to get back on time here. Uh, that was a fantastic first session. We got some debate which we wanted, and we're going to continue that, I'm sure. Uh, we are going to now move on to a topic. I'm, I'm very excited to invite our next guests here. Uh, as you know, each year we try to bring in people that we think are shaking up the field, changing the field, keeping us on track on what's new. Uh, and through the American P Paediatric Surgical Association, APSA. A committee was developed by the gentleman here and some, and Marge Arka, who's not here, uh, developed this committee called the Professional Development Committee, which they will explain what that is and what they have been doing. they have been looking through data to try to figure out where the gaps are and what are the things that we need to, to make sure that we're up to date on, what are the new ideas that we need to pay attention to. So, we've actually invited, uh, three of the, of the PDC here, uh, Doctor Craig Lillihi, uh, who's from Boston Children's, uh, Doctor David Powell, who is from, uh, where you, Stanford, and, uh, and uh. Who's at Children's Mercy, Kansas City. And, uh, and they are going to uh talk us through what is the PDC gonna teach us today. Dave, thanks, Todd. First, I wanna thank Todd and everybody for inviting us to this platform. This is exactly what the Professional Development Committee of ABSA is designed for. I've noticed that nobody else has had any disclosure slides, and we really should because we should all identify what our biases are. None of us unfortunately have any financial disclosures, but we do have to say that we do have bias. We're all editors and contributors to a website called Peedsurge Library.com, which is essentially the home of the product of the professional development community at ABSA. Todd points this out a lot. We need to know a lot. There are over 900 items in the American Board of Surgery scope of pediatric surgery curriculum. We have over 1200 questions in our online continuing medical education platform, which is called Expert. There are over 1500 learning objectives in the pediatric score trainee curriculum. There are over 7000 new pediatric surgery articles published in the medical literature every year, and our pediatric surgery online reference called the NAT or not a textbook as I stopped counting at 12,000 different learning objectives. That's a lot to know. Doctor Holcomb, you're, you're, I guess you're kind of the moderator for our session. I wonder if you'd tell me, how do you feel when you have a complication. Well, um, I'm sure I feel like, um, almost every pediatric surgeon does, and I feel bad. And hypothetically speaking, when you have a complication, how do you feel bad and you, you rack your brain to try to figure out if you did something wrong, uh, if, or if it was just, uh, patient's, uh, comorbidities that, you know, are attributed to the complication. And you try to actually learn from the complication, how not to have that complication happen again. Sure. So the point of this being none of us, we don't know what we don't know, right? Uh, we, we at the PDC described that as a practice gap, and a practice gap is the distance between what is best practices or evidence-based and what you should be doing and what actually happens. And the goal of the PDC is to meet those practice gaps that pediatric surgeons have. The fact is, I feel bad when I have a complication too, but I don't really feel bad when I caused the complication because I didn't know it at the time, right? You know, I felt pretty good when I put that esophagus together and it looked pretty good on the screen. It's only 3 days later when the kid gets a leak that I feel bad. So not only do I not know what I don't know, I don't know when I don't know it. And that's the idea behind the PDC is to identify through multiple inputs through the literature, through the committee structure, through individuals, uh, through people listening to this podcast. Tell us what your practice gaps are. We collate those and try and prioritize those ones and then rebroadcast out again through forms like this, uh, the medical literature, our expert, expert. NAT Pizzer library.com site, try and prioritize those 7000 new pediatric surgery articles or the 12,000 learning objectives or those complications that we have so that we can all be more efficient in knowing what it is that we don't know. Right. The one thing I would encourage the audience to do is we do have an email address at think@ EASA.org. Everyone is encouraged, not just American pediatric surgeons, but globally. This is a global resource to submit if you have a question, if you have a complication, if you have a problem, if you would like to suggest a practice gap that you know you have, because guess what, everybody up here at the table likely has those same practice gaps as well. What we're gonna go through today is the top 10, thank you, David Letterman, the top 10 practice gaps as identified by and prioritized by the ABSA Professional Development Committee. We're gonna go in reverse order, so we need to stay on time, I'm told, because otherwise we won't get to the most important one. All right. Who, uh, who's first? It's, uh, the, so the first case that we're going to describe for you is a 1 month old ex 32 week gestational infant who has a hemoglobin of 7.5. He's non-tachycardic, non-tachypnic, and you're advancing slowly on the feeds. The NICU adheres to a restrictive blood transfusion protocol, and by that we mean a blood transfusion only when the hemoglobin goes under 7. Compared to a more liberal transfusion policy, a restrictive transfusion policy results in And there's the question for you. So No difference in mortality. This is the choices we were, we, do we have this poll up? OK, cause I don't, let's see. Um All right, so what are, what are some thoughts here among the faculty? A restrictive transfusion or transfusion policy, is there no difference? In mortality, no change in the incidence of apnea. No change in the number of red blood cell transfusions. Well, Todd, I don't know the answer to this question. That's why it's here, uh, but I would, I would quote guess that it's a. So what does your hospital, does your NICU practice a restrictive transfusion? I don't think so. But what we're seeing is increasingly this is becoming, uh, becoming the norm for, for, uh, for our NICUs across the, across the US and I suspect across the world. Yeah. So is the sole goal to preserve the blood supply they're not tattoos and babies? That's a good question, Rusty. The fact of the matter is, obviously we want to use our resources appropriately and so number one is to say, well, if you don't need that. Blood transfusion that uh uh that can go to somebody else that resource. The other side of it though is that blood transfusions actually carry some morbidity associated with them and in fact the adult literature, it's very interesting that that there are a number of adult studies that will tell you that the more transfusions, the higher the mortality, so in places that have a liberal transfusion policy that actually they pay. There's a toll for that, and this is a preemie, right, for the age, but there is an incidence of neck associated with transfusion transfusion associated NEC, which is why, why they're very careful about the, uh, in terms of feeding in association with that. Yeah, yeah, so I was gonna say the same thing. I mean, you have, you have the risk of neck. The other thing that's that not many people realize is, uh, you are, you are transfusing with adult hemoglobin versus fetal hemoglobin. So all of a sudden your oxygen dissociation curve is affected. And uh which is, which is adverse, um, a good point. One of the things though that, that as pediatric surgeons and, and uh neonatologists is that uh we also worry about the white cell antigens. Unfortunately, primarily we're trying to use leukote leukocyte reduced uh products for a transfusion. So yeah, the answer, you're right. I think that the old thinking was that we wanted to keep the The hemoglobin around 10 or thereabouts and, and um I think the no difference in in mortality really is going to push us to, to get, get off that. Uh, and down to a more, uh, we'll call it adult level of of hemoglobin. Well, Ron, you're right on target. So number one, there is no difference in mortality or adverse events, certainly in the PICU. That's, that's uh well determined. So in our PICUs that we really ought to be looking to this uh reduced transfusion strategy. The NICU. A little bit more complicated and it gets more complicated in preemies, so that the results are somewhat mixed and there may be in some studies there has been evidence of a higher rate of periveventricular leukomalacia and other adverse neurologic outcomes. So in the in the preemie and the very small preemies, we have studies on both both sides of the coin, but clearly mortality is not affected. So can I ask, can I ask you a question that with these questions and the answers, is there a greater recommendation of A or B for, for the answers? Uh, that is how strong is the literature to support these answers? David, do you wanna It depends. We've included all the references to our projects, including what we're talking about today, uh, is as evidence-based as we can make it for our specialty. And in fact we had to change our slides around because we have so many references for all these questions and discussions, and they're all at the end. So if you want, you can go see what it is. Uh, this is pretty good evidence, as Craig says in the PICU. This is pretty good evidence out on the floor. Uh, depending on who you talk to, they think there's good evidence in the NICU, but there are conflicting studies. Uh, this is all as evidence-based as we can make it, but unfortunately for our specialty, there's not a lot of really good evidence, good guideline-based things. But that's a good question. This is the best we can offer you at, uh, at this point. We'll take that now, yeah. Yeah What we got. And you just showed the answer. You were good. Oh, go forward. We want to discuss the.