Paediatric Intensive Care Adaptive Platform Trial
CLINICAL TRAINING:Blood Transfusion Thresholds Domain
v1.1 09 March 2026
To navigate this training package, use the arrows on either side of the screen
Use this button to view the contents of the training and move between different sections:
Click on the three dots in the bottom right hand corner of the screen if you want to navigate to a specific page...
www.icnarc.org
www.icnarc.org
PIVOTAL training packs
There are 4 separate training packs for the PIVOTAL research study. One for ‘core’ platform training and one for each domain:
- Core platform training: Overall summary of platform, eligibility and examples of scenarios for possible randomisations
- Fluid domain
- Sedation domain
- Blood transfusion thresholds domain
It is recommended to undertake the core training first
www.icnarc.org
www.icnarc.org
PIVOTAL training packs
Blood transfusion thresholds domain
Core platform
Fluid domain
Sedation domain
www.icnarc.org
www.icnarc.org
Contents
- Why this domain in PIVOTAL?
- Patient flow
- Platform eligibility – reminder
- Blood transfusion thresholds domain – eligibility
- Domain timeline for randomisation
- Strategies and thresholds
- Cardiovascular stability assessments
- Implementation
- Worked examples
- Review your knowledge (quiz)
- Next steps
- Support and resources
- Questions
- Training confirmation form
www.icnarc.org
www.icnarc.org
Why this domain in PIVOTAL?
Anaemia is common in PICU - up to 74% of children admitted
Blood transfusions are a core process in PICU
Anaemia may be harmful by limiting oxygen delivery
Blood transfusions are commonly used to increase Hb in PICU
Transfusions may be harmful 10-17% children in PICU receive blood transfusions, more in cardiac ICU
www.icnarc.org
www.icnarc.org
Why this domain in PIVOTAL?
- Transfusion is a costly biological therapy and carries risks such as Infection, transfusion reactions, fluid overload
- Associations with increased mortality, worse respiratory function, longer ventilation, delirium
- Effects of untreated anaemia are less clear but may impact neurodevelopment
To find out more about current practice, click on the buttons below...
Variability in UK current practice
What is current practice informed by?
www.icnarc.org
www.icnarc.org
Patient flow
www.icnarc.org
www.icnarc.org
Platform eligibility – Reminder
Must be eligible for platform first, then assess for Transfusion domain
Inclusion criteria:
Gestational age at birth ≥37 weeks, or combined gestational age and post-birth age ≥37 weeks, and <16 years at the time of randomisation
Receiving at least one of respiratory, cardiovascular, or renal support
Expected to remain on organ support the following day
Face-to-face contact with PICU or transport team
Exclusion criteria:
Previously recruited to a domain in PIVOTAL either in the last 30 days or during the same hospital admission
Death perceived as imminent
www.icnarc.org
www.icnarc.org
Blood transfusion thresholds - eligibility
Patients confirmed platform eligible and meet all blood transfusion thresholds eligibility criteria.
Click below to reveal more information about the domain...
- Latest Hb less than or equal to the relevant threshold outlined below:
Use this side of the card to provide more information about a topic. Focus on one concept. Make learning and communication more efficient.
Inclusion criteria
Non-cardiac and cardiac patients
Title
Use this side to give more information about a topic.
Strata
Subtitle
Title
Write a brief description here
www.icnarc.org
www.icnarc.org
Blood transfusion thresholds - eligibility
Click below to reveal more information about the domain...
- Haemoglobinopathies (e.g. sickle cell disease, thalassemia) where red blood cell transfusions may be used to prevent haemolytic or aggregation crises
- Unrepaired cyanotic congenital heart disease and/or functionally single ventricle circulation and/or palliated parallel circulation
- Known advance decision refusing blood/blood component transfusions (e.g. Jehovah’s Witnesses)
- Receiving Extracorporeal Membrane Oxygenation (ECMO)
- Receipt of RBC transfusion for a reason other than bleeding or extracorporeal support (on ECMO or for priming renal replacement circuit) since meeting the platform inclusion criteria
Exclusion criteria
Title
Use this side to give more information about a topic.
Subtitle
www.icnarc.org
www.icnarc.org
Blood transfusion thresholds – eligibility criteria: NOTE
- Patients may become eligible for the Transfusion domain at a later timepoint following randomisation into another domain(s), [Sedation and/or Fluids*]
- Must become domain eligible before the end of day 4 (calendar days) post-initial randomisation
- If so, a second randomisation will be used on confirmation of Transfusion domain-specific eligibility
- Participant list tab on ‘Sealed Envelope’ (randomisation system) – will only show patients who are still within the window to be randomised to transfusion
*Note: non-cardiac only patients for Fluid domain
www.icnarc.org
www.icnarc.org
Domain timeline for randomisation
Once eligible for the Transfusion domain, children will be randomised to a:
OR
red blood cell transfusion strategy The strategy determines the transfusion threshold
i.e. a haemoglobin (Hb) level below which they should receive a blood transfusion
www.icnarc.org
www.icnarc.org
Within each strategy, threshold decided by
Non-cardiac
Cardiac
Stratum
Acute brain injury (ABI)
Disease/age
No ABI
Neonate
Infant/child
Low cardiac output state AND
- Fluid bolus in last 3 h, or
- ↑ in vasoactives in last 3h, or
- Lactate>3 in last 3h, or
- ScvO2<60% in last 3h, or
- NIRS<60%
– see next slides for details
Cardiovascular status at time of transfusion
Fluid bolus in last 3 h, or
↑ in vasoactives in last 3h
– see next slides for details
www.icnarc.org
www.icnarc.org
Blood transfusion thresholds
www.icnarc.org
www.icnarc.org
Cardiovascular assessments
Click on the buttons below to read more about the assessments by stratum...
Non-cardiac patients
Cardiac patients
Use Administration guide at bedside
www.icnarc.org
www.icnarc.org
Implemention: a series of steps…
Click on the numbers below to reveal more about the series of steps...
Randomised to restrictive or liberal strategy once domain eligible
If Hb equal to or less than higher threshold, assess if cardiovascularly stable or unstable (use Administration guide)
Two thresholds given based on stratum and disease/age
- If cardiovascularly unstable (higher)
- If cardiovascularly
stable (lower)
If cardiovascularly stable
If cardiovascularly unstable
(up to 15ml/kg allowed to avoid waste or donor exposure)
Wait until Hb equal to or less than lower threshold...
Transfuse with 10ml/kg or 1 unit packed red blood cells
Transfuse with 10ml/kg or 1 unit packed red blood cells
(up to 15ml/kg allowed to avoid waste or donor exposure)
www.icnarc.org
www.icnarc.org
This means that it stays in place for the duration of the PICU stay and the child will only receive a blood transfusion if their Hb is less than the corresponding threshold within the strategy.
The allocated strategy commences at randomisation and continues until day 30, or PICU discharge, whichever comes first.
If a patient is re-admitted to PICU within the 30 days, treatment according to the allocated strategy will be recommenced.
Clinical team will guide the frequency of ongoing monitoring of the Hb values.
www.icnarc.org
www.icnarc.org
Blood transfusion thresholds domain
Click the triangles to see reasons transfusion thresholds should be suspended temporarily...
Bleeding
Moderate to severe bleeding, defined as any of the following:
- Fresh bleeding in drains ≥ 5ml/kg/hr for at least one hour
- Intra-cavity bleeding needing drainage/surgery
- The local major haemorrhage protocol is activated
Surgical procedures in operating theatre during ICU stay
Patient cannulated for ECMO
Transfusion thresholds should re-apply once bleeding stopped, return from surgery, decannulated from ECMO.
www.icnarc.org
www.icnarc.org
What do I have to do as the bedside nurse when the patient is randomised to the Transfusion Domain? (or team leader supporting less experienced nurses)
- At randomisation, the system will tell you which transfusion strategy the patient is allocated to
- Use the relevant PIVOTAL Transfusion Threshold domain administration guide and keep it at the bedside
- Check the patient’s latest Hb, compare to the administration guide to note whether they should or should not receive a blood transfusion
- If so, this is prescribed (10ml/kg) and administered following your usual procedures
- Document all transfusions/volume received using your usual PICU system
- Make sure there is a clear notice at the child’s bedside stating which Transfusion threshold they have been allocated and when they should receive a transfusion
- Hand this over at all shift changes
- Contact your senior team or research team with any questions
www.icnarc.org
www.icnarc.org
Worked examples
www.icnarc.org
www.icnarc.org
Worked example (1)
Harry 10 day old 3.8kg baby admitted with possible sepsis, sedated and ventilated. He is eligible for PIVOTAL:
- Sedation domain
- Fluid domain
He would be eligible for the Transfusion domain if his Hb is less than or equal to 85g/L, now or within 4 days of randomisation into the other domains of PIVOTAL.
This is because he is
- In the non-cardiac stratum
- Does not have acute brain injury
www.icnarc.org
www.icnarc.org
Worked example (1)
Harry’s Hb is 74g/L. He is randomised to the Restrictive transfusion strategy. He is currently cardiovascularly unstable (started adrenaline 2 hours ago). BUT he WOULD NOT receive a blood transfusion.
This is because he is:
Regardless of cardiovascular instability
www.icnarc.org
www.icnarc.org
Worked example (2)
Shalina, a 14-year-old girl, suffered a severe traumatic brain injury and pelvic #. She is sedated, ventilated and neuroprotected. She is eligible for PIVOTAL:
- Sedation domain
- Fluid domain
She would be eligible for the Transfusion domain if her Hb is less than or equal to 100g/L, now or within 4 days of randomisation into other PIVOTAL domains.
This is because she is
- In the non-cardiac stratum
- Has acute brain injury (ABI)
www.icnarc.org
www.icnarc.org
Worked example (2)
Shalina’s Hb is 69g/L. She is randomised to the Restrictive transfusion strategy. She is currently cardiovascularly stable. She WOULD receive a blood transfusion.
This is because she is
- In the non-cardiac stratum
- Has ABI
Regardless of cardiovascular instability
www.icnarc.org
www.icnarc.org
Worked example (3)
Joe, 4 year old boy admitted post cardiac surgery. He is sedated and ventilated. He is eligible for PIVOTAL:
He would be eligible for the Transfusion domain if his Hb is less than or equal to 100g/L, now or within 4 days of randomisation into other domains of PIVOTAL.
This is because he is
- In the cardiac stratum
- Is >28 days old
www.icnarc.org
www.icnarc.org
Worked example (3)
Joe’s Hb is 86g/L. He is randomised to the Restrictive transfusion strategy. He currently is not in a low cardiac output state (LCOS) and is cardiovascularly stable. Therefore, he WOULD NOT receive a blood transfusion.
This is because he is
- In the cardiac stratum
- Age >28d
- No signs of CVS instability
www.icnarc.org
www.icnarc.org
Review your knowledge
www.icnarc.org
www.icnarc.org
Review knowledge: Scenario 1
Ahmed, an 8-year-old boy (25kg), has been admitted to your PICU for LRTI with a pARDS picture. He’s randomised to all domains of PIVOTAL: i.e. Sedation, Fluid, Transfusion. He has been randomised to the Restrictive transfusion strategy.
www.icnarc.org
www.icnarc.org
Review knowledge: Scenario 1
Ahmed, is currently cardiovascular unstable. His Hb is 82g/L.
www.icnarc.org
www.icnarc.org
Review knowledge: Scenario 2
Dolly, a 5-day old term baby, is admitted after being found unresponsive at home, by her parents. She was intubated, sedated and ventilated in ED. She is diagnosed with sepsis and has a normal head scan. 2 hours after PICU admission she was randomised to PIVOTAL: Sedation and Fluid domains. This is called Day 1. Her Hb was 87g/L so she was not eligible for the Transfusion domain.
www.icnarc.org
www.icnarc.org
Review knowledge: Scenario 2
2 days after her admission to PICU, Dolly’s Hb falls to 81g/L. She is eligible for randomisation. You have not been trained to randomise to PIVOTAL.
www.icnarc.org
www.icnarc.org
Review knowledge: Scenario 2
2 days after her admission to PICU, Dolly’s Hb falls to 81g/L. She is randomised to the Liberal strategy of the transfusion domain which means she would receive a blood transfusion if her Hb is: ≤80g/L if cardiovascularly stable ≤85g/L if cardiovascularly unstable as she is being treated for Group B Strep sepsis without ABI.
www.icnarc.org
www.icnarc.org
Review knowledge: Scenario 2
5 days later, Dolly remains ventilated and is now on CVVH. Her Hb has fallen to 75g/L.
www.icnarc.org
www.icnarc.org
Review knowledge: Scenario 2
Two weeks later, Dolly remains on PICU and is much improved. She is off the ventilator and CVVH. She is cardiovascularly stable. Her Hb is 80g/L.
www.icnarc.org
www.icnarc.org
Next steps
Other PIVOTAL training packs available
- Core: Recommended to undertake first
www.icnarc.org
www.icnarc.org
Support and resources
Click here
- Core and domain training packs
- Administration guides (one per domain)
- Trial summary for bedside teaching
- Bedside notices
- Stickers for charts
- AFR assessment form
www.icnarc.org
www.icnarc.org
Questions
If you have any questions on this domain or any part of the PIVOTAL trial, please ask your PICU research team first or contact the clinical trials unit at PIVOTAL@icnarc.org
www.icnarc.org
www.icnarc.org
Training confirmation form
Once you have completed this training pack, complete the online form via this link:
Click here
www.icnarc.org
www.icnarc.org
Answer: No, Dolly should not receive a blood transfusion now. See table below...
Answer: No, Dolly should not receive a blood transfusion now. See table below...
Cardiac
For children in the cardiac stratum, the threshold to be used depends upon clinical assessments of BOTH low cardiac output syndrome and cardiovascular stability. Low cardiac output syndrome: As diagnosed by the treating clinician. Cardiovascular instability Defined as one or more of:
(i) a fluid bolus administration in the previous 3 hours, or
(ii) vasoactive infusions (e.g., adrenaline, noradrenaline, dopamine, dobutamine, milrinone, vasopressin, angiotensin or methylene blue) started or the rate of infusion increased in the previous 3 hours, or
(iii) the most recent measured arterial lactate (within 3 hours) is greater than 3.0 mmol/L, or
(iv) the most recent upper body central venous oxygen saturations (ScvO2) (within 3 hours) is less than 60%, or
(v) the cerebral or somatic near infra-red spectroscopy (NIRS) measurement is less than 60%
Practice largely informed by single multi-centre RCT (TRIPICU)
- Nearly 20 years ago
- Low proportion of eligible patients recruited
- Several exclusions
- Recent adult evidence suggest potential neurological benefits from liberal transfusion strategy
Current UK practice variable- Median pre-transfusion Hb 78g/L in non-cardiac, 91g/L in cardiac
- Higher in cardiovascular instability
Non-cardiac
For children in the non-cardiac stratum, the threshold to be used depends upon a clinical assessment of cardiovascular stability. Cardiovascular instability
Defined as one or more of:
(i) a fluid bolus administration in the previous 3 hours, or
(ii) vasoactive infusions (e.g., adrenaline, noradrenaline, dopamine, dobutamine, milrinone, vasopressin, angiotensin or methylene blue) started or the rate of infusion increased in the previous 3 hours
PIVOTAL Clinical Training - Transfusion Domain v1.0 21.01.2026
ICNARC CTU
Created on February 27, 2026
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Transcript
Paediatric Intensive Care Adaptive Platform Trial
CLINICAL TRAINING:Blood Transfusion Thresholds Domain
v1.1 09 March 2026
To navigate this training package, use the arrows on either side of the screen
Use this button to view the contents of the training and move between different sections:
Click on the three dots in the bottom right hand corner of the screen if you want to navigate to a specific page...
www.icnarc.org
www.icnarc.org
PIVOTAL training packs
There are 4 separate training packs for the PIVOTAL research study. One for ‘core’ platform training and one for each domain:
It is recommended to undertake the core training first
www.icnarc.org
www.icnarc.org
PIVOTAL training packs
Blood transfusion thresholds domain
Core platform
Fluid domain
Sedation domain
www.icnarc.org
www.icnarc.org
Contents
www.icnarc.org
www.icnarc.org
Why this domain in PIVOTAL?
Anaemia is common in PICU - up to 74% of children admitted
Blood transfusions are a core process in PICU
Anaemia may be harmful by limiting oxygen delivery
Blood transfusions are commonly used to increase Hb in PICU
Transfusions may be harmful 10-17% children in PICU receive blood transfusions, more in cardiac ICU
www.icnarc.org
www.icnarc.org
Why this domain in PIVOTAL?
To find out more about current practice, click on the buttons below...
Variability in UK current practice
What is current practice informed by?
www.icnarc.org
www.icnarc.org
Patient flow
www.icnarc.org
www.icnarc.org
Platform eligibility – Reminder
Must be eligible for platform first, then assess for Transfusion domain
Inclusion criteria:
Gestational age at birth ≥37 weeks, or combined gestational age and post-birth age ≥37 weeks, and <16 years at the time of randomisation
Receiving at least one of respiratory, cardiovascular, or renal support
Expected to remain on organ support the following day
Face-to-face contact with PICU or transport team
Exclusion criteria:
Previously recruited to a domain in PIVOTAL either in the last 30 days or during the same hospital admission
Death perceived as imminent
www.icnarc.org
www.icnarc.org
Blood transfusion thresholds - eligibility
Patients confirmed platform eligible and meet all blood transfusion thresholds eligibility criteria.
Click below to reveal more information about the domain...
Use this side of the card to provide more information about a topic. Focus on one concept. Make learning and communication more efficient.
Inclusion criteria
Non-cardiac and cardiac patients
Title
Use this side to give more information about a topic.
Strata
Subtitle
Title
Write a brief description here
www.icnarc.org
www.icnarc.org
Blood transfusion thresholds - eligibility
Click below to reveal more information about the domain...
Exclusion criteria
Title
Use this side to give more information about a topic.
Subtitle
www.icnarc.org
www.icnarc.org
Blood transfusion thresholds – eligibility criteria: NOTE
*Note: non-cardiac only patients for Fluid domain
www.icnarc.org
www.icnarc.org
Domain timeline for randomisation
Once eligible for the Transfusion domain, children will be randomised to a:
- Restrictive
OR- Liberal
red blood cell transfusion strategy The strategy determines the transfusion thresholdi.e. a haemoglobin (Hb) level below which they should receive a blood transfusion
www.icnarc.org
www.icnarc.org
Within each strategy, threshold decided by
Non-cardiac
Cardiac
Stratum
Acute brain injury (ABI)
Disease/age
No ABI
Neonate
Infant/child
Low cardiac output state AND
- Fluid bolus in last 3 h, or
- ↑ in vasoactives in last 3h, or
- Lactate>3 in last 3h, or
- ScvO2<60% in last 3h, or
- NIRS<60%
– see next slides for detailsCardiovascular status at time of transfusion
Fluid bolus in last 3 h, or ↑ in vasoactives in last 3h – see next slides for details
www.icnarc.org
www.icnarc.org
Blood transfusion thresholds
www.icnarc.org
www.icnarc.org
Cardiovascular assessments
Click on the buttons below to read more about the assessments by stratum...
Non-cardiac patients
Cardiac patients
Use Administration guide at bedside
www.icnarc.org
www.icnarc.org
Implemention: a series of steps…
Click on the numbers below to reveal more about the series of steps...
Randomised to restrictive or liberal strategy once domain eligible
If Hb equal to or less than higher threshold, assess if cardiovascularly stable or unstable (use Administration guide)
Two thresholds given based on stratum and disease/age
- If cardiovascularly unstable (higher)
- If cardiovascularly
stable (lower)If cardiovascularly stable
If cardiovascularly unstable
(up to 15ml/kg allowed to avoid waste or donor exposure)
Wait until Hb equal to or less than lower threshold...
Transfuse with 10ml/kg or 1 unit packed red blood cells
Transfuse with 10ml/kg or 1 unit packed red blood cells
(up to 15ml/kg allowed to avoid waste or donor exposure)
www.icnarc.org
www.icnarc.org
This means that it stays in place for the duration of the PICU stay and the child will only receive a blood transfusion if their Hb is less than the corresponding threshold within the strategy.
The allocated strategy commences at randomisation and continues until day 30, or PICU discharge, whichever comes first.
If a patient is re-admitted to PICU within the 30 days, treatment according to the allocated strategy will be recommenced.
Clinical team will guide the frequency of ongoing monitoring of the Hb values.
www.icnarc.org
www.icnarc.org
Blood transfusion thresholds domain
Click the triangles to see reasons transfusion thresholds should be suspended temporarily...
Bleeding Moderate to severe bleeding, defined as any of the following:- Fresh bleeding in drains ≥ 5ml/kg/hr for at least one hour
- Intra-cavity bleeding needing drainage/surgery
- The local major haemorrhage protocol is activated
Surgical procedures in operating theatre during ICU stay
Patient cannulated for ECMO
Transfusion thresholds should re-apply once bleeding stopped, return from surgery, decannulated from ECMO.
www.icnarc.org
www.icnarc.org
What do I have to do as the bedside nurse when the patient is randomised to the Transfusion Domain? (or team leader supporting less experienced nurses)
www.icnarc.org
www.icnarc.org
Worked examples
www.icnarc.org
www.icnarc.org
Worked example (1)
Harry 10 day old 3.8kg baby admitted with possible sepsis, sedated and ventilated. He is eligible for PIVOTAL:
He would be eligible for the Transfusion domain if his Hb is less than or equal to 85g/L, now or within 4 days of randomisation into the other domains of PIVOTAL.
This is because he is
www.icnarc.org
www.icnarc.org
Worked example (1)
Harry’s Hb is 74g/L. He is randomised to the Restrictive transfusion strategy. He is currently cardiovascularly unstable (started adrenaline 2 hours ago). BUT he WOULD NOT receive a blood transfusion.
This is because he is:
- Non-cardiac
- Non-ABI
Regardless of cardiovascular instabilitywww.icnarc.org
www.icnarc.org
Worked example (2)
Shalina, a 14-year-old girl, suffered a severe traumatic brain injury and pelvic #. She is sedated, ventilated and neuroprotected. She is eligible for PIVOTAL:
- Sedation domain
- Fluid domain
She would be eligible for the Transfusion domain if her Hb is less than or equal to 100g/L, now or within 4 days of randomisation into other PIVOTAL domains.This is because she is
www.icnarc.org
www.icnarc.org
Worked example (2)
Shalina’s Hb is 69g/L. She is randomised to the Restrictive transfusion strategy. She is currently cardiovascularly stable. She WOULD receive a blood transfusion.
This is because she is
- In the non-cardiac stratum
- Has ABI
Regardless of cardiovascular instabilitywww.icnarc.org
www.icnarc.org
Worked example (3)
Joe, 4 year old boy admitted post cardiac surgery. He is sedated and ventilated. He is eligible for PIVOTAL:
He would be eligible for the Transfusion domain if his Hb is less than or equal to 100g/L, now or within 4 days of randomisation into other domains of PIVOTAL.
This is because he is
www.icnarc.org
www.icnarc.org
Worked example (3)
Joe’s Hb is 86g/L. He is randomised to the Restrictive transfusion strategy. He currently is not in a low cardiac output state (LCOS) and is cardiovascularly stable. Therefore, he WOULD NOT receive a blood transfusion.
This is because he is
www.icnarc.org
www.icnarc.org
Review your knowledge
www.icnarc.org
www.icnarc.org
Review knowledge: Scenario 1
Ahmed, an 8-year-old boy (25kg), has been admitted to your PICU for LRTI with a pARDS picture. He’s randomised to all domains of PIVOTAL: i.e. Sedation, Fluid, Transfusion. He has been randomised to the Restrictive transfusion strategy.
www.icnarc.org
www.icnarc.org
Review knowledge: Scenario 1
Ahmed, is currently cardiovascular unstable. His Hb is 82g/L.
www.icnarc.org
www.icnarc.org
Review knowledge: Scenario 2
Dolly, a 5-day old term baby, is admitted after being found unresponsive at home, by her parents. She was intubated, sedated and ventilated in ED. She is diagnosed with sepsis and has a normal head scan. 2 hours after PICU admission she was randomised to PIVOTAL: Sedation and Fluid domains. This is called Day 1. Her Hb was 87g/L so she was not eligible for the Transfusion domain.
www.icnarc.org
www.icnarc.org
Review knowledge: Scenario 2
2 days after her admission to PICU, Dolly’s Hb falls to 81g/L. She is eligible for randomisation. You have not been trained to randomise to PIVOTAL.
www.icnarc.org
www.icnarc.org
Review knowledge: Scenario 2
2 days after her admission to PICU, Dolly’s Hb falls to 81g/L. She is randomised to the Liberal strategy of the transfusion domain which means she would receive a blood transfusion if her Hb is: ≤80g/L if cardiovascularly stable ≤85g/L if cardiovascularly unstable as she is being treated for Group B Strep sepsis without ABI.
www.icnarc.org
www.icnarc.org
Review knowledge: Scenario 2
5 days later, Dolly remains ventilated and is now on CVVH. Her Hb has fallen to 75g/L.
www.icnarc.org
www.icnarc.org
Review knowledge: Scenario 2
Two weeks later, Dolly remains on PICU and is much improved. She is off the ventilator and CVVH. She is cardiovascularly stable. Her Hb is 80g/L.
www.icnarc.org
www.icnarc.org
Next steps
Other PIVOTAL training packs available
www.icnarc.org
www.icnarc.org
Support and resources
Click here
www.icnarc.org
www.icnarc.org
Questions
If you have any questions on this domain or any part of the PIVOTAL trial, please ask your PICU research team first or contact the clinical trials unit at PIVOTAL@icnarc.org
www.icnarc.org
www.icnarc.org
Training confirmation form
Once you have completed this training pack, complete the online form via this link:
Click here
www.icnarc.org
www.icnarc.org
Answer: No, Dolly should not receive a blood transfusion now. See table below...
Answer: No, Dolly should not receive a blood transfusion now. See table below...
Cardiac
For children in the cardiac stratum, the threshold to be used depends upon clinical assessments of BOTH low cardiac output syndrome and cardiovascular stability. Low cardiac output syndrome: As diagnosed by the treating clinician. Cardiovascular instability Defined as one or more of: (i) a fluid bolus administration in the previous 3 hours, or (ii) vasoactive infusions (e.g., adrenaline, noradrenaline, dopamine, dobutamine, milrinone, vasopressin, angiotensin or methylene blue) started or the rate of infusion increased in the previous 3 hours, or (iii) the most recent measured arterial lactate (within 3 hours) is greater than 3.0 mmol/L, or (iv) the most recent upper body central venous oxygen saturations (ScvO2) (within 3 hours) is less than 60%, or (v) the cerebral or somatic near infra-red spectroscopy (NIRS) measurement is less than 60%
Practice largely informed by single multi-centre RCT (TRIPICU)- Nearly 20 years ago
- Low proportion of eligible patients recruited
- Several exclusions
- Recent adult evidence suggest potential neurological benefits from liberal transfusion strategy
Current UK practice variable- Median pre-transfusion Hb 78g/L in non-cardiac, 91g/L in cardiac
- Higher in cardiovascular instability
Non-cardiac
For children in the non-cardiac stratum, the threshold to be used depends upon a clinical assessment of cardiovascular stability. Cardiovascular instability Defined as one or more of: (i) a fluid bolus administration in the previous 3 hours, or (ii) vasoactive infusions (e.g., adrenaline, noradrenaline, dopamine, dobutamine, milrinone, vasopressin, angiotensin or methylene blue) started or the rate of infusion increased in the previous 3 hours