Sarah Barnhard

Purpose of the Review: Anemia in the critically ill is both insidious and highly prevalent; and has been implicated in poor outcomes in patients with and recovering from critical illness. Patient-oriented approaches to blood management (PBM) are gaining momentum and have widespread applications as a superior approach to anemia. The volume of publications pertaining to PBM has dramatically increased in the past 4 years, warranting further review of emerging paradigms in the ICU. Recent Findings: IV iron alone and in conjunction with erythropoietin are being studied prospectively. Factor concentrates are used more frequently, and both point of care and viscoelastic testing algorithms have been shown to reduce utilization of blood products. Both whole blood and thrombopoietin also show promise in reducing transfusions. Summary: Careful attention to PBM approaches has the potential to improve the quality and reduce the cost of care of patients in the ICU. Significant work remains, especially in the areas of education of care teams on the importance of reducing phlebotomy and updating knowledge of current indications for therapies aimed at increasing hemoglobin levels and reducing blood product transfusions.

Trauma is the leading cause of morbidity and mortality in children in the United States. The antifibrinolytic drug tranexamic acid (TXA) improves survival in adults with traumatic hemorrhage, however, the drug has not been evaluated in a clinical trial in severely injured children. We designed the Traumatic Injury Clinical Trial Evaluating Tranexamic Acid in Children (TIC-TOC) trial to evaluate the feasibility of conducting a confirmatory clinical trial that evaluates the effects of TXA in children with severe trauma and hemorrhagic injuries. Children with severe trauma and evidence of hemorrhagic torso or brain injuries will be randomized to one of three arms: (1) TXA dose A (15 mg/kg bolus dose over 20 min, followed by 2 mg/kg/hr infusion over 8 h), (2) TXA dose B (30 mg/kg bolus dose over 20 min, followed by 4 mg/kg/hr infusion over 8 h), or (3) placebo. We will use permuted-block randomization by injury type: hemorrhagic brain injury, hemorrhagic torso injury, and combined hemorrhagic brain and torso injury. The trial will be conducted at four pediatric Level I trauma centers. We will collect the following outcome measures: global functioning as measured by the Pediatric Quality of Life (PedsQL) and Pediatric Glasgow Outcome Scale Extended (GOS-E Peds), working memory (digit span test), total amount of blood products transfused in the initial 48 h, intracranial hemorrhage progression at 24 h, coagulation biomarkers, and adverse events (specifically thromboembolic events and seizures). This multicenter trial will provide important preliminary data and assess the feasibility of conducting a confirmatory clinical trial that evaluates the benefits of TXA in children with severe trauma and hemorrhagic injuries to the torso and/or brain. ClinicalTrials.gov registration number: NCT02840097 . Registered on 14 July 2016.