Preoperative screening for COVID-19 is required in low-risk pediatric patients under the urgent surgical condition

SummaryThree to five percent of patients undergoing surgery have either an acquired or congenital platelet defect or von Willebrand disease (vWD). The predictive value of preoperative coagulation screening is questionable. PFA-100 is now routinely used in preoperative screening in our pediatric outpatient service. We wanted to assess whether the PFA-100 would help to identify patients with primary haemostatic defects or if the additional use of PFA-100 would add to the problem of unnecessary pathologic preoperative laboratory values resulting in delay of surgical procedure. We investigated 500 children consecutively seen in our outpatient service before surgery. Blood cell count, aPTT, PFA-100 closure times (CT) were done in all patients. If abnormalities were found, the patient was presented to a haemostatic expert. vWF:AG, R:Cof and factorVIII were analysed in all patients with prolonged closure times and APTT values. One hundred twenty-six patients (25.2%) showed abnormalities in APTT and/or PFA-100. Further investigations in 89 of these 126 patients did not yield a specific diagnosis; neither diagnostic criteria for impaired haemostasis were found by questionnaire. None of these 89 patients had a bleeding complication during surgery. Forty-eight patients showed prolonged CTs. Twelve patients with low vWF:AG were detected, 10 of these patients were found by PFA-100. Four of these patients did present with normal APTT values. Our study shows that similar to the APTT the PFA-100 is probably only a good screening method when a haemostatic defect in a patient is clinically likely, especially to screen forVWD, and the test should not be used in general unselective screening.

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Assessing Bleeding Risk in Pediatric Patients Undergoing Major Spinal Surgery

Blood ◽

10.1182/blood.v126.23.3518.3518 ◽

2015 ◽

Vol 126 (23) ◽

pp. 3518-3518

Author(s):

Jennifer Anadio ◽

Adam Lane ◽

Cristina Tarango ◽

Peter Sturm ◽

Joseph S. Palumbo

Keyword(s):

Platelet Count ◽

Platelet Transfusion ◽

Pediatric Patients ◽

Bleeding Risk ◽

Bleeding Disorder ◽

Bleeding Complications ◽

Type I ◽

Preoperative Screening ◽

History Of ◽

Clinically Significant

Abstract Preoperative screening for bleeding disorders in pediatric patients is problematic due to children's limited exposures to significant hemostatic challenges and the inherent difficulty in obtaining blood samples from young patients. Overcoming these challenges is of particular importance for surgical procedures that carry a significant bleeding risk, such as spinal surgeries. Many pediatric surgeons, including the Pediatric Orthopedic team at our Institution, rely on an unfocused history and measurement of general markers of hemostasis for preoperative screening. In order to improve preoperative screening of pediatric patients undergoing spinal procedures, we instituted the use of a detailed semi-quantitative questionnaire based on the ISTH Bleeding Assessment Tool (BAT), in combination with evaluation of PT, aPTT, platelet count, and PFA. The BAT gives positive points for a personal or family history of bleeding, and negative points for significant hemostatic challenges that did not result in bleeding complications. It was decided a priori that a BAT score of ≥3 would result in referral to Pediatric Hematology. A total of 212 patients presenting for major spinal surgeries (e.g., spinal fusion, growth rod placement) ranging in age from 3 to 25 years were prospectively evaluated in this fashion. A total of 41 patients (19.3%) had a prolongation of the PT and/or aPTT, none of which had a high BAT score. The majority of the abnormal PT/aPTT values were minimal prolongations that were not reproducible on repeat testing. Prolongation of the PT and/or aPTT revealed 3 patients with mild deficiencies of either factors VII, X, or XI, none of which were felt to be clinically significant. Prolonged PFAs were observed in 32 patients (16%), 1 of which was diagnosed with type I VWD (BAT score = 1), and the other with "possible VWD" based on a borderline VWF antigen level (BAT score = 0). Both were treated with Humate P. The remainder of the patients with a prolonged PFA were determined not to have a significant bleeding disorder after further testing. A total of 15 patients were referred to Hematology based on a high BAT score. Of these, 2 had a history of thrombocytopenia (1 with known DiGeorge syndrome and 1 with Depakote-related thrombocytopenia). Neither required platelet transfusion. One patient with a high BAT score was known to have type I VWD and was treated with Humate P, another was diagnosed with low expression of glycoprotein GP1b and was treated with Humate P and platelet transfusion. The remainder of the patients with high BAT scores were not felt to have a clinically significant bleeding disorder based on a Hematologist's assessment. None of the 212 patients evaluated were felt to have excessive intraoperative bleeding by the surgical team, suggesting that none of the patients had a significant undiagnosed hemostatic defect. Together, these results suggest that reliance on history or screening labs alone may not be sufficient for many pediatric surgery patients. While the PFA identified 2 patients with mild/possible VWD that would have been missed by the BAT, the PFA also had a significant number of apparent false positives. The combination of a BAT and a platelet count, as well as assessment of VWF activity for patients without previous hemostatic system challenges, may provide a more effective screening methodology for institutions with ready access to VWF activity measurement. Disclosures No relevant conflicts of interest to declare.

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Pediatric patients with traumatic epidural hematoma at low risk for deterioration and need for surgical treatment

Journal of Pediatric Surgery ◽

10.1016/j.jpedsurg.2016.09.005 ◽

2017 ◽

Vol 52 (2) ◽

pp. 334-339 ◽

Cited By ~ 8

Author(s):

Brian F. Flaherty ◽

Hannah E. Moore ◽

Jay Riva-Cambrin ◽

Susan L. Bratton

Keyword(s):

Surgical Treatment ◽

Epidural Hematoma ◽

Pediatric Patients ◽

Low Risk

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Prospective Implementation of a Risk Prediction Model for Bloodstream Infection Safely Reduces Antibiotic Usage in Febrile Pediatric Cancer Patients Without Severe Neutropenia

Journal of Clinical Oncology ◽

10.1200/jco.20.00591 ◽

2020 ◽

Vol 38 (27) ◽

pp. 3150-3160

Author(s):

Adam J. Esbenshade ◽

Zhiguo Zhao ◽

Alaina Baird ◽

Emily A. Holmes ◽

Daniel E. Dulek ◽

...

Keyword(s):

High Risk ◽

Bloodstream Infection ◽

Risk Prediction ◽

Pediatric Patients ◽

Prediction Models ◽

Low Risk ◽

Severe Neutropenia ◽

Patients With Cancer ◽

Intravenous Antibiotics ◽

Pediatric Cancer Patients

PURPOSE Management of febrile pediatric patients with cancer with an absolute neutrophil count of 500/µL or greater is unclear. The Esbenshade Vanderbilt (EsVan) risk prediction models have been shown to predict bloodstream infection (BSI) likelihood in this population, and this study sought to prospectively validate and implement these models in clinical practice. METHODS Data were prospectively collected on febrile pediatric patients with cancer with a central venous catheter from April 2015 to August 2019 at a single site, at which the models (EsVan: 2015 to 2017; EsVan2: October 2017 to 2019) were initially developed and subsequently implemented for clinical management in well-appearing nonseverely neutropenic individuals. It was recommended that patients with low BSI risk (< 10%) be discharged home without antibiotics, those with intermediate BSI risk (10%-39.9%) be administered an antibiotic before discharge, and those with high BSI risk (> 40%) be admitted on broad-spectrum antibiotics. Seven-day outcomes were then collected and EsVan models were prospectively validated and C-statistics estimated. RESULTS In 937 febrile, nonsevere neutropenia episodes, frequencies of low-, intermediate-, and high-risk episodes were 88.9%, 8.6%, and 2.3% respectively. BSI incidence was 4.2% (39 of 937). Within risk groups, low-risk BSI incidence was 1.9% (16 of 834) with BSI incidence of 13.6% and 54.5% for intermediate- and high-risk episodes, respectively. Empirical intravenous antibiotics were administered in 21.1% of low-risk episodes at presentation and at 7 days postpresentation, 72.3% of episodes never required intravenous antibiotics. There were no deaths or clinical decompensations attributable to antibiotic delay. For BSI detection, EsVan and EsVan2 models applied to the new cohort achieved C-statistics of 0.802 and 0.824, respectively. CONCLUSION Prospective, real-time clinical utilization of the EsVan models accurately predicts BSI risk and safely reduces unnecessary antibiotic use in febrile, nonseverely neutropenic pediatric patients with cancer.

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