title: Red cell transfusions as an independent risk for mortality in critically ill children.
abstract: BACKGROUND
  Severity of illness is an important consideration in making the decision to transfuse as it is the sicker patient that often needs a red cell transfusion. Red blood cell (RBC) transfusions could potentially have direct effects and interact with presenting illness by contributing to pathologies such as multi-organ dysfunction and acute lung injury thus exerting a considerable impact on overall morbidity and mortality. In this study, we examine if transfusion is an independent predictor of mortality, or if outcomes are merely a result of the initial severity as predicted by Pediatric Risk of Mortality (PRISM) III, Pediatric Index of Mortality (PIM2), and day 1 Pediatric Logistic Organ Dysfunction (PELOD) scores.
  
  
  METHODS
  A single center retrospective study was conducted using data from a prospectively maintained transfusion database and center-specific data at our pediatric ICU between January 2009 and December 2012. Multivariate regression was used to control for the effects of clinical findings, therapy, and severity scores, with mortality as the dependent variable. Likelihood ratios and area under the curve were used to test the fidelity of severity scores by comparing transfused vs. non-transfused patients.
  
  
  RESULTS
  There were 4975 admissions that met entry criteria. In multivariate analysis, PRISM III scores and serum hemoglobin were significant predictors of transfusion (p < 0.05). Transfused and non-transfused subjects were distinctly disparate, so multivariate regression was used to control for differences. Severity scores, age, volume transfused, and vasoactive agents were significantly associated with mortality whereas hemoglobin was not. A substantial number of transfusions (45 %) occurred in the first 24 h, and patients transfused later (24-48 h) were more likely to die compared to this earlier time point. Likelihood ratio testing revealed statistically significant differences in severity scoring systems to predict mortality in transfused vs. non-transfused patients.
  
  
  CONCLUSIONS
  This study suggests that RBC transfusion is an important risk factor that is statistically independent of severity. The timing of transfusions that related strongest to mortality remained outside the purview of severity scoring, as these happened beyond the timing of data collection for most scoring systems.
authors.affiliation: Department of Pediatric Critical Care Medicine, Helen DeVos Children's Hospital, 100 Michigan St N.E., Grand Rapids, MI 49503 USA ; Department of Pediatrics, Michigan State University College of Human Medicine. Grand Rapids, Grand Rapids, MI USA.
authors.forename: Surender
authors.initials: S
authors.lastname: Rajasekaran
authors.affiliation: Department of Pediatric Hospitalists, Helen DeVos Children's Hospital, Grand Rapids, MI USA ; Department of Pediatrics, Michigan State University College of Human Medicine. Grand Rapids, Grand Rapids, MI USA.
authors.forename: Eric
authors.initials: E
authors.lastname: Kort
authors.affiliation: Department of Pediatric Critical Care Medicine, Helen DeVos Children's Hospital, 100 Michigan St N.E., Grand Rapids, MI 49503 USA ; Department of Pediatrics, Michigan State University College of Human Medicine. Grand Rapids, Grand Rapids, MI USA.
authors.forename: Richard
authors.initials: R
authors.lastname: Hackbarth
authors.affiliation: Department of Research, Grand Rapids Medical Education Partners and Michigan State University, Grand Rapids, MI USA ; Department of Surgery, Michigan State University, Grand Rapids, MI USA.
authors.forename: Alan T
authors.initials: AT
authors.lastname: Davis
authors.affiliation: Department of Pediatric Critical Care Medicine, Helen DeVos Children's Hospital, 100 Michigan St N.E., Grand Rapids, MI 49503 USA ; Department of Pediatrics, Michigan State University College of Human Medicine. Grand Rapids, Grand Rapids, MI USA.
authors.forename: Dominic
authors.initials: D
authors.lastname: Sanfilippo
authors.affiliation: Department of Pediatric Critical Care Medicine, Helen DeVos Children's Hospital, 100 Michigan St N.E., Grand Rapids, MI 49503 USA ; Department of Pediatrics, Michigan State University College of Human Medicine. Grand Rapids, Grand Rapids, MI USA.
authors.forename: Robert
authors.initials: R
authors.lastname: Fitzgerald
authors.affiliation: Department of Pediatric Critical Care Medicine, Helen DeVos Children's Hospital, 100 Michigan St N.E., Grand Rapids, MI 49503 USA.
authors.forename: Sandra
authors.initials: S
authors.lastname: Zuiderveen
authors.affiliation: Department of Pediatric Critical Care Medicine, Helen DeVos Children's Hospital, 100 Michigan St N.E., Grand Rapids, MI 49503 USA.
authors.forename: Akunne N
authors.initials: AN
authors.lastname: Ndika
authors.affiliation: Department of Pediatrics, Michigan State University College of Human Medicine. Grand Rapids, Grand Rapids, MI USA.
authors.forename: Hilary
authors.initials: H
authors.lastname: Beauchamp
authors.affiliation: Department of Pediatric Critical Care Medicine, Helen DeVos Children's Hospital, 100 Michigan St N.E., Grand Rapids, MI 49503 USA ; Department of Pediatrics, Michigan State University College of Human Medicine. Grand Rapids, Grand Rapids, MI USA.
authors.forename: Anthony
authors.initials: A
authors.lastname: Olivero
authors.affiliation: Department of Pediatric Critical Care Medicine, Helen DeVos Children's Hospital, 100 Michigan St N.E., Grand Rapids, MI 49503 USA ; Department of Pediatrics, Michigan State University College of Human Medicine. Grand Rapids, Grand Rapids, MI USA.
authors.forename: Nabil
authors.initials: N
authors.lastname: Hassan
keywords: Acuity scores; Mortality prediction; PELOD; PIM2; PRISM; Pediatric critical care; Pediatric outcome scores; Transfusion